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Gravesteijn BY, Sewalt CA, Ercole A, Lecky F, Menon D, Steyerberg EW, Maas AIR, Lingsma HF, Klimek M. Variation in the practice of tracheal intubation in Europe after traumatic brain injury: a prospective cohort study. Anaesthesia 2019; 75:45-53. [PMID: 31520421 PMCID: PMC7344983 DOI: 10.1111/anae.14838] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2019] [Indexed: 01/03/2023]
Abstract
Traumatic brain injury patients frequently undergo tracheal intubation. We aimed to assess current intubation practice in Europe and identify variation in practice. We analysed data from patients with traumatic brain injury included in the prospective cohort study collaborative European neurotrauma effectiveness research in traumatic brain injury (CENTER‐TBI) in 45 centres in 16 European countries. We included patients who were transported to hospital by emergency medical services. We used mixed‐effects multinomial regression to quantify 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. Of these, 1322 (34%) had their tracheas intubated; 839 (22%) pre‐hospital and 483 (13%) in‐hospital. The fit of the model with only patient characteristics predicting intubation was good (Nagelkerke R2 64%). The probability of tracheal intubation increased with the following: younger age; lower pre‐hospital or emergency department GCS; higher abbreviated injury scale scores (head and neck, thorax and chest, face or abdomen abbreviated injury score); and one or more unreactive pupils. The adjusted median odds ratio for intubation between two randomly 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 are allowed to intubate (OR 0.5, 95%CI 0.3–0.8). In conclusion, patient and injury characteristics are key drivers of tracheal intubation. Between‐centre differences were also substantial. Further studies are needed to improve the evidence base supporting recommendations for tracheal intubation.
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Affiliation(s)
- B Y Gravesteijn
- Departments of Anesthesiology and Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - C A Sewalt
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - A Ercole
- Department of Anaesthesiology, University of Cambridge, UK
| | - F Lecky
- Emergency Medicine Research in Sheffield, School of Health and Related Research, Faculty of Medicine, Dentistry and Health, University of Sheffield, UK
| | - D Menon
- Department of Anaesthesia, University of Cambridge, UK
| | - E W Steyerberg
- Department of Biostatistics, Leiden University Medical Centre, Leiden, The Netherlands
| | - A I R Maas
- Department of Neurosurgery, University Hospital Antwerp, Belgium
| | - H F Lingsma
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - M Klimek
- Department of Anesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Gamberini L, Baldazzi M, Coniglio C, Gordini G, Bardi T. Prehospital Airway Management in Severe Traumatic Brain Injury. Air Med J 2019; 38:366-373. [PMID: 31578976 DOI: 10.1016/j.amj.2019.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 05/12/2019] [Accepted: 06/13/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Traumatic brain injury (TBI) is a leading cause of death and disability among trauma patients. The final outcome of TBI results from a complex interaction between primary and secondary mechanisms of injury that begin immediately after the traumatic event. The aim of this review was to evaluate the latest evidence regarding the impact of prehospital airway management and the outcome after traumatic brain injury. METHODS PubMed, Embase, and Cochrane searches were conducted using the MeSH database. Airway management, traumatic brain injury, pneumonia, and the subheadings of these Medical Subject Headings were combined. RESULTS The review is structured into 4 major topics: airway management devices, prehospital pharmacologic management, mortality and neurologic outcomes, and early respiratory infections. The available literature shows a shift toward a more comprehensive view of prehospital airway management, taking into account not only the location where airway management is attempted but also the drugs administered, the airway management devices used, and the skills of the main professional figures attending the scene. CONCLUSIONS Literature about this topic is still inconclusive; however, new evidence taking into consideration more complex aspects of airway management rather than orotracheal intubation per se shows improved outcomes with aggressive prehospital airway management.
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Affiliation(s)
- Lorenzo Gamberini
- Division of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy.
| | - Marzia Baldazzi
- Division of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Carlo Coniglio
- Division of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Giovanni Gordini
- Division of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Tommaso Bardi
- Division of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
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53
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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; 74:1158-1164. [DOI: 10.1111/anae.14692] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2019] [Indexed: 11/27/2022]
Affiliation(s)
| | | | - D. J. Lockey
- North Bristol NHS Trust BristolUK
- Blizard Institute for Trauma and Neurosciences Queen Mary University London UK
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54
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Gamberini L, Giugni A, Ranieri S, Meconi T, Coniglio C, Gordini G, Bardi T. Early-Onset Ventilator-Associated Pneumonia in Severe Traumatic Brain Injury: is There a Relationship with Prehospital Airway Management? J Emerg Med 2019; 56:657-665. [PMID: 31000428 DOI: 10.1016/j.jemermed.2019.02.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 01/22/2019] [Accepted: 02/02/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Prehospital airway management in severe traumatic brain injury (TBI) is widely recommended by international guidelines for the management of trauma. Early-onset ventilator-associated pneumonia (EOVAP) is a common occurrence in this population and can worsen mortality and functional outcome. OBJECTIVES In this retrospective observational study, we aimed to evaluate the association between different prehospital airway management variables and the occurrence of EOVAP. Secondarily we evaluated the correlation between EOVAP and mortality and neurological outcome. METHODS The study retrospectively evaluated 223 patients admitted from 2010 to 2017 in our trauma intensive care unit for severe TBI. The population was divided into three groups on the basis of the airway management technique adopted (bag mask ventilation, laryngeal tube, orotracheal intubation). Uni- and multivariate logistic regression analyses were performed using the occurrence of EOVAP as the dependent variable, to investigate potential associations with prehospital airway management. RESULTS A total of 131 episodes (58.7%) of EOVAP were registered in the study population (223 patients). Laryngeal tube and orotracheal intubation were used in patients with significantly lower Glasgow Coma Scale score on scene and a higher Face Abbreviated Injury Scale; advanced airway management significantly increased the total rescue time. The prehospital airway management technique adopted, prehospital type of sedation or use of muscle relaxants, type of transport, and rescue times were not associated with the occurrence of EOVAP. CONCLUSIONS Prehospital airway management does not have a significant impact on the occurrence of EOVAP in severe TBI patients. Similarly, it does not have a significant impact on mortality or long-term neurological outcome despite increasing duration of mechanical ventilation, intensive care unit, and hospital stay.
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Affiliation(s)
- Lorenzo Gamberini
- Division of Anesthesia, Intensive Care, and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Aimone Giugni
- Division of Anesthesia, Intensive Care, and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Serena Ranieri
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum, University of Bologna and S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Tommaso Meconi
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum, University of Bologna and S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Carlo Coniglio
- Division of Anesthesia, Intensive Care, and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Giovanni Gordini
- Division of Anesthesia, Intensive Care, and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Tommaso Bardi
- Division of Anesthesia, Intensive Care, and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
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Effect of Pre-Hospital Intubation in Patients with Severe Traumatic Brain Injury on Outcome: A Prospective Cohort Study. J Clin Med 2019; 8:jcm8040470. [PMID: 30959868 PMCID: PMC6517889 DOI: 10.3390/jcm8040470] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 03/27/2019] [Accepted: 04/02/2019] [Indexed: 01/22/2023] Open
Abstract
Secondary injuries are associated with bad outcomes in the case of severe traumatic brain injury (sTBI). Patients with a Glasgow Coma Scale (GCS) < 9 should undergo pre-hospital intubation (PHI). There is controversy about whether PHI is beneficial. The aim of this study was to estimate the effect of PHI in patients after sTBI. A multicenter, prospective cohort study was performed in Switzerland, including 832 adults with sTBI. Outcomes were death and impaired consciousness at 14 days. Associations between risk factors and outcomes were assessed with univariate and multivariate Cox models for survival, and univariate and multivariate regression models for impaired consciousness. Potential risk factors were age, GCS on scene, pupil reaction, Injury Severity Score (ISS), PHI, oxygen administration, and type of admission to trauma center. Age, GCS on scene < 9, abnormal pupil reaction and ISS ≥ 25 were associated with mortality. GCS < 9 and ISS ≥ 25 were correlated with impaired consciousness. PHI was overall not associated with short-term mortality and consciousness. However, there was a significative interaction with PHI and major trauma. PHI improves outcome from patients with sTBI and an ISS ≥ 25.
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Bossers SM, Boer C, Greuters S, Bloemers FW, Den Hartog D, Van Lieshout EMM, Hoogerwerf N, Innemee G, van der Naalt J, Absalom AR, Peerdeman SM, de Visser M, Loer S, Schober P. Dutch Prospective Observational Study on Prehospital Treatment of Severe Traumatic Brain Injury: The BRAIN-PROTECT Study Protocol. PREHOSP EMERG CARE 2019; 23:820-827. [PMID: 30893571 DOI: 10.1080/10903127.2019.1587126] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: Severe traumatic brain injury (TBI) is associated with a high mortality rate and those that survive commonly have permanent disability. While there is a broad consensus that appropriate prehospital treatment is crucial for a favorable neurological outcome, evidence to support currently applied treatment strategies is scarce. In particular, the relationship between prehospital treatments and patient outcomes is unclear. The BRAIN-PROTECT study therefore aims to identify prehospital treatment strategies associated with beneficial or detrimental outcomes. Here, we present the study protocol. Study Protocol: BRAIN-PROTECT is the acronym for BRAin INjury: Prehospital Registry of Outcome, Treatments and Epidemiology of Cerebral Trauma. It is a prospective observational study on the prehospital treatment of patients with suspected severe TBI in the Netherlands. Prehospital epidemiology, interventions, medication strategies, and nonmedical factors that may affect outcome are studied. Multivariable regression based modeling will be used to identify confounder-adjusted relationships between these factors and patient outcomes, including mortality at 30 days (primary outcome) or mortality and functional neurological outcome at 1 year (secondary outcomes). Patients in whom severe TBI is suspected during prehospital treatment (Glasgow Coma Scale score ≤ 8 in combination with a trauma mechanism or clinical findings suggestive of head injury) are identified by all four helicopter emergency medical services (HEMS) in the Netherlands. Patients are prospectively followed up in 9 participating trauma centers for up to one year. The manuscript reports in detail the objectives, setting, study design, patient inclusion, and data collection process. Ethical and juridical aspects, statistical considerations, as well as limitations of the study design are discussed. Discussion: Current prehospital treatment of patients with suspected severe TBI is based on marginal evidence, and optimal treatment is basically unknown. The BRAIN-PROTECT study provides an opportunity to evaluate and compare different treatment strategies with respect to patient outcomes. To our knowledge, this study project is the first large-scale prospective prehospital registry of patients with severe TBI that also collects long-term follow-up data and may provide the best available evidence at this time to give useful insights on how prehospital care can be improved.
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Saar S, Brinck T, Laos J, Handolin L, Talving P. Severe blunt trauma in Finland and Estonia: comparison of two regional trauma repositories. Eur J Trauma Emerg Surg 2019; 46:371-376. [PMID: 30847535 PMCID: PMC7223228 DOI: 10.1007/s00068-018-01068-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Accepted: 12/26/2018] [Indexed: 11/18/2022]
Abstract
Purpose Evolving trauma system of Estonia has undergone several reforms; however, performance and outcome indicators have not been benchmarked previously. Thus, we initiated a baseline study to compare demographics, management and outcomes of severely injured patients between Southern Finland and Northern Estonia utilizing regional trauma repositories. Methods A comparison of data fields of the Helsinki University Hospital trauma registry (HTR) and trauma registry at the North Estonia Medical Centre in Tallinn (TTR) between 1/1/2015 and 31/12/2016 was performed. The inclusion criterion was Injury Severity Score > 15. Transferred patients, patients with penetrating injuries, and pediatric patients were excluded. The data for comparison included demographics, Trauma Score-Injury Severity Score (TRISS), mortality, and standardized mortality ratio (SMR). Primary outcome was mortality and SMR per TRISS methodology. Results During the 2-year study period, 324 patients from the HTR and 152 from the TTR were included. Demographic profile was similar between the repositories with the exception of severe abdominal injuries being more prevalent at the TTR (25.0% vs. 13.3%, p = 0.002). Predominant injury mechanism was non-ground level fall in both repositories. Mortality was similar at 14.5% and 13.6% at the TTR and HTR, respectively (adj. p = 0.762; OR 1.13, 95% CI 0.64–1.99). SMR was lower at the HTR compared to the TTR (0.65 vs. 0.77, p > 0.05), however, the difference did not reach statistical significance. Conclusion Benchmarking trauma repositories at a national level provides opportunities for quality and performance improvements. We observed comparable demographic profile and outcome indicators in the compared regional trauma systems.
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Affiliation(s)
- Sten Saar
- School of Medicine, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.,Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Centre, J. Sütiste tee 19, 13149, Tallinn, Estonia
| | - Tuomas Brinck
- Trauma Unit, Department of Orthopaedics and Traumatology, Töölö Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Juhan Laos
- School of Medicine, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.,Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Centre, J. Sütiste tee 19, 13149, Tallinn, Estonia
| | - Lauri Handolin
- Trauma Unit, Department of Orthopaedics and Traumatology, Töölö Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Peep Talving
- School of Medicine, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia. .,Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Centre, J. Sütiste tee 19, 13149, Tallinn, Estonia.
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What is the impact of physicians in prehospital treatment for patients in need of acute critical care? - An overview of reviews. Int J Technol Assess Health Care 2019; 35:27-35. [PMID: 30722802 DOI: 10.1017/s0266462318003616] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES The aim of this overview was to systematically identify and synthesize existing evidence from systematic reviews on the impact of prehospital physician involvement. METHODS The Medline, Embase, and Cochrane library were searched from 1 January 2000 to 17 November 2017. We included systematic reviews comparing physician-based with non-physician-based prehospital treatment in patients with one of five critical conditions requiring a rapid response. RESULTS Ten reviews published from 2009 to 2017 were included. Physician treatment was associated with increased survival in patients with out-of-hospital cardiac arrest and patients with severe trauma; in the latter group, the result was based on more limited evidence. The success rate of prehospital endotracheal intubation (ETI) has improved over the years, but ETI by physicians is still associated with higher success rates than intubation by paramedics. In patients with severe traumatic brain injury, intubation by paramedics who were not well skilled to do so markedly increased mortality. CONCLUSIONS Current evidence is hinting at a benefit of physicians in selected aspects of prehospital emergency services, including treatment of patients with out-of-hospital cardiac arrest and critically ill or injured patients in need of prehospital intubation. Evidence is, however, limited by confounding and bias, and comparison is hampered by differences in case mix and the organization of emergency medical services. Future research should strive to design studies that enable appropriate control of baseline confounding and obtain follow-up data for the proportion of patients who die in the prehospital setting.
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Guo Y, Li R. The effect of pre-hospital intubation on prognosis in infants, children and adolescents with severe traumatic brain injury: A protocol of systematic review and meta-analysis. Medicine (Baltimore) 2019; 98:e14690. [PMID: 30813217 PMCID: PMC6408067 DOI: 10.1097/md.0000000000014690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 02/05/2019] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Traumatic brain injury is one of the leading causes of death and sources of heavy societal burden. Hypoxemia and hypercapnia are the 2 common complications of brain injury. Intubation seems to be an effective intervention for preventing the 2 complications in pre-hospital setting. But the results of the existing studies on the effect of pre-hospital intubation on prognosis of patients (aged less than 18) with severe traumatic brain injury are conflict. Thus, in this study, we aim to conduct a systematic review and meta-analysis to evaluate whether pre-hospital intubation is benefit for the prognosis in infants, children and adolescents with severe traumatic brain injury. METHODS We will develop a systematic search strategy which includes MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Chinese Biomedical Literature Database, WanFang Data and China National Knowledge Infrastructure. The WHO International Clinical Trials Registry Platform will be searched for the ongoing studies as well. The cohort studies which aim to evaluate the effect of pre-hospital intubation for infants, children and adolescents with severe traumatic brain injury will be selected. The Newcastle-Ottawa Scale will be used for assessing the risk of bias of the included studies. RESULTS The results of this study will be presented in the full-text of the systematic review. CONCLUSION This is the first systematic review and meta-analysis about evaluation of the effect of pre-hospital intubation on prognosis in infants, children and adolescents with traumatic brain injury. PRESPERO REGISTRATION NUMBER CRD42019121214.
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Affiliation(s)
- Yichen Guo
- Department of Emergency, The First Hospital of Lanzhou University
| | - Ruilin Li
- Department of Neurology, The First Hospital of Lanzhou, Lanzhou, China
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60
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Emami P, Czorlich P, Fritzsche FS, Westphal M, Rueger JM, Lefering R, Hoffmann M. Observed versus expected mortality in pediatric patients intubated in the field with Glasgow Coma Scale scores < 9. Eur J Trauma Emerg Surg 2019; 45:769-776. [PMID: 30631886 DOI: 10.1007/s00068-018-01065-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 12/26/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE 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. METHODS 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. RESULTS 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). CONCLUSIONS 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.
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Affiliation(s)
- Pedram Emami
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf (UKE), Martinistrasse 52, 20246, Hamburg, Germany.
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf (UKE), Martinistrasse 52, 20246, Hamburg, Germany
| | - Friederike S Fritzsche
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf (UKE), Martinistrasse 52, 20246, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf (UKE), Martinistrasse 52, 20246, Hamburg, Germany
| | - Johannes M Rueger
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Ostmerheimerstrasse 200, 51109, Cologne, Germany
| | - Michael Hoffmann
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
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Volpi PC, Robba C, Rota M, Vargiolu A, Citerio G. Trajectories of early secondary insults correlate to outcomes of traumatic brain injury: results from a large, single centre, observational study. BMC Emerg Med 2018; 18:52. [PMID: 30518336 PMCID: PMC6280374 DOI: 10.1186/s12873-018-0197-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 11/08/2018] [Indexed: 11/29/2022] Open
Abstract
Background Secondary insults (SI), such as hypotension, hypoxia, and intracranial hypertension frequently occur after traumatic brain injury (TBI), and have a strong impact on patients’ clinical outcomes. The aim of this study is to examine the trajectories of SI from the early phase of injury in the prehospital setting to hospital admission in a cohort of TBI patients. Methods This is a retrospective, observational, single centre study on consecutive patients admitted from 1997 to 2016 to the Neuro Intensive Care Unit (NICU) at San Gerardo Hospital, in Monza, Italy. Trajectories of SI from the prehospital to hospital settings were defined as “sustained”, “resolved”, “new event”, and “none”. Univariate and multivariate logistic regression analyses were performed to correlate SI trajectories to a 6-months outcome. Results Nine hundred sixty-seven patients were enrolled in the final analysis. About 20% had hypoxic or hypotensive events and 30.7% of patients had pupillary abnormalities. Hypotension and hypoxia were associated with an unfavourable outcome when “sustained” and “resolved”, while pupillary abnormalities were associated with a poor outcome when “sustained” and as “new events”. After adjusting for confounding factors, 6-month mortality strongly correlated with “sustained” hypotension (OR 11.25, 95% CI, 3.52–35.99), “sustained” pupillary abnormalities (OR 2.8, 95% CI, 1.51–5.2) and “new event” pupillary abnormalities (OR 2.8, 95% CI, 1.16–6.76). Conclusions After TBI, sustained hypotension and pupillary abnormalities are important determinants for patients’ outcomes. Early trajectories define the dynamics of SI and contribute to a better understanding of how early recognition and treatments in emergency settings could impact on 6-month outcomes and mortality.
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Affiliation(s)
- Paola Cristina Volpi
- School of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, 20900, Monza, MB, Italy.
| | - Chiara Robba
- Neurocritical Care Unit, Addenbrooke's Hospital, Cambridge University, Box 1, Addenbrooke's Hospital, Cambridge University Hospitals Trust, Hills Road, Cambridge, CB2 0QQ, UK.,Anaesthesia and Intensive Care, Policlinico San Martino IRCCS for Oncology, Largo Rosanna Benzi, 16132, Genoa, GE, Italy
| | - Matteo Rota
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Alessia Vargiolu
- Neurointensive Care Unit, San Gerardo Hospital, ASST-Monza, Via G. B. Pergolesi 33, 20835, Monza, MB, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, 20900, Monza, MB, Italy.,Neurointensive Care Unit, San Gerardo Hospital, ASST-Monza, Via G. B. Pergolesi 33, 20835, Monza, MB, Italy
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Lazarus R, Helmick K, Malik S, Gregory E, Agimi Y, Marion D. Continuum of the United States military’s traumatic brain injury care: adjusting to the changing battlefield. Neurosurg Focus 2018; 45:E15. [DOI: 10.3171/2018.9.focus18396] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 09/10/2018] [Indexed: 01/23/2023]
Abstract
Over the past 8 years, advances in the US Military Health System (MHS) have led to extensive changes in the way combat casualty care is provided to deployed service members with a traumatic brain injury (TBI). Changes include the application of cutting-edge Clinical Practice Guidelines, use of pioneering technologies, and advances in evacuation procedures. Compared with previous engagements, current operations occur on a much smaller scale, and more frequently in austere environments, such that effective medical support is increasingly challenging. In this paper, the authors describe key aspects of the current continuum of TBI care in the US military, from the point of injury through rehabilitation, with an emphasis on how emerging technologies and evidence-based Clinical Practice Guidelines assist MHS clinicians with providing the best clinical care possible in the changing battlefield.
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Affiliation(s)
- Rachel Lazarus
- 1Defense and Veterans Brain Injury Center, Silver Spring, Maryland; and
- 2General Dynamics Health Solutions, and
| | - Katherine Helmick
- 1Defense and Veterans Brain Injury Center, Silver Spring, Maryland; and
| | - Saafan Malik
- 1Defense and Veterans Brain Injury Center, Silver Spring, Maryland; and
| | - Emma Gregory
- 1Defense and Veterans Brain Injury Center, Silver Spring, Maryland; and
| | - Yll Agimi
- 1Defense and Veterans Brain Injury Center, Silver Spring, Maryland; and
- 3Salient CRGT, Fairfax, Virginia
| | - Donald Marion
- 1Defense and Veterans Brain Injury Center, Silver Spring, Maryland; and
- 2General Dynamics Health Solutions, and
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Crewdson K, Rehn M, Lockey D. Airway management in pre-hospital critical care: a review of the evidence for a 'top five' research priority. Scand J Trauma Resusc Emerg Med 2018; 26:89. [PMID: 30342543 PMCID: PMC6196027 DOI: 10.1186/s13049-018-0556-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 10/04/2018] [Indexed: 12/21/2022] Open
Abstract
The conduct and benefit of pre-hospital advanced airway management and pre-hospital emergency anaesthesia have been widely debated for many years. In 2011, prehospital advanced airway management was identified as a ‘top five’ in physician-provided pre-hospital critical care. This article summarises the evidence for and against this intervention since 2011 and attempts to address some of the more controversial areas of this topic.
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Affiliation(s)
- K Crewdson
- Department of Anaesthesia, North Bristol NHS Trust, Southmead Hospital, Southmead Way, Bristol, BS10 5NB, UK.
| | - M Rehn
- Department of Research, Norwegian Air Ambulance Foundation, Drøbak, Norway.,Pre-hospital Division, Air Ambulance Department, Oslo University Hospital, Oslo, Norway.,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - D Lockey
- Department of Anaesthesia, North Bristol NHS Trust, Southmead Hospital, Southmead Way, Bristol, BS10 5NB, UK.,Department of Research, Norwegian Air Ambulance Foundation, Drøbak, Norway.,Bristol University, Bristol, UK
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64
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Braude DA, Davis D. Out-of-Hospital Medication-Facilitated Airway Management: Important Lessons and Limitations. Ann Emerg Med 2018; 72:280-281. [DOI: 10.1016/j.annemergmed.2018.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Indexed: 11/26/2022]
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65
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Synnot A, Bragge P, Lunny C, Menon D, Clavisi O, Pattuwage L, Volovici V, Mondello S, Cnossen MC, Donoghue E, Gruen RL, Maas A. The currency, completeness and quality of systematic reviews of acute management of moderate to severe traumatic brain injury: A comprehensive evidence map. PLoS One 2018; 13:e0198676. [PMID: 29927963 PMCID: PMC6013193 DOI: 10.1371/journal.pone.0198676] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 05/23/2018] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To appraise the currency, completeness and quality of evidence from systematic reviews (SRs) of acute management of moderate to severe traumatic brain injury (TBI). METHODS We conducted comprehensive searches to March 2016 for published, English-language SRs and RCTs of acute management of moderate to severe TBI. Systematic reviews and RCTs were grouped under 12 broad intervention categories. For each review, we mapped the included and non-included RCTs, noting the reasons why RCTs were omitted. An SR was judged as 'current' when it included the most recently published RCT we found on their topic, and 'complete' when it included every RCT we found that met its inclusion criteria, taking account of when the review was conducted. Quality was assessed using the AMSTAR checklist (trichotomised into low, moderate and high quality). FINDINGS We included 85 SRs and 213 RCTs examining the effectiveness of treatments for acute management of moderate to severe TBI. The most frequently reviewed interventions were hypothermia (n = 17, 14.2%), hypertonic saline and/or mannitol (n = 9, 7.5%) and surgery (n = 8, 6.7%). Of the 80 single-intervention SRs, approximately half (n = 44, 55%) were judged as current and two-thirds (n = 52, 65.0%) as complete. When considering only the most recently published review on each intervention (n = 25), currency increased to 72.0% (n = 18). Less than half of the 85 SRs were judged as high quality (n = 38, 44.7%), and nearly 20% were low quality (n = 16, 18.8%). Only 16 (20.0%) of the single-intervention reviews (and none of the five multi-intervention reviews) were judged as current, complete and high-quality. These included reviews of red blood cell transfusion, hypothermia, management guided by intracranial pressure, pharmacological agents (various) and prehospital intubation. Over three-quarters (n = 167, 78.4%) of the 213 RCTs were included in one or more SR. Of the remainder, 17 (8.0%) RCTs post-dated or were out of scope of existing SRs, and 29 (13.6%) were on interventions that have not been assessed in SRs. CONCLUSION A substantial number of SRs in acute management of moderate to severe TBI lack currency, completeness and quality. We have identified both potential evidence gaps and also substantial research waste. Novel review methods, such as Living Systematic Reviews, may ameliorate these shortcomings and enhance utility and reliability of the evidence underpinning clinical care.
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Affiliation(s)
- Anneliese Synnot
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- National Trauma Research Institute, The Alfred, Monash University, Melbourne, Victoria, Australia
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Cochrane Consumers and Communication, School of Psychology and Public Health, La Trobe University, Melbourne, Victoria, Australia
| | - Peter Bragge
- BehaviourWorks Australia, Monash Sustainable Development Institute, Monash University, Melbourne, Victoria, Australia
| | - Carole Lunny
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - David Menon
- Division of Anaesthesia, University of Cambridge; Neurosciences Critical Care Unit, Addenbrooke’s Hospital; Queens’ College, Cambridge, United Kingdom
| | - Ornella Clavisi
- National Trauma Research Institute, The Alfred, Monash University, Melbourne, Victoria, Australia
- MOVE: Muscle, Bone and Joint Health Ltd, Melbourne, Victoria, Australia
| | - Loyal Pattuwage
- National Trauma Research Institute, The Alfred, Monash University, Melbourne, Victoria, Australia
- Monash Centre for Occupational and Environmental Health (MonCOEH), Monash University, Melbourne, Victoria, Australia
| | - Victor Volovici
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Neurosurgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Maryse C. Cnossen
- Center for Medical Decision Making, Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Emma Donoghue
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Russell L. Gruen
- Nanyang Technical University, Singapore
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Andrew Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
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Expert-Performed Endotracheal Intubation-Related Complications in Trauma Patients: Incidence, Possible Risk Factors, and Outcomes in the Prehospital Setting and Emergency Department. Emerg Med Int 2018; 2018:5649476. [PMID: 29984001 PMCID: PMC6015695 DOI: 10.1155/2018/5649476] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 04/19/2018] [Accepted: 05/16/2018] [Indexed: 11/18/2022] Open
Abstract
The aim of this study was to determine complication rates and possible risk factors of expert-performed endotracheal intubation (ETI) in patients with trauma, in both the prehospital setting and the emergency department. We also investigated how the occurrence of ETI-related complications affected the survival of trauma patients. This single-center retrospective observational study included all injured patients who underwent anesthesiologist-performed ETI from 2007 to 2017. ETI-related complications were defined as hypoxemia, unrecognized esophageal intubation, regurgitation, cardiac arrest, ETI failure rescued by emergency surgical airway, dental trauma, cuff leak, and mainstem bronchus intubation. Of the 537 patients included, 23.5% experienced at least one complication. Multivariable logistic regression analysis revealed that low Glasgow Coma Scale Score (adjusted odds ratio [AOR], 0.93; 95% confidence interval [CI], 0.88-0.98), elevated heart rate (AOR, 1.01; 95% CI, 1.00-1.02), and three or more ETI attempts (AOR, 15.71; 95% CI, 3.37-73.2) were independent predictors of ETI-related complications. We also found that ETI-related complications decreased the likelihood of survival of trauma patients (AOR, 0.60; 95% CI, 0.38-0.95), independently of age, male sex, Injury Severity Score, Glasgow Coma Scale Score, and off-hours presentation. Our results suggest that airway management in trauma patients carries a very high risk; this finding has implications for the practice of airway management in injured patients.
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Sunde GA, Kottmann A, Heltne JK, Sandberg M, Gellerfors M, Krüger A, Lockey D, Sollid SJM. Standardised data reporting from pre-hospital advanced airway management - a nominal group technique update of the Utstein-style airway template. Scand J Trauma Resusc Emerg Med 2018; 26:46. [PMID: 29866144 PMCID: PMC5987657 DOI: 10.1186/s13049-018-0509-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 05/09/2018] [Indexed: 12/31/2022] Open
Abstract
Background Pre-hospital advanced airway management with oxygenation and ventilation may be vital for managing critically ill or injured patients. To improve pre-hospital critical care and develop evidence-based guidelines, research on standardised high-quality data is important. We aimed to identify which airway data were most important to report today and to revise and update a previously reported Utstein-style airway management dataset. Methods We recruited sixteen international experts in pre-hospital airway management from Australia, United States of America, and Europe. We used a five-step modified nominal group technique to revise the dataset, and clinical study results from the original template were used to guide the process. Results The experts agreed on a key dataset of thirty-two operational variables with six additional system variables, organised in time, patient, airway management and system sections. Of the original variables, one remained unchanged, while nineteen were modified in name, category, definition or value. Sixteen new variables were added. The updated dataset covers risk factors for difficult intubation, checklist and standard operating procedure use, pre-oxygenation strategies, the use of drugs in airway management, airway currency training, developments in airway devices, airway management strategies, and patient safety issues not previously described. Conclusions Using a modified nominal group technique with international airway management experts, we have updated the Utstein-style dataset to report standardised data from pre-hospital advanced airway management. The dataset enables future airway management research to produce comparable high-quality data across emergency medical systems. We believe this approach will promote research and improve treatment strategies and outcomes for patients receiving pre-hospital advanced airway management. Trial registration The Regional Committee for Medical and Health Research Ethics in Western Norway exempted this study from ethical review (Reference: REK-Vest/2017/260). Electronic supplementary material The online version of this article (10.1186/s13049-018-0509-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- G A Sunde
- Norwegian Air Ambulance Foundation, Drøbak, Norway. .,Dept. of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway. .,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.
| | - A Kottmann
- Norwegian Air Ambulance Foundation, Drøbak, Norway.,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.,Emergency Dept., University Hospital of Lausanne, Lausanne, Switzerland.,Swiss Air Ambulance - Rega, Zürich, Switzerland
| | - J K Heltne
- Dept. of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway.,Dept. of Medical Sciences, University of Bergen, Bergen, Norway
| | - M Sandberg
- Air Ambulance Dept., Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - M Gellerfors
- Karolinska Institutet, Dept. of Clinical Science and Education, Section of Anaesthesiology and Intensive Care, Stockholm, Sweden.,Swedish Air Ambulance (SLA), Mora, Sweden.,Dept. of Anaesthesiology and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - A Krüger
- Norwegian Air Ambulance Foundation, Drøbak, Norway.,Dept. of Emergency Medicine and Pre-hospital Services, St. Olavs Hospital, Trondheim, Norway
| | - D Lockey
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.,London's Air Ambulance, Bartshealth NHS Trust, London, UK
| | - S J M Sollid
- Norwegian Air Ambulance Foundation, Drøbak, Norway.,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.,Air Ambulance Dept., Oslo University Hospital, Oslo, Norway
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Hardy GB, Maddry JK, Ng PC, Savell SC, Arana AA, Kester A, Bebarta VS. Impact of prehospital airway management on combat mortality. Am J Emerg Med 2018; 37:349-350. [DOI: 10.1016/j.ajem.2018.02.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 01/11/2018] [Accepted: 06/21/2018] [Indexed: 10/18/2022] Open
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Airway and ventilation management strategies for hemorrhagic shock. To tube, or not to tube, that is the question! J Trauma Acute Care Surg 2018; 84:S77-S82. [DOI: 10.1097/ta.0000000000001822] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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70
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Pre-hospital advanced airway management by anaesthetist and nurse anaesthetist critical care teams: a prospective observational study of 2028 pre-hospital tracheal intubations. Br J Anaesth 2018; 120:1103-1109. [DOI: 10.1016/j.bja.2017.12.036] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 12/19/2017] [Accepted: 12/27/2017] [Indexed: 12/12/2022] Open
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Rubenson Wahlin R, Nelson DW, Bellander BM, Svensson M, Helmy A, Thelin EP. Prehospital Intubation and Outcome in Traumatic Brain Injury-Assessing Intervention Efficacy in a Modern Trauma Cohort. Front Neurol 2018; 9:194. [PMID: 29692755 PMCID: PMC5903008 DOI: 10.3389/fneur.2018.00194] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 03/13/2018] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Prehospital intubation in traumatic brain injury (TBI) focuses on limiting the effects of secondary insults such as hypoxia, but no indisputable evidence has been presented that it is beneficial for outcome. The aim of this study was to explore the characteristics of patients who undergo prehospital intubation and, in turn, if these parameters affect outcome. MATERIAL AND METHODS Patients ≥15 years admitted to the Department of Neurosurgery, Stockholm, Sweden with TBI from 2008 through 2014 were included. Data were extracted from prehospital and hospital charts, including prospectively collected Glasgow Outcome Score (GOS) after 12 months. Univariate and multivariable logistic regression models were employed to examine parameters independently correlated to prehospital intubation and outcome. RESULTS A total of 458 patients were included (n = 178 unconscious, among them, n = 61 intubated). Multivariable analyses indicated that high energy trauma, prehospital hypotension, pupil unresponsiveness, mode of transportation, and distance to the hospital were independently correlated with intubation, and among them, only pupil responsiveness was independently associated with outcome. Prehospital intubation did not add independent information in a step-up model versus GOS (p = 0.154). Prehospital reports revealed that hypoxia was not the primary cause of prehospital intubation, and that the procedure did not improve oxygen saturation during transport, while an increasing distance from the hospital increased the intubation frequency. CONCLUSION In this modern trauma cohort, prehospital intubation was not independently associated with outcome; however, hypoxia was not a common reason for prehospital intubation. Prospective trials to assess efficacy of prehospital airway intubation will be difficult due to logistical and ethical considerations.
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Affiliation(s)
- Rebecka Rubenson Wahlin
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Department of Anesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - David W. Nelson
- Section of Anesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Bo-Michael Bellander
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Mikael Svensson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Eric Peter Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
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Thomas SH, Blumen I. Helicopter Emergency Medical Services Literature 2014 to 2016: Lessons and Perspectives, Part 1-Helicopter Transport for Trauma. Air Med J 2018; 37:54-63. [PMID: 29332779 DOI: 10.1016/j.amj.2017.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 10/30/2017] [Indexed: 11/30/2022]
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Discrepancy between the initial assessment of injury severity and post hoc determination of injury severity in patients with apparently mild traumatic brain injury: a retrospective multicenter cohort analysis. Eur J Trauma Emerg Surg 2017; 44:889-896. [PMID: 29032474 PMCID: PMC6267145 DOI: 10.1007/s00068-017-0861-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 10/09/2017] [Indexed: 11/10/2022]
Abstract
Purpose Traumatic brain injury (TBI) is a major cause of trauma-related visits to emergency departments (ED). Determination of monitoring requirements of patients with apparently mild TBI is challenging. Patients may turn out to be more severely injured than initially assumed, and failure to identify these patients constitutes a serious threat to patient safety. We, therefore, aimed to identify clinical risk factors for more severe injuries in patients with apparently mild TBI. Methods In a retrospective cohort analysis performed at two level I trauma centers, 808 patients aged ≥ 16 presenting to the ED with head trauma and a Glasgow Coma Scale (GCS) score 13–15 who received a head CT scan were studied. Discrepancies between the initial TBI severity as determined by GCS and severity as determined post hoc by the Head Abbreviated Injury Score were assessed. Multiple logistic regression was used to identify risk factors of such discrepancies. Results 104 (12.9%) patients were more severely injured than initially classified. A GCS < 15 at presentation (GCS 13: OR 6.2, [95% CI 3.8–9.9]; GCS 14: OR 2.7, [2.0–3.7]), an SpO2 < 90% (OR 5.4, [1.2–23.4]), loss of consciousness (OR 2.3, [1.5–3.5]), absence of equal and reactive pupils (OR 2.1, [1.6–2.7]), transport by ambulance (OR 2.0, [1.7–2.4]), and use of anticoagulant drugs (OR 1.2, [1.1–1.3]) were independent risk factors of more severe injury. Conclusions Six risk factors of more severe injury in patients presenting with apparently mild TBI were identified. Patients with any of these factors should be thoroughly monitored for signs of neurologic deterioration.
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Increased mortality in trauma patients who develop postintubation hypotension. J Trauma Acute Care Surg 2017; 83:569-574. [PMID: 28930950 DOI: 10.1097/ta.0000000000001561] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Postintubation hypotension (PIH) is common and associated with poor outcomes in critically ill patient populations requiring emergency endotracheal intubation (ETI). The importance of PIH in the trauma population remains unclear. The objective of this study was to determine the prevalence of PIH in trauma patients and assess the association of PIH with patient outcomes. METHODS Retrospective case series of adult (≥16 years) patients who were intubated on arrival at a tertiary trauma center in Halifax, Nova Scotia, Canada, between 2000 and 2015. Data were collected from the Nova Scotia Trauma Registry and patient chart, and included demographics, comorbidities, trauma characteristics, intubation time, as well as all fluids, medications, adverse events, interventions, and vital signs during the 15 minutes before/after ETI. We evaluated the prevalence of PIH and created a logistic regression model to determine likelihood of mortality in the PIH and non-PIH groups after controlling for patient and provider characteristics. RESULTS Overall, 477 patients required ETI on assessment by the trauma service, of which 444 patients met eligibility criteria and were included in the analysis. The prevalence of PIH was 36.3% (161 of 444) in our study population. In-hospital mortality occurred in 29.8% (48 of 161) of patients in the PIH group, compared with 15.9% (45 of 283) of patients in the non-PIH group (p = 0.001). Development of PIH was associated with increased mortality in the emergency department (adjusted odds ratio, 3.45; 95% confidence interval, 1.42-8.36) and in-hospital (adjusted odds ratio, 1.83; 95% confidence interval, 1.01-3.31). CONCLUSION In our study of trauma patients requiring ETI, development of PIH was common (36.3%) and associated with increased mortality. Intubation practices in critically ill trauma patients is an important patient safety issue that requires further investigation. LEVEL OF EVIDENCE Prognostic and epidemiological, level III; Level IV, Therapeutic.
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Martin-Gill C, Guyette FX. Hypotension in Traumatic Brain Injury: Describing the Depth of the Problem. Ann Emerg Med 2017; 70:531-532. [DOI: 10.1016/j.annemergmed.2017.04.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Indexed: 11/15/2022]
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76
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Fouche PF, Stein C, Simpson P, Carlson JN, Doi SA. Nonphysician Out-of-Hospital Rapid Sequence Intubation Success and Adverse Events: A Systematic Review and Meta-Analysis. Ann Emerg Med 2017; 70:449-459.e20. [DOI: 10.1016/j.annemergmed.2017.03.026] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Revised: 03/12/2017] [Accepted: 03/16/2017] [Indexed: 12/20/2022]
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77
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Pakkanen T, Kämäräinen A, Huhtala H, Silfvast T, Nurmi J, Virkkunen I, Yli-Hankala A. Physician-staffed helicopter emergency medical service has a beneficial impact on the incidence of prehospital hypoxia and secured airways on patients with severe traumatic brain injury. Scand J Trauma Resusc Emerg Med 2017; 25:94. [PMID: 28915898 PMCID: PMC5603088 DOI: 10.1186/s13049-017-0438-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 09/06/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND After traumatic brain injury (TBI), hypotension, hypoxia and hypercapnia have been shown to result in secondary brain injury that can lead to increased mortality and disability. Effective prehospital assessment and treatment by emergency medical service (EMS) is considered essential for favourable outcome. The aim of this study was to evaluate the effect of a physician-staffed helicopter emergency medical service (HEMS) in the treatment of TBI patients. METHODS This was a retrospective cohort study. Prehospital data from two periods were collected: before (EMS group) and after (HEMS group) the implementation of a physician-staffed HEMS. Unconscious prehospital patients due to severe TBI were included in the study. Unconsciousness was defined as a Glasgow coma scale (GCS) score ≤ 8 and was documented either on-scene, during transportation or by an on-call neurosurgeon on hospital admission. Modified Glasgow Outcome Score (GOS) was used for assessment of six-month neurological outcome and good neurological outcome was defined as GOS 4-5. RESULTS Data from 181 patients in the EMS group and 85 patients in the HEMS group were available for neurological outcome analyses. The baseline characteristics and the first recorded vital signs of the two cohorts were similar. Good neurological outcome was more frequent in the HEMS group; 42% of the HEMS managed patients and 28% (p = 0.022) of the EMS managed patients had a good neurological recovery. The airway was more frequently secured in the HEMS group (p < 0.001). On arrival at the emergency department, the patients in the HEMS group were less often hypoxic (p = 0.024). In univariate analysis HEMS period, lower age and secured airway were associated with good neurological outcome. CONCLUSION The introduction of a physician-staffed HEMS unit resulted in decreased incidence of prehospital hypoxia and increased the number of secured airways. This may have contributed to the observed improved neurological outcome during the HEMS period. TRIAL REGISTRATION ClinicalTrials.gov IDNCT02659046. Registered January 15th, 2016.
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Affiliation(s)
- Toni Pakkanen
- FinnHEMS Ltd, Research and Development Unit, Vantaa, Finland. .,Department of Anaesthesia, Tampere University Hospital, Tampere, Finland.
| | - Antti Kämäräinen
- Tays Emergency Medical Service, FinnHEMS 30, Tampere University Hospital, Tampere, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, University of Tampere, Tampere, Finland
| | - Tom Silfvast
- Department of Anaesthesia and Intensive Care, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Jouni Nurmi
- Department of Emergency Medicine and Services, Helsinki University Hospital and Emergency Medicine, University of Helsinki, Helsinki, Finland
| | - Ilkka Virkkunen
- FinnHEMS Ltd, Research and Development Unit, Vantaa, Finland
| | - Arvi Yli-Hankala
- Department of Anaesthesia, Tampere University Hospital, Tampere, Finland.,Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
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Aleksandrowicz D, Gaszyński T. Airway management with simultaneous cervical spine immobilisation: A comparison between the Macintosh laryngoscope and the Airtraq ® optical laryngoscope used by experienced paramedics – A manikin study. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2017. [DOI: 10.1016/j.tacc.2017.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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80
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Sunde GA, Sandberg M, Lyon R, Fredriksen K, Burns B, Hufthammer KO, Røislien J, Soti A, Jäntti H, Lockey D, Heltne JK, Sollid SJM. Hypoxia and hypotension in patients intubated by physician staffed helicopter emergency medical services - a prospective observational multi-centre study. BMC Emerg Med 2017; 17:22. [PMID: 28693491 PMCID: PMC5504565 DOI: 10.1186/s12873-017-0134-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 06/30/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The effective treatment of airway compromise in trauma and non-trauma patients is important. Hypoxia and hypotension are predictors of negative patient outcomes and increased mortality, and may be important quality indicators of care provided by emergency medical services. Excluding cardiac arrests, critical trauma and non-trauma patients remain the two major groups to which helicopter emergency medical services (HEMS) are dispatched. Several studies describe the impact of pre-hospital hypoxia or hypotension on trauma patients, but few studies compare this in trauma and non-trauma patients. The primary aim was to describe the incidence of pre-hospital hypoxia and hypotension in the two groups receiving pre-hospital tracheal intubation (TI) by physician-staffed HEMS. METHODS Data were collected prospectively over a 12-month period, using a uniform Utstein-style airway template. Twenty-one physician-staffed HEMS in Europe and Australia participated. We compared peripheral oxygen saturation and systolic blood pressure before and after definitive airway management. Data were analysed using Cochran-Mantel-Haenszel methods and mixed-effects models. RESULTS Eight hundred forty three trauma patients and 422 non-trauma patients receiving pre-hospital TI were included. Non-trauma patients had significantly lower predicted mean pre-intervention SpO2 compared to trauma patients. Post-intervention and admission SpO2 for the two groups were comparable. However, 3% in both groups were still hypoxic at admission. For hypotension, the differences between the groups were less prominent. However, 9% of trauma and 10% of non-trauma patients were still hypotensive at admission. There was no difference in short-term survival between trauma (97%) and non-trauma patients (95%). Decreased level of consciousness was the most frequent indication for TI, and was associated with increased survival to hospital (cOR 2.8; 95% CI: 1.4-5.4). CONCLUSIONS Our results showed that non-trauma patients had a higher incidence of hypoxia before TI than trauma patients, but few were hypoxic at admission. The difference for hypotension was less prominent, but one in ten patients were still hypotensive at admission. Further investigations are needed to identify reversible causes that may be corrected to improve haemodynamics in the pre-hospital setting. We found high survival rates to hospital in both groups, suggesting that physician-staffed HEMS provide high-quality emergency airway management in trauma and non-trauma patients. TRIAL REGISTRATION Clinicaltrials.gov Identifier: NCT01502111 . Registered 22 Desember 2011.
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Affiliation(s)
- Geir Arne Sunde
- Norwegian Air Ambulance Foundation, Drøbak, Norway. .,Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway. .,Department of Health Sciences, University of Stavanger, Stavanger, Norway. .,Norwegian Air Ambulance Foundation, Møllendalsveien 34, 5009, Bergen, Norway.
| | - Mårten Sandberg
- Air Ambulance Department, Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Richard Lyon
- University of Surrey, Guildford, UK.,Kent, Surrey & Sussex Air Ambulance Trust, Marden, UK
| | - Knut Fredriksen
- UiT - The Arctic University of Norway, Tromsø, Norway.,The University Hospital of North Norway, Tromsø, Norway
| | - Brian Burns
- Sydney HEMS, NSW Ambulance, Sydney, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia
| | | | - Jo Røislien
- Norwegian Air Ambulance Foundation, Drøbak, Norway.,Department of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Akos Soti
- Hungarian Air Ambulance Nonprofit Ltd, Budaors, Hungary
| | - Helena Jäntti
- Centre for Pre-hospital Emergency Care, Kuopio University Hospital, Kuopio, Finland
| | - David Lockey
- Department of Health Sciences, University of Stavanger, Stavanger, Norway.,London's Air Ambulance, Bartshealth NHS Trust, London, UK
| | - Jon-Kenneth Heltne
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway.,Department of Medical Sciences, University of Bergen, Bergen, Norway
| | - Stephen J M Sollid
- Norwegian Air Ambulance Foundation, Drøbak, Norway.,Department of Health Sciences, University of Stavanger, Stavanger, Norway.,Air Ambulance Department, Oslo University Hospital, Oslo, Norway
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81
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Trimmel H, Beywinkler C, Hornung S, Kreutziger J, Voelckel WG. In-hospital airway management training for non-anesthesiologist EMS physicians: a descriptive quality control study. Scand J Trauma Resusc Emerg Med 2017; 25:45. [PMID: 28441963 PMCID: PMC5405543 DOI: 10.1186/s13049-017-0386-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 04/07/2017] [Indexed: 11/13/2022] Open
Abstract
Background Pre-hospital airway management is a major challenge for emergency medical service (EMS) personnel. Despite convincing evidence that the rescuer’s qualifications determine efficacy of tracheal intubation, in-hospital airway management training is not mandatory in Austria, and often neglected. Thus we sought to prove that airway management competence of EMS physicians can be established and maintained by a tailored training program. Methods In this descriptive quality control study we retrospectively evaluated all in- and pre-hospital airway cases managed by EMS physicians who underwent a structured in-hospital training program in anesthesia at General Hospital Wiener Neustadt. Data was obtained from electronic anesthesia and EMS documentation systems. Results From 2006 to 2016, 32 EMS physicians with 3-year post-graduate education, but without any prior experience in anesthesia were trained. Airway management proficiency was imparted in three steps: initial training, followed by an ongoing practice schedule in the operating room (OR). Median and interquartile range of number of in-hospital tracheal intubations (TIs) vs. use of supra-glottic airway devices (SGA) were 33.5 (27.5–42.5) vs. 19.0 (15.0–27.0) during initial training; 62.0 (41.8–86.5) vs. 33.5 (18.0–54.5) during the first, and 64.0 (34.5–93.8) vs. 27 (12.5–56.0) during the second year. Pre-hospitaly, every physician performed 9.0 (5.0–14.8) TIs vs. 0.0 (0.0–0.0) SGA cases during the first, and 9.0 (7.0–13.8) TIs vs. 0.0 (0.0–0.3) SGA during the second year. Use of an SGA was mandatory when TI failed after the second attempt, thus accounting for a total of 33 cases. In 8 cases, both TI and SGA failed, but bag mask ventilation was successfully performed. No critical events related to airway management were noted and overall success rate for TI with a max of 2 attempts was 95.3%. Discussion Number of TIs per EMS physician is low in the pre-hospital setting. A training concept that assures an additional 60+ TIs per year appears to minimize failure rates. Thus, a fixed amount of working days in anesthesia seems crucial to maintain proficiency. Conclusions In-hospital training programs are mandatory for non-anesthetist EMS physicians to gain competence in airway management and emergency anesthesia.Our results might be helpful when discussing the need for regulation and financing with the authorities.
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Affiliation(s)
- Helmut Trimmel
- From the Department of Anesthesiology, Emergency and Critical Care Medicine and Karl Landsteiner Institute of Emergency Medicine, General Hospital Wiener Neustadt, Corvinusring 3-5, A 2700, Wiener Neustadt, Austria. .,ÖAMTC Air Rescue, Vienna, Austria.
| | - Christoph Beywinkler
- From the Department of Anesthesiology, Emergency and Critical Care Medicine and Karl Landsteiner Institute of Emergency Medicine, General Hospital Wiener Neustadt, Corvinusring 3-5, A 2700, Wiener Neustadt, Austria
| | - Sonja Hornung
- From the Department of Anesthesiology, Emergency and Critical Care Medicine and Karl Landsteiner Institute of Emergency Medicine, General Hospital Wiener Neustadt, Corvinusring 3-5, A 2700, Wiener Neustadt, Austria.,ÖAMTC Air Rescue, Vienna, Austria
| | - Janett Kreutziger
- Department of Anesthesiology and Critical Care Medicine, Medical University, Innsbruck, Austria
| | - Wolfgang G Voelckel
- Norwegian Air Ambulance, Bergen, Norway.,Department of Anesthesiology and Critical Care Medicine, AUVA Trauma Center Salzburg, Salzburg, Austria.,University of Stavanger, Network for Medical Science, Stavanger, Norway
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82
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Advanced airway management in an anaesthesiologist-staffed Helicopter Emergency Medical Service (HEMS): A retrospective analysis of 1047 out-of-hospital intubations. Resuscitation 2016; 105:66-9. [DOI: 10.1016/j.resuscitation.2016.04.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 04/13/2016] [Accepted: 04/15/2016] [Indexed: 01/23/2023]
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83
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Rehn M, Hyldmo PK, Magnusson V, Kurola J, Kongstad P, Rognås L, Juvet LK, Sandberg M. Scandinavian SSAI clinical practice guideline on pre-hospital airway management. Acta Anaesthesiol Scand 2016; 60:852-64. [PMID: 27255435 PMCID: PMC5089575 DOI: 10.1111/aas.12746] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 04/13/2016] [Accepted: 04/24/2016] [Indexed: 12/17/2022]
Abstract
Background The Scandinavian society of anaesthesiology and intensive care medicine task force on pre‐hospital airway management was asked to formulate recommendations following standards for trustworthy clinical practice guidelines. Methods The literature was systematically reviewed and the grading of recommendations assessment, development and evaluation (GRADE) system was applied to move from evidence to recommendations. Results We recommend that all emergency medical service (EMS) providers consider to: apply basic airway manoeuvres and airway adjuncts (good practice recommendation); turn unconscious non‐trauma patients into the recovery position when advanced airway management is unavailable (good practice recommendation); turn unconscious trauma patients to the lateral trauma position while maintaining spinal alignment when advanced airway management is unavailable [strong recommendation, low quality of evidence (QoE)]. We suggest that intermediately trained providers use a supraglottic airway device (SAD) or basic airway manoeuvres on patients in cardiac arrest (weak recommendation, low QoE). We recommend that advanced trained providers consider using an SAD in selected indications or as a rescue device after failed endotracheal intubation (ETI) (good practice recommendation). We recommend that ETI should only be performed by advanced trained providers (strong recommendation, low QoE). We suggest that videolaryngoscopy is considered for ETI when direct laryngoscopy fails or is expected to be difficult (weak recommendation, low QoE). We suggest that advanced trained providers apply cricothyroidotomy in ‘cannot intubate, cannot ventilate’ situations (weak recommendation, low QoE). Conclusion This guideline for pre‐hospital airway management includes a combination of techniques applied in a stepwise fashion appropriate to patient clinical status and provider training.
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Affiliation(s)
- M. Rehn
- The Norwegian Air Ambulance Foundation Drøbak Norway
- London's Air Ambulance Barts Health Trust London UK
- Field of Pre‐hospital Critical Care University of Stavanger Stavanger Norway
| | - P. K. Hyldmo
- The Norwegian Air Ambulance Foundation Drøbak Norway
- Department of Anaesthesiology and Intensive Care Sørlandet Hospital Kristiansand Norway
| | - V. Magnusson
- Department of Anaesthesia and Intensive Care Medicine Landspitali University Hospital Reykjavik Iceland
| | - J. Kurola
- Centre for Pre‐hospital Emergency Care Kuopio University Hospital Kuopio Finland
| | - P. Kongstad
- Department of Pre‐hospital Care and Disaster Medicine Region of Skåne Lund Sweden
| | - L. Rognås
- Pre‐hospital Critical Care Service Aarhus University Hospital Aarhus Denmark
- The Danish Air Ambulance Aarhus Denmark
| | - L. K. Juvet
- Norwegian Institute of Public Health Oslo Norway
- University College of Southeast Norway Notodden Norway
| | - M. Sandberg
- Air Ambulance Department Oslo University Hospital Oslo Norway
- University of Oslo Oslo Norway
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84
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Zhang C, Li JM, Dou DZ, Hu JL. Clinical study on acute craniocerebral injury treated with mild hypothermia auxiliary therapy. JOURNAL OF ACUTE DISEASE 2016. [DOI: 10.1016/j.joad.2016.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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85
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Hilbert-Carius P, Helm M, Lier H, Fischer M, Hofmann G, Lott C, Wurmb T, Bauer M, Winning J, Böttiger BW, Bernhard M. Um klar zu sehen, genügt oft ein Wechsel der Blickrichtung. Unfallchirurg 2016; 119:323-6. [DOI: 10.1007/s00113-016-0147-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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