Airway management in trauma patients with active hemorrhage: Does intubation location matter? A nationwide...

Trauma is a leading cause of morbidity and mortality worldwide, with hemorrhage accounting for approximately 40 % of trauma-related deaths. While early airway management is crucial for trauma patients requiring emergent surgery, the optimal timing and setting for intubation remain controversial. This study compares outcomes of trauma patients intubated in the Emergency Department (ED) versus the Operating Room (OR) prior to emergent hemorrhage control.

We retrospectively analyzed adult trauma patients from the Israel National Trauma Registry (2013-2023) who underwent emergent hemorrhage control surgery. Patients requiring immediate ED intubation were excluded. Outcomes-including mortality, ICU admission, and ED blood transfusion-were compared between ED and OR intubation groups using multivariable logistic regression and exact matching.

Of 1527 patients, 279 (18.3 %) were intubated in the ED and 1248 in the OR. Most were male (89.6 %), median age 29 years, with 69.8 % sustaining penetrating injuries. Exploratory laparotomy was performed in 53.2 %. After adjustment for confounders, ED intubation was independently associated with higher mortality (aOR 5.01, 95 % CI 1.68-17.05, p = 0.006), increased ICU admission (aOR 1.17, 95 % CI 2.34-4.31, p < 0.001), and greater need for blood transfusion (aOR 4.81, 95 % CI 3.51-6.61, p < 0.001). Exact matching for age, Injury Severity Score, hemodynamic status, and injury mechanism confirmed a trend toward higher mortality with ED intubation (aOR 3.10, 95 % CI 1.00-11.76, p = 0.065).

For bleeding trauma patients, clinicians should prioritize volume resuscitation before intubation and minimize ED airway interventions unless clearly indicated.