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A systematic review of the timing of intubation in patients with traumatic brain injury: pre-hospital versus in-hospital intubation

Abstract

Purpose

The objective of this systematic review was to examine current evidence on the risks versus benefit of pre-hospital intubation when compared with in-hospital intubation in adult patients with traumatic brain injuries.

Methods

We conducted electronic searches of PubMed, Medline, Embase, CIANHL and the Cochrane library up to March 2021. Data extracted compared mortality, length of hospital and intensive care stay, pneumonia and functional outcomes in traumatic brain injured patients undergoing pre-hospital intubation versus in-hospital intubation. The risk of bias was assessed using the Grading of Recommendations Assessment, Development and Evaluation.

Results

Ten studies including 25,766 patients were analysed. Seven were retrospective studies, two prospective cohort studies and one randomised control study. The mean mortality rate in patients who underwent pre-hospital intubation was 44.5% and 31.98% for in-hospital intubation. The odds ratio for an effect of pre-hospital intubation on mortality ranged from 0.31 (favouring in-hospital intubation) to 3.99 (favouring pre-hospital). The overall quality of evidence is low; however, the only randomised control study showed an improved functional outcome for pre-hospital intubation at 6 months.

Conclusions

The existing evidence does not support widespread pre-hospital intubation in all traumatic brain injured patients. This does not, however, contradict the need for the intervention when there is severe airway compromise; instead, it must be assessed by experienced personnel if a time critical transfer to hospital is more advantageous. Favourable neurological outcomes highlighted by the randomised control trial favours pre-hospital intubation, but further research is required in this field.

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Funding

No funding, grants, or support was received to conduct this review.

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Authors

Corresponding author

Correspondence to Archchana Radhakrishnan.

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Conflict of interest

The authors have no relevant financial or non-financial interests to disclose and have no competing interests to declare that are relevant to the content of this article.

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Ethics was not required for this review.

Appendices

Appendix

Search strategy file 1

HDAS search

1st search

“Traumatic Brain Injury”

or

“Head Injury”

or

“Neurotrauma”

2nd search

“Pre-hospital Intubation”

or

“In-hospital intubation”

or

“Endotracheal intubation”

or

“Early intubation”

or

“Emergency intubation”

Combine search one and two

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Cite this article

Radhakrishnan, A., McCahill, C., Atwal, R.S. et al. A systematic review of the timing of intubation in patients with traumatic brain injury: pre-hospital versus in-hospital intubation. Eur J Trauma Emerg Surg (2022). https://doi.org/10.1007/s00068-022-02048-0

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  • DOI: https://doi.org/10.1007/s00068-022-02048-0

Keywords

  • Traumatic brain injury
  • Endotracheal intubation
  • Pre-hospital intubation
  • Head injury