title: Timing is everything: delayed intubation is associated with increased mortality in initially stable trauma patients.
abstract: 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.
authors.affiliation: Department of Surgery, UCSF-East Bay, Alameda County Medical Center, Oakland 94602, California, USA.
authors.forename: Emily
authors.initials: E
authors.lastname: Miraflor
authors.forename: Kelly
authors.initials: K
authors.lastname: Chuang
authors.forename: Marvin A
authors.initials: MA
authors.lastname: Miranda
authors.forename: Wendy
authors.initials: W
authors.lastname: Dryden
authors.forename: Louise
authors.initials: L
authors.lastname: Yeung
authors.forename: Aaron
authors.initials: A
authors.lastname: Strumwasser
authors.forename: Gregory P
authors.initials: GP
authors.lastname: Victorino
mesh_terms: D000368:Aged; D004632:Emergency Medical Services / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007442:Intubation, Intratracheal / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D012131:Respiratory Insufficiency / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy; D012253:Rib Fractures / Q000401:mortality; D012307:Risk Factors; D012887:Skull Fractures / Q000401:mortality; D013997:Time Factors; D015599:Trauma Severity Indices; D014947:Wounds and Injuries / Q000401:mortality* / Q000628:therapy; D014948:Wounds, Gunshot / Q000401:mortality; D055815:Young Adult