Emergency department versus operating room intubation of patients undergoing immediate hemorrhage control surgery

Abstract

BACKGROUNDHemorrhage control surgery is an essential trauma center function. Airway management of the unstable bleeding patient in the emergency department (ED) presents a challenge. Premature intubation in the ED can exacerbate shock and precipitate extremis. We hypothesized that ED versus operating room intubation of patients requiring urgent hemorrhage control surgery is associated with adverse outcomes at the patient and hospital-levels.METHODSPatients who underwent hemorrhage control within 60 minutes of arrival at level 1 or 2 trauma centers were identified (National Trauma Data Bank 2017–2019). To minimize confounding, patients dead on arrival, undergoing ED thoracotomy, or with clinical indications for intubation (severe head/neck/face injury or Glasgow Coma Scale score of ≤8) were excluded. Two analytic approaches were used. First, hierarchical logistic regression measured the risk-adjusted association between ED intubation and mortality. Secondary outcomes included ED dwell time, units of blood transfused, and major complications (cardiac arrest, acute respiratory distress syndrome, acute kidney injury, sepsis). Second, a hospital-level analysis determined whether hospital tendency ED intubation was associated with adverse outcomes.RESULTSWe identified 9,667 patients who underwent hemorrhage control surgery at 253 trauma centers. Patients were predominantly young men (median age, 33 years) who suffered penetrating injuries (71%). The median initial Glasgow Coma Scale and systolic blood pressure were 15 and 108 mm Hg, respectively. One in five (20%) of patients underwent ED intubation. After risk-adjustment, ED intubation was associated with significantly increased odds of mortality, longer ED dwell time, greater blood transfusion, and major complications. Hospital-level analysis identified significant variation in use of ED intubation between hospitals not explained by patient case mix. After risk adjustment, patients treated at hospitals with high tendency for ED intubation (compared with those with low tendency) were significantly more likely to suffer in-hospital cardiac arrest (6% vs. 4%; adjusted odds ratio, 1.46; 95% confidence interval, 1.04–2.03).CONCLUSIONEmergency department intubation of patients who require urgent hemorrhage control surgery is associated with adverse outcomes. Significant variation in ED intubation exists between trauma centers not explained by patient characteristics. Where feasible, intubation should be deferred in favor of rapid resuscitation and transport to the operating room.LEVEL OF EVIDENCETherapeutic/Care Management; Level III.

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“…This retrospective cohort study using the US National Trauma Data Bank identified adult patients transferred to the operating theatre for HCS within 60 min of hospital arrival and compared in-hospital mortality among those intubated in the ED versus in theatre. The authors also performed a hospital-level analysis comparing mortality in hospitals with high versus low tendency for ED intubation 5…”

Intubation of bleeding patients in the emergency department or the operating room: A medical decision to be justified

“…The patients intubated in the ED are more severe (median injury severity score 22 Vs 17, p < 0.001) and more frequently suffer chest trauma (50% Vs 34.6%, p < 0.001) than those intubated in the OR. 1 However, we have no clinical (saturation or respiratory rate) or paraclinical (arterial blood gas) data to determine their degree of respiratory failure. There is a great risk of comparing patients who present a double failure, respiratory and circulatory, with patients presenting only a circulatory failure.…”

“…The analysis of 9,667 patients shows that patients intubated in the ER die significantly more than those intubated in the OR (17.4% Vs 7.1%, p < 0.001). 1 To minimize confounding, the authors take the choice to exclude patients deadon-arrival, undergoing ED thoracotomy, or with clinical indications for intubation (severe head/neck/face injury or GCS <8). 1 Despite this, a certain number of missing elements, whether in the profile of the patients or the timeline of their management, limit us in the analysis of the results.…”

“…We read with attention the recently published online work of Dunton et al 1 analyzing the outcomes of patients undergoing immediate hemorrhage control surgery intubated in an emergency department (ED) or an operating room (OR). The analysis of 9,667 patients shows that patients intubated in the ER die significantly more than those intubated in the OR (17.4% Vs 7.1%, p < 0.001) 1 .…”

Intubation of bleeding patients in the emergency department or the operating room: A medical decision to be justified—reply

“…Thank you to Corcostegui et al for their interest in our recent article entitled “Emergency Department Versus Operating Room Intubation of Patients Undergoing Immediate Hemorrhage Control Surgery” 1 …”