European Journal of Cardiovascular Medicine

Tracheal intubation is a critical intervention in the management of trauma patients, often performed in emergency settings to secure the airway, facilitate ventilation, and prevent aspiration. The procedure, however, is fraught with challenges and potential complications, particularly in trauma victims who may present with complex injuries, altered anatomy, or physiological instability. Trauma remains a leading cause of morbidity and mortality worldwide, necessitating prompt and effective airway management to ensure patient survival and optimize outcomes. [1,2] Tracheal intubation is often the preferred method for airway management in trauma patients due to its ability to provide definitive airway control. The indications for tracheal intubation in trauma victims include compromised airway patency, inadequate ventilation or oxygenation, altered mental status, and the need for general anaesthesia during surgical interventions . [3,4]

The practices of tracheal intubation in trauma settings have evolved with advances in medical technology and training. Rapid Sequence Intubation (RSI) is the most commonly employed technique, combining rapid administration of a sedative and a neuromuscular blocking agent to facilitate quick and efficient intubation while minimizing the risk of aspiration. [5,6] The use of video laryngoscopy has become increasingly prevalent, providing enhanced visualization of the vocal cords and potentially improving intubation success rates . Prehospital intubation performed by emergency medical services (EMS) personnel plays a crucial role in the early management of trauma patients. Studies have shown that prehospital intubation can improve oxygenation and reduce the time to definitive care, although it also carries risks of complications if performed under suboptimal conditions. In-hospital intubation, typically carried out in the emergency department or operating room, benefits from a controlled environment and the availability of advanced airway management tools and personnel.

Airway management in the trauma patient presents numerous unique challenges beyond placement of an endotracheal tube (ETT), with outcomes dependent on the provider’s ability to predict and anticipate difficulty and have a safe and executable plan. Present study was aimed to study tracheal intubation practices and adverse events in trauma victims on arrival at trauma center at a tertiary hospital.

This was a prospective, observational study, conducted in trauma center in ED airway registry for immediate outcomes of endotracheal intubation at the Emergency Department. All patients who were intubated in the ED and recorded on the registry data form between May 2020 to November 2022 were included. 267 patients who were intubated in the prehospital environment or intubated from other hospitals were excluded unless they required reintubation in the ED. The following variables were extracted from the registry data. Intubation success rates, number of attempts, associated immediate complications, indications, method of pre-oxygenation, categories of personnel who intubated patients and medications used to facilitate intubation. This is a record review study, where we analyzed the data of all the patients who underwent endotracheal intubation.

Inclusion criteria: Trauma victims, age > 18 years, of either gender, requiring definitive airway control with endotracheal intubation in patients of life-threatening injury requiring immediate emergency care were considered for present study.

Exclusion criteria: Patients do not have life threatening injury/do not require immediate emergency care. Patients who were intubated before arrival in trauma triage, Patients with incomplete data/documentation of intubation events

The ED airway registry where records of all patients who are intubated in ED are maintained. After the intubation, the intubating doctor recorded intubation details in the airway registry form. The primary airway operator was responsible for retrospectively completing the registry after the patient had been stabilized. The investigators ensured the completeness of the records on a regular basis and regularly checked log records to ensure all patients were included. If a registry was not completed, a form is sent to the intubating doctor for completion.

Patients received preoxygenation with either bag-valve-mask ventilation (BVM) or positive pressure ventilation (PPV) including CPAP or BIPAP. Alternatively, preoxygenation via nonrebreather face masks was conducted. During intubation apneac oxygenation was used at the discretion of the intubating physician.

An intubation attempt was defined as placement of the laryngoscope into the patient’s mouth and an attempt was made to pass an endotracheal tube. Different doctors’ techniques vary depending on their training and experience. Most perform rapid sequence intubation (RSI) but other methods are being practiced at times. For the study, RSI is defined as intubation with the concurrent use of sedative and neuromuscular blocking agents (NMBA). Other methods included sedative only intubation and crash intubation (intubation without use of drugs).

Several immediate complications were monitored and defined as adverse events following intubation. Complications were defined as follows: a cardiac arrest was defined as a loss of pulses during or immediately after intubation. Desaturation was defined as a decrease in oxygen saturation by pulse oximetry to less than 93% during intubation attempts. Hypotension was defined as a drop in systolic blood pressure to less than 90 mm Hg and bradycardia as heart rate less than 60 beats per minute. Mainstem intubation was considered to have occurred if demonstrated on the post-intubation chest radiograph. Vomiting was defined as witnessed regurgitation of gastric content during intubation. Dental trauma included any damage to the teeth that was attributed to laryngoscopy.

Data was collected and compiled using Microsoft Excel, analysed using SPSS 23.0 version. Statistical analysis was done using descriptive statistics.

267 intubations done in trauma center were studied.

Table-1: Demographic data of trauma victims requiring intubation

Most common group is 11-20 years. Mean age of patients was 35.21 ± 12.43 years, majority were male (78.7 %).

had history of RTA (76 %), penetrating injury (18 %) and burns (6 %). Common injuries observed were head injury (45.3 %), blunt trauma chest (23.6 %), penetrating injury (12 %), blunt trauma abdomen (7.5 %), burns (5.6 %), cervical spine injury (3.4 %) and faciomaxillary injury (2.6%).

Table-2: Intubation in present study

Among 267 intubations, successful intubations were majority in 1st attempt (71.5%), followed by in 2nd attempt (22.8 %) and 11 cases were difficult intubations (3 attempts) (4.1 %). Failed intubation were 9 (1.5 %).

Table-3: Immediate complications during Intubation

Desaturation was the most commonly reported complication occurring in 39 (14.6%) patients, followed by esophageal intubation at 12 (4.5%). Other complications were equipment failure 7(2.6%), bradycardia 5(1.9%), and dental trauma. Cardiac arrest was reported in 2 (0.7%) patients.

In this study, Mean age of patients was 35.21 ± 12.43 years. The mean age of our trauma patients was consistent with the general data on national trauma-related injury [12]. There was an apparent difference in the mean age of intubated patients in our study, which is less compared to that of other Asian countries as Hong Kong (60.7 years) and Singapore (63 years) [7,8]. In our study most of the patents were male (78.7 %) which is similar to study done by Binu Kumar Bhanu et al[9] showed majority were male (69.53 %).

In present study common injuries observed were head injury (45.3 %), blunt trauma chest (23.6 %). Shahridan Mohd. Fathil[10] study head injury (18.4%), respiratory failure (15.4%), polytrauma (9.6%) and cerebrovascular accident (7.0%)

Among 267 intubations in our experience, successful intubations were majority in 1st attempt (71.5%), followed by in 2nd attempt (22.8 %) and 11 cases were difficult intubations (3 attempts) (4.1 %). Binu Kumar Bhanu et al[10] study showed successful intubations were majority in 1st attempt (77.73 %), followed by in 2nd attempt (14.45 %) and 11 cases were difficult intubations (3 attempts) (4.30 %). Driver BE et al[11] noted that successful intubation on the first attempt occurred in 447 patients (80.4%) in the bougie group and 453 patients (83.0%) in the stylet group (P = 0.27). Shadab et al[12] study first attempt success rate for speciality and anaesthesia residents was 63.1% , respectively.  These findings reflect the different staffing levels and the limited expertise available on arrival to trauma triage. An observational study in the emergency department of an academic centre, reported the working of various levels of health care professionals as a team.[13] Whereas, in accordance to our research, Walls et al.[14] reported that anaesthesiologists performed only 3% of the intubations, and the remaining 97% of the intubations were performed by emergency physicians (87%) and physicians from other specialities (10%).  Ono et al., [15] reported that the experience of the laryngoscopies plays a pivotal role, and hence their finding that the success rate of intubation increases when an anaesthesiologist performed intubation; this is supported by our data too.

Our study desaturation was the most commonly reported complication occurring in 39 (14.6%) patients, followed by esophageal intubation at 12 (4.5%). Other complications were equipment failure 7(2.6%), bradycardia 5(1.9%), and dental trauma. Cardiac arrest was reported in 2 (0.7%) patients. Binu Kumar Bhanu et al [9]showed common complications in present study were hypotension (9.38 %), followed by desaturation (6.64 %), airway injuries (6.25 %), oesophageal intubation (2.34 %), aspiration of blood (1.95 %) and aspiration of gastric contents (0.78 %). Russotto et al. [16] conducted an observational study to evaluate the incidence of adverse peri-intubation events during intubation of critically injured patients. Primary outcome included the incidence of major adverse events within 30 minutes of tracheal intubation, which included cardiovascular instability.

The findings of this study support the need for the development of an emergency response system and team in emergency departments in low resource settings, regular simulation-based training in advanced trauma life support and airway management and the presence of difficult airway cart in trauma triage bay. The rate of complications can also be reduced by the adaptation of a checklist and a standardised protocol.

Primary goal of tracheal intubation, especially in trauma patients, is to achieve first pass success without adverse events. We had majority successful intubations, that too in first attempt, with few complications due to rigorous training and monitoring,

The study does reveal areas for improvement and better airway training including increased use of video-assisted laryngoscopy for education, further focus on induction medications with a focus on consistent use of a sedative, and airway oxygenation methods to achieve lower complications rates, especially desaturation. This study suggests potential advantages for ongoing data collection via development of an airway registry to further research to improve patient care.

1. Schmidt, Sarah K. MD1; Brou, Lina MS1; Deakyne, Sara J. MPH2; Mistry, Rakesh D. MD, MS1; Scott, Halden F. MD1. Frequency and Characterization of Tracheal Intubation Adverse Events in Pediatric Sepsis. Pediatric Critical Care Medicine February 2018: 19(2):p e80-e87.
2. Smith M, Perel A, Heim C. Airway management in trauma. Curr Opin Crit Care. 2020;26 (6):681-687.
3. Sakles JC, Mosier JM, Patanwala AE. The importance of airway management in trauma patients. Curr Opin Anaesthesiol. 2021; 34(2) :189-195.
4. Mosier JM, Sakles JC, Law JA. Rapid sequence intubation in trauma patients. Trauma Surg Acute Care Open. 2021;6(1).
5. Aziz MF, Dillman D, Fu R. Video laryngoscopy for intubation in the emergency department: a systematic review. Eur J Emerg Med. 2020; 27(2):86-92
6. Lockey DJ, Crewdson K, Lossius HM. Prehospital anaesthesia: the immediate management of traumatic airway emergencies. Scand J Trauma Resusc Emerg Med. 2020;28(1):52.
7. Tam AY, Lau FL: A prospective study of tracheal intubation in an emergency department in Hong Kong. Eur J Emerg Med: 2001: 8(4):305–310
8. Wong E, Fong YT, Ho KK : Emergency airway management—experience of tertiary hospital in south-east Asia. Resuscitation: 2004: 61:349–355
9. Binu Kumar Bhanu, Suroor Veetilavalapil, Vishwas Sathe, Amarjeet D Patil, Sujay Mysore. Study of tracheal intubation practices and adverse events in trauma victims on arrival at trauma center at a tertiary hospital. MedPulse International Journal of Anesthesiology. October 2022; 24(1): 06-09.
10. Fathil SM, Mohd Mahdi SN, Che'man Z, Hassan A, Ahmad Z, Ismail AK. A prospective study of tracheal intubation in an academic emergency department in Malaysia. Int J Emerg Med. 2010 Sep 21;3(4):233-7.
11. Driver B, Prekker M, Moore J, Schick AL, Reardon RF, Miner JR. Direct versus video laryngoscopy using the CMAC for tracheal intubation in the emergency department, a randomized controlled trial. Acad Emerg Med. 2016;23(4):433–9.
12. Madiha Shadab, Shrutika Bhagat, Sudama Prasad: A Retrospective Study Evaluates Tracheal Intubation Procedures and Complications in Trauma Patients: International Journal of Toxicological and Pharmacological Research 2024; 14(3); 254-259
13. Sorbello M, Afshari A, De Hert S. Training and simulation for tracheal intubation. Anaesthesia. 2021;76(Suppl 1):37-44.
14. Walls RM, Brown CA, Bair AE, Pallin DJ NEAR II Investigators. Emergency airway management:A multi-center report of 8937 emergency department intubations. J Emerg Med. 2011; 41:347–54
15. Ono Y, Kakamu T, Kikuchi H, Mori Y, Watanabe Y, Shinohara K. Expert-performed endotracheal intubation- related complications in trauma patients:Incidence, possible risk factors, and outcomes in the prehospital setting and emergency department. Emerg Med Int. 2018; 2018:5649476
16. Russotto V, Myatra SN, Laffey JG, Tassistro E, Antolini L, Bauer P, et al. Intubation practices and adverse peri intubation events in critically ill patients from 29 countries. JAMA. 2021; 325:1164–72.