Variation in the practice of tracheal intubation in Europe after traumatic brain injury : a prospective cohort study

Traumatic brain injury patients frequently undergo tracheal intubation. We aimed to assess current intubationpractice in Europe and identify variation in practice. We analysed data from patients with traumatic brain injuryincluded in the prospective cohort study collaborative European neurotrauma effectiveness research intraumatic brain injury (CENTER-TBI) in 45 centres in 16 European countries. We included patients who weretransported to hospital by emergency medical services. We used mixed-effects multinomial regression toquantify the effects on pre-hospital or in-hospital tracheal intubation of the following: patient characteristics;injury characteristics; centre; and trauma system characteristics. A total of 3843 patients were included. Ofthese, 1322 (34%) had their tracheas intubated; 839 (22%) pre-hospital and 483 (13%) in-hospital. Thefit of themodel with only patient characteristics predicting intubation was good (Nagelkerke R2 64%). The probability oftracheal intubation increased with the following: younger age; lower pre-hospital or emergency departmentGCS; higher abbreviated injury scale scores (head and neck, thorax and chest, face or abdomen abbreviatedinjury score); and one or more unreactive pupils. The adjusted median odds ratio for intubation between tworandomly chosen centres was 3.1 (95%CI 2.1–4.3) for pre-hospital intubation, and 2.7 (95%CI 1.9–3.5) for in-hospital intubation. Furthermore, the presence of an anaesthetist was independently associated with more pre-hospital intubation (OR 2.9, 95%CI 1.3–6.6), in contrast to the presence of ambulance personnel who areallowed to intubate (OR 0.5, 95%CI 0.3–0.8). In conclusion, patient and injury characteristics are key drivers oftracheal intubation. Between-centre differences were also substantial. Further studies are needed to improvethe evidence base supporting recommendations for tracheal intubation.