Elsevier

Journal of Surgical Research

Volume 170, Issue 1, September 2011, Pages e117-e121
Journal of Surgical Research

Association for Academic Surgery
Pre-Hospital Intubation is Associated with Increased Mortality After Traumatic Brain Injury1

https://doi.org/10.1016/j.jss.2011.04.005Get rights and content

Background

Early endotracheal intubation in patients sustaining moderate to severe traumatic brain injury (TBI) is considered the standard of care. Yet the benefit of pre-hospital intubation (PHI) in patients with TBI is questionable. The purpose of this study was to investigate the relationship between pre-hospital endotracheal intubation and mortality in patients with isolated moderate to severe TBI.

Methods

The Los Angeles County Trauma System Database was queried for all patients > 14 y of age with isolated moderate to severe TBI admitted between 2005 and 2009. The study population was then stratified into two groups: those patients requiring intubation in the field (PHI group) and those patients with delayed airway management (No-PHI group). Demographic characteristics and outcomes were compared between groups. Multivariate analysis was used to determine the relationship between pre-hospital endotracheal intubation and mortality.

Results

A total of 2549 patients were analyzed and then stratified into the two groups: PHI and No-PHI. There was a significant difference noted in overall mortality (90.2% versus 12.4%), with the PHI group being more likely to succumb to their injuries. After adjusting for possible confounding factors, multivariable logistic regression analysis demonstrated that PHI was independently associated with increased mortality (AOR 5, 95% CI: 1.7–13.7, P = 0.004).

Conclusions

Pre-hospital endotracheal intubation in isolated, moderate to severe TBI patients is associated with a nearly 5-fold increase in mortality. Further prospective studies are required to establish guidelines for optimal pre-hospital management of this critically injured patient population.

Introduction

Traumatic brain injury (TBI) is the most common cause of death and disability in trauma patients, affecting over 1 million Americans per year. Most of these disabilities are a direct result of secondary injury processes following the initial mechanical insult 1, 2. Secondary injury processes include systemic hypotension and hypoxia, which are known to play a critical role in the development of irreversible tissue damage. Hypoxia in TBI patients has shown to be significantly associated with increased morbidity and mortality and is also a strong predictor of poor neurological outcomes 3, 4, 5, 6, 7. Additionally, hypoventilation and resultant hypercapnia can lead to cerebral vasodilation and subsequent exacerbation of intracranial hypertension. In order to prevent secondary brain injury from hypoxia and hypercapnia, aggressive pre-hospital airway control has been advocated 1, 3, 8. However, despite multiple studies, the benefit of pre-hospital intubation (PHI) remains unproven 9, 10, 11.

To our knowledge, the role of PHI has not been evaluated in an urban trauma setting where transport times remain relatively short compared with those in a more rural environment. We hypothesized that pre-hospital endotracheal intubation for patients with isolated moderate to severe TBI in this environment would be rare, and would be associated with poor outcomes.

Section snippets

Methods

This is a retrospective database review of the Los Angeles County Trauma System Database, consisting of 5 Level I and 8 Level II trauma centers. The 13 trauma centers consist of 5 Level I adult centers in the more densely populated areas surrounded by seven Level II centers, with one pediatric Level I center, covering an area of approximately 4079 square miles and providing care for approximately ten million people. As part of the county trauma system policy, transport times are required to be

Results

During the study period, 2366 patients with isolated moderate to severe TBI requiring intubation were identified. Of note, only 61 patients (2.6%) were managed with PHI, which is lower than other reports in the literature 9, 10, 11, 12. Table 1 depicts the study population and compares the characteristics between the PHI and No PHI groups. Though the two groups were demographically similar, the injury and physiologic parameters vary significantly with the PHI group presenting with a higher

Discussion

Our review of an urban countywide database found that PHI for isolated moderate to severe TBI occurred rarely (2.6%) and was associated with significantly increased mortality (AOR 5, 95% CI: 1.7–13.7, P = 0.004). Although a secure airway to optimize oxygenation and control ventilation with a secure airway are well known to improve outcomes in hospitalized TBI patients, numerous studies in the literature have demonstrated results similar to those in the current investigation by suggesting that

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1

Quick shot oral presentation at the Annual Meeting of the Association of Academic Surgery, February 1–3, 2011, Huntington Beach, California.

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