Emergency airway management at the Emergency Department: Indications and characteristics in acute endotracheal intubation in the Academic Hospitals of Amsterdam. A retrospective study.

Objective
The aim of this study was a descriptive analysis of adult patients requiring intubation at the Emergency Department. The primary objective was to analyze and quantify the different indications for intubation, with a sub-analysis for Covid-19 versus non-Covid patients.
Study design
Retrospective observational study.
Setting
Both EDs of the Amsterdam UMC are Level-1 Trauma Centers, with an annual ED census of 25000-30000 patients in each department and serving a heterogeneous population.
Subjects
Adult patients, intubated at the ED between February 2020 and May 2022 were included. Patients under 18 or already intubated in the pre-hospital setting were excluded.
Methods
The primary outcome was a description of the indications for intubation in the ED with the associated diagnosis. The secondary outcomes included the comparison of intubation procedures in Covid-19 versus non-Covid-19 patients, including method of intubation; medication strategies; and the occurrence of adverse events.
Statistics
Characteristics of intubation procedure related variables were described using proportions. Continous variables were described as means or medians with corresponding spreading values. Statistical analyses were performed utilizing Chi-squared testing and multivariable logistic regression analysis and Odds ratios and proportions with 95%-Confidence Intervals were reported. A p-value of <0.05 was considered statistically significant.
Results
180 patients were eligible for inclusion and after screening 160 remained. The primary indication for intubation was neurological impairment in 72 patients (45%); 44 patients (27.5%) were intubated for cardiorespiratory arrest; 34 patients (21.3%) for respiratory insufficiency and 10 (6.3%) patients due to rapid deterioration. Patients with a Covid-19 infection mostly required intubation due to respiratory insufficiency (p<.001), while in the non-Covid group, neurological impairment was the main indication (p<.05). In the population without a Covid-19 infection, non-traumatic neurological or cardiac disorders were seen more (p<.05) and propofol is frequently used as anesthetic (p<.05)..
The respiratory diseases were more prevalent in the Covid-infected group (p<.001), even as the use of a video-assisted laryngoscope (p<.05) and the use of midazolam (p<.05). Patients with a Covid-19 infection were more likely to experience desaturation as a complication during intubation (p<.05).
Multivariable logistic regression analysis identified age (OR.97; p<.05) and being a polytrauma patient (OR .27; p<.05) as independent factors predictive for the use of Propofol during intubation. Midazolam was used mainly in patients needing intubation due to Covid-19 (OR56.7; p<.01) and Ketamine in patients with a higher GCS (OR 1.0; p<.05) and when being a polytrauma patient (OR 4.59;p<.01).
Conclusion
Non-traumatic neurological, respiratory and cardiac diseases were the most common underlying factor of an intubation in the ED. As expected, patients with a Covid-19 infection were considerably more likely to require intubation due to respiratory insufficiency, while in the non-covid group, neurologic impairment was more frequently cited as the indication for intubation Midazolam and video-assisted laryngoscopy were used more often in a Covid-intubation as compared to non-Covid intubations, with a significant higher risk on desaturation as adverse event. Propofol was used more frequently in patients without a Covid-19 infection.