Airway management in trauma patients: A seven-year review of emergency department intubations.

introductionEndotracheal intubation (ETI) is a high-risk procedure frequently performed in the emergency department (ED), particularly in trauma patients, where it presents unique challenges. These include anatomically difficult airways, adverse effects of medications used for rapid sequence intubation (RSI), and the need to manage hemodynamically unstable patients. This study characterizes the incidence of ED ETI over a six-year period, with 24-h survival as the primary outcome and secondary outcomes including all-cause ED mortality, factors associated with ED ETI, and subgroup analyses in pediatric patients.

methodsWe conducted a retrospective cohort study using data from the American College of Surgeons Trauma Quality Improvement Program (TQIP), focusing on trauma patients who underwent ETI in the ED. Descriptive statistics, inferential analyses, and multivariable logistic regression were used to assess associated factors.

resultsFrom 2017 to 2023, 7,620,399 trauma encounters met inclusion criteria, of which 279,627 (3.7 %) underwent ED ETI. The primary outcome of 24-h survival was significantly lower in patients who underwent ED ETI compared to those who did not (69.8 % vs. 97.5 %; difference 27.6 %, 95 % confidence interval [CI] 26.5-27.8). Among intubated patients, the secondary outcome of all-cause mortality in ED was 10.2 %. Factors independently associated with ED ETI included male sex (odds ratio [OR] 1.40, CI 1.38-1.42), firearm injury (1.52, 1.48-1.55), stabbing (1.34, 1.31-1.38), head/neck injury (2.40, 2.37-2.42), face (1.57, 1.51-1.63), thorax (1.61, 1.59-1.63), abdomen (1.66, 1.63-1.69), extremities (1.23, 1.22-1.25), skin (1.84, 1.78-1.91), elevated shock index (1.73, 1.71-1.75), depressed Glasgow Coma Scale (GCS) (0.69, 0.69-0.69), need for respiratory assistance on arrival (5.70, 5.61-5.79), and EMS arrival (2.14, 2.09-2.19). In the pediatric subgroup (<18 years, a secondary outcome analysis), 815,531 encounters met inclusion, with 18,417 (2.3 %) undergoing ED ETI. Similar factors were associated with ED ETI, including male sex (1.05, 1.01-1.09), collision (1.08, 1.01-1.09), firearm injury (2.29, 2.11-2.48), head/neck injury (3.55, 3.41-3.71), face (1.26, 1.08-1.47), thorax (1.91, 1.85-2.00), abdomen (1.64, 1.55-1.76), extremities (1.26, 1.19-1.32), skin (1.79, 1.55-2.06), elevated SI (1.19, 1.15-1.23), depressed GCS (0.69, 0.69-0.70), respiratory assistance on arrival (6.51, 6.14-6.91), and EMS arrival (1.90, 1.77-2.04).

conclusionsIn this large, national trauma cohort, approximately 3.7 % of patients underwent ED ETI. These primary outcome of 24-h survival was significantly lower in patients requiring intubation, and secondary analyses demonstrated high all-cause ED mortality, distinct predictors of ETI and similar associations in pediatric patients. The findings underscore the critical importance of optimizing emergency airway management in trauma care.