Review article: Emergency endotracheal intubation in non‐traumatic brain pathologies: A systematic review and meta‐analysis

Abstract

Endotracheal intubation is an advanced airway procedure performed in the ED and the out-ofhospital setting for acquired brain injuries that include non-traumatic brain pathologies such as stroke, encephalopathies, seizures and toxidromes. Controlled trial evidence supports intubation in traumatic brain injuries, but it is not clear that this evidence can be applied to nontraumatic brain pathologies. We sought to analyse the impact of emergency intubation on survival in non-traumatic brain pathologies and also to quantify the prevalence of intubation in these pathologies. We conducted a systematic literature search of Medline, Embase and the Cochrane Library. Eligibility, data extraction and assessment of risk of bias were assessed independently by two reviewers. A bias-adjusted metaanalysis using a quality-effects model pooled prevalence of intubation in non-traumatic brain pathologies. Forty-six studies were included in this systematic review. No studies were suitable for meta-analysis the primary outcome of survival. Thirtynine studies reported the prevalence of intubation in non-traumatic brain pathologies and a meta-analysis showed that emergency intubation was used in 12% (95% CI 0-33) of pathologies. Endotracheal intubation was used commonly in haemorrhagic stroke 79% (95% CI 47-100) and to a lesser extent for seizures 18% (95% CI 10-27) and toxidromes 25% (95% CI 6-48). This systematic review shows that there is no high-quality clinical evidence to support or refute emergency intubation in non-traumatic brain pathologies. Our analysis shows that intubation is commonly used in non-traumatic brain pathologies, and the need for rigorous evidence is apparent.

The utility of the brain trauma evidence to inform paramedic rapid sequence intubation in out-of-hospital stroke

“…Strokes account for 10% of deaths worldwide [1]. Rapid Sequence intubation (RSI) is used in the emergency setting to improve survival in strokes, with perhaps 6 to 79% of strokes receiving intubation, depending on the stroke type [2]. Rapid sequence intubation is used to secure the airway using sedative and paralytic drugs to facilitate endotracheal intubation [2].…”

“…Rapid Sequence intubation (RSI) is used in the emergency setting to improve survival in strokes, with perhaps 6 to 79% of strokes receiving intubation, depending on the stroke type [2]. Rapid sequence intubation is used to secure the airway using sedative and paralytic drugs to facilitate endotracheal intubation [2]. Strokes form 37% of RSI for non-traumatic brain pathologies undertaken by paramedics in Victoria, Australia [3].…”

“…Strokes form 37% of RSI for non-traumatic brain pathologies undertaken by paramedics in Victoria, Australia [3]. Despite the notinfrequent use of RSI in unconscious out-of-hospital acquired brain injuries, no high quality evidence exists to support the use of RSI for strokes [2][3][4]. A randomized controlled trial of RSI in traumatic brain injury (TBI) exist [5], but the evidence from this trial cannot necessarily be applied to stroke RSI due to differences between the stroke and TBI patient [2][3][4].…”

Association of blood pressure changes with survival after paramedic rapid sequence intubation in out‐of‐hospital patients with stroke

“…Rapid sequence intubation (RSI) is used in the emergency setting to protect the airway in strokes, with perhaps 6–79% of strokes receiving intubation, depending on the stroke type 2 . RSI is used to secure the airway using sedative and paralytic drugs to facilitate endotracheal intubation 2 . Stroke patients form 37% of RSI undertaken by paramedics in Victoria, Australia 3 .…”

“…Stroke patients form 37% of RSI undertaken by paramedics in Victoria, Australia 3 . Despite the not‐infrequent use of RSI in unconscious out‐of‐hospital stroke patients, no high‐quality evidence exists to support the use of RSI for strokes 2–5 . However, a recent propensity‐matched cohort study of paramedic RSI found decreased odds of survival for RSI in both haemorrhagic and ischaemic strokes 4 .…”