title: Intubation patterns and outcomes in patients with computed tomography-verified traumatic brain injury.
abstract: 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 (PH: 4.1 and ED: 5.9 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.
authors.affiliation: Department of Surgery, Section of Trauma, Burns, and Surgical Critical Care, University of Alabama at Birmingham, Birmingham, Alabama 35294, USA.
authors.forename: Marianne J
authors.initials: MJ
authors.lastname: Vandromme
authors.forename: Sherry M
authors.initials: SM
authors.lastname: Melton
authors.forename: Russell
authors.initials: R
authors.lastname: Griffin
authors.forename: Gerald
authors.initials: G
authors.lastname: McGwin
authors.forename: Jordan A
authors.initials: JA
authors.lastname: Weinberg
authors.forename: Michael
authors.initials: M
authors.lastname: Minor
authors.forename: Loring W
authors.initials: LW
authors.lastname: Rue
authors.forename: Jeffrey D
authors.initials: JD
authors.lastname: Kerby
mesh_terms: D000704:Analysis of Variance; D001930:Brain Injuries / Q000000981:diagnostic imaging* / Q000401:mortality / Q000628:therapy; D015331:Cohort Studies; D016001:Confidence Intervals; D004632:Emergency Medical Services / Q000379:methods*; D005260:Female; D015600:Glasgow Coma Scale; D016489:Head Injuries, Closed / Q000000981:diagnostic imaging* / Q000401:mortality / Q000628:therapy; D006801:Humans; D015601:Injury Severity Score; D007442:Intubation, Intratracheal / Q000401:mortality* / Q000639:trends*; D008297:Male; D011237:Predictive Value of Tests; D011379:Prognosis; D011859:Radiography; D012189:Retrospective Studies; D018570:Risk Assessment; D015996:Survival Rate; D014193:Trauma Centers; D016896:Treatment Outcome