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Should Trauma Patients Be Intubated in the Emergency Department or the OR?

April 19, 2023

Written by Andy Hogan

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Patients who required hemorrhage control surgery after major trauma and were intubated in the ED had higher rates of adverse outcomes than those intubated in the OR. Importantly, patients with “clinical indications for intubation” were excluded from analysis.

Why does this matter?
The conclusions of this study may seem inflammatory if the exclusion criteria are overlooked. More precisely, trauma patients without immediate airway threats seem to have fewer adverse outcomes when ED intubation is deferred.

Early intubation or expedited operation?
This retrospective cohort study evaluated 9667 patients requiring hemorrhage control surgery within 1 hour of arrival at 253 level 1 or 2 trauma centers. Notably, the study excluded 7303 patients with “clear clinical indications for intubation” (GCS ≤8, severe head/face/neck injury, or ED thoracotomy). After risk adjustment between groups, patients intubated in the ED were observed to have significantly higher rates of mortality (aOR 1.85), cardiac arrest (aOR 1.72), and end-organ complications than those intubated in the OR. The retrospective nature of this study makes it impossible to determine indications for intubation for individual patients. While authors adjusted for differences in rates of major chest trauma, SBP, and HR between the 2 groups, they did not include potential differences in RR, SpO2, or ETCO2. Furthermore, when trauma centers were stratified by “tendency for ED intubation,” low outliers did not have significantly lower rates of mortality than high outliers. These details suggest additional indications for intubation or confounding clinical factors may not have been accounted for. Nevertheless, intubation is physiologically stressful for any patient, especially a critically injured one. Based on these findings, trauma clinicians should carefully consider whether each ED intubation is essential or should be deferred in favor of rapid transport to surgical care.

Emergency Department Versus Operating Room Intubation of Patients Undergoing Immediate Hemorrhage Control Surgery. J Trauma Acute Care Surg. 2023 Feb 28. doi: 10.1097/TA.0000000000003907. Online ahead of print.

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