Artikel
The impact of prehospital intubation on the outcome of severe traumatic brain injury in children and adults with a Glasgow Coma Scale of 8 or less
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Veröffentlicht: | 8. Juni 2016 |
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Objective: Although unconsciousness (Glasgow Coma Scale, GCS 3-8) necessitates intubation according to the common guidelines, there is a notable lack of evidence to support this approach. This study evaluates the impact of prehospital intubation on mortality in children and adults with severe traumatic brain injury (TBI) with a GCS of 8 or less based on a large registry.
Method: A retrospective cohort analysis of patients suffering from severe TBI registered in the TraumaRegister DGU® of the German Trauma Society (DGU) from 2002 to 2013 was conducted. Severe TBI was defined as an Abbreviated Injury Scale (AIS) of the head of 3 or more and AIS in any other part of the body not exceeding the AIS of the head. In addition patients were qualified for this analysis if the Injury Severity Score (ISS) was 9 or more. Patients were sub classified into 5 subgroups according to age: Group I (1-6 years of age (yoa)), Group II (7-15 yoa) Group III (16-55 yoa), Group IV (56-79 yoa), Group V (80 yoa and older). The observed mortality was matched with the expected mortality derived from the Revised Injury Severity Classification, version II (RISC II). Furthermore, a Standardized Mortality Ratio (SMR) was calculated for various subgroups.
Results: A total of 21.804 patients with a prehospital GCS of 8 or less and complete documentation were available for analysis. The female-male ratio was approximately 1:3. Intubated patients demonstrated a higher mean ISS (32.1 vs. 24.3) with an associated higher observed mortality (41.3% vs. 28.6%) compared to non-intubated patients. No significant mean ISS differences were detected between all subgroups. Non-intubated patients between 1 and 6 yoa with a GCS of 8 or less demonstrated a significantly lower mortality compared to those who had been intubated (6.8% vs. 41.0%). In addition those intubated had a higher mortality rate than expected in the RISC II prognosis (41.0% vs. 32.7%; SMR 1.251 (95% CI: 1.057-1.446), p=0.03). Regarding mortality, no significant differences were detected between Group 2 and 3 intubated vs. non-intubated patients. Non-intubated patients in Group IV and V demonstrated a higher mortality rate than expected (Group IV 34.6% vs. 31.5%; Group V 68.5% vs. 60.9%).
Conclusions: Intubation in children with severe TBI, 1-6 yoa, was associated with a higher mortality than expected in this large retrospective cohort analysis. It must be questioned whether a GCS of 8 or less is the only reliable criterion for intubation in this cohort.