# Possible detrimental effects of postponed intubation during interhospital transfer of severely brain injured patients: retrospective analysis of the Traumaregister DGU®

## TL;DR

This study suggests that delaying intubation during the transfer of severely brain-injured patients may lead to worse outcomes, including higher mortality and complications.

## Contribution

The study provides new evidence on the risks of postponed intubation during interhospital transfers for traumatic brain injury patients.

## Key findings

- Postponed intubation was linked to higher mortality, sepsis, and multiple organ failure rates in patients requiring emergency intubation.
- Age over 70, coagulopathy, and severe head injury were significant predictors of mortality.
- No significant differences were found between spontaneously breathing and already intubated patients at admission.

## Abstract

Prehospitally, the paradigm of obliged intubation in traumatic brain injured (TBI) patients with a reduced Glasgow Coma Scale (GCS) < 9 has been debated. Many patients with severe TBI need interhospital transfer to definitive care, so we sought to elucidate possible disadvantages for patients with a reduced level of consciousness where intubation prior transportation was withheld.

Transferred patients with at least serious blunt injury to the head (Abbreviated Injury ScaleHead ≥3) were analyzed. In depth analysis was conducted in patients with GCS 4–9. We applied multivariate regression analysis to search for relevant variables for mortality differences and scrutinized patients who needed immediate intubation upon arrival in the emergency room (ER ITN). In this context a “postponed” intubation refers to an intubation performed upon arrival at the receiving hospital rather than prior to transfer.

Comparing spontaneously breathing versus already intubated patients (ITN) at admission we did not find statistically significant differences in mortality (33.2% vs. 20.4%; p = 0.067), multiple organ failure (MOF) (37.1% vs. 34%; p = 0.667) or sepsis rates (13.6% vs. 4.2%; p = 0.069). Multiple regression analysis for mortality revealed only age > 70 years, coagulopathy and AISHead ≥ 5 as significantly associated independent variables. But, comparing patients requiring intubation in the emergency room upon admission (ER ITN) to patients already intubated prior transportation (ITN), we detected significant differences in MOF (53.7% vs. 34%; p = 0.025), sepsis (20.5% vs. 4.2%; p = 0.011) and mortality rate (38.1% vs. 20.4%; p = 0.028).

Our results may suggest an inferior outcome when intubation in patients with GCS 4–9 is needed during admission at the receiving hospital. Further research is warranted to scrutinize optimal airway management for interhospital transfer of TBI patients with reduced GCS.