A Systematic Review And Meta-analysis Comparing Mortality In Pre-hospital Tracheal Intubation To Emergency Department Intubation In Trauma Patients

Background: Pre-hospital endotracheal intubation is frequently used for trauma patients in many emergency medical systems.Despite a wide range of publications in the field,it is debated whether the intervention is associated with a favourable outcome,when compared to more conservative airway measures.Methods: A systematic literature search was conducted to identify interventional and observational studies where the mortality rates of adult trauma patients undergoing pre-hospital endotracheal intubation were compared to those undergoing emergency department intubation.Results: Twenty-one studies examining 35,838 patients were included.The median mortality rate in patients undergoing pre-hospital intubation was 48%(range 8–94%),compared to 29%(range 6 – 67%)in patients undergoing intubation in the emergency department.Odds ratios were in favour of emergency department intubation both in crude and adjusted mortality,with2.56(95% CI: 2.06,3.18)and 2.59(95% CI: 1.97,3.39),respectively.The overall quality of evidence is very low.Twelve of the twenty-one studies found a significantly higher mortality rate after pre-hospital intubation,seven found no significant differences,one found a positive effect,and for one study an analysis of the mortality rate was beyond the scope of the article.Conclusions: The rationale for wide and unspecific indicationsfor pre-hospital intubation seems to lack support in the literature,despite several publications involving a relatively large number of patients.Pre-hospital intubation is a complex intervention where guidelines and research findings should be approached cautiously.The association between pre-hospital intubation and a higher mortality rate does not necessarily contradict the importance of the intervention,but it does call for a thorough investigation by clinicians and researchers into possible causes for this finding.