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BJA Advance Access originally published online on July 31, 2009
British Journal of Anaesthesia 2009 103(3):371-386; doi:10.1093/bja/aep202
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 BJA: September 2009
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© The Author [2009]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournal.org

Pre-hospital tracheal intubation in patients with traumatic brain injury: systematic review of current evidence

E. von Elm1,2,*, P. Schoettker3, I. Henzi4, J. Osterwalder5 and B. Walder4

1 German Cochrane Centre, Department of Medical Biometry and Statistics, University Medical Centre Freiburg, Stefan-Meier-Strasse 26, D-79104 Freiburg, Germany
2 Swiss Paraplegia Research, Nottwil, Switzerland
3 Department of Anaesthesiology, University Hospitals of Vaud, Lausanne, Switzerland
4 Division of Anaesthesiology, University Hospitals of Geneva, Geneva, Switzerland
5 Emergency Department, St Gallen Cantonal Hospital, St Gallen, Switzerland

* Corresponding author. E-mail: vonelm{at}cochrane.de

Background: We reviewed the current evidence on the benefit and harm of pre-hospital tracheal intubation and mechanical ventilation after traumatic brain injury (TBI).

Methods: We conducted a systematic literature search up to December 2007 without language restriction to identify interventional and observational studies comparing pre-hospital intubation with other airway management (e.g. bag-valve-mask or oxygen administration) in patients with TBI. Information on study design, population, interventions, and outcomes was abstracted by two investigators and cross-checked by two others. Seventeen studies were included with data for 15 335 patients collected from 1985 to 2004. There were 12 retrospective analyses of trauma registries or hospital databases, three cohort studies, one case–control study, and one controlled trial. Using Brain Trauma Foundation classification of evidence, there were 14 class 3 studies, three class 2 studies, and no class 1 study. Six studies were of adults, five of children, and three of both; age groups were unclear in three studies. Maximum follow-up was up to 6 months or hospital discharge.

Results: In 13 studies, the unadjusted odds ratios (ORs) for an effect of pre-hospital intubation on in-hospital mortality ranged from 0.17 (favouring control interventions) to 2.43 (favouring pre-hospital intubation); adjusted ORs ranged from 0.24 to 1.42. Estimates for functional outcomes after TBI were equivocal. Three studies indicated higher risk of pneumonia associated with pre-hospital (when compared with in-hospital) intubation.

Conclusions: Overall, the available evidence did not support any benefit from pre-hospital intubation and mechanical ventilation after TBI. Additional arguments need to be taken into account, including medical and procedural aspects.

Keywords: airway; brain, injury; complications, intubation tracheal; ventilation, mechanical


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