Prehospital endotracheal intubation and 30-day survival in severe trauma: a matched cohort study from Navarra, Spain

Prehospital endotracheal intubation (ETI) is frequently used in major trauma, but its association with 30-day survival remains debated. We evaluated the association between prehospital ETI and 30-day survival and assessed whether sex modifies the age-related increase in mortality risk.

We conducted a retrospective cohort study using the Navarra Major Trauma Registry (2010-2019). Patients aged ≥15 years with New Injury Severity Score (NISS) ≥15 were included; patients who died before hospital admission or had incomplete records were excluded. To mitigate confounding by indication, intubated and non-intubated patients were matched 1:1 using prehospital Glasgow Coma Scale (GCS), respiratory distress, and prehospital cardiac arrest as matching variables. Because the proportional hazards assumption for Cox regression was not met, parametric Weibull survival models were fitted, including a sex-by-age interaction term.

Overall, 1,909 patients were included; 212 (11.1%) underwent prehospital ETI. Matching yielded 190 pairs (n=380). In the matched cohort, prehospital ETI was not independently associated with 30-day survival (adjusted HR 0.91, 95% CI 0.65-1.27). Mortality risk was independently associated with lower GCS (per 1-point increase: HR 0.86, 95% CI 0.82-0.91) and respiratory distress (HR 7.63, 95% CI 4.34-13.4). A significant sex-by-age interaction was observed (HR 1.02, 95% CI 1.01-1.04).

In this matched registry cohort, prehospital ETI was not independently associated with improved 30-day survival. Sex- and age-related heterogeneity supports the incorporation of sex-informed analyses when evaluating trauma outcomes and prehospital airway management.