title: The Impact of Prehospital Intubation With and Without Sedation on Outcome in Trauma Patients With a GCS of 8 or Less.
abstract: BACKGROUND
  Although unconsciousness (Glasgow Coma Scale [GCS] 3 to 8) necessitates intubation according national guidelines, there is a notable lack of evidence to support this approach. This study evaluates the impact on outcome of prehospital intubation with and without sedation in trauma patients with a GCS of ≤8.
  
  
  METHODS
  A retrospective cohort analysis of severely injured trauma patients registered in the TraumaRegister DGU of the German Trauma Society (DGU) from 2002 to 2013 was conducted. Only directly admitted patients alive on admission and with a GCS of ≤8 at the scene were included. The observed outcome was matched with the expected outcome deriving from the Revised Injury Severity Classification, version II (RISC-II). Furthermore, a Standardized Mortality Ratio (SMR) was calculated for various subgroups. Early neurological outcome was classified using the Glasgow Outcome Scale.
  
  
  RESULTS
  A total of 21,242 patients fulfilled the study inclusion criteria. A total of 18,975 patients (89.3%) received prehospital intubation. Intubation rates were continuously increasing with decreasing GCS score values. Difference between observed and expected mortality was lower in intubated patients (42.2% [95% confidence interval (CI), 41.5%-42.9%]; RISC-II prognosis 41.4%; SMR 1.020 [95% CI, 1.003-1.037]) compared with nonintubated (30.0% [95% CI, 28.1-31.9%] RISC-II prognosis 26.6% and SMR 1.128 [95% CI, 1.057-1.199]). Patients being sedated before intubation presented significant (P<0.001) lower observed mortality (37.7% [95% CI, 36.7-38.7%], RISC-II prognosis 39.0%, SMR 0.967 [95% CI, 0.951-0.983]) associated with a less poor early neurological outcome compared with those being intubated without sedation.
  
  
  CONCLUSIONS
  Observed outcome of prehospital intubated patients with a GCS of ≤8 seems less poor than predicted compared with nonintubated patients. Sedation before intubation might potentially decrease mortality and improve early neurological outcome. Further studies are required to clarify this issue.
authors.affiliation: Departments of *Trauma, Hand and Reconstructive Surgery †Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg ‡Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Cologne, Germany.
authors.forename: Michael
authors.initials: M
authors.lastname: Hoffmann
authors.forename: Patrick
authors.initials: P
authors.lastname: Czorlich
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Lehmann
authors.forename: Alexander S
authors.initials: AS
authors.lastname: Spiro
authors.forename: Johannes M
authors.initials: JM
authors.lastname: Rueger
authors.forename: Rolf
authors.initials: R
authors.lastname: Lefering
mesh_terms: D000758:Anesthesia / Q000379:methods*; D000070642:Brain Injuries, Traumatic / Q000503:physiopathology*; D015331:Cohort Studies; D004632:Emergency Medical Services / Q000379:methods*; D005260:Female; D005858:Germany; D015600:Glasgow Coma Scale / Q000706:statistics & numerical data*; D006801:Humans; D007442:Intubation, Intratracheal / Q000379:methods*; D008297:Male; D008875:Middle Aged; D012042:Registries; D012189:Retrospective Studies; D016896:Treatment Outcome; D014947:Wounds and Injuries / Q000503:physiopathology*