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Three Part Question

In [Paediatric patients with head injury and needing prehospital airway management] is [endotracheal intubation better than bag and mask ventilation] for [improved survival and neurological outcome]

Clinical Scenario

A 11yr old boy is involved in a pedestrian versus car traffic accident, sustaining head injuries with reduced consciousness. On scene he has a GCS of 6. He is intubated and brought to the major trauma centre emergency department. You wonder whether the evidence supports endotracheal intubation prehospitally for this patient.

Search Strategy

Pubmed database 1966 – 16th May 2018
Medline using OVID interface 1966 – 16th May 2018
Search: ((((((Prehospital OR Pre-hospital)) AND (RSI OR Rapid sequence induction OR intubation)) AND (children OR paediatric)) AND ("brain injury" OR "head injury")))

Search Outcome

Abstracts were read for 36 papers from Pubmed and 117 papers from the OVID interface

8 Papers were considered the most relevant and higher quality so were appraised in full.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Stefab Heschl, May 2018 Australia	Children <14yrs with suspected TBI 106 patients	Observational study with 6 month follow up	Number intubated pre-hospital	87 intubated and 19 BVM. Head AISS similar in both groups	Non-randomised study using registry data. Small sample size so results do not reach significance for all criteria
			ICU and hospital length of stay	ICU and hospital length of stay longer in those not intubated p=0.3
			Functional outcome – Glasgow outcome scale	67% of intubated plus RSI had favourable functional outcome compared to 54% of non-intubated. 53 children at 6 month follow up data and from this group 66% of intubated vs. 17% non-intubated (p=0.06) had a favourable outcome
Sokol, K et al. December 2015 Camp Bastion	Children <18yrs presenting to the camp. Stratified by severity of injury and TBI 766 patients	Retrospective data analysis	Rate of pre-hospital airway interventions	8% of 766 required prehospital intubation	Non-randomised study using pre-existing registry Not just head injuries and primarily penetrating trauma which is more unusual in a civilian setting
			Mortality	In those with severe TBI endtracheal intubations were associated with higher unadjusted mortality (56% vs 20% p <0.01) On multivariate logistic regression model Prehospital intubation remained a strong predictor of mortality (OR 5.9 p = 0.001)
Davis, A 2015 USA	Children <18yrs 75% had head injuries 621 patients	Retrospective data analysis	Mortality	Independent mortality predictors were the BIG score (OR 11, 95% CI 6-25), prior fluid bolus (OR 3, 95% CI 1.3-9), and prior intubation(OR 8, 95% CI 2-40). 23.1% of survivors intubated prior to arrival and 90% of non-survivors intubated prior to arrival. Significance <0.001	Non-randomised study using pre-existing data Study focus was primarily to look at BIG score but does have statistical power for pre-hospital intubation No information on functional outcomes
DiRusso et al. 2005 USA	Children <20yrs with major trauma 50,199 patients	Retrospective database study	Mortality	Unadjusted mortality 38.5% intubated prehospital compared to 13.2% if intubated at trauma centre. Stratified by degree of head injury statistically significant difference in mortality between in-field or trauma centre intubation. Consistent across all degrees of injury. Independent strong negative predictor of survival despite adjustment for severity of injury	Non-randomised study from pre-existing data Results for all injuries but some stratification by severity of injury and degree of head injury. Functional outcome measured by discharge to home rather than validated score
			Functional outcome – discharged to home	Percentage of patients discharged home was reduced in the in-field intubation group across all degrees of head injury. Only statistically significant in moderate and mild head injury
Davis, D et al. 2005 USA	All ages 13,625 patients	Retrospective database study	Mortality	Prehospital intubation is associated with a decrease in survival among all patients with moderate-to-severe TBI. More critically injured patients may benefit from prehospital intubation but may be difficult to identify prospectively. (OR 0.36 p<0.001) Even when adjusting for age invasive prehospital airway management was still associated with increased mortality	Non-randomised study from pre-existing database. Some age adjustment done grossly but not powered for children No information for functional outcomes
Cooper et al. 2001 USA	Children <18yrs with severe head injury 578 patients	Retrospective database study	Mortality	Mortality was virtually identical between ETI and BVM at 48% (p <0.5)	Non-randomised study from pre-existing database Functional outcome score used only valid for children >7yrs (183 patients)
			Injury complications	Injury complications occurred less often in ETI at 58% vs. 71% for BVM
			Functional outcome	No difference in functional outcomes using Functional Independent Measures (FIM) scores in those >7yrs
Gausche et al. 2000 USA	Children <12yrs requiring airway intervention 830 patients	Controlled trial with treatment allocation by alternate day	Mortality	No significant difference in survival overall between BVM and ETI group (OR 0.82; 95% CI, 0.61-1.11) For head injury survival was 32% BVM vs 25% ETI (OR 0.71 95% CI 0.23-2.19)	Clinical controlled trial Few cases for head injury as the main injury Functional outcome based on modified pediatric cerebral performance category scale
			Neurological outcome	No significant difference overall in good neurological outcome (OR 0.87; 95% CI, 0.62-1.22) For head injury alone good neurological outcome in 8% BVM vs. 11% ETI (OR 1.44; 95% CI, 0.24-8.52)
Suominen et al. 2000 Finland	Children <18yrs with severe blunt head injury 176 patients	Retrospective data analysis	Mortality	Survival was better for children intubated in the field compared to non-trauma centre EDs (p=0.05) Overall higher mortality for children who underwent in field or non-trauma centre intubation	Non-randomised study from pre-existing database. Only 176 children identified for the study No functional outcome data

Comment(s)

There are quite a lot of studies focusing on the effect of prehospital airway management but only a few focus specifically on the paediatric age group. Of these studies, the clear majority are retrospective analysis of registry data with one clinical trial which contained only a small number of children with head injury as the primary injury. Most of the studies found an association with increased mortality in patients intubated in the pre-hospital environment even with stratification for severity of injury. The reasons could be multifactorial including varying paramedic experience in different countries, insufficient pre-oxygenation, hyperoxia or increased transit times. The retrospective studies share the same disadvantages including reliance on accurate record keeping by the prehospital clinicians which is subject to recall bias. Additionally, some studies used unadjusted data so the results are more likely to be confounded by other factors and less comparable between the studies. Intubation is often the first or last resort for airway management and many studies did not differentiate between those where intubation was used first line and those who resorted to intubation after failed LMA or I-Gel management when considering outcome data. Few studies had long term neurological outcome data and used a variety of rating scales with one scale was only validated for children aged 7 and over.

Clinical Bottom Line

Pre-hospital endotracheal intubation in children with head injury is associated with increased mortality but more controlled trials and studies including outcomes need to be completed to ascertain the long-term consequences.

References

1. Heschl, Stefan et al. Efficacy of pre-hospital rapid sequence intubation in paediatric traumatic brain injury: A 9-year observational study. Injury Volume 49 , Issue 5 , 916 – 920
2. Sokol, K et al. Prehospital interventions in severely injured pediatric patients: Rethinking the ABCs. Journal of Trauma and acute Care surgery December 2015; Volume 79 – issue 6, 983-990
3. Davis, Adrienne et al. The BIG score and prediction of mortality in Pediatric blunt trauma. The Journal of Pediatrics 2015; Volume 167, Issue 3, 593-598
4. DiRusso, S et al. Intubation of Pediatric trauma patients in the field: predictor of negative outcome despite risk stratification. Journal of Trauma and Acute Care surgery 2005; Volume 59 – issue 1, 84-91
5. Davis, D et al. The Impact of Prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injury. The Journal of trauma 2005; Volume 58 – Issue 5, 933-939
6. Cooper et al. Prehospital endotracheal intubation for severe head injury in children: a reappraisal. Seminars in pediatric surgery 2001; Volume 10 – issue 1, 3-6
7. Gausche, M et al. Effect of Out-of-hospital pediatric endotracheal intubation on survival and neurological outcome. A controlled clinical trial. JAMA 2000; Volume 283 – issue 6, 783-790
8. Suominen et al. Intubation and survival in severe paediatric blunt head injury European journal of emergency medicine 2000; Volume 7 – issue 1, 3-6