Abstract TP281: Frequency and Predictors of Early Intubation for Acute Stroke Patients Presenting within 2 Hours of Stroke Symptom Onset

Abstract

Background: Stroke patients presenting acutely to the emergency department (ED) very early in their clinical course may require urgent intubation for failure to protect their airway or respiratory compromise. Intubated stroke patients are likely to represent the most severe cases and are likely to have the worst long-term outcomes. We aimed to characterize the rate and prehospital predictors of urgent ED intubation and intubation over 24 hours in stroke patients presenting within 2 hours of onset. Methods: Subjects were participating in the Field Administration of Stroke Therapy Magnesium (FAST-MAG) clinical trial of prehospital intravenous magnesium vs placebo initiated within 2 hours of symptoms onset. Intubation was recorded during nurses’ examination in the ED and 24 hours after admission. Results: Of 1200 consecutive cases there were 848 (71%) cerebral ischemia, 301 (25%) intracranial hemorrhage (ICH) and 68 (4%) stroke mimics. A total of 68 (6%) were intubated on ED evaluation (median (IQR) of 84 (62-107) minutes after arrival), and 123 (10%) were intubated at the 24 hour evaluation (23 (19-25) hours after arrival). Intubation was more common among patients with ICH (18% vs. 1% in ED, 30% vs. 4% at 24 hours, both p<0.001). Among patients with cerebral ischemia, those who were intubated at 24 hours (n=33) had lower prehospital and ED Glasgow Coma Scale scores (12.8 vs. 14.1, 9.8 vs. 14.22, both p<0.001), and higher ED NIHSS (29 vs 13, p<0.001) but were similar in age, gender, ethnicity, prehospital and ED blood pressure, and time from symptom onset to ED arrival. Among patients with ICH, intubation at 24 hours was associated with younger age (62 vs. 66, p=0.032), higher ED NIHSS (29 vs. 13, P<0.001), higher hospital arrival BP (185/102 vs. 173/94, p<0.001), lower prehospital and ED GCS (13.9 vs 14.6, 8 vs 14.0) but similar prehospital BP, time to ED arrival, gender, ethnicity. Conclusions: Patients with hyperacute intracerebral hemorrhage have high rates of intubation, which may have implications for processes of consent and data collection. Overall, more severe neurological deficit and lower GCS scores were associated with intubation. For ICH, blood pressure on ED arrival, and not prehospital blood pressure, was associated with intubation.