Written by Aaron Lacy
Spoon Feed
This trauma database study found that patients intubated in the emergency department (ED) who required hemorrhage control surgery had worse outcomes than those who were intubated in the operating room (OR). But there’s more to the story.
The devil is in the details (methods)
Appraisal of today’s study requires a refresher on what came before it.
In 2023, we covered an article that found patients who required urgent hemorrhage control surgery (i.e. bleeding to death) had worse outcomes if intubated in the ED vs OR. They excluded patients with, “clear clinical indication for intubation (including head trauma).” The concern in this retrospective study was the presence of confounding factors that were not adjusted for in the analysis.
Using a more sophisticated statistical approach, a recent article found no difference in adverse outcomes in patients based on intubation location who required emergency surgery (this time including head trauma patients). This was from the Israel National Trauma Registry, with high injury severity scores (ISS >16) over a period from 2016-2023 and did not exclude patients with “clear clinical indication for intubation.” Similar to above, patients who were intubated in the ED were sicker overall and had higher mortality compared to those who didn’t require ED intubation. When similar patients were propensity matched, there was no difference in adverse outcomes based on intubation location (ED vs. OR). This study showed the location of intubation may not matter as much as how sick you are when you get intubated.
Today’s study also used the Israel National Trauma Registry, including patients with a high ISS (>15) from a similar time period (2013-2023) requiring urgent hemorrhage control surgery. They found that patients intubated in the ED, after adjusting for various confounders, had a 5x higher odds of mortality (aOR 5.01, 95%CI 1.68-17.05, p = 0.006). Why were results so different, despite using the same database? The key is this study, similar to the 2023 study, excluded patients “requiring immediate ED intubation” and those who required urgent neurosurgical intervention for head injuries and used a different statistical approach (i.e. no propensity score matching).
How does this change my practice?
We can’t just take conclusions at face value – we need to look at the details. If I have a patient who needs to be intubated, I intubate them. If I have a patient for whom intubation can be delayed or deferred for other interventions (volume resuscitation, pH optimization, non-invasive positive pressure, transfer to the OR for hemorrhage control surgery, etc), I don’t intubate them.
I love intubating – but I avoid it when possible, because anyone who is intubated for critical illness has a high chance of an adverse event and mortality. If I have a patient who is bleeding to death and is protecting their airway, I want them to go to the OR as fast as possible. I will continue to work with my team to prioritize the right intervention, at the right time, in the right place.
Editor’s note: This post is longer than usual, but when studies we cover have directly conflicting results, we need to unpack why. Thanks Aaron! ~Clay Smith
Source
Airway management in trauma patients with active hemorrhage: Does intubation location matter? A nationwide retrospective cohort study. Am J Emerg Med. 2025 Jun 14;96:41-47. doi: 10.1016/j.ajem.2025.06.023. Epub ahead of print. PMID: 40517708
