Skip to main content Accessibility help

Is Prehospital Endotracheal Intubation Associated with Improved Outcomes In Isolated Severe Head Injury? A Matched Cohort Analysis

  • Efstathios Karamanos (a1), Peep Talving (a1), Dimitra Skiada (a1), Melanie Osby (a1), Kenji Inaba (a1), Lydia Lam (a1), Ozgur Albuz (a1) and Demetrios Demetriades (a1)...



Prehospital endotracheal intubation (ETI) following traumatic brain injury in urban settings is controversial. Studies investigating admission arterial blood gas (ABG) patterns in these instances are scant.


Outcomes in patients subjected to divergent prehospital airway management options following severe head injury were studied.


This was a retrospective propensity-matched study in patients with isolated TBI (head Abbreviated Injury Scale (AIS) ≥ 3) and Glasgow Coma Scale (GCS) score of ≤ 8 admitted to a Level 1 urban trauma center from January 1, 2003 through October 31, 2011. Cases that had prehospital ETI were compared to controls subjected to oxygen by mask in a one to three ratio for demographics, mechanism of injury, tachycardia/hypotension, Injury Severity Score, type of intracranial lesion, and all major surgical interventions. Primary outcome was mortality and secondary outcomes included admission gas profile, in-hospital morbidity, ICU length of stay (ICU LOS) and hospital length of stay (HLOS).


Cases (n = 55) and controls (n = 165) had statistically similar prehospital and in-hospital variables after propensity matching. Mortality was significantly higher for the ETI group (69.1% vs 55.2% respectively, P = .011). There was no difference in pH, base deficit, and pCO2 on admission blood gases; however the ETI group had significantly lower pO2 (187 (SD = 14) vs 213 (SD = 13), P = .034). There was a significantly increased incidence of septic shock in the ETI group. Patients subjected to prehospital ETI had a longer HLOS and ICU LOS.


In isolated severe traumatic brain injury, prehospital endotracheal intubation was associated with significantly higher adjusted mortality rate and worsened admission oxygenation. Further prospective validation of these findings is warranted.

Karamanos E , Talving P , Skiada D , Osby M , Inaba K , Lam L , Albuz O , Demetriades D . Is Prehospital Endotracheal Intubation Associated with Improved Outcomes In Isolated Severe Head Injury? A Matched Cohort Analysis. Prehosp Disaster Med. 2013;28(6):1-5 .


Corresponding author

Correspondence: Efstathios Karamanos, MD University of Southern California Keck School of Medicine Department of Surgery LAC+USC Medical Center Division of Acute Care Surgery 1200 North State Street, Room 6341 Los Angeles, CA 90033 USA E-mail


Hide All
1. Andiressen, TM, Horn, J, Franschman, A, et al. Epidemiology, severity classification, and outcome of moderate and severe traumatic brain injury: a prospective multicenter study. J Neurotrauma. 2011, Oct; 28(10):2019-2031.
2. Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons, et al. Guidelines for the management of severe traumatic brain injury. I. blood pressure and oxygenation. J Neurotrauma. 2007;24(Suppl 1):S7-S13.
3. Enriquez, P, Bullock, R. Molecular and cellular mechanisms in the pathophysiology of severe head injury. Curr Pharm Des. 2004;10(18):2131-2143.
4. Graham, DI, Adams, JH. Ischaemic brain damage in fatal head injuries. Lancet. 1971;1(7693):265-266.
5. Hellewell, SC, Yan, EB, Agyapomaa, DA, Bye, N, Morganti Kossman, MC. Post-traumatic hypoxia exacerbates brain tissue damage: Analysis of axonal injury and glial responses. J Neurotrauma. 2010;27(11):1997-2010.
6. Chesnut, RM, Marshall, LF, Klauber, MR, et al. The role of secondary brain injury in determining outcome from severe head injury. J Trauma. 1993;34(2):216-222.
7. Pigula, FA, Wald, SL, Shackford, SR, Vane, DW. The effect of hypotension and hypoxia on children with severe head injuries. J Pediatr Surg. 1993;28(3):310-314; discussion 315-316.
8. Stocchetti, N, Furlan, A, Volta, F. Hypoxemia and arterial hypotension at the accident scene in head injury. J Trauma. 1996;40(5):764-767.
9. Davis, DP, Koprowicz, KM, Newgard, CD, et al. The relationship between out-of-hospital airway management and outcome among trauma patients with glasgow coma scale scores of 8 or less. Prehosp Emerg Care. 2011;15(2):184-192.
10. Davis, DP, Peay, J, Sise, MJ, et al. Prehospital airway and ventilation management: A trauma score and injury severity score-based analysis. J Trauma. 2010;69(2):294-301.
11. Bauer, K. Prehospital airway management: High tech meets trauma: An air medical perspective. Crit Care Nurs Q. 2012;35(3):281-291.
12. Von Elm, E, Schoettker, P, Henzi, I, et al. Pre-hospital tracheal intubation in patients with traumatic brain injury: Systematic review of current evidence. Br J Anaesth. 2009;103(3):371-386.
13. Murray, JA, Demetriades, D, Berne, TV, et al. Prehospital intubation in patients with severe head injury. J Trauma. 2000;49(6):1065-1070.
14. Helm, M, Hauke, J, Lampl, L. A prospective study of the quality of pre-hospital emergency ventilation in patients with severe head injury. Br J Anaesth. 2002;88(3):345-349.
15. Wang, HE, Peitzman, AB, Cassidy, LD, et al. Out-of-hospital endotracheal intubation and outcome after traumatic brain injury. Ann Emerg Med. 2004;44(5):439-450.
16. Bochicchio, GV, Scalea, TM. Is field intubation useful? Curr Opin Crit Care. 2003;9(6):524-529.
17. Lossius, HM, Sollid, SJ, Rehn, M, Lockey, DJ. Revisiting the value of pre-hospital tracheal intubation: an all time systematic literature review extracting the utstein airway core variables. Crit Care. 2011;15(1):R26.
18. Dupanovic, M, Fox, H, Kovac, A. Management of the airway in multitrauma. Curr Opin Anaesthesiol. 2010;23(2):276-282.
19. Davis, DP. Early ventilation in traumatic brain injury. Resuscitation. 2008;76(3):333-340.



Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed