Intubation Patterns and Outcomes in Patients With Computed Tomography-Verified Traumatic Brain Injury

• Published in: The Journal of trauma, injury, infection, and critical care Vol. 71; no. 6; pp. 1615 - 1619
• Main Authors: Vandromme, Marianne J., Melton, Sherry M., Griffin, Russell, McGwin, Gerald, Weinberg, Jordan A., Minor, Michael, Rue, Loring W., Kerby, Jeffrey D.
• Format: Journal Article
• Language: English
• Published: Hagerstown, MD Lippincott Williams & Wilkins, Inc 01-12-2011; Lippincott Williams & Wilkins
• Subjects: Adult and adolescent clinical studies; Analysis of Variance; Biological and medical sciences; Brain Injuries - diagnostic imaging; Brain Injuries - mortality; Brain Injuries - therapy; Cohort Studies; Confidence Intervals; Diseases of the osteoarticular system; Emergency Medical Services - methods; Female; Glasgow Coma Scale; Head Injuries, Closed - diagnostic imaging; Head Injuries, Closed - mortality; Head Injuries, Closed - therapy; Humans; Injuries of the nervous system and the skull. Diseases due to physical agents; Injury Severity Score; Intubation, Intratracheal - mortality; Intubation, Intratracheal - trends; Male; Medical sciences; Organic mental disorders. Neuropsychology; Predictive Value of Tests; Prognosis; Psychology. Psychoanalysis. Psychiatry; Psychopathology. Psychiatry; Radiography; Retrospective Studies; Risk Assessment; Survival Rate; Trauma Centers; Traumas. Diseases due to physical agents; Treatment Outcome; Human; Nervous system diseases; Prognosis; Traumatic brain injury; Radiodiagnosis; Medical imagery; Anesthesia; Prehospital care; Computerized axial tomography; Intubation; Head trauma; Care
• ISSN: 0022-5282; 1529-8809
• DOI: 10.1097/TA.0b013e31822a30a1

BACKGROUND:Studies evaluating traumatic brain injury (TBI) patients have shown an association between prehospital (PH) intubation and worse outcomes. However, previous studies have used surrogates, e.g., Glasgow Coma Scale (GCS) score ≤8 and Abbreviated Injury Severity Scale (AIS) score ≥3, which may overestimate the true presence of TBI. This study evaluated the impact of PH intubation in patients with PH GCS score ≤8 and radiographically proven TBI.
METHODS:Trauma patients routed to a Level I trauma center over a 3-year period with blunt injury and PH GCS score ≤8 were included. PH and in-hospital records were linked and head computed tomography scans were assigned a Marshall Score (MS). Patients with TBI (MS >1) were categorized into groups based on intubation status (PH, emergency department [ED], and no intubation). Comparisons were made using analysis of variance and χ statistics. Mortality differences, crude and adjusted risk ratios (RRs), and 95% confidence intervals (CIs) were calculated using proportions hazards modeling.
RESULTS:Of 334 patients with PH GCS score ≤8, 149 (50%) had TBI by MS. Among the TBI patients, 42.7% of patients were PH intubated, 47.7% were ED intubated, and 9.4% were not intubated during the initial resuscitation. Intubated patients had lower ED GCS score (PH4.1 and ED5.9 vs. 14.0; p < 0.0001) compared with patients not intubated. Also PH intubated patients had higher mean Injury Severity Score (38.0 vs. 33.7 vs. 23.5, p < 0.001) when compared with ED intubated and nonintubated patients. None of the nonintubated patients had a MS >2. Mortality for TBI patients who required PH intubation was 46.9% and 41.4% among ED-intubated patients. The crude RR of mortality for PH compared with ED intubation was 1.13 (95% CI, 0.68–1.89), and remained nonsignificant (RR, 0.68; 95% CI, 0.36–1.19) when adjusted for key markers of injury severity.
CONCLUSIONS:Patients with PH GCS score ≤8 and proven TBI had a high overall rate of intubation (>90%). PH intubation seems to be a marker for more severe injury and conveyed no increased risk for mortality over ED intubation.