ED Intubation May Raise Mortality Risk in Active Hemorrhage

TOPLINE:

In a cohort study of patients with active hemorrhage, endotracheal intubation in the emergency department (ED) was associated with higher mortality rates, more frequent ICU admissions, and a greater need for blood transfusion compared with intubation in the operating room (OR).

METHODOLOGY:

• Researchers conducted a nationwide, retrospective cohort analysis using data from the Israel National Trauma Registry between 2013 and 2023.
• A total of 1527 patients (median age, 29 years; 89.6% men) who required transfer to the OR for hemorrhage control surgery within 90 minutes of ED arrival were included.
• A total of 279 participants underwent endotracheal intubation in the ED and 1248 were intubated upon arrival in the OR. Indications for immediate intubation in the ED included having a Glasgow Coma Scale score < 9 or serious injuries (Abbreviated Injury Score [AIS] ≥ 3) to the head, face, neck, or thorax.
• The primary outcome was survival to hospital discharge for patients with an Injury Severity Score (ISS) > 14, and secondary outcomes included blood transfusion requirements and ICU admission following hemorrhage control procedures.
• Patients were followed up until discharge from their respective trauma care centers, and potential confounders included age, sex, systolic blood pressure on admission, ISS, and blunt vs penetrating trauma.

TAKEAWAY:

• Patients intubated in the ED had higher in-hospital mortality (5.0% vs 0.5%; P < .001), higher ICU admission rates (63.1% vs 28.9%; P < .001), and a greater need for blood transfusion in the ED (49.8% vs 15.0%; P < .001) than those intubated in the OR.
• After adjustment for confounders, ED intubation was independently associated with increased mortality (adjusted odds ratio [aOR], 5.01; P = .006). In the matched cohort, ED intubation trended toward higher mortality (8.0% vs 2.9%; aOR, 3.10; P = .065)
• Among the patients intubated in the ED, 44.1% were hospitalized for 14 or more days, whereas 19.6% of those intubated in the OR were hospitalized for the same duration (P < .001).
• For the whole cohort, intubation in the ED was independently associated with increased ICU admission (aOR, 3.17; P < .001) and a greater need for blood product transfusion (aOR, 4.81; P < .001).

IN PRACTICE:

“Trauma [care] providers should prioritize blood-based resuscitation to optimize the patient’s physiology before proceeding with intubation, while also minimizing delays to definitive care in the OR. Airway management, particularly in the ED, should be performed only when there is a clear indication and, whenever possible, after the patient has been physiologically optimized,” the authors wrote.

SOURCE:

The study was led by Danny Epstein, Rambam Health Care Campus, Haifa, Israel. It was published online on June 14, 2025, in The American Journal of Emergency Medicine.

LIMITATIONS:

The study was limited by incomplete registry data on the specific clinical indications and timing of ED intubations. The exact factors contributing to mortality could not be determined, and the exclusion of patients who died before reaching the OR may have led to underestimated mortality rates. Additionally, the registry did not capture patient comorbidities, which could have influenced hemodynamic stability and intubation-related complications.

DISCLOSURES:

The authors reported no funding sources or relevant conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.