Observed versus expected mortality in pediatric patients intubated in the field with Glasgow Coma Scale scores < 9

  • Pedram EmamiEmail author
  • Patrick Czorlich
  • Friederike S. Fritzsche
  • Manfred Westphal
  • Johannes M. Rueger
  • Rolf Lefering
  • Michael Hoffmann
  • TraumaRegister DGU® of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie; DGU)
Original Article



A Glasgow Coma Scale (GCS) score of 8 or less in patients suffering from severe traumatic brain injury (TBI) represents a decision-making marker in terms of intubation. This study evaluated the impact of prehospital intubation on the mortality of these TBI cases among different age groups.


This study included the data from patients predominantly suffering from severe TBI [Abbreviated Injury Scale (AIS) of the head ≥ 3, GCS score < 9, Injury Severity Score (ISS) > 9] who were registered in TraumaRegister DGU® from 2002 to 2013. An age-related analysis of five subgroups was performed (1–6, 7–15, 16–55, 56–79, and ≥ 80 years old). The observed and expected mortality were matched according to the Revised Injury Severity Classification, version II.


A total of 21,242 patients were included. More often, the intubated patients were severely injured when compared to the non-intubated patients (median ISS 29, IQR 22–41 vs. 24, IQR 16–29, respectively), with an associated higher mortality (42.2% vs. 30.0%, respectively). When compared to the calculated expected mortality, the observed mortality was significantly higher among the intubated patients within the youngest subgroup (42.2% vs. 33.4%, respectively; p = 0.03).


The observed mortality in the intubated children 1–6 years old suffering from severe TBI seemed to be higher than expected. Whether or not a GCS score of 8 or less is the only reliable criterion for intubation in this age group should be investigated in further trials.


Glasgow Coma Scale Intubation Pediatric Prehospital Traumatic brain injury 


Compliance with ethical standards

Conflict of interest

Rolf Lefering’s Institute (IFOM) has a service agreement with the AUC GmbH who is the owner of the TraumaRegister DGU. This includes support in data analysis for scientific publications. All other authors declare that they have no conflict of interest.


  1. 1.
    Bernard SA, Nguyen V, Cameron P, Masci K, Fitzgerald M, Cooper DJ, et al. Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury: a randomized controlled trial. Ann Surg. 2010;252(6):959–65.CrossRefGoogle Scholar
  2. 2.
    Boer C, Franschman G, Loer SA. Prehospital management of severe traumatic brain injury: concepts and ongoing controversies. Curr Opin Anesthesiol 2012;25:556–62.CrossRefGoogle Scholar
  3. 3.
    Davis DP, Peay J, Sise MJ, Kennedy F, Simon F, Tominaga G, et al. Prehospital airway and ventilation management: a trauma score and injury severity score-based analysis. J Trauma 2010;69(2):294–301.CrossRefGoogle Scholar
  4. 4.
    AWMF (Association of the Scientific Medical Societies in Germany). Accessed 23 Nov 2017.
  5. 5.
    Maegele M. Prehospital care for multiple trauma patients in Germany. Chin J Traumatol. 2015;18(3):125–34.CrossRefGoogle Scholar
  6. 6.
    Haltmeier T, Benjamin E, Siboni S, Dilektasli E, Inaba K, Demetriades D. Prehospital intubation for isolated severe blunt traumatic brain injury: worse outcomes and higher mortality. Eur J Trauma Emerg Surg 2017;43(6)731–739.CrossRefGoogle Scholar
  7. 7.
    Dumont TM, Visioni AJ, Rughani AI, Tranmer BI, Crookes B. Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortality. J Neurotrauma. 2010;27(7):1233–41.CrossRefGoogle Scholar
  8. 8.
    Hoffmann M, Czorlich P, Lehmann W, Spiro AS, Rueger JM, Lefering R, et al. The impact of prehospital intubation with and without sedation on outcome in trauma patients with a GCS of 8 or less. J Neurosurg Anesthesiol. 2016;29:161.CrossRefGoogle Scholar
  9. 9.
    Bieler D, Franke A, Lefering R, Hentsch S, Willms A, Kulla M, et al. Does the presence of an emergency physician influence pre-hospital time, pre-hospital interventions and the mortality of severely injured patients? A matched-pair analysis based on the trauma registry of the German Trauma Society (TraumaRegister DGU®). Injury 2017;48(1):32–40CrossRefGoogle Scholar
  10. 10.
    Garner AA, Mann KP, Fearnside M, Poynter E, Gebski V. The head injury retrieval trial (HIRT): a single-centre randomised controlled trial of physician prehospital management of severe blunt head injury compared with management by paramedics only. Emerg Med J 2015;32(11):869–875.CrossRefGoogle Scholar
  11. 11.
    Gausche M, Lewis RJ, Stratton SJ, Haynes BE, Gunter CS, Goodrich SM, et al. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial. JAMA. 2000;283(6):783–790CrossRefGoogle Scholar
  12. 12.
    Lefering R, Huber-Wagner S, Nienaber U, Maegele M, Bouillon B. Update of the trauma risk adjustment model of the TraumaRegister DGU: the revised injury severity classification, version II. Crit Care. 2014;18:476. Scholar
  13. 13.
    Lichte P, Andruszkow H, Kappe M, Horst K, Pishnamaz M, Hildebrand F, et al. Increased in-hospital mortality following severe head injury in young children: results from a nationwide trauma registry. Eur J Med Res 2015;20(1):65CrossRefGoogle Scholar
  14. 14.
    Elm von E, Schoettker P, Henzi I, Osterwalder J, Walder B. Pre-hospital tracheal intubation in patients with traumatic brain injury: systematic review of current evidence. Br J Anaesth 2009;103(3):371–386CrossRefGoogle Scholar
  15. 15.
    Wang HE, Peitzman AB, Cassidy LD, Adelson PD, Yealy DM. Out-of-hospital endotracheal intubation and outcome after traumatic brain injury. Ann Emerg Med 2004;44(5):439–50.CrossRefGoogle Scholar
  16. 16.
    Karamanos E, Talving P, Skiada D, Osby M, Inaba K, Lam L, et al. Is prehospital endotracheal intubation associated with improved outcomes in isolated severe head injury? A matched cohort analysis. Prehosp Disaster Med 2014;29(1):32–36.CrossRefGoogle Scholar
  17. 17.
    Bossers SM, Schwarte LA, Loer SA, Twisk JWR, Boer C, Schober P. Experience in prehospital endotracheal intubation significantly influences mortality of patients with severe traumatic brain injury: a systematic review and meta-analysis. PLoS One 2015;10(10):e0141034.CrossRefGoogle Scholar
  18. 18.
    Helm M, Hauke J, Lampl L. A prospective study of the quality of pre-hospital emergency ventilation in patients with severe head injury. Br J Anaesth 2002;88(3):345–9.CrossRefGoogle Scholar
  19. 19.
    Rognås L, Hansen TM, Kirkegaard H, Tønnesen E. Anaesthesiologist-provided prehospital airway management in patients with traumatic brain injury: an observational study. Eur J Emerg Med 2014;21(6):418–23CrossRefGoogle Scholar
  20. 20.
    Sokol KK, Black GE, Azarow KS, Long W, Martin MJ, Eckert MJ. Prehospital interventions in severely injured pediatric patients: rethinking the ABCs. J Trauma Acute Care Surg 2015;79(6):983–990CrossRefGoogle Scholar
  21. 21.
    Davis DP. Should invasive airway management be done in the field? CMAJ. Can Med Assoc 2008;178(9):1171–1173CrossRefGoogle Scholar
  22. 22.
    Davis DP. Prehospital intubation of brain-injured patients. Curr Opin Crit Care. 2008;14(2):142–8CrossRefGoogle Scholar
  23. 23.
    Franschman G, Peerdeman SM, Andriessen TMJC, Greuters S, Toor AE, Vos PE, et al. Effect of secondary prehospital risk factors on outcome in severe traumatic brain injury in the context of fast access to trauma care. J Trauma 2011;71(4):826–32.CrossRefGoogle Scholar
  24. 24.
    Fakhry SM, Trask AL, Waller MA, Watts DD, IRTC Neurotrauma Task Force. Management of brain-injured patients by an evidence-based medicine protocol improves outcomes and decreases hospital charges. J Trauma 2004;56(3):492–9 (discussion 499–500)CrossRefGoogle Scholar
  25. 25.
    Cooper A, DiScala C, Foltin G, Tunik M, Markenson D, Welborn C. Prehospital endotracheal intubation for severe head injury in children: a reappraisal. Semin Pediatr Surg 2001;10(1):3–6.CrossRefGoogle Scholar
  26. 26.
    Pointer JE. Clinical characteristics of paramedics’ performance of pediatric endotracheal intubation. Am J Emerg Med 1989;7(4):364–6.CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Pedram Emami
    • 1
    Email author
  • Patrick Czorlich
    • 1
  • Friederike S. Fritzsche
    • 1
  • Manfred Westphal
    • 1
  • Johannes M. Rueger
    • 2
  • Rolf Lefering
    • 3
  • Michael Hoffmann
    • 2
  • TraumaRegister DGU® of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie; DGU)
  1. 1.Department of NeurosurgeryUniversity Medical Center Hamburg-Eppendorf (UKE)HamburgGermany
  2. 2.Department of Trauma, Hand and Reconstructive SurgeryUniversity Medical Center Hamburg-EppendorfHamburgGermany
  3. 3.Institute for Research in Operative Medicine (IFOM)Witten/Herdecke UniversityCologneGermany

Personalised recommendations