Experience in Prehospital Endotracheal Intubation Significantly Influences Mortality of Patients with Severe Traumatic Brain Injury: A Systematic Review and Meta-Analysis.

Sebastiaan M Bossers,Christa Boer,Lothar A Schwarte,Patrick Schober,Stephan A Loer,Jos W R Twisk,Firas H Kobeissy

doi:10.1371/journal.pone.0141034

Sebastiaan M Bossers, Christa Boer + Show 5 more

Open Access

https://doi.org/10.1371/journal.pone.0141034

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Journal: PloS one	Publication Date: Oct 23, 2015
Citations: 105	License type: CC BY 4.0

Affiliation: Amsterdam UMC Location VUmc

Abstract

BackgroundPatients with severe traumatic brain injury (TBI) are at high risk for airway obstruction and hypoxia at the accident scene, and routine prehospital endotracheal intubation has been widely advocated. However, the effects on outcome are unclear. We therefore aim to determine effects of prehospital intubation on mortality and hypothesize that such effects may depend on the emergency medical service providers’ skill and experience in performing this intervention.Methods and FindingsPubMed, Embase and Web of Science were searched without restrictions up to July 2015. Studies comparing effects of prehospital intubation versus non-invasive airway management on mortality in non-paediatric patients with severe TBI were selected for the systematic review. Results were pooled across a subset of studies that met predefined quality criteria. Random effects meta-analysis, stratified by experience, was used to obtain pooled estimates of the effect of prehospital intubation on mortality. Meta-regression was used to formally assess differences between experience groups. Mortality was the main outcome measure, and odds ratios refer to the odds of mortality in patients undergoing prehospital intubation versus odds of mortality in patients who are not intubated in the field. The study was registered at the International Prospective Register of Systematic Reviews (PROSPERO) with number CRD42014015506. The search provided 733 studies, of which 6 studies including data from 4772 patients met inclusion and quality criteria for the meta-analysis. Prehospital intubation by providers with limited experience was associated with an approximately twofold increase in the odds of mortality (OR 2.33, 95% CI 1.61 to 3.38, p<0.001). In contrast, there was no evidence for higher mortality in patients who were intubated by providers with extended level of training (OR 0.75, 95% CI 0.52 to 1.08, p = 0.126). Meta-regression confirmed that experience is a significant predictor of mortality (p = 0.009).ConclusionsEffects of prehospital endotracheal intubation depend on the experience of prehospital healthcare providers. Intubation by paramedics who are not well skilled to do so markedly increases mortality, suggesting that routine prehospital intubation of TBI patients should be abandoned in emergency medical services in which providers do not have ample training, skill and experience in performing this intervention.

Highlights

Severe traumatic brain injury (TBI) is a leading cause of death and morbidity in the first decades of life, with a tremendous burden on the society due to high costs of care and loss of productive life years [1,2,3,4,5,6,7]
Effects of prehospital endotracheal intubation depend on the experience of prehospital healthcare providers
Intubation by paramedics who are not well skilled to do so markedly increases mortality, suggesting that routine prehospital intubation of TBI patients should be abandoned in emergency medical services in which providers do not have ample training, skill and experience in performing this intervention

Summary

Introduction

Severe traumatic brain injury (TBI) is a leading cause of death and morbidity in the first decades of life, with a tremendous burden on the society due to high costs of care and loss of productive life years [1,2,3,4,5,6,7]. Airway obstruction is common at the accident scene in patients with severe TBI [10, 11], and resulting hypoxaemia and hypercapnia are known to trigger secondary injuries that adversely affect outcome [12, 13]. Patients with severe traumatic brain injury (TBI) are at high risk for airway obstruction and hypoxia at the accident scene, and routine prehospital endotracheal intubation has been widely advocated. We aim to determine effects of prehospital intubation on mortality and hypothesize that such effects may depend on the emergency medical service providers’ skill and experience in performing this intervention

Methods

Results

Conclusion