Effects of pre-hospital endotracheal intubation on mortality in children with severe traumatic brain injury: a systematic review. 
Juliette J.E. Albersen1, Sebastiaan M. Bossers1, Christa Boer1, Stephan A. Loer1, Lothar A. Schwarte1,2, Patrick Schober1,2

1 Department of Anaesthesiology, VU University Medical Centre, Amsterdam, The Netherlands,
2 Helicopter Emergency Medical Service "Lifeliner 1", VU University Medical Centre, Amsterdam, The
Netherlands

Abstract

Background and goal of study: Hypoxemia and hypercapnia are associated with secondary brain injury and poor outcome following traumatic brain injury (TBI). Therefore, routine prehospital endotracheal intubation has been widely advocated in patients with severe TBI. However, in the paediatric patient population, effects of prehospital intubation on outcome are unclear. Prehospital healthcare providers often have limited experience in intubating children, and adverse effects of poorly performed intubation (e.g., wrong choice and dose of medication, prolonged and failed attempts, hyper- or hypoventilation after intubation) may outweigh potential benefits. We therefore performed a systematic review and meta-analysis to determine the effects of pre-hospital endotracheal intubation on mortality in this patient population.

Material and methods: PubMed, Embase and Web of Science were searched using a predefined search-strategy up to June 2016. Studies comparing effects of prehospital intubation versus non-invasive airway management on mortality in paediatric patients (<18 years) with severe TBI (Glasgow Coma Scale ≤8 or Head Abbreviated Injury Score ≥3) were eligible for inclusion. Abstracts were screened, and the full-text of all potentially eligible articles were retrieved. Random-effects meta-analysis (STATA 13) was used to pool results across studies. 

Results and discussion: The search yielded 211 studies. Six studies with a total number of 2094 patients were included in the systematic review. One randomized controlled trial did not find a significant difference in survival between intubated and non-intubated patients. (OR 0.8; 95% CI 0.6-1.1). The other studies were observational studies. Pooled results suggest a significant increase in mortality in children with TBI undergoing prehospital intubation (OR 2.5 95% CI 1.2-5.2). However, limited comparability of the intervention and control groups in the observational studies (e.g., differences in injury severity) and a high heterogeneity across studies (I2 = 94%) preclude a general conclusion on the effects of prehospital intubation on mortality. 

Conclusion: Current literature does not provide any evidence for beneficial effects of pre-hospital intubation on mortality. In contrast, limited evidence suggests that prehospital intubation might even be detrimental for outcome. Additional high quality studies are warranted to address the relationship between prehospital intubation and outcome in paediatric patients.