title: Timing of intubation and ventilator-associated pneumonia following injury.
abstract: OBJECTIVE
  In an emergency medical system with established rapid-sequence intubation protocols, prehospital (PH) intubation of patients with trauma is not associated with a higher rate of ventilator-associated pneumonia (VAP) than emergency department (ED) intubation.
  
  
  METHODS
  Retrospective observational cohort.
  
  
  METHODS
  Level I trauma center.
  
  
  METHODS
  Adult patients with trauma intubated in a PH or an ED setting from July 1, 2007, through July 31, 2008.
  
  
  METHODS
  Diagnosis of VAP by means of bronchoscopic alveolar lavage or clinical assessment when bronchoscopic alveolar lavage was impossible. Secondary outcomes included time to VAP, length of hospitalization, and in-hospital mortality.
  
  
  RESULTS
  Of 572 patients, 412 (72.0%) underwent PH intubation. The ED group was older than the PH group (mean ages, 46.4 vs 39.1 years; P < .001) and had a higher incidence of blunt injury (142 [88.8%] vs 322 [78.2%]; P = .002). The mean (SD) lowest recorded ED systolic blood pressure was lower in the ED group (102.8 [1.9] vs 111.4 [1.2] mm Hg; P < .001), despite similar mean injury severity scores in both groups (27.2 [0.7] vs 27.0 [1.1]; P = .94). There was no difference in the mean rate of VAP (30 [18.8%] vs 71 [17.2%]; P = .66) or mean time to diagnosis (8.1 [1.2] vs 7.8 [1.0] days; P = .89). Logistic regression analysis identified history of drug abuse, lowest recorded ED systolic blood pressure, and injury severity score as 3 independent factors predictive of VAP.
  
  
  CONCLUSIONS
  Prehospital intubation of patients with trauma is not associated with higher risk of VAP. Further investigation of intubation factors and the incidence and timing of aspiration is required to identify potentially modifiable factors to prevent VAP.
authors.affiliation: Department of Surgery, Harborview Medical Center, University of Washington, Seattle, 98104, USA. hlevans@uw.edu
authors.forename: Heather L
authors.initials: HL
authors.lastname: Evans
authors.forename: David H
authors.initials: DH
authors.lastname: Zonies
authors.forename: Keir J
authors.initials: KJ
authors.lastname: Warner
authors.forename: Eileen M
authors.initials: EM
authors.lastname: Bulger
authors.forename: Sam R
authors.initials: SR
authors.lastname: Sharar
authors.forename: Ronald V
authors.initials: RV
authors.lastname: Maier
authors.forename: Joseph
authors.initials: J
authors.lastname: Cuschieri
mesh_terms: D000328:Adult; D018893:Bronchoalveolar Lavage; D001999:Bronchoscopy; D016009:Chi-Square Distribution; D015897:Comorbidity; D003428:Cross Infection / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality; D004638:Emergency Treatment; D005260:Female; D015600:Glasgow Coma Scale; D017052:Hospital Mortality; D006801:Humans; D015601:Injury Severity Score; D007442:Intubation, Intratracheal / Q000379:methods* / Q000401:mortality; D007902:Length of Stay / Q000706:statistics & numerical data; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D053717:Pneumonia, Ventilator-Associated / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D014193:Trauma Centers; D014947:Wounds and Injuries / Q000401:mortality