Abstract
Introduction:
Endotracheal 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.
Methods:
We 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.
Results:
From 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).
Conclusions:
In 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.
Keywords: Emergency, Airway, Trauma, Intubation, Endotracheal, Injury
1. Introduction
1.1. Background
Airway assessment and intervention is a critical early step in the evaluation of trauma patients [1–3]. Prompt treatment of hypoxemia is associated with reduced morbidity and mortality, with the greatest benefit seen in patients with traumatic brain injury (TBI) [4]. Endotracheal intubation (ETI) is a high-risk procedure used to definitively address airway compromise. Intubations performed outside of the controlled conditions of the operating room (OR), such as in the Emergency Department (ED), are associated with a higher incidence of difficult intubations and procedural complications [5,6]. These include hypoxemia, hypotension, and cardiac arrest [7–10]. First-attempt success of ETI is crucial since multiple attempts are associated with an increase in adverse events [10–14].
Before 2015, first-attempt intubation success rates ranged 54–78 %. With the widespread adoption of video laryngoscopy, first-attempt success improved to greater than 80 % in two recent clinical trials [15,16]. Greater first-attempt success rates have also been reported in contemporary observational data [10,17]. Despite improvements in first-attempt success, severe complications still occur in 24–28 % of ETIs performed in critically ill patients [12,18]. Risk factors for peri-intubation complications and hemodynamic collapse include hypoxemia, hypotension, and severe acidosis [13,18]. Notably, peri-intubation cardiac arrest occurs in as many as 1 in 25 emergency intubations [8,19,20].
1.2. Importance
Patients with acute traumatic injury account for approximately 20–30 % of intubations performed in the ED, adding a distinct set of challenges [19]. Many trauma patients present with altered mental status and are unable to provide relevant medical history [20]. Additionally, they may have specific injuries such as maxillofacial trauma, penetrating neck wounds, burns, cervical spine injuries, or TBIs [20–22]. These conditions can result in anatomical difficulties, including limited mouth opening, jaw displacement, poor patient positioning, and the presence of blood or vomitus in the oropharynx. Moreover, trauma-specific factors such as cervical spine immobilization increase procedural difficulty [21]. Beyond technical challenges related to airway anatomy and laryngoscopy, trauma patients often require intubation in the absence of direct airway injury [22]. In these cases, providers must navigate profound physiological challenges – including hemorrhagic shock, traumatic brain injury, or multisystem trauma – that all reduce the likelihood of first-attempt success and increase the risk of complications [1]. These systemic challenges highlight the complex and high-stakes nature of emergency airway management in trauma care. Despite the high-risk nature of these procedures in this vulnerable population, data on incidence and short-term survival remain limited, particularly outside of large academic centers.
1.3. Goal of this study
We aim to describe the incidence of ED ETI, with a primary outcome of 24-h survival. Secondary outcomes include ED mortality, factors associated with ED ETI, and subgroup outcomes in pediatric patients, using data from a large national database.
2. Methods
2.1. Ethics
We obtained data from the American College of Surgeons Trauma Quality Improvement Program (TQIP) database including the additional facilities keys. The US Army Medical Center of Excellence regulatory office reviewed protocol 24–00011n and determined it met the definition of research not involving human subjects. Therefore, IRB oversight was not required.
2.2. Trauma Quality Improvement Program (TQIP) description
The TQIP database has been maintained by the American College of Surgeons since 2008. TQIP collects mandatory data from verified Level 1 trauma centers in addition to voluntary participation by centers that do not meet Level 1 criteria [23]. As of 2023, there are over 800 participating centers where trained registrars submit data for trauma encounters that meet entry criteria [24]. The aim of the program is to aid trauma centers in standardizing care by providing data to implement best practice guidelines and, subsequently, to increase the quality of care for trauma patients at both local and national levels.
2.3. Case selection and variables
We identified all trauma encounters with documented procedure codes 0BH17EZ and 0BH18EZ according to the International Classification of Diseases, 10th revision (ICD-10), where the procedure time was less than or equal to the ED length of stay [25]. Patients were assumed alive at 24 h post-hospital arrival if their total length of stay exceeded 24 h. Intubations without documented procedure times or encounters lacking ED length of stay were excluded. Pediatric patients were defined as individuals under 18 years of age. Encounters with missing age data were excluded from age-specific analyses. Pediatric patients were further categorized according to the Centers for Disease Control and Prevention age groups: < 4, 5–9, 10–14, and 15–17 years, consistent with our prior work [26]. Injury severity was categorized using the Abbreviated Injury Scale by body region, with scores of ≥3 indicating serious injury and < 3 indicating non-serious injury [27]. Isolated TBI was defined as an AIS of zero for all body regions except the head/neck. Blood transfusion volumes were recorded for the first 4 h of admission. We used a threshold of 3 or more units of packed red cells or whole blood to define large volume [28]. For pediatric patients, a volume threshold of 20 ml/kg was used to define massive transfusion, which is based on half of our previously published 24-h volume [26]. Vital signs were limited to arrival measurements, including the need for immediate respiratory assistance. Mechanisms of injury were converted into separate binary variables to facilitate analysis. Shock index was determined by dividing the arrival heart rate by the arrival systolic pressure. If the systolic pressure was zero, the shock index was documented as zero. Respiratory assistance is captured as a core metric and is defined as the receipt of respiratory assistance within 30 min of arrival.
2.4. Data analysis
All statistical analyses were conducted using Microsoft Excel (version 365, Redmond, Washington, USA) and JMP Statistical Discovery from SAS (version 17, Cary, North Carolina, USA). Descriptive statistics were used to characterize the intubation events. Continuous and ordinal variables are reported as medians and interquartile ranges with inferential comparison using the Wilcoxon rank sum test. Nominal variables are reported as numbers and percentages with inferential comparison using difference size with 95 % confidence interval (CI). Trend data was assessed using the Cochran-Armitage test for trend. Multivariable logistic regression models were constructed to assess associations with ED ETI compared to no ED ETI and adjust for potential effect modifiers. Continuous and ordinal predictors are reported as unit odds ratios (uORs) with 95 % CIs while nominal variables are reported as odds ratios (ORs) with 95 % CIs. Pediatric age groups and mechanism of injury were modeled with each category as an independent binary variable. Of those with mutually exclusive variables, one variable was excluded as noted from the multivariable logistic regression models to prevent model dissociation.
3. Results
From 2017 to 2023, there were a total of 8,014,737 encounters, of which, 7,620,399 had a documented ED LOS and met inclusion for this analysis. There was a total of 466,275 that had documented intubation during their entire hospital stay, of which, 459,687 had a documented time associated with the intubation procedure and 279,627 in the ED. Most of the intubations occurred at Level 1 verified centers (Fig. 1). The proportion undergoing ED ETI ranged from 3.5 % to 3.9 % (Fig. 2). Survival at 24 h following ED ETI, the primary outcome, ranged from 67.0 % to 72.6 % (Supplemental Fig. 1). Patients with TBI demonstrated lower survival at both 24 h and discharge (Supplemental Fig. 2).
Fig. 1.
Incidence of intubation by trauma center verification.
Fig. 2.
Proportion undergoing ETI by year.
There were 279,627 (3.7 %) that had a documented intubation that occurred within the ED (Table 1). The median time from arrival to ETI start was 10.2 min (IQR 6.0–22.2). As a secondary outcome, review of ED mortality showed 24,480 patient deaths in the ED after ED ETI (Supplemental Table 1). Of those that died in the ED, the median time from ETI to death was 15.6 min (IQR 6.6–41.4). Patients undergoing ED ETI were more likely to receive a large-volume transfusion (18.3 % versus 1.1 % in the non-ETI group; 17.1, 16.9–17.2). In our multivariable logistic regression model, factors independently associated with ED ETI included male sex, penetrating mechanisms, serious injuries to all body regions, arrival shock index, depressed GCS, arrival respiratory assistance, and arrival by EMS (Table 2).
Table 1.
Patient characteristics.
| No ETI n = 7,340,772 |
Yes ETI n = 279,627 |
Difference + CI or p-value | ||
|---|---|---|---|---|
| Demographics | Age* | 53 (28–72) | 39 (26–59) | <0.001 |
| Male (%) | 4,288,252 (58.4) | 211,876 (75.8) | 17.3 (17.2–17.5) | |
| Mechanism of injury | Collision (%) | 2,556,269 (34.8) | 136,359 (48.8) | 13.9 (13.8–14.1) |
| Fall (%) | 3,739,013 (50.9) | 65,893 (23.6) | 27.3 (27.2–27.5) | |
| Firearm (%) | 302,697 (4.1) | 43,577 (15.6) | 11.5 (11.3–11.6) | |
| Stabbing (%) | 286,497 (3.9) | 12,765 (4.6) | 0.6 (0.6–0.7) | |
| Other (%) | 456,296 (6.2) | 21,033 (7.5) | 1.3 (1.2–1.4) | |
| Composite injury severity* | 8 (4–10) | 20 (10–29) | <0.001 | |
| Serious injury by body region | Head/neck (%) | 1,188,375 (16.2) | 144,730 (51.8) | 35.6 (35.4–35.7) |
| Face (%) | 20,816 (0.3) | 6320 (2.3) | 1.9 (1.9–2.0) | |
| Thorax (%) | 942,742 (12.8) | 93,125 (33.3) | 20.5 (20.3–20.6) | |
| Abdomen (%) | 309,039 (4.2) | 37,291 (13.3) | 9.2 (8.9–9.3) | |
| Extremities (%) | 1,407,130 (19.2) | 51,218 (18.3) | 0.8 (0.7–0.9) | |
| Skin (%) | 27,300 (0.4) | 7231 (2.6) | 2.2 (2.2–2.3) | |
| Arrival vitals | Shock index | 0.6 (0.5–0.8) | 0.7 (0.5–1.0) | <0.001 |
| Respiratory rate | 18 (16–20) | 20 (16–24) | <0.001 | |
| Glasgow coma scale | 15 (15–15) | 7 (3–14) | <0.001 | |
| Pulse oximetry | 98 (96–99) | 98 (94–100) | <0.001 | |
| Respiratory assistance (%) | 224,855 (3.0) | 77,158 (27.6) | 24.5 (24.4–24.7) | |
| Interfacility transfer | 14,629 (24.9) | 147,629 (5.2) | 19.7 (19.6–19.8) | |
| Arrival by EMS | 6,057,935 (82.5) | 266,753 (95.4) | 12.9 (12.8–13.0) | |
| Trauma verification | Level 1 (%) | 3,006,555 (41.0) | 123,707 (44.2) | 3.3 (3.1–3.5) |
| Level 2 (%) | 1,744,373 (23.8) | 71,543 (25.6) | 1.8 (1.7–1.9) | |
| Level 3 (%) | 487,352 (6.6) | 11,548 (4.1) | 2.5 (2.4–2.6) | |
| Unverified (%) | 2,102,492 (28.6) | 72,829 (26.1) | 2.6 (2.4–2.8) | |
| Disposition location after ED | Operating room (%) | 766,754 (10.5) | 63,521 (22.7) | 12.3 (12.1–12.4) |
| Intensive care unit (%) | 1,192,298 (16.2) | 162,442 (58.1) | 41.9 (41.7–42.0) | |
| Non-ICU floor (%) | 4,241,220 (57.8) | 8209 (2.9) | 54.8 (54.7–54.9) | |
| Transferred (%) | 263,167 (3.6) | 14,650 (5.2) | 1.7 (1.6–1.7) | |
| Discharge (%) | 800,671 (10.9) | 1779 (0.6) | 10.3 (10.2–10.3) | |
| Dead (%) | 47,851 (0.7) | 28,480 (10.2) | 9.5 (9.4–9.6) | |
| Other/unknown (%) | 28,811 (0.4) | 546 (0.2) | 0.2 (0.2–0.2) | |
| Survival | 24-h (%) | 7,155,268 (97.5) | 195,230 69.8 | 27.6 (26.5–27.8) |
| Discharge (%) | 7,154,677 (97.5) | 195,029 (69.8) | 27.7 (27.5–27.9) |
Table 2.
Multivariable logistic regression model with ED intubation as the outcome variable.
| Age | 0.99 (0.99–0.99) |
| Sex | |
| Male | 1.40 (1.38–1.42) |
| Female (reference) | |
| Mechanism of injury | |
| Collision | 0.86 (0.85–0.88) |
| Fall | 0.54 (0.52–0.55) |
| Firearm | 1.52 (1.48–1.55) |
| Stabbing | 1.34 (1.31–1.38) |
| Other (omitted) | |
| Serious injury to the head/neck | 2.40 (2.37–2.42) |
| Serious injury to the face | 1.57 (1.51–1.63) |
| Serious injury to the thorax | 1.61 (1.59–1.63) |
| Serious injury to the abdomen | 1.66 (1.63–1.69) |
| Serious injury to the extremities | 1.23 (1.22–1.25) |
| Serious injury to the skin | 1.84 (1.78–1.91) |
| Arrival shock index | 1.73 (1.71–1.75) |
| Arrival Glasgow coma scale | 0.69 (0.69–0.69) |
| Arrival respiratory assistance | 5.70 (5.61–5.79) |
| Arrival by any EMS | 2.14 (2.09–2.19) |
There were 815,531 that met criteria for the pediatric subgroup analysis, of which 18,417 (2.3 %) underwent ED ETI (Table 3). In this subgroup, patients receiving ETI were also more likely to undergo large-volume transfusion (17.6 % versus 0.7 % in the non-ETI group; 16.9, 16.3–17.5). In our pediatric subgroup multivariable logistic regression model, predictors of ED ETI mirrored those in adults, including male sex, collision and penetrating mechanisms, serious injuries to all body regions, arrival shock index, depressed GCS, arrival respiratory assistance, and arrival by EMS (Table 4). Most pediatric ED ETIs occurred at non-pediatric verified centers (Supplemental Fig. 3).
Table 3.
Pediatric subgroup analysis.
| No ETI n = 797,114 |
Yes ETI n = 18,417 |
Effect size/p-value | ||
|---|---|---|---|---|
| Demographics | <4 years | 172,219 (21.6) | 3467 (18.8) | 2.8 (2.2–3.3) |
| 5–9 years | 210,772 (26.4) | 2788 (15.1) | 11.3 (10.7–11.8) | |
| 10–14 years | 214,696 (26.9) | 3702 (20.1) | 6.8 (6.2–7.4) | |
| 15–17 years | 199,427 (25.0) | 8460 (45.9) | 20.9 (20.1–21.6) | |
| Male | 517,872 (64.9) | 12,823 (69.6) | 4.6 (3.9–5.3) | |
| Mechanism of injury | Collision | 339,750 (46.2) | 10,821 (58.7) | 16.1 (15.4–16.8) |
| Fall | 305,575 (38.3) | 1952 (10.6) | 27.7 (27.2–28.1) | |
| Firearm | 34,262 (4.3) | 3646 (19.8) | 15.4 (14.9–16.1) | |
| Stabbing | 24,842 (3.1) | 350 (1.9) | 1.2 (1.0–1.4) | |
| Other | 92,685 (11.6) | 1648 (9.0) | 2.7 (2.2–3.1) | |
| Composite injury severity | 4 (4–9) | 21 (10–29) | <0.001 | |
| Serious injury by body region | Head/neck | 90,400 (11.3) | 11,464 (62.2) | 50.9 (50.0–51.6) |
| Face | 1499 (0.2) | 332 (1.8) | 1.6 (1.4–1.8) | |
| Thorax | 38,138 (4.8) | 5877 (31.9) | 27.1 (26.4–27.8) | |
| Abdomen | 35,623 (4.5) | 2760 (15.0) | 10.5 (10.0–11.0) | |
| Extremities | 91,488 (11.5) | 2922 (15.9) | 4.3 (3.8–4.9) | |
| Skin | 3755 (0.5) | 503 (2.7) | 2.3 (2.0–2.5) | |
| Arrival vitals | Shock index | 0.8 (0.7–1.0) | 0.9 (0.6–1.2) | <0.001 |
| Respiratory rate | 20 (18–24) | 21 (16–26) | 0.003 | |
| Glasgow coma scale | 15 (15–15) | 7 (3–12) | <0.001 | |
| Pulse oximetry | 99 (98–100) | 99 (95–100) | <0.001 | |
| Respiratory assistance | 20,449 (2.6) | 5924 (32.2) | 29.6 (28.9–30.2) | |
| Interfacility transfer | 320,686 (40.2) | 1116 (6.1) | 34.1 (33.8–34.5) | |
| Any EMS | 531,824 (66.7) | 17,104 (92.9) | 26.1 (25.7–26.5) | |
| Trauma verification | Level 1 | 252,161 (31.6) | 7186 (39.0) | 7.4 (6.6–8.1) |
| Level 2 | 98,739 (12.4) | 3782 (20.5) | 8.1 (7.5–8.7) | |
| Level 3 | 29,123 (3.7) | 699 (3.8) | −0.1 (−0.4–0.1) | |
| Unverified | 417,091 (52.3) | 6750 (36.7) | 15.6 (14.9–16.3) | |
| Pediatric verification | Level | 290,731 (36.5) | 4231 (23.0) | 13.4 (12.9–14.1) |
| Level 2 | 113,560 (14.3) | 2202 (12.0) | 2.3 (1.8–2.8) | |
| Unverified | 392,823 (49.3) | 11,984 (65.1) | 15.7 (15.0–16.4) | |
| Disposition location after ED | Operating room | 111,608 (14.0) | 3854 (20.9) | 6.9 (6.3–7.5) |
| Intensive care unit | 83,077 (10.4) | 9336 (50.7) | 40.3 (39.5–40.9) | |
| Non-ICU floor | 365,903 (45.9) | 318 (1.7) | 44.1 (43.9–44.4) | |
| Transferred | 76,032 (9.5) | 2831 (15.4) | 5.8 (5.3–6.4) | |
| Discharge | 154,588 (19.4) | 49 (0.3) | 19.1 (19.0–19.2) | |
| Dead | 3188 (0.4) | 1998 (10.9) | 10.4 (9.9–10.9) | |
| Other/unknown | 2718 (0.3) | 31 (0.2) | 1.7 (1.1–2.3) | |
| Survival | 24-h | 789,891 (99.1) | 14,018 (76.1) | 22.9 (22.3–23.6) |
| Discharge | 789,882 (99.1) | 14,011 (76.1) | 23.0 (22.3–23.6) |
Table 4.
Multivariable logistic regression model with ED intubation as the outcome variable among the pediatric subgroup.
| Age group | |
| <4 years | 0.86 (0.81–0.91) |
| 5–9 years | 0.70 (0.66–0.74) |
| 10–14 years | 0.65 (0.62–0.68) |
| 15–17 years (omitted) | |
| Sex | |
| Male | 1.05 (1.01–1.09) |
| Female (reference) | |
| Mechanism of injury | |
| Collision | 1.08 (1.01–1.15) |
| Fall | 0.61 (0.56–0.66) |
| Firearm | 2.29 (2.11–2.48) |
| Stabbing | 1.32 (1.15–1.51) |
| Other (omitted) | |
| Serious injury to the head/neck | 3.55 (3.41–3.71) |
| Serious injury to the face | 1.26 (1.08–1.47) |
| Serious injury to the thorax | 1.91 (1.85–2.00) |
| Serious injury to the abdomen | 1.64 (1.55–1.76) |
| Serious injury to the extremities | 1.26 (1.19–1.32) |
| Serious injury to the skin | 1.79 (1.55–2.06) |
| Arrival shock index | 1.19 (1.15–1.23) |
| Arrival Glasgow coma scale | 0.69 (0.69–0.70) |
| Arrival respiratory assistance | 6.51 (6.14–6.91) |
| Arrival by any EMS | 1.90 (1.77–2.04) |
4. Discussion
Our study found that approximately 3.7 % of trauma patients underwent intubation in the emergency department (ED). The majority of these intubations were performed at verified Level 1 trauma centers, consistent with prehospital triage practices that prioritize transporting critically injured patients to higher-level trauma facilities. We also identified several patient characteristics associated with ED intubation, including a predominance of male patients and those sustaining collisions and falls. With 279,627 ED intubations, our study provides the largest characterization of trauma airway management to date. We recognize, however, that unlike the National Emergency Airway Registry (NEAR), our dataset does not capture the same breadth of procedure-specific clinical variables [29]. As such, our findings should be viewed as complementary, offering a large-scale, nationally representative perspective rather than a replacement for more detailed registries.
Among pediatric trauma patients, approximately 2.3 % received ED ETI, with the majority of these occurring at non-pediatric verified trauma centers. This finding is especially important given the well-documented challenges of pediatric airway management [30–33]. Furthermore, this finding is particularly relevant given the recent endorsement by the American College of Surgeons of the Pediatric Readiness Project, which seeks to improve the preparedness of non-pediatric centers to manage critically ill or injured children by ensuring appropriate training, staffing and equipment [34,35].
The high mortality among patients undergoing ED ETI underscores the need for continued research to improve care for this high-risk population. Multiple Department of Defense–funded trials, including DEVICE and PREOXI, have advanced practices in emergency airway management among critically ill adults. It is important to note, however, that these studies do not distinguish between medical and trauma populations [36]. For example, the PREOXI study found a reduced incidence of peri-intubation cardiac arrest and hypoxemia among critically ill patients who received preoxygenation using noninvasive ventilation prior to ETI. Ongoing secondary analyses of these trials may generate hypotheses for future trauma-specific studies. A limitation of current research is the inclusion of mixed medical and trauma populations. This study also inspires several future directions, including a comparison of clinical outcomes between trauma patients intubated in the ED (given recent airway advancements) and those intubated in the OR. Further investment in trauma-specific research may identify additional areas for practice improvement, particularly as existing research networks can facilitate rapid enrollment of trauma patients. Given this study's finding of a strong association between TBI and the need for ED ETI, this represents a particularly promising area for scientific advancement, given the extreme vulnerability of these injuries to even minor hemodynamic instability [37–39].
5. Limitations
This study has several limitations, many of which stem from its retrospective design. First, encounters with missing or incomplete data (e.g., procedure timing, ED length of stay) were excluded, which may have introduced selection bias, recall and hindsight bias, as well as data entry inaccuracies. Given the observational nature of the study, we were limited to identifying associations rather than establishing causal relationships between ED intubations and outcomes. In addition, our dataset lacked detail on several procedure-specific variables, such as medications used during intubation, choice of airway equipment, pre-oxygenation method, peri-intubation complications, and the training level of the intubating operator. For the purposes of analysis, the operator was assumed to be an Emergency Medicine provider, though their background was not available. Finally, airway management decision-making is inherently multifactorial, incorporating both technical and physiologic considerations, many of which could not be fully captured in this dataset. These limitations should be considered when interpreting our findings.
6. Conclusion
In this national cohort of over 7.6 million trauma encounters, 3.7 % of patients underwent ED endotracheal intubation (ETI), with a median time to intubation of 10 min. The primary outcome, 24-h survival, ranged from 67 to 73 % over the six-year study period, with all-cause mortality in the ED nearing 10.2 %. Patients requiring ED ETI were more likely to receive large-volume transfusions and had distinct predictors including male sex, penetrating trauma, severe injuries, shock, depressed GCS, respiratory assistance, and EMS arrival. In pediatric patients, ED ETI was less common (2.3 %) but demonstrated similar transfusion associations and predictive factors, with most intubations occurring at non-pediatric centers. These findings highlight the high-risk nature of ED ETI and the need for optimized airway and resuscitation strategies specific to trauma care.
Supplementary Material
Acknowledgements
We would like to thank the Trauma Quality Improvement Program for providing us with this data.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.org/10.1016/j.ajem.2025.10.023.
Footnotes
IRB approval
Only de-identified data was obtained, therefore our study met criteria for research not involving human subjects and IRB approval was not required.
CRediT authorship contribution statement
Lucia C. Lin: Writing – review & editing, Writing – original draft. Michael D. April: Writing – review & editing, Methodology, Conceptualization. David J. Douin: Writing – review & editing, Methodology. Julie M. Winkle: Writing – review & editing. Whitney R. Jenson: Writing – review & editing. Julie A. Rizzo: Writing – review & editing, Methodology. Steven G. Schauer: Writing – review & editing, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization.
Disclaimer
The views expressed in this article are those of the authors and do not reflect the official policy or position of the US Army Medical Department, Department of the Army, Department of Defense, or the US Government.
Declaration of competing interest
We have no additional potential declarations to report.
Data availability
The data from this study was obtained from a public data source and is available upon request from the American College of Surgeons.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data from this study was obtained from a public data source and is available upon request from the American College of Surgeons.