Tracheal intubation in traumatic brain injury: a multicentre prospective observational study

[en] Background: We aimed to study the associations between pre- and in-hospital tracheal intubation and outcomes in traumatic brain injury (TBI), and whether the association varied according to injury severity. Methods: Data from the international prospective pan-European cohort study, Collaborative European NeuroTrauma Effectiveness Research for TBI (CENTER-TBI), were used (n=4509). For prehospital intubation, we excluded self-presenters. For in-hospital intubation, patients whose tracheas were intubated on-scene were excluded. The association between intubation and outcome was analysed with ordinal regression with adjustment for the International Mission for Prognosis and Analysis of Clinical Trials in TBI variables and extracranial injury. We assessed whether the effect of intubation varied by injury severity by testing the added value of an interaction term with likelihood ratio tests. Results: In the prehospital analysis, 890/3736 (24%) patients had their tracheas intubated at scene. In the in-hospital analysis, 460/2930 (16%) patients had their tracheas intubated in the emergency department. There was no adjusted overall effect on functional outcome of prehospital intubation (odds ratio=1.01; 95% confidence interval, 0.79–1.28; P=0.96), and the adjusted overall effect of in-hospital intubation was not significant (odds ratio=0.86; 95% confidence interval, 0.65–1.13; P=0.28). However, prehospital intubation was associated with better functional outcome in patients with higher thorax and abdominal Abbreviated Injury Scale scores (P=0.009 and P=0.02, respectively), whereas in-hospital intubation was associated with better outcome in patients with lower Glasgow Coma Scale scores (P=0.01): in-hospital intubation was associated with better functional outcome in patients with Glasgow Coma Scale scores of 10 or lower. Conclusion: The benefits and harms of tracheal intubation should be carefully evaluated in patients with TBI to optimise benefit. This study suggests that extracranial injury should influence the decision in the prehospital setting, and level of consciousness in the in-hospital setting. Clinical trial registration: NCT02210221. © 2020 The Author(s)

Research Center/Unit :

CHU de Liège-Centre du Cerveau² - ULiège

Disciplines :

Public health, health care sciences & services

Author, co-author :

Gravesteijn, B. Y.; Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, Netherlands, Department of Public Health, Erasmus University Medical Centre, Rotterdam, Netherlands

Sewalt, C. A.; Department of Public Health, Erasmus University Medical Centre, Rotterdam, Netherlands

Nieboer, D.; Department of Public Health, Erasmus University Medical Centre, Rotterdam, Netherlands, Department of Public Health, Erasmus Medical Center-University Medical Center, Rotterdam, Netherlands

Menon, D. K.; Department of Anaesthesiology, University of Cambridge, United Kingdom

Maas, A.; Department of Neurosurgery, University Hospital Antwerp, Antwerp, Belgium

Lecky, F.; Emergency Medicine Research in Sheffield (EMRiS), School of Health and Related Research (ScHARR), Faculty of Medicine, Dentistry and Health, University of Sheffield, Sheffield, United Kingdom, Centre for Urgent and Emergency Care Research (CURE), Health Services Research Section, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, United Kingdom, Emergency Department, Salford Royal Hospital, Salford, United Kingdom

Klimek, M.; Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, Netherlands

Lingsma, H. F.; Department of Public Health, Erasmus University Medical Centre, Rotterdam, Netherlands

Åkerlund, C.; Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden

Amrein, K.; János Szentágothai Research Centre, University of Pécs, Pécs, Hungary

More authors (242 more)

Language :

English

Title :

Tracheal intubation in traumatic brain injury: a multicentre prospective observational study

Publication date :

2020

Journal title :

British Journal of Anaesthesia

ISSN :

0007-0912

eISSN :

1471-6771

Publisher :

Elsevier Ltd

Peer reviewed :

Peer Reviewed verified by ORBi

Available on ORBi :

since 07 March 2021

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Bibliography

Maas, A.I.R., Menon, D.K., Adelson, P.D., et al. Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research. Lancet Neurol 16 (2017), 987–1048.
Majdan, M., Plancikova, D., Brazinova, A., et al. Epidemiology of traumatic brain injuries in Europe: a cross-sectional analysis. Lancet Public Health 1 (2016), e76–e83.
booksmedicosorg. Advanced trauma Life support ATLS, 9th Edn.
Green, R.S., Butler, M.B., Erdogan, M., Increased mortality in trauma patients who develop postintubation hypotension. J Trauma Acute Care Surg 83 (2017), 569–574.
Manley, G., Hypotension, hypoxia, and head injury. Arch Surg 136 (2001), 1118–1123.
Badjatia, N., Carney, N., Crocco, T.J., et al. Guidelines for prehospital management of traumatic brain injury, 2nd edition. Prehosp Emerg Care 12:Suppl 1 (2008), S1–S52.
Carney, N., Totten, A.M., Hawryluk, G.W.J., et al. Guidelines for the management of severe traumatic brain injury, 4th edition. Neurosurgery 80 (2017), 6–15.
Shafi, S., Gentilello, L., Pre-hospital endotracheal intubation and positive pressure ventilation is associated with hypotension and decreased survival in hypovolemic trauma patients: an analysis of the National Trauma Data Bank. J Trauma 59 (2005), 1140–1145 discussion 1145–7.
Burney, R.G., Winn, R., Increased cerbrospinal fluid pressure during laryngoscopy and intubation for induction of anesthesia. Anesth Analg 54 (1975), 687–690.
Davis, D.P., Meade, W., Sise, M.J., et al. Both hypoxemia and extreme hyperoxemia may be detrimental in patients with severe traumatic brain injury. J Neurotrauma 26 (2009), 2217–2223.
Davis, D., Dunford, J., Poste, J., et al. The impact of hypoxia and hyperventilation on outcome after paramedic rapid sequence intubation of severely head-injured patients. J Trauma Inj Infect Crit Care 57 (2004), 1–10.
Marmarou, A., Anderson, R.L., Ward, J.D., et al. Impact of ICP instability and hypotension on outcome in patients with severe head trauma. J Neurosurg 75 (1991), S59–S66.
Stocchetti, N., Maas, A.I.R., Traumatic intracranial hypertension. N Engl J Med 370 (2014), 2121–2130.
Badjatia, N., Carney, N., Crocco, T.J., et al. Guidelines for prehospital management of traumatic brain injury prehospital guidelines. 2nd Edn., 2006, Brain Trauma Foundation, New York.
Bernard, S.A., Nguyen, V., Cameron, P., et al. Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury. Ann Surg 252 (2010), 959–965.
Davis, D.P., Aguilar, S., Sonnleitner, C., Cohen, M., Jennings, M., Latency and loss of pulse oximetry signal with the use of digital probes during prehospital rapid-sequence intubation. Prehosp Emerg Care 15 (2011), 18–22.
Cnossen, M.C., Polinder, S., Lingsma, H.F., et al. Variation in structure and process of care in traumatic brain injury: provider profiles of European Neurotrauma Centers participating in the CENTER-TBI study. PLoS One 11 (2016), 1–21.
Cnossen, M.C., Scholten, A.C., Lingsma, H.F., et al. Adherence to guidelines in adult patients with traumatic brain injury: a living systematic review. J Neurotrauma, 14, 2016 [Epub ahead of print].
Franschman, G., Peerdeman, S.M., Greuters, S., et al. Prehospital endotracheal intubation in patients with severe traumatic brain injury: guidelines versus reality. Resuscitation 80 (2009), 1147–1151.
von Elm, E., Altman, D.G., Egger, M., et al. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ 335 (2007), 806–808.
Maas, A.I.R., Menon, D.K., Steyerberg, E.W., et al. Collaborative European neurotrauma effectiveness research in traumatic brain injury (CENTER-TBI): a prospective longitudinal observational study. Neurosurgery 76 (2015), 67–80.
Steyerberg, E.W., Wiegers, E., Sewalt, C., et al. Case-mix, care pathways, and outcomes in patients with traumatic brain injury in CENTER-TBI: a European prospective, multicentre, longitudinal, cohort study. Lancet Neurol 18 (2019), 923–934.
Weir, J., Steyerberg, E.W., Butcher, I., et al. Does the extended Glasgow outcome scale add value to the conventional Glasgow outcome scale?. J Neurotrauma 29 (2012), 53–58.
Steyerberg, E.W., Mushkudiani, N., Perel, P., et al. Predicting outcome after traumatic brain injury: development and international validation of prognostic scores based on admission characteristics. PLoS Med 5 (2008), 1251–1261.
Davis, D.P., Peay, J., Sise, M.J., et al. Prehospital airway and ventilation management: a trauma score and injury severity score-based analysis. J Trauma Inj Infect Crit Care 69 (2010), 294–301.
Pape, M., Giannakópoulos, G.F., Zuidema, W.P., et al. Is there an association between female gender and outcome in severe trauma? A multi-center analysis in The Netherlands. Scand J Trauma Resusc Emerg Med, 27, 2019, 16.
Buuren, S van, Flexible imputation of missing data. 2018, CRC Press, Boca Raton, FL.
Gravesteijn, B.Y., Sewalt, C.A., Ercole, A., et al. Variation in the practice of tracheal intubation in Europe after traumatic brain injury: a prospective cohort study. Anaesthesia 75 (2020), 45–53.
Von Elm, E., Schoettker, P., Henzi, I., Osterwalder, J., Walder, B., Pre-hospital tracheal intubation in patients with traumatic brain injury: systematic review of current evidence. Br J Anaesth 103 (2009), 371–386.
Haltmeier, T., Benjamin, E., Siboni, S., Dilektasli, E., Inaba, K., Demetriades, D., Prehospital intubation for isolated severe blunt traumatic brain injury: worse outcomes and higher mortality. Eur J Trauma Emerg Surg 43 (2017), 731–739.
Karamanos, E., Talving, P., Skiada, D., et al. Is prehospital endotracheal intubation associated with improved outcomes in isolated severe head injury? A matched cohort analysis. Prehosp Disaster Med 29 (2014), 32–36.
Spaite, D.W., Hu, C., Bobrow, B.J., et al. Association of out-of-hospital hypotension depth and duration with traumatic brain injury mortality. Ann Emerg Med 70 (2017), 522–530.
Davis, D.P., Heister, R., Poste, J.C., Hoyt, D.B., Ochs, M., Dunford, J.V., Ventilation patterns in patients with severe traumatic brain injury following paramedic rapid sequence intubation. Neurocrit Care 2 (2005), 165–171.
Gaither, J.B., Spaite, D.W., Bobrow, B.J., et al. Balancing the potential risks and benefits of out-of-hospital intubation in traumatic brain injury: the intubation/hyperventilation effect. Ann Emerg Med 60 (2012), 732–736.
Warner, K.J., Cuschieri, J., Copass, M.K., Jurkovich, G.J., Bulger, E.M., The impact of prehospital ventilation on outcome after severe traumatic brain injury. J Trauma Inj Infect Crit Care 62 (2007), 1330–1336.
Chi, J.H., Knudson, M.M., Vassar, M.J., et al. Prehospital hypoxia affects outcome in patients with traumatic brain injury: a prospective multicenter study. J Trauma 61 (2006), 1134–1141.
Benjamin, E., Haltmeier, T., Chouliaras, K., et al. Witnessed aspiration in trauma: frequent occurrence, rare morbidity—a prospective analysis. J Trauma Acute Care Surg 79 (2015), 1030–1036.
Greenland, S., Morgenstern, H., Ecological bias, confounding, and effect modification. Int J Epidemiol 18 (1989), 269–274.