Isolated traumatic brain injury: Routine intubation for GCS 7 or 8 may be harmful!

J Trauma Acute Care Surg. 2021 Feb 16. doi: 10.1097/TA.0000000000003123. Online ahead of print.

Abstract

Introduction: Despite strong recommendations, there is no direct evidence supporting routine intubation of trauma patients with GCS of 7 or 8. We hypothesized that routine intubation may not be beneficial in isolated blunt head injury.

Methods: Retrospective TQIP study, including adult blunt trauma patients with GCS of 7 or 8 and isolated head injury. Epidemiological and clinical characteristics, neurosurgical procedures, timing of intubation, and outcome variables were collected. The study population was stratified by the intubation procedure: Immediate intubation (≤1 hour of admission), delayed intubation (>1 hour of admission) and no intubation. Multivariable regression analysis was used to determine risk factors for mortality and complications, as well as factors predictive of the decision to intubate.

Results: Of 2,727 patients with GCS 7 or 8 and isolated blunt head trauma, 1,866 (68.4%) patients were intubated within 1 hour of admission (immediate intubation), 223 (8.2%) had an intubation >1 hour of admission (delayed intubation), and 638 (23.4%) patients were not intubated at all. After correcting for age, gender, overall comorbidities, tachycardia, GCS, alcohol, illegal drug use, and head injury severity, immediate intubation was independently associated with higher mortality (OR 1.79, CI 95% 1.31-2.44, p<0.001) and more overall complications (OR 2.46, CI 95% 1.62-3.73, p<0.001). Increasing head AIS, GCS 7, and tachycardia were identified as independent clinical factors associated with the decision to intubate. A policy of intubating all isolated blunt head injury patients ≤45 years with head AIS 5 and GCS 7 would have improved intubation management, with 7 immediate instead of delayed intubations and only three potentially unnecessary intubations.

Conclusion: In patients with GCS of 7 or 8 and isolated head injury, immediate intubation was associated with higher mortality and more overall complications. Intubation management could have been improved by intubating all patients younger than 45 years old with head AIS 5, and a GCS of 7 on admission.

Level of evidence: Therapeutic, level III.