ED Intubation in Active Hemorrhage Linked to Increased Mortality: Insights from a Nationwide Cohort Study

Highlights

• Emergency department (ED) intubation in trauma patients with active hemorrhage is associated with higher in-hospital mortality compared to intubation in the operating room (OR).
• Patients intubated in the ED required more frequent ICU admissions and blood transfusions.
• Appropriate patient selection and physiological optimization prior to ED intubation are critical to improve outcomes.

Clinical Background and Disease Burden

Active hemorrhage remains a leading cause of preventable death in trauma, particularly in young adults. Airway management is a cornerstone of resuscitation, but its timing and location—especially in the setting of ongoing bleeding—can profoundly influence outcomes. The need to secure the airway must be balanced against the risk of exacerbating hemodynamic instability in patients who are already physiologically compromised. Despite advances in trauma care, optimal strategies for airway management in hemorrhaging patients remain debated, and clinical practice varies widely.

Research Methodology

Epstein and colleagues conducted a nationwide, retrospective cohort study using the Israel National Trauma Registry, analyzing data from 2013 to 2023. The study included 1,527 trauma patients (median age, 29 years; 89.6% male) who required transfer to the OR for hemorrhage control surgery within 90 minutes of ED arrival. Of these, 279 patients underwent intubation in the ED, while 1,248 were intubated upon arrival in the OR. Immediate ED intubation was indicated for patients with a Glasgow Coma Scale (GCS) score 14. Secondary endpoints included blood transfusion requirements and ICU admission post-operatively. The analysis adjusted for potential confounders including age, sex, admission systolic blood pressure, ISS, and trauma type (blunt vs. penetrating).

Key Findings

The study revealed significant differences in outcomes related to the location of intubation:

• In-hospital mortality was markedly higher for patients intubated in the ED compared to those intubated in the OR (5.0% vs 0.5%, P < .001).
• ICU admission rates were 63.1% in the ED group versus 28.9% in the OR group (P < .001).
• The need for blood transfusion in the ED was substantially greater among those intubated in the ED (49.8% vs 15.0%, P < .001).
• Following adjustment for confounders, ED intubation was independently associated with increased mortality (adjusted odds ratio [aOR] 5.01; P = .006), higher ICU admission (aOR 3.17; P < .001), and greater transfusion requirements (aOR 4.81; P < .001).
• Among a propensity-matched cohort, the trend toward increased mortality with ED intubation persisted (8.0% vs 2.9%; aOR 3.10; P = .065).
• Longer hospitalization was more common in the ED intubation group, with 44.1% staying 14 or more days, compared to 19.6% in the OR group (P < .001).

Mechanistic Insights and Biological Plausibility

Trauma patients with active hemorrhage are at high risk for hemodynamic collapse, particularly during induction of anesthesia and positive pressure ventilation, which can exacerbate hypovolemia and reduce venous return. Intubation—especially if performed before adequate volume resuscitation—may precipitate cardiovascular decompensation, leading to adverse outcomes. The ED environment, often less controlled than the OR, may also contribute to increased risk due to variable team composition, time pressures, and resource limitations.

Expert Commentary

The authors underscore the importance of prioritizing blood-based resuscitation and physiological optimization before intubation whenever feasible. They recommend that airway management in the ED be reserved for patients with clear indications (e.g., severe head injury, airway compromise) and that unnecessary delays to definitive surgical care should be minimized. These findings align with emerging trauma guidelines emphasizing the need for a tailored, physiology-driven approach to resuscitation and airway management.

Controversies and Limitations

Although the study adjusted for key confounders and utilized a national database, several limitations warrant consideration:

• Retrospective design introduces potential for residual confounding and selection bias.
• Indications for intubation in the ED, though protocolized, may reflect a population with greater injury severity or physiologic instability.
• Data on pre-intubation hemodynamics, resuscitation specifics, and provider experience were not available, which may influence outcomes.
• Generalizability may be affected by local trauma systems and resources.

Despite these limitations, the large sample size and robust statistical adjustment lend credibility to the findings.

Conclusion

In trauma patients with active hemorrhage requiring rapid operative intervention, intubation in the ED is associated with significantly higher mortality, greater ICU utilization, and increased transfusion needs compared to intubation in the OR. Clinicians should prioritize early hemorrhage control and blood-based resuscitation, reserving ED intubation for patients with unequivocal indications. These results highlight the need for further prospective studies to refine airway management strategies in hemorrhaging trauma patients and inform evidence-based guidelines.

References

Epstein D, Goldman S, Radomislensky I, Givon A, Shina M, Raz A, Twig G, Shapira S, Lipsky AM. Airway management in trauma patients with active hemorrhage: Does intubation location matter? A nationwide retrospective cohort study. Am J Emerg Med. 2025 Jun 14;96:41-47. doi: 10.1016/j.ajem.2025.06.023. Epub ahead of print. PMID: 40517708.

Additional relevant readings:
– Moore LJ, Brenner M, Kozar RA, et al. Implementation of resuscitation protocols for trauma patients with hemorrhagic shock. J Trauma Acute Care Surg. 2016;80(6):1015-1023.
– American College of Surgeons Committee on Trauma. ATLS: Advanced Trauma Life Support, 10th Edition. 2018.