J. S. Hatchimonji1, R. P. Dumas2, E. J. Kaufman1, D. Scantling1, J. B. Stoecker1, D. N. Holena1 1Hospital Of The University Of Pennsylvania,Philadelphia, PA, USA 2University Of Texas Southwestern Medical Center,Dallas, TX, USA
Introduction: The American College of Surgeons’ Advanced Trauma Life Support curriculum recommends that patients with a Glasgow Coma Scale (GCS) score of 8 or lower be intubated for airway protection. However, there is no specific evidence supporting this GCS cutoff and unnecessary mechanical ventilation can lead to complications. We investigated the effect of intubation in trauma patients with a GCS between 6 and 8, with the hypothesis that intubation would increase mortality and length of stay.
Methods: We included patients aged 16 years or older with GCS 6-8 from the 2016 National Trauma Data Bank, excluding transfers, patients intubated in the field, patients dead on arrival, and patients with an advanced directive limiting care. Patients were identified as having undergone intubation if they had an ICD-9 or -10 code for intubation timestamped within an hour of arrival. Inverse probability weighted regression (IPW) was used to control for injury severity and patient characteristics. Missing values were managed with multiple imputation. The primary outcome was mortality. Stratified analysis was performed to investigate the effect in patients with and without head injuries (abbreviated injury scale [AIS] for head 1-6 vs. 0). Secondary outcomes were intensive care unit length of stay (ICU LOS) and total LOS.
Results: Among 6,676 patients with a GCS between 6 and 8, 4,078 were intubated within 1 hour of presentation. Characteristics of the cohort are shown in the table. The overall raw mortality rate was 15.1%. IPW adjusted logistic regression revealed an increase in mortality associated with intubation (OR 1.05, 95% CI 1.03, 1.06). Results were similar in an analysis stratified by head injury (head injured: OR 1.04, 95% CI 1.02, 1.06; non-head injured: OR 1.06, 95% CI 1.03, 1.10). Among the 5,742 patients admitted to the ICU in this cohort, IPW adjusted linear regression models showed a 14% increase in ICU length of stay (95% CI 8-19%), or an increase in the mean of 4.8 days to 5.5 days. A similar analysis utilizing the entire cohort resulted in 27% increase in overall length of stay (95% CI 20-34%) in intubated patients, or an increase in mean LOS from 6.0 days to 7.6 days.
Conclusion: Among patients with GCS of 6 to 8 who were not intubated in the field, intubation on arrival was not associated with a mortality benefit and in fact may be associated with increased mortality. Intubation was associated with longer ICU and overall length of stay.
