ED Intubation May Raise Mortality Risk in Active Hemorrhage
In a cohort study of patients with active hemorrhage, endotracheal intubation in the emergency department (ED) was associated with higher mortality rates, more frequent ICU admissions, and a greater need for blood transfusion compared with intubation in the operating room (OR).
METHODOLOGY:
Researchers conducted a nationwide, retrospective cohort analysis using data from the Israel National Trauma Registry between 2013 and 2023.
A total of 1527 patients (median age, 29 years; 89.6% men) who required transfer to the OR for hemorrhage control surgery within 90 minutes of ED arrival were included.
A total of 279 participants underwent endotracheal intubation in the ED and 1248 were intubated upon arrival in the OR. Indications for immediate intubation in the ED included having a Glasgow Coma Scale score < 9 or serious injuries (Abbreviated Injury Score [AIS] ≥ 3) to the head, face, neck, or thorax.
The primary outcome was survival to hospital discharge for patients with an Injury Severity Score (ISS) > 14, and secondary outcomes included blood transfusion requirements and ICU admission following hemorrhage control procedures.
Patients were followed up until discharge from their respective trauma care centers, and potential confounders included age, sex, systolic blood pressure on admission, ISS, and blunt vs penetrating trauma.
TAKEAWAY:
Patients intubated in the ED had higher in-hospital mortality (5.0% vs 0.5%; P < .001), higher ICU admission rates (63.1% vs 28.9%; P < .001), and a greater need for blood transfusion in the ED (49.8% vs 15.0%; P < .001) than those intubated in the OR.
After adjustment for confounders, ED intubation was independently associated with increased mortality (adjusted odds ratio [aOR], 5.01; P = .006). In the matched cohort, ED intubation trended toward higher mortality (8.0% vs 2.9%; aOR, 3.10; P = .065)
Among the patients intubated in the ED, 44.1% were hospitalized for 14 or more days, whereas 19.6% of those intubated in the OR were hospitalized for the same duration ( P < .001).
For the whole cohort, intubation in the ED was independently associated with increased ICU admission (aOR, 3.17; P < .001) and a greater need for blood product transfusion (aOR, 4.81; P < .001).
IN PRACTICE:
"Trauma [care] providers should prioritize blood-based resuscitation to optimize the patient's physiology before proceeding with intubation, while also minimizing delays to definitive care in the OR. Airway management, particularly in the ED, should be performed only when there is a clear indication and, whenever possible, after the patient has been physiologically optimized," the authors wrote.
SOURCE:
The study was led by Danny Epstein, Rambam Health Care Campus, Haifa, Israel. It was published online on June 14, 2025, in The American Journal of Emergency Medicine.
LIMITATIONS:
The study was limited by incomplete registry data on the specific clinical indications and timing of ED intubations. The exact factors contributing to mortality could not be determined, and the exclusion of patients who died before reaching the OR may have led to underestimated mortality rates. Additionally, the registry did not capture patient comorbidities, which could have influenced hemodynamic stability and intubation-related complications.
DISCLOSURES:
The authors reported no funding sources or relevant conflicts of interest.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.
Hashtags
Try Our AI Features
Explore what Daily8 AI can do for you:
Comments
No comments yet...
Related Articles
Yahoo
3 hours ago
- Yahoo
Gaza food crisis is ‘worst-case scenario,' say experts
The worst-case scenario of famine is playing out in the Gaza Strip, the leading international authority on food crisis said in an alert Tuesday as aid workers urge immediate action to avoid thousands of preventable deaths. The Integrated Food Security Phase Classification, or IPC, issued the alert but stopped short of a formal famine declaration. The warning comes amid international outrage over images of emaciated children and increased reports of death due to starvation in Gaza. The crisis follows months of Israel's tightening of humanitarian aid deliveries in the Strip amid its war against Hamas for the Oct. 7, 2023, terrorist attack. On Monday, President Trump said there was 'real starvation' in Gaza, signaling a break with Israeli Prime Minister Benjamin Netanyahu, who had said there was no starvation in Gaza. The president said the U.S would look into setting up 'food centers' in Gaza. But the administration is drawing scrutiny and criticism for its support of the American-founded Gaza Humanitarian Foundation, which has handled distribution of food in the Strip for months and is criticized for contributing to chaotic, dangerous and undignified aid deliveries with people killed and injured searching for food. Amid international pressure and France's declaration it will recognize an independent Palestinian state last week, the Israeli government announced over the weekend it would carry out tactical pauses in fighting to allow for aid distribution. Jerusalem said it opened up additional corridors for humanitarian assistance and carried out and granted air drops of aid. But humanitarian workers in the Strip say this is far short of the response needed to prevent thousands or potentially tens of thousands of people from dying. 'Air drops are just not a solution. They're a spectacle. They're theatrics,' Bushra Khalidi of Oxfam said during a briefing of humanitarian workers organized Tuesday by the nongovernmental organization Save the Children. 'You can't feed starving children by tossing energy bars from the sky. People have already been injured by falling palettes. They've died by falling palettes, and the chaos around these drops only adds to the suffering.' The Gaza Health Ministry is reporting that 147 people, including 88 children, have died from malnutrition and starvation since October 2023, part of the more than 60,000 people killed since the start of the war. Hamas killed approximately 1,200 people and took 251 hostage in its 2023 attack on Israel. While the health ministry does not distinguish Hamas militants in the figures, the numbers are widely accepted by the United Nations and other international organizations. Israel estimates it has killed 20,000 Palestinian militants. The IPC alert said malnutrition has been rising rapidly in the first half of July and has reached the famine threshold in Gaza City. More than 20,000 children have been admitted for treatment for acute malnutrition between April and mid-July, with more than 3,000 severely malnourished, the report said. 'We have many children now in our child protection services saying that they wish to die. In heaven, in paradise, there is food, there is water,' Rachael Cummings, humanitarian director for Save the Children International in Gaza, said in the briefing. 'Yesterday, in the clinic, one of the things that struck me, not only was the sort of visual impact of seeing so many people extremely thin, it was nearly silent … because children cry, but they're so exhausted, they're so sick, they're no longer able to cry. And that, I think for me, was really one of the most significant things I've ever seen in my career.' Tarek Loubani, a Canadian doctor working in Gaza, said the malnutrition numbers are extremely conservative and that death due to malnutrition is only classified when there is no other comorbidity. 'What we've seen every other time is that the numbers are about 10 percent of the reality, and probably that's what we're looking at here in terms of malnutrition and starvation,' said Loubani, who is also the medical director for the Glia Project, which provides medical supplies to impoverished locations. Loubani also pointed out that malnutrition is another devastating hardship on top of scarce resources for patients. Families donating blood for relatives wounded in bombings or shootings have difficulty replenishing their own blood supply because 'there's no iron, there's no nutritious food.' Loubani said he has lost about 44 pounds living and working in Gaza because there is so little food to eat for medical and aid workers. He said a handful of rice was his recent meal. 'In terms of the physicians and health care workers I work with, they are suffering. Their families are suffering. Everybody here is suffering,' he said. The IPC report said the sufficient delivery of humanitarian assistance can only be possible with a ceasefire, and that would require scaling up the flow of goods, restoring basic services and ensuring safe, unimpeded access to life-saving assistance. Trump's special envoy for peace missions left talks with Hamas last week blaming the U.S.-designated terrorist group as being the obstacle to a deal. He said the administration will consider 'alternative options to bring the hostages home and try to create a more stable environment for the people of Gaza.' Hamas holds about 20 living hostages it kidnapped from Israel on Oct. 7 and about 30 bodies. Copyright 2025 Nexstar Media, Inc. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed. Solve the daily Crossword
Yahoo
10 hours ago
- Yahoo
Israeli human rights groups accuse Netanyahu's gov't of Gaza genocide in new report
The report outlines what the organization calls a deliberate state-led effort to dismantle Palestinian civil infrastructure and social cohesion in Gaza. Israeli left-wing human rights organization B'Tselem accused the Israeli government of executing a "coordinated action to intentionally destroy Palestinian society in the Gaza Strip," characterizing it as a developing "genocidal regime," in a new report on Monday. The report, which included testimonies, statistical data, and documentation, outlined what the organization calls a deliberate state-led effort to dismantle Palestinian civil infrastructure and social cohesion in Gaza. 'An examination of Israel's policy in the Gaza Strip and its horrific outcomes, together with statements by senior Israeli politicians and military commanders about the goals of the attack, leads us to the unequivocal conclusion that Israel is taking coordinated action to intentionally destroy Palestinian society in the Gaza Strip,' the report states. Alongside this publication, Physicians for Human Rights-Israel (PHRI) issued a legal-medical analysis that concluded Israel's ongoing military campaign meets the criteria for genocide as defined by the Convention on the Prevention and Punishment of the Crime of Genocide, to which Israel is a signatory. The PHRI report cited direct attacks on hospitals, restrictions on medical aid and evacuations, and the targeting of medical personnel as evidence of 'a deliberate policy aimed at harming the Palestinian population as a group.' B'Tselem warns destructive model currently unfolding in Gaza may extend to West Bank B'Tselem said that the destructive model currently unfolding in Gaza may soon extend into the West Bank, where it said similar patterns are already emerging on a smaller scale. 'There is a real risk the genocide will spread beyond the Gaza Strip,' the organization cautioned. Yuli Novak, Executive Director of B'Tselem, described the findings as a moral crisis for Israeli society: 'Nothing prepares you for the realization that you are part of a society committing genocide. This is a deeply painful moment for us.' She added, 'After decades of separation, and of dehumanization of Palestinians, the horrors of the Hamas-led attack on October 7, 2023, created deep existential fear among Israelis. The extremist, far-right messianic government is using that fear to promote an agenda of destruction and expulsion.' Physicians for Human Rights-Israel emphasized the specific targeting of Gaza's health infrastructure. 'This is not incidental damage from war – it is a deliberate policy,' the organization's report claims. PHRI Executive Director Dr. Guy Shalev stated, 'Israel is knowingly destroying Gaza's health system. As people who believe in the sanctity of life, we are obligated to speak the truth: this is genocide, and we must fight it.' Shalev cited over 22 months of attacks on hospitals, denial of life-saving treatment, and blocked humanitarian aid as evidence of a sustained strategy of destruction. 'It is our duty as medical professionals, and to our colleagues in Gaza who are risking their lives to save others under impossible conditions, to face the truth and do everything we can to protect them,' he said. Both B'Tselem and PHRI issued an urgent call to the international community, asserting that global actors, through action or silence, are complicit in Israel's actions. They urged world leaders to intervene using all available legal mechanisms under international law to halt what they described as an ongoing genocide in Gaza.
Yahoo
14 hours ago
- Yahoo
Defining famine: the complex process behind Gaza's hunger crisis
Despite mounting international concern over widespread hunger in Gaza, no official famine has been declared in the territory – highlighting the complexities of determining a country's famine status. The World Food Programme (WFP), Unicef and the Food and Agriculture Organisation warned this week that time is running out, with Gaza "on the brink of a full-scale famine". "We need to flood Gaza with large-scale food aid, immediately and without obstruction, and keep it flowing each and every day to prevent mass starvation," WFP executive director Cindy McCain said in a joint statement from the agencies. Images of severely undernourished children have prompted outrage. According to data from the United Nations Relief and Works Agency (UNRWA), one in five children under the age of five in Gaza City is now malnourished. The Hamas-controlled Gaza Ministry of Health has reported 147 deaths from hunger, including 88 children, since the Israel-Hamas conflict erupted following the 7 October 2023 terror attack. However, there has been no official determination or declaration of famine, leading to questions over whether one exists. Determining a famine The United Nations uses a tool called the Integrated Food Security Phase Classification (IPC) to measure hunger. Created in 2004, the IPC is used by 21 agencies, including the WFP and Unicef. It sets out five levels of food insecurity, with Phase 5 meaning famine or catastrophe. Three things must happen at the same time for famine to be declared: At least 2 people per 10,000 (or 4 per 10,000 children) die daily of starvation, disease and malnutrition At least 20 percent of households face extreme food shortages At least 30 percent of children suffer from acute malnutrition Even if those thresholds appear to be met, an independent review committee must confirm it. This panel includes experts in nutrition, health and food security. Only then can a formal declaration be made – usually by the government of the affected area or the UN. "It's a very high bar and the nature of the process is that if the data aren't there, you say it's not a famine," Alex de Waal, executive director of the World Peace Foundation at Tufts University, told the ABC. "It has no legal force. The word 'famine' has no meaning in law." As of June 2025, Sudan is the only country currently experiencing famine, according to the IPC. First confirmed in North Darfur's Zamzam camp for displaced people in August, 2024, famine has since spread to 10 areas of the country, with another 17 at risk. More than 110 aid and human rights groups denounce Gaza 'mass starvation' Data collection challenges The IPC puts Gaza at Phase 4 (emergency) across the territory, with half a million people projected to reach Phase 5 by September. Earlier this month, the IPC issued an alert warning that the "worst-case scenario of famine is currently playing out," though this falls short of an official classification. Collecting the necessary data to determine whether a country is officially suffering from famine requires the systematic surveying of populations to measure malnutrition rates and mortality. Israel's partial blockade on delivery of humanitarian aid to Gaza has not only contributed to the risk of famine, the conflict and restrictions on international media have made gathering data near-impossible, aid agencies say. "Our colleagues in Gaza right now are trying to work under bombardment with no guarantee of safety," Scott Paul, director of peace and security at Oxfam America, told the ABC. "Aid workers conducting assessments face the same dire conditions as the general population, including food shortages and restricted movement." Sudan government rejects UN-backed famine declaration Politics has also affected how famine is assessed. Doctors Without Borders has accused Israel of using 'deliberate starvation' as a weapon of war. Israeli officials have pushed back on that, questioning the accuracy of the figures and suggesting the viral images of emaciated children are misleading. "In most cases, their extreme malnutrition is due to underlying medical conditions rather than food scarcity alone," a spokesperson for the Israeli army told Le Point magazine. Israel also argues that previous IPC warnings proved inaccurate, noting that predictions of imminent famine in March 2024, and then again in March of this year, failed to materialise. By June, the World Health Organization had recorded 32 hunger-related deaths – far below projections. Even so, many aid groups say action should not be delayed just because a formal famine has not been declared. In Somalia in 2012, around half of the 250,000 famine deaths happened before the official announcement was made. "The importance of taking action before famine is declared cannot be overstated," Paul said, adding that severely malnourished individuals may be harmed by certain foods if distribution is not carefully managed.
