Prehospital Advanced Airway Management in Traumatic Out-of-Hospital Cardiac Arrest: A Nationwide Cohort Study Using Time-Dependent Propensity Score Sequential Matching

OBJECTIVES: Traumatic out-of-hospital cardiac arrest (TCA) has extremely poor outcomes, and the benefit of prehospital advanced airway management (AAM) remains uncertain, partly because previous observational studies may have been affected by resuscitation time bias. We examined the association between prehospital AAM and clinical outcomes in adults with TCA using a time-dependent analytic approach. METHODS: We conducted a nationwide retrospective observational cohort study using the All-Japan Utstein Registry linked with emergency medical services transport records from 2021 to 2023. Adults (≥18 years) with TCA were included. The exposure was successful prehospital AAM, including supraglottic airway placement or endotracheal intubation. The primary outcome was 30-day survival, and the secondary outcome was favorable neurological outcome (Cerebral Performance Category 1-2) at 30 days. We applied time-dependent propensity score sequential matching and estimated corrected risk differences (RDs) using generalized estimating equations with inverse-frequency weighting. RESULTS: Among 7,217 patients, 2,653 (36.8%) received prehospital AAM, of whom 2,637 were successfully matched within the analytic cohort. Thirty-day survival was 1.8% in the AAM group and 1.4% among matched controls (corrected RD, 0.6%; 95% confidence interval (CI), -0.1 to 1.2). Favorable neurological outcome occurred in 0.2% and 0.4%, respectively (corrected RD, -0.2%; 95% CI, -0.6 to 0.1). No significant timing-dependent association or prespecified subgroup heterogeneity was observed. CONCLUSIONS: In this nationwide cohort study using time-dependent propensity score sequential matching, prehospital AAM was not significantly associated with improved outcomes in adults with TCA.