Emergency Medical ServiceOut-of-hospital endotracheal intubation and outcome after traumatic brain injury
Introduction
Hypoxia is believed to be deleterious after traumatic brain injury.1., 2., 3. Current guidelines for acute traumatic brain injury therapy call for aggressive measures to prevent hypoxia, including the use of endotracheal intubation.4., 5., 6.
Although endotracheal intubation is readily accomplished in the inhospital setting, multiple factors may complicate the performance of this complex procedure in the out-of-hospital setting, especially in traumatic brain injury patients.7., 8., 9. Recent efforts have introduced controversial advanced airway management techniques to the setting for this patient subset, including the use of neuromuscular blockade–assisted endotracheal intubation.10 However, results from previous studies have generated conflicting data about the potential benefit of out-of-hospital endotracheal intubation in the therapy of traumatic brain injury, with some studies suggesting positive effects and others demonstrating adverse associations.11., 12., 13., 14.
The purpose of this study was to compare the effects of out-of-hospital endotracheal intubation versus emergency department (ED) endotracheal intubation on mortality and neurologic and functional outcome after traumatic brain injury.
Section snippets
Study design, setting, and data collection and processing
This study was approved by the University of Pittsburgh institutional review board.
We conducted a retrospective analysis using data from the Pennsylvania Trauma Outcome Study, a statewide registry of all patients presenting to accredited trauma centers in the Commonwealth of Pennsylvania. The registry includes patients presenting to a trauma center with a primary International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) injury code of 800 to 995. All trauma
Characteristics of study subjects
Of 69,226 patients meeting Pennsylvania Trauma Outcome Study inclusion criteria, we excluded 26,104 pediatric or transferred patients. Of the remaining 43,122 patients, there were 9,720 patients with a head/neck Abbreviated Injury Scale score of 3 or greater. Of these 9,720 patients, 4,098 received endotracheal intubation during the ED phase, including 1,797 (43.9%) out-of-hospital endotracheal intubation and 2,301 (56.1%) ED endotracheal intubation. The ED endotracheal intubation group
Limitations
The most evident limitation of this effort is the use of a preexisting, unvalidated registry. We believe that this approach was justified for several reasons. The use of preexisting data is efficient; we had immediate access to a large-scale body of data with numerous characteristics for outcome identification and risk adjustment. The Pennsylvania Trauma Outcome Study registry collects data on more than 10,000 patients per year using rigorous quality control measures, including detailed audits
Discussion
Although numerous publications exist describing out-of-hospital endotracheal intubation, there are only limited reports linking out-of-hospital endotracheal intubation with inhospital outcomes in either medical or trauma patients.12., 13., 14., 48., 49., 50., 51. Our findings reinforce the importance of this potential connection. Although the patients in the out-of-hospital endotracheal intubation group appear to be more severely injured, our data suggest that an association between
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Author contributions: HEW, ABP, LDC, PDA, and DMY conceived and designed the study. HEW performed the statistical analyses. HEW drafted the manuscript, and all authors contributed to its revision. HEW takes responsibility for the paper as a whole.
Presented at the National Association of EMS Physicians annual meeting, Tucson, AZ, January 10, 2004.
Dr. Wang is supported by Clinical Research Training Award 1 K08 HSO13628 from the Agency for Healthcare Research and Quality.
Reprints not available from the authors.