Should trauma patients with a Glasgow Coma Scale score of 3 be intubated prior to hospital arrival?

Previous studies of heterogeneous populations (Glasgow Coma Scale (GCS) scores<9) suggest that endotracheal intubation of trauma patients prior to hospital arrival (i.e., prehospital intubated) is associated with an increased mortality compared to those patients not intubated in the prehospital setting. Deeply comatose patients (GCS=3) represent a unique population of severely traumatized patients and may benefit from intubation in the prehospital setting. The objective of this study was to compare mortality rates of severely comatose patients (scene GCS=3) with prehospital endotracheal intubation to those intubated at the hospital.

Using the National Trauma Data Bank (V. 6.2), the following variables were analyzed retrospectively: (1) age; (2) injury type (blunt or penetrating); (3) Injury Severity Score (ISS); (4) scene GCS=3 (scored prior to intubation/without sedation); (5) emergency department GCS score; (6) arrival emergency department intubation status; (7) first systolic blood pressure in the emergency department (>0); (8) discharge status (alive or dead); (9) Abbreviated Injury Scale Score (AIS); and (10) AIS body region.

Of the 10,948 patients analyzed, 23% (2,491/10,948) were endotracheally intubated in a prehospital setting. Mortality rate for those hospital intubated was 35% vs. 62% for those with prehospital intubation (p<0.0001); mean ISS scores 24.2±16.0 vs. 31.6±16.2, respectively (p<0.0001). Using logistic regression, controlling for first systolic blood pressure, ISS, emergency department GCS, age, and type of trauma, those with prehospital intubation were more likely to die (OR=1.9, 95% CI=1.7-2.2). For patients with only head AIS scores (no other body region injury, n=1,504), logistic regression (controlling for all other variables) indicated that those with prehospital intubation were still more likely to die (OR=2.0. 95% CI=1.4-2.9).

Prehospital endotracheal intubation is associated with an increased mortality in completely comatose trauma patients (GCS = 3). Although the exact reasons for this remain unclear, these results support other studies and suggest the need for future research and re-appraisal of current policies for prehospital intubation in these severely traumatized patients.