Association for Academic Surgery
Timing is Everything: Delayed Intubation is Associated with Increased Mortality in Initially Stable Trauma Patients1

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Background

The indications for immediate intubation in trauma are not controversial, but some patients who initially appear stable later deteriorate and require intubation. We postulated that initially stable, moderately injured trauma patients who experienced delayed intubation have higher mortality than those intubated earlier.

Methods

Medical records of trauma patients intubated within 3 h of arrival in the emergency department at our university-based trauma center were reviewed. Moderately injured patients were defined as an ISS < 20. Early intubation was defined as patients intubated from 10–24 min of arrival. Delayed intubation was defined as patients intubated ≥25 min after arrival. Patients requiring immediate intubation, within 10 min of arrival, were excluded.

Results

From February 2006 to December 2007, 279 trauma patients were intubated in the emergency department. In moderately injured patients, mortality was higher with delayed intubation than with early intubation, 11.8% versus 1.8% (P = 0.045). Patients with delayed intubations had greater frequency of rib fractures than their early intubation counterparts, 23.5% versus 3.6% (P = 0.004). Patients in the delayed intubation group had lower rates of cervical gunshot wounds than the early intubation group, 0% versus 10.7% (P = 0.048) and a trend toward fewer of skull fractures 2.9% versus 16.1%, (P = 0.054).

Conclusions

These findings suggest that delayed intubation is associated with increased mortality in moderately injured patients who are initially stable but later require intubation and can be predicted by the presence of rib fractures.

Introduction

Airway management is a top priority in trauma resuscitation. The Eastern Association for the Surgery of Trauma (EAST) has established indications for immediate intubation in trauma patients [1]. EAST recommends immediate intubation for patients with airway obstruction, severe hypoxemia, smoke inhalation, cognitive impairment, and cardiac arrest. Most trauma surgeons would agree that none of these indications is subject to much interpretation. But what of the subset of moderately injured patients whose condition appears clinically stable upon initial presentation, without any acute indications for intubation, but later deteriorates and requires emergent intubation? In these patients, the advantages of airway control, oxygenation, and ventilation must be weighed against the immediate and long-term complications of intubation 2, 3, 4. This decision-making process is never easy and no distinct guidelines exist to help guide surgeons in this particular situation. To address this gap, we sought to determine whether initially stable, moderately injured trauma patients who experience delayed intubation have higher mortality than those intubated earlier, and to determine any potential risk factors that may predict the need for earlier intubation in this patient population.

Section snippets

Materials and Methods

The medical records of trauma patients who were treated at our university-based urban trauma center between February 2006 and December 2007 were reviewed. Inclusion criteria included moderately injured patients who were endotracheally intubated in the emergency department. Moderately injured was defined as an ISS <20. Exclusion criteria included patients who required immediate intubation, defined as patients who were intubated within 10 min of arrival. Patients were separated into an early

Results

Of the 279 trauma patients who were intubated in the emergency department during the study period, 146 were moderately injured with an ISS <20. Fifty-six were intubated immediately within 10 min of arrival and were excluded, leaving 90 for the study group (Fig. 1).

In this group of patients, 56 (62.2%) were intubated between 10 and 24 min of arrival; the remaining 34 (37.8%) were intubated more than 25 min after arrival (range 25 min to 2 h and 41 min). Demographic data are shown in Table 1.

Discussion

No one would argue about the indications for the immediate endotracheal intubation of severely injured patients, but in the stable patient with moderate injury severity, the decision to intubate can be challenging. Our study therefore sought to determine whether the timing of intubation of initially stable, moderately injured trauma patients affected mortality. We found that for moderately injured patients (ISS < 20) mortality was higher for patients whose intubation was delayed versus those

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1

Presented at the Academic Surgical Congress in February, 2011.

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