Effect of tracheal intubation performed by trauma surgeons on patients with severe traumatic brain injury

doi:10.21203/rs.3.rs-4377345/v1

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Effect of tracheal intubation performed by trauma surgeons on patients with severe traumatic brain injury

https://doi.org/10.21203/rs.3.rs-4377345/v1

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Background: An early intubation is predominantly performed by anesthesiologists for patients experiencing severe traumatic brain injury (STBI). Currently, a growing number of trauma surgeons in China have acquired proficient skills in tracheal intubation through rigorous training offered at trauma centers. In this article, we performed a retrospective observational cohort investigation with the aim of comparing the outcomes of endotracheal intubation conducted by trauma surgeons and anesthesiologists in the emergency room, specifically focusing on patients suffering from STBI.

Methods: Data were gathered from all STBI patients who received intubation between January 2018 and March 2023. There are two study groups based on the intubation performers: the trauma surgeon's intubation (TI) group and the anesthesiologist's intubation (AI) group. The age, sex, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), admission SpO2, PO2, PCO2, SBP, RR, HR, injury mechanism, intracranial lesion type, duration of endotracheal intubation, 1-min success rate of intubation, complications related to intubation, time from admission to intubation, duration of mechanical ventilation, incidence of aspiration pneumonia, 3-day mortality rate and the 30-day mortality rate were recorded.

Results: Among the 356 patients with STBI, 219 individuals fulfilled the inclusion criteria (comprising of 142 patients in the TI group and 77 patients in the AI group). No notable statistical differences were observed between the two groups in terms of age, sex, ISS, GCS, admission SpO2, PO2, PCO2, SBP, RR, HR, injury mechanism, and intracranial lesion type. The AI group exhibited a considerably shorter time from admission to intubation (p<0.01). Furthermore, the AI group demonstrated a reduced incidence of aspiration pneumonia as well as a decreased duration of mechanical ventilation (p<0.05).

Conclusion: The intubation of patients with STBI by trauma surgeons early can reduce aspiration pneumonia incidents and duration of mechanical ventilation.

Health sciences/Diseases

Health sciences/Health care

trauma care center

severe traumatic brain injury

endotracheal intubation

trauma surgeons

anesthesiologists

Traumatic brain injury (TBI) is the leading cause contributing to mortality rates in developing nations. The TBI incident has been rising in China and has reached 100 per 100,000 cases. Severe traumatic brain injury (STBI) accounts for approximately 18–20% of all documented cases.^1,2 Recent findings indicate that in the United States alone, over 1 million individuals experience STBI every year; among them, 50,000 will unfortunately die due to injuries, while another 90,000 will be left with a lasting neurological impairment. Therefore, STBI imposes a significant socioeconomic burden as a result of enduring disabilities. The primary causes of STBI are motor vehicle collisions and accidental falls.³ Additionally, considering the growing elderly population and the escalating usage of motorized transportation worldwide, STBI will persist as a fundamental healthcare concern in the coming years.

It has been established that individuals with STBI frequently exhibit hypoxemia and hypotension. By appropriately managing hypoxemia and hypercapnia, the heightened intracranial pressure that plays a crucial role in STBI can be attenuated. Undoubtedly, immediate intubation is imperative for patients with STBI to secure their airway and normalize their ventilation.⁴ In the United States as well as European nations, the responsibility of performing tracheal intubation is shared by emergency physicians and anesthesiologists. However, in the majority of Chinese hospitals, anesthesiologists are primarily responsible for performing tracheal intubation on trauma patients. In cases where a patient necessitates tracheal intubation, the trauma surgeon requests the presence of an anesthesiologist. It’ll take approximately 10 minutes for the anesthesiologist to rush to the emergency room (ER) for the intubation. Our trauma care center is the pioneer trauma treatment center acknowledged by the China Trauma Treatment Alliance. In addition, it functions as the officially designated trauma care center for Jiang Su Province. Our hospital's trauma care center strongly advocates immediate intubation for patients with STBI upon admission to the ER. Early tracheal intubation serves to safeguard the airway, availably prevent the occurrence of hypoxemia and hypercapnia, mitigate the risk of aspiration due to vomiting, and expedite the preoperative preparations. The trauma surgeons within trauma care center comprise emergency surgeons as well as a selection of specialist surgeons. All members of this team have completed the China Trauma Care Training (CTCT) program and are in possession of CTCT certificates. They have acquired proficient skills in tracheal intubation by means of standardized training, and the majority of trauma patients receive intubation from trauma surgeons. We conducted a research on tracheal intubation in the ER to investigate the impact of traumatic surgeons and anesthesiologists performing respective tracheal intubation on patients with STBI.

Study design

We conducted a cohort investigation encompassing all individuals with STBI who underwent intubation in the ER within the period from January 2018 to March 2023 at the trauma care center affiliated with the First Affiliated Hospital of Soochow University. All participants and/or their legal guardians in this study obtained informed consent and signed an informed consent form. The group of patients with STBI who underwent intubation performed by trauma surgeons will be referred to as the Trauma Surgeons' Intubation (TI) group. Conversely, the group of patients intubated by anesthesiologists will be referred to as the Anesthesiologists' Intubation (AI) group. All trauma surgeons in the TI group have received tracheal intubation training, China Trauma Care Training (CTCT), and rapid sequence induction (RSI) training. All intubation doctors utilized the Zhejiang UE Medical Corp video laryngoscope for intubation. Intubation procedures were conducted in the ER on admission or following the completion of CT scans. The time points for tracheal intubation included: (1) presence of airway obstruction; (2) the Glasgow Coma Scale (GCS) < 9; (3) abnormal respiratory rate and rhythm, for instance, respiratory rate < 10 or > 30, nose-like breathing, sobbing breathing; (4) PO2 < 60 mmHg and (or) PCO2 > 50 mmHg, and sustained SpO2 < 90% following mask oxygen inhalation. Immediate intubation is deemed necessary when patients with STBI meet one or more of the aforementioned criteria. Our approach to intubating these patients involves utilizing a standardized rapid sequence induction (RSI) technique. This approach comprises of preoxygenation with pure oxygen (100%) and the administration of propofol (2.0 mg/kg) and succinylcholine (2.0 mg/kg) to STBI patients. Throughout the procedure, continuous monitoring of blood pressure, oxygen saturation and cardiac rhythm is implemented.

Inclusion criteria

The inclusion criteria for participants enrolled in this research were shown below: (1) patients with STBI, age > 16 years old; GCS < 9; (2) Confirmed presence of trauma; (3) intubation in the ER (4) All patients received mechanical ventilatory support subsequent to tracheal intubation.

Exclusion criteria

The exclusion criteria for the participants enrolled in this research were shown below: (1) Participants aged over 70 years; (2) Patients experiencing a cardiac arrest upon admission; (3) The patients who succumbed to their injuries within 24 hours; (4) The patients were intubated prior to reaching the hospital; (5) Patients with unstable hemodynamics upon admission; (6) The patients were linked to additional life-threatening injuries, including tension pneumothorax, hemopneumothorax, pericardial tamponade, solid organ rupture and hemorrhagic shock; (7) Patients with pre-existing long-term respiratory disease or long-term cardiac disease; (8) Pregnant females.

Data collection

Data were gathered from all patients with STBI who underwent tracheal intubation in the ER. The intubating physicians promptly recorded relevant information using a specifically-designed form following the intubation procedure. The particulars were documented across three distinct sections: 1) patient’s history; 2) specifics of the intubation process; 3) immediate complications linked to tracheal intubation. We obtained data from both the trauma care center database and the hospital's electronic patient records. The recorded variables include age, sex, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), admission SpO2, PO2, PCO2, SBP, RR, HR, injury mechanism, intracranial lesion type, duration of tracheal intubation, 1-min success rate of intubation, complications related to intubation (misplacement of endotracheal tube into the mainstem bronchus, esophageal intubation, dental or oropharyngeal injury), time from admission to intubation, duration of mechanical ventilation, incidence of aspiration pneumonia (witnessed aspiration by radiologic evidence or gastric contents are aspirated from the endotracheal tube), the 3-day mortality rate, and the 30-day mortality rate. All patients were treated in accordance with advanced trauma life support (ATLS) principles and trauma brain foundation guidelines as deemed necessary.

Statistical analysis

"The statistical analysis utilized SPSS 25.0 software (IBM, Armonk, NY). For data that followed a normal distribution, the means along with their corresponding standard deviations (SD) were reported, and the independent samples t-test was utilized for making comparisons. The chi-square test was employed to compare categorical data. Nonparametric variables were compared using the Mann-Whitney U test. A p-value lower than 0.05 indicated statistical significance.

Comparing the demographic and clinical features of patients in the TI group and the AI group

During the designated period, a total of 356 individuals were enrolled in the study. Of these, 137 patients met the exclusion criteria. Out of the remaining 219 patients, trauma surgeons intubated 142 individuals (64.8%) forming the TI group, while the AI group, comprising of 77 patients (35.2%), was intubated by anesthesiologists. The average age of patients was 45 years, with males comprising 64% of the total. Motor-vehicle accidents emerged as the primary cause of injury. Notably, no significant statistical disparities were observed between the groups regarding age, sex, ISS, GCS, admission SpO2, PO2, PCO2, SBP, RR, HR, injury mechanism, and intracranial lesion type (Table 1).

Comparison of tracheal intubation between the TI group and AI group

There were no noteworthy statistical disparities between the two groups regarding duration of tracheal intubation and 1-min success rate of intubation. Within the TI group, 9 individuals encountered intubation-related complications, while in the AI group, this number was 3. No significant statistical disparities were found between the two groups. The time from admission to intubation was significantly shorter in the TI group compared to the AI group [(19.5 ± 9.3 min) vs (31.7 ± 13.2 min); p < 0.01] (Table 2).

Comparison outcome between the TI group and AI group

The incidence of aspiration pneumonia was significantly lower in the TI group compared to the AI group [7.8% vs 18.2%; (p = 0.02)]. Furthermore, compared to the AI group, the duration of mechanical ventilators [3(1–46) vs 4(1–58); p = 0.02] in the TI group was noticeably decreased. Despite not reaching statistical significance, the TI group exhibited lower 3-day mortality rate (10.6% vs 16.9%, p = 0.21) and 30-day mortality rate (21.8% vs 28.6%, p = 0.32) when compared to the AI group (Table 3).

Table 1

Comparison of the demographic and clinical features of patients between TI group and PI group
Variables	TI group	AI group	P value
Variables	(n = 142)	(n = 77)	P value
Age (mean ± SD) (years)	45.2 ± 14.5	46.5 ± 15.1	0.53
Sex (male/female)	89/53	51/26	0.66
Mechanism of injury			0.72 for all
Traffic related injuries (%)	74.6	70.1
Fall from height (%)	12.0	10.4
Fall of heavy object (%)	2.1	5.2
Blow or assault (%)	6.3	7.8
Other (%)	5.0	6.5
GCS	6 (3–8)	5 (3–8)	0.84
ISS	22.5 ± 7.6	23.1 ± 8.8	0.60
Admission SBP (mmHg)	151.4 ± 43.7	154.2 ± 46.5	0.66
Admission HR(beats/minute)	97.6 ± 31.8	98.9 ± 33.3	0.78
Admission RR (beats/minute)	22.1 ± 8.2	21.3 ± 9.5	0.52
Admission SpO₂ (%)	93.8 ± 25.1	93.1 ± 28.4	0.86
Admission PO₂ (mmHg)	117.2 ± 41.4	111.6 ± 44.5	0.35
Admission PCO₂ (mmHg)	40.6 ± 11.1	42.4 ± 11.9	0.27
Intracranial lesion type			0.91 for all
Subdural hematoma (%)	17.6	14.3
Epidural hematoma (%)	21.8	24.7
Cerebral contusion (%)	44.4	45.5
Intracerebral hemorrhage (%)	16.2	15.5
GCS: Glasgow coma scale; ISS: injury severity score; SBP: systolic blood pressure; HR: Heart rate; RR: Respiratory rate

Table 2

Comparison of tracheal intubation between TI group and AI group
Variables	TI group	AI group	P value
Variables	(n = 142)	(n = 77)	P value
Tracheal intubation time (s)	27.5 ± 7.1	25.1 ± 6.7	0.02
1-min success rate of intubation (%)	94.4	96.1	0.75
Complications related to intubation, n	9	3	0.55
The time from admission to intubation (min)	19.5 ± 9.3	31.7 ± 13.2	< 0.01

Table 3

Comparison of the outcome of patients between TI group and AI group
Variables	TI group	AI group	P value
Variables	(n = 142)	(n = 77)	P value
Aspiration pneumonia, n (%)	11(7.8)	14(18.2)	0.03
Duration of mechanical ventilation (d)	3(1–46)	4(1–58)	0.02
3-day mortality rate, n (%)	15(10.6)	13(16.9)	0.21
30-day mortality rate, n (%)	31(21.8)	23(28.6)	0.32

The observational cohort study examined the effects of tracheal intubation in the ER, specifically focusing on the outcomes of patients with STBI when administered by trauma surgeons and anesthesiologists. The study revealed no statistically significant differences in the duration of tracheal intubation, 1-min success rate of intubation, and complications related to intubation between the two groups. However, the time from admission to intubation was notably shorter in the TI group compared to the AI group. Furthermore, the TI group exhibited lower incidence of aspiration pneumonia and duration of mechanical ventilation compared to the AI group. Nonetheless, early intubation did not result in a significant reduction in hospital mortality.

Unconscious STBI patients frequently encounter glossoptosis, difficulties with swallowing, and loss of coughing reflexes. This can result in the ingestion of oral secretions, vomit, traumatic bleeding, or leakage of cerebrospinal fluid, leading to respiratory blockage and subsequent occurrences of hypoxemia and hypercapnia.⁵ Early management of hypoxemia and hypercapnia during the acute phase can prevent the development of secondary injury caused by pathological processes. The connection between elevated intracranial pressure resulting from STBI and hypoxemia creates a detrimental cycle.⁶ STBI results in cerebral edema and elevates intracranial pressure, consequently causing respiratory depression. Furthermore, it exacerbates hypoxemia, which progressively inflicts harm upon the brain cells and tissues. Consequently, cerebral edema once again occurs, intensifying intracranial pressure. At the same time, hypoxemia exacerbates the damage to cardiovascular and pulmonary tissues, resulting in hypotension and the onset of acute respiratory distress syndrome (ARDS).⁷ Hypoxemia leads to gastrointestinal mucosa erosion and bleeding, disruption of the intestinal mucosal barrier, bacterial invasion, and the translocation of endotoxins into the bloodstream. These processes trigger a cascade of systemic inflammatory mediators and inflict damage on the body through free radicals, ultimately leading to systemic inflammatory response syndrome (SIRS). The consequences include extensive tissue injury and the development of multiple organ dysfunction syndromes (MODS). Research has been conducted to explore the adverse repercussions of hypoxemia in patients with STBI. ^8–10

Airway management plays a pivotal role in the primary intervention of patients with STBI who experience respiratory distress. Tracheal intubation not only serves as the quickest and most efficient technique for ensuring airway openness, but also facilitates oxygenation, sustains proper ventilation, and minimizes the potential for aspiration.¹¹ Acknowledging the significance of airway management, the Eastern Association for the Surgery of Trauma (EAST) has issued guidelines outlining the early intubation considerations for trauma patients. The guidelines outline the necessity of tracheal intubation in situations including but not limited to: cardiac arrest, obstruction of the airway, extreme hemorrhagic shock, profound oxygen deficiency, inadequate ventilation, and severe cognitive impairment (GCS < 9).¹² The GCS plays a crucial role in evaluating STBI, and a revised edition has been endorsed in the ATLS − 10.¹³ Early tracheal intubation is necessary for patients with STBI.¹⁴ In the past, the anesthesiologists were the ones who performed the intubations which were time-consuming till they got to ER. Therefore, the concept of training trauma surgeons emerged. The establishment of a training and certification mechanism, with the aim of enhancing the professional skills of trauma rescuers, led to the formation of China Trauma Care Training (CTCT) by the Chinese Medical Doctor Association and trauma surgeon section. Comparable to the American ATLS, the CTCT programs were organized nationwide, with the objective of advocating the implementation of the 'Chinese mode' within the trauma care system.¹⁵ The CTCT events were conducted consecutively nationwide with the goal of promoting the 'Chinese model' of the trauma care system. Tracheal intubation is an essential component of the CTCT training program. All the trauma surgeons at our trauma care center have completed the China Trauma Care Training and received certification from CTCT. Moreover, trauma surgeons have also received standardized training in tracheal intubation under the guidance of an experienced anesthesiologist. Consequently, they have acquired proficiency in rapid sequence induction and tracheal intubation techniques. This article is the first to investigate the impact of tracheal intubation carried out by trauma surgeons and anesthesiologists on patients with STBI. The results of this research suggest that there is no noteworthy discrepancy in intubation outcomes for STBI patients between trained trauma surgeons and anesthesiologists. Prompt intubation in the emergency room reduces the incidence of aspiration pneumonia and the duration of mechanical ventilation. While there is a lack of specific comparative studies between trauma surgeons and anesthesiologists in terms of tracheal intubation, comparative studies have been conducted between emergency physicians and anesthesiologists. Previously, a survey conducted in UK emergency departments revealed that nearly 80% of intubations were performed by anesthesiologists, while Dean Kerslake's study indicated that emergency physicians were responsible for performing nearly three-quarters of the intubations.^16,17 During the 13-year analysis, emergency physicians achieved comparable laryngoscopic views but had slightly lower rates of initial intubation success compared to anesthesiologists. However, since 2007, any discrepancy in the initial success rate has become indiscernible for the first-time successful intubation (anesthesiologists at 88%, emergency physicians at 87%, p = 0.909). The data indicates that emergency physicians have improved their intubation skills following training, while anesthesiologists are increasingly involved in challenging intubation cases. The study revealed that approximately 95% of practitioners had completed a minimum of three months of formal training in anesthesia. This could account for the higher rate of successful intubation procedures observed among emergency physicians.¹⁷

Proficient airway management plays a pivotal role in emergency departments. Currently, emergency physicians employ rapid-sequence intubation to handle the majority of urgent intubations in such settings, boasting an impressive success rate of up to 99%.^19,20 Due to the widespread utilization of video laryngoscopes and the implementation of standardized anesthesia intubation training, trauma surgeons have acquired proficiency in tracheal intubation techniques. Consequently, there are negligible disparities in both the success rate of intubation and the incidence of complications related to intubation, when compared to anesthesiologists. Trauma medical practitioners are well-acquainted with the significance of effective time management. When it comes to providing emergency care to critically injured patients, it is imperative to comprehend the correlation between priorities and time. The fundamental principle in traumatology can be summed up by the adage "time is life, time is speed", which underscores the crucial requirements of this field.^21,22 For patients experiencing severe trauma, prompt intubation performed by the trauma surgeon facilitates immediate airway protection and mitigates the risks of hypoxemia and hypercapnia.

This study found no statistically significant disparities in hospital mortality rates between the two cohorts of patients with STBI. Various factors, including age, admission GCS score, volume and location of intracranial hematoma, surgical method, and complications (such as hypernatremia, hyperthermia, gastrointestinal bleeding, and multiple organ failure), can influence patient mortality with STBI. ^23,24 Therefore, the study suggests that early tracheal intubation has no significant impact on hospital mortality rates.

Trauma surgeons can acquire proficiency in tracheal intubation through standardized training, demonstrating a success rate comparable to that of anesthesiologists. The inclusion of trauma surgeons in performing tracheal intubation enables prompt intubation of patients with STBI, leading to a reduction in the occurrence of aspiration pneumonia and the duration of mechanical ventilation. The early initiation of intubation proves advantageous for patients with STBI, thus emphasizing the importance of encouraging trauma surgeons to master tracheal intubation skills.

Ethical statement

The ethical committee of the first affiliated hospital of soochow university approved this study.

Declaration of competing interest

The authors declare that they have no competing interests.

Funding

This work was supported by the Basic Research on Medical and Health Application of the People's Livelihood Science and Technology Project of Suzhou Science and Technology Bureau (SYS2020102), China Scholarship Councils (NO. 202006920081); and the Jiangsu Provincial Medical Innovation Center for Trauma Medicine (CXZX202231).

Author Contribution

Liang Wang, Zhengjie Sun and Xionghui Chen wrote the manuscript text. Feng Xu, Nona Hashem Sharifi, Pengjie Zhang and Weihua Ling participated in clinical data receipt and data statistical analysis. All authors reviewed the manuscript.

Acknowledgement

Thanks to all who participated in the study for their valuable contributions.

Data Availability

Data Availability StatementThe data that support the findings of this study are available from the corresponding author upon reasonable request.

Feng J, Jiang J. Traumatic brain injury in 2019: databases, biomarkers, and stratified treatment. The Lancet Neurology. 2020;19(1):5-7.
Escobedo L, Habboushe J, Kaafarani H, et al. Traumatic brain injury: A case-based review. World J Emerg Med. 2013;4(4):252-259.
Haltmeier T, Schnuriger B, Benjamin E, et al. Isolated blunt severe traumatic brain injury in Bern, Switzerland, and the United States: A matched cohort study. J Trauma Acute Care Surg. 2016;80(2):296-301.
Wahlen BM, El-Menyar A, Asim M, et al. Rapid sequence induction (RSI) in trauma patients: Insights from healthcare providers. World J Emerg Med. 2019;10(1):19-26.
Crewdson K, Fragoso-Iniguez M, Lockey DJ. Requirement for urgent tracheal intubation after traumatic injury: a retrospective analysis of 11,010 patients in the Trauma Audit Research Network database. Anaesthesia. 2019;74(9):1158-1164.
Davis D, Dunford J, Poste J, et al. The impact of hypoxia and hyperventilation on outcome after paramedic rapid sequence intubation of severely head-injured patients. J Trauma. 2004;57(1):1-8; discussion 8-10.
Cornelius BG, Webb E, Cornelius A, et al. Effect of sedative agent selection on morbidity, mortality and length of stay in patients with increase in intracranial pressure. World J Emerg Med. 2018;9(4):256-261.
Beckers SK, Brokmann JC, Rossaint R. Airway and ventilator management in trauma patients. Curr Opin Crit Care. 2014;20(6):626-631.
Gravesteijn BY, Sewalt CA, Ercole A, et al. Variation in the practice of tracheal intubation in Europe after traumatic brain injury: a prospective cohort study. Anaesthesia. 2020;75(1):45-53.
Jenkins R, Morris NA, Haac B, et al. Outcome predictors for severely brain-injured patients directly admitted or transferred from emergency departments to a trauma center. World J Emerg Med. 2020;11(2):120-121.
Lockey DJ, Wilson M. Early airway management of patients with severe head injury: opportunities missed? Anaesthesia. 2020;75(1):7-10.
Mayglothling J, Duane T, Gibbs M, et al. Emergency tracheal intubation immediately following traumatic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S333-340.
Galvagno SM, Jr., Nahmias JT, Young DA. Advanced Trauma Life Support((R)) Update 2019: Management and Applications for Adults and Special Populations. Anesthesiol Clin. 2019;37(1):13-32.
Carney N, Totten AM, O'Reilly C, et al. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery. 2017;80(1):6-15.
Liu T, Bai XJ. Trauma care system in China. Chin J Traumatol. 2018;21(2):80-83.
Benger J, Hopkinson S. Rapid sequence induction of anaesthesia in UK emergency departments: a national census. Emerg Med J. 2011;28(3):217-220.
Kerslake D, Oglesby AJ, Di Rollo N, et al. Tracheal intubation in an urban emergency department in Scotland: a prospective, observational study of 3738 intubations. Resuscitation. 2015;89:20-24.
Goto T, Goto Y, Hagiwara Y, et al. Advancing emergency airway management practice and research. Acute Med Surg. 2019;6(4):336-351.
Lentz S, Grossman A, Koyfman A, et al. High-Risk Airway Management in the Emergency Department. Part I: Diseases and Approaches. J Emerg Med. 2020;59(1):84-95.
Brown CA, 3rd, Bair AE, Pallin DJ, et al. Techniques, success, and adverse events of emergency department adult intubations. Ann Emerg Med. 2015;65(4):363-370 e361.
Wang L, Chen XH, Ling WH, et al. Application of trauma time axis management in the treatment of severe trauma patients. Chin J Traumatol. 2021;24(1):39-44.
Newgard CD, Meier EN, Bulger EM, et al. Revisiting the "Golden Hour": An Evaluation of Out-of-Hospital Time in Shock and Traumatic Brain Injury. Ann Emerg Med. 2015;66(1):30-41, 41 e31-33.
Ogunlade J, Elia C, Duong J, et al. Severe Traumatic Brain Injury Requiring Surgical Decompression in the Young Adult: Factors Influencing Morbidity and Mortality - A Retrospective Analysis. Cureus. 2018;10(7):e3042.
Vedantam A, Robertson CS, Gopinath SP. Morbidity and mortality associated with hypernatremia in patients with severe traumatic brain injury. Neurosurg Focus. 2017;43(5):E2.

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You are reading this latest preprint version

Effect of tracheal intubation performed by trauma surgeons on patients with severe traumatic brain injury

Status:

Version 1

Abstract

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Introduction

Materials and Methods

Statistical analysis

Results

Discussion

Conclusions

Declarations

Ethical statement

Declaration of competing interest

Funding

Author Contribution

Acknowledgement

Data Availability

References

Additional Declarations

Status:

Version 1