Is prehospital intubation of severely injured children in accordance with guidelines?

BACKGROUND: The current German S3 guideline for polytrauma lists five criteria for prehospital intubation: apnea, severe traumatic brain injury (GCS ≤8), severe chest trauma with respiratory failure, hypoxia, and persistent hemodynamic instability. These guideline criteria, used in adults in daily practice, have not been previously studied in a collection of severely injured children. The aim of this study was to assess the extent to which the criteria are implemented in clinical practice using a multivariate risk analysis of severely injured children. METHODS: Data of 289,698 patients from the TraumaRegister DGU® were analyzed. Children meeting the following criteria were included: Maximum Abbreviated Injury Scale 3+, primary admission, German-speaking countries, years 2008–2017, and declaration of intubation. Since children show age-dependent deviating physiology, four age groups were defined (years old: 0–2; 3–6; 7–11; 12–15). An adult collective served as a control group (age: 20–50). After a descriptive analysis in the first step, factors leading to prehospital intubation in severely injured children were analyzed with a multivariate regression analysis. RESULTS: A total of 4489 children met the inclusion criteria. In this cohort, young children up to 2 years old had the significantly highest injury severity (Injury Severity Score: 21; p ≤ 0.001). Falls from both high (> 3 m) and low heights (< 3 m) were more common in children than in adults. The same finding applied to the occurrence of severe traumatic brain injury. When at least one intubation criterion was formally present, the group up to 6 years old was least likely to actually be intubated (61.4%; p ≤ 0.001). Multivariate regression analysis showed that Glasgow Coma Scale score ≤ 8 in particular had the greatest influence on intubation (odds ratio: 26.9; p ≤ 0.001). CONCLUSIONS: The data presented here show for the first time that the existing criteria in the guideline for prehospital intubation are applied in clinical practice (approximately 70% of cases), compared to adults, in the vast majority of injured children. Although severely injured children still represent a minority of all injured patients, future guidelines should focus more on them and address them in a specialized manner.