Wang Henry E, Peitzman Andrew B, Cassidy Laura D, Adelson P David, Yealy Donald M
Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA.
Ann Emerg Med. 2004 Nov;44(5):439-50. doi: 10.1016/j.annemergmed.2004.04.008.
Previous studies disagree about the effect of out-of-hospital endotracheal intubation on traumatic brain injury. This study compares the effects of out-of-hospital endotracheal intubation versus emergency department (ED) endotracheal intubation on mortality and neurologic and functional outcome after severe traumatic brain injury.
From the 2000 to 2002 Pennsylvania Trauma Outcome Study (a registry of all patients treated at trauma centers in the Commonwealth of Pennsylvania), adult patients with head/neck Abbreviated Injury Scale score of 3 or greater and undergoing out-of-hospital endotracheal intubation or ED endotracheal intubation were included. Transferred patients were excluded. The primary outcome was death (on hospital discharge). The secondary outcomes were neurologic (good versus poor, inferred from discharge to home versus long-term care facility) and functional outcome (determined from a Functional Impairment Score). The key exposure was endotracheal intubation (out-of-hospital endotracheal intubation versus ED endotracheal intubation). Using multivariate logistic regression, odds estimates for out-of-hospital endotracheal intubation were adjusted using age, sex, head/neck Abbreviated Injury Scale score, Injury Severity Score, mechanism of injury (penetrating versus blunt), admission systolic blood pressure, mode of transport (ground only versus helicopter or helicopter + ground), and the use of out-of-hospital neuromuscular blocking agents. A propensity score adjustment accounted for the potential effects of preexisting conditions, inhospital complications, and social factors (drug and alcohol use, race, and insurance coverage).
There were 4,098 patients with head/neck Abbreviated Injury Scale score of 3 or greater who received either out-of-hospital endotracheal intubation (n=1,797, 43.9%) or ED endotracheal intubation (n=2,301, 56.1%). Adjusted odds of death were higher for out-of-hospital endotracheal intubation than ED endotracheal intubation (odds ratio [OR] 3.99; 95% confidence interval [CI] 3.21 to 4.93). Out-of-hospital endotracheal intubation was associated with an increased adjusted odds of poor neurologic outcome (OR 1.61; 95% CI 1.15 to 2.26), moderate or severe functional impairment (Functional Impairment Score 6 to 15; OR 1.92; 95% CI 1.40 to 2.64), and severe functional impairment (Functional Impairment Score 11 to 15; OR 1.80; 95% CI 1.29 to 2.52).
Out-of-hospital endotracheal intubation was associated with adverse outcomes after severe traumatic brain injury. The implications for current clinical care remain undefined.
以往的研究对于院外气管插管对创伤性脑损伤的影响存在分歧。本研究比较了院外气管插管与急诊科气管插管对严重创伤性脑损伤后死亡率、神经及功能预后的影响。
从2000年至2002年宾夕法尼亚创伤结局研究（宾夕法尼亚州所有在创伤中心接受治疗患者的登记资料）中，纳入头部/颈部简明损伤定级标准（Abbreviated Injury Scale）评分3分或更高且接受院外气管插管或急诊科气管插管的成年患者。转诊患者被排除。主要结局为死亡（出院时）。次要结局为神经预后（良好与不良，根据出院回家与入住长期护理机构推断）及功能预后（由功能障碍评分确定）。关键暴露因素为气管插管（院外气管插管与急诊科气管插管）。使用多因素逻辑回归分析，采用年龄、性别、头部/颈部简明损伤定级标准评分、损伤严重程度评分、损伤机制（穿透伤与钝器伤）、入院收缩压、转运方式（仅地面转运与直升机或直升机 + 地面转运）及院外神经肌肉阻滞剂的使用情况对院外气管插管的比值比进行校正。倾向评分调整考虑了既往疾病、院内并发症及社会因素（药物和酒精使用、种族及保险覆盖情况）的潜在影响。
共有4098例头部/颈部简明损伤定级标准评分3分或更高的患者，其中1797例（43.9%）接受院外气管插管，2301例（56.1%）接受急诊科气管插管。院外气管插管组校正后的死亡几率高于急诊科气管插管组（比值比[OR] 3.99；95%置信区间[CI] 3.21至4.93）。院外气管插管与神经预后不良校正后的几率增加相关（OR 1.61；95% CI 1.15至2.26），与中度或重度功能障碍（功能障碍评分6至15；OR 1.92；95% CI 1.40至2.64）及重度功能障碍（功能障碍评分11至15；OR 1.80；95% CI 1.29至2.52）相关。
院外气管插管与严重创伤性脑损伤后的不良结局相关。对当前临床护理的影响尚不明确。
