Danny Epstein1, Stav Rakedzon2, Ben Kaplan3, Hen Ben Lulu4, Jacob Chen5, Nir Samuel6, Ari M Lipsky7, Asaf Miller8, Hany Bahouth9, Aeyal Raz10. 1. Critical Care Division, Rambam Health Care Campus, HaAliya HaShniya St 8, Haifa 3109601, Israel. Electronic address: danyep@gmail.com. 2. Department of Internal Medicine B, Rambam Health Care Campus, HaAliya HaShniya St 8, Haifa 3109601, Israel. 3. Ruth and Bruce Rappaport Faculty of Medicine, Technion, Efron St 1, Haifa 3109601, Israel. 4. Trauma and Emergency Surgery, Rambam Health Care Campus, HaAliya HaShniya St 8, Haifa 3109601, Israel. 5. Hospital Management, Meir Medical Center, Tchernichovsky St 59, Kefar Saba 4428164, Israel; Sackler Faculty of Medicine, Tel Aviv University, Klachkin St 35, Tel Aviv 6997801, Israel. 6. Pediatric Emergency Department, Schneider Children's Medical Center, Kaplan St 14, Petah Tikva 4920235, Israel. 7. Emergency Department, Emek Medical Center, Yitshak Rabin Boulevard 21, Afula 1834111, Israel. 8. Medical Intensive Care Unit, Rambam Health Care Campus, HaAliya HaShniya St 8, Haifa 3109601, Israel. 9. Ruth and Bruce Rappaport Faculty of Medicine, Technion, Efron St 1, Haifa 3109601, Israel; Trauma and Emergency Surgery, Rambam Health Care Campus, HaAliya HaShniya St 8, Haifa 3109601, Israel. 10. Ruth and Bruce Rappaport Faculty of Medicine, Technion, Efron St 1, Haifa 3109601, Israel; Department of Anesthesiology, Rambam Health Care Campus, HaAliya HaShniya St 8, Haifa 3109601, Israel.
Abstract
OBJECTIVE: Current guidelines advocate prehospital endotracheal intubation (ETI) in patients with suspected severe head injury and impaired level of consciousness. However, the ability to identify patients with traumatic brain injury (TBI) in the prehospital setting is limited and prehospital ETI carries a high complication rate. We investigated the prevalence of significant TBI among patients intubated in the field for that reason. METHODS: Data were retrospectively collected from emergency medical services and hospital records of trauma patients for whom prehospital ETI was attempted and who were transferred to Rambam Health Care Campus, Israel. The indication for ETI was extracted. The primary outcome was significant TBI (clinical or radiographic) among patients intubated due to suspected severe head trauma. RESULTS: In 57.3% (379/662) of the trauma patients, ETI was attempted due to impaired consciousness. 349 patients were included in the final analysis: 82.8% were male, the median age was 34 years (IQR 23.0-57.3), and 95.7% suffered blunt trauma. 253 patients (72.5%) had significant TBI. In a multivariable analysis, Glasgow Coma Scale>8 and alcohol intoxication were associated with a lower risk of TBI with OR of 0.26 (95% CI 0.13-0.51, p < 0.001) and 0.16 (95% CI 0.06-0.46, p < 0.001), respectively. CONCLUSION: Altered mental status in the setting of trauma is a major reason for prehospital ETI. Although most of these patients had TBI, one in four of them did not suffer a significant TBI. Patients with a higher field GCS and those suffering from intoxication have a higher risk of misdiagnosis. Future studies should explore better tools for prehospital assessment of TBI and ways to better define and characterize patients who may benefit from early ETI.
OBJECTIVE: Current guidelines advocate prehospital endotracheal intubation (ETI) in patients with suspected severe head injury and impaired level of consciousness. However, the ability to identify patients with traumatic brain injury (TBI) in the prehospital setting is limited and prehospital ETI carries a high complication rate. We investigated the prevalence of significant TBI among patients intubated in the field for that reason. METHODS: Data were retrospectively collected from emergency medical services and hospital records of trauma patients for whom prehospital ETI was attempted and who were transferred to Rambam Health Care Campus, Israel. The indication for ETI was extracted. The primary outcome was significant TBI (clinical or radiographic) among patients intubated due to suspected severe head trauma. RESULTS: In 57.3% (379/662) of the trauma patients, ETI was attempted due to impaired consciousness. 349 patients were included in the final analysis: 82.8% were male, the median age was 34 years (IQR 23.0-57.3), and 95.7% suffered blunt trauma. 253 patients (72.5%) had significant TBI. In a multivariable analysis, Glasgow Coma Scale>8 and alcohol intoxication were associated with a lower risk of TBI with OR of 0.26 (95% CI 0.13-0.51, p < 0.001) and 0.16 (95% CI 0.06-0.46, p < 0.001), respectively. CONCLUSION: Altered mental status in the setting of trauma is a major reason for prehospital ETI. Although most of these patients had TBI, one in four of them did not suffer a significant TBI. Patients with a higher field GCS and those suffering from intoxication have a higher risk of misdiagnosis. Future studies should explore better tools for prehospital assessment of TBI and ways to better define and characterize patients who may benefit from early ETI.
Authors: Nir Samuel; Yoav Hoffmann; Stav Rakedzon; Ari M Lipsky; Aeyal Raz; Hen Ben Lulu; Hany Bahouth; Danny Epstein Journal: Eur J Trauma Emerg Surg Date: 2022-05-07 Impact factor: 3.693