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Weigeldt M, Schulz-Drost S, Stengel D, Lefering R, Treskatsch S, Berger C. In-hospital mortality after prehospital endotracheal intubation versus alternative methods of airway management in trauma patients. A cohort study from the TraumaRegister DGU®. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02498-8. [PMID: 38509186 DOI: 10.1007/s00068-024-02498-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 03/10/2024] [Indexed: 03/22/2024]
Abstract
PURPOSE Prehospital airway management in trauma is a key component of care and is associated with particular risks. Endotracheal intubation (ETI) is the gold standard, while extraglottic airway devices (EGAs) are recommended alternatives. There is limited evidence comparing their effectiveness. In this retrospective analysis from the TraumaRegister DGU®, we compared ETI with EGA in prehospital airway management regarding in-hospital mortality in patients with trauma. METHODS We included cases only from German hospitals with a minimum Abbreviated Injury Scale score ≥ 2 and age ≥ 16 years. All patients without prehospital airway protection were excluded. We performed a multivariate logistic regression to adjust with the outcome measure of hospital mortality. RESULTS We included n = 10,408 cases of whom 92.5% received ETI and 7.5% EGA. The mean injury severity score was higher in the ETI group (28.8 ± 14.2) than in the EGA group (26.3 ± 14.2), and in-hospital mortality was comparable: ETI 33.0%; EGA 30.7% (27.5 to 33.9). After conducting logistic regression, the odds ratio for mortality in the ETI group was 1.091 (0.87 to 1.37). The standardized mortality ratio was 1.04 (1.01 to 1.07) in the ETI group and 1.1 (1.02 to 1.26) in the EGA group. CONCLUSIONS There was no significant difference in mortality rates between the use of ETI or EGA, or the ratio of expected versus observed mortality when using ETI.
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Affiliation(s)
- Moritz Weigeldt
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany.
| | | | - Dirk Stengel
- BG Kliniken - Hospital Group of the German Federal Statutory Accident Insurance, Leipziger Platz 1, 10117, Berlin, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), Faculty of Health, Witten/Herdecke University, 51109, Cologne, Germany
- Committee On Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS) of the German Trauma Society (DGU), Berlin, Germany
| | - Sascha Treskatsch
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Christian Berger
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
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Gilaed A, Shorbaji N, Katzir O, Ankol S, Badarni K, Andrawus E, Roimi M, Katz A, Bar-Lavie Y, Raz A, Epstein D. Early risk factors for prolonged mechanical ventilation in patients with severe blunt thoracic trauma: A retrospective cohort study. Injury 2024; 55:111194. [PMID: 37978015 DOI: 10.1016/j.injury.2023.111194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 10/14/2023] [Accepted: 11/07/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND A significant proportion of patients with severe chest trauma require mechanical ventilation (MV). Early prediction of the duration of MV may influence clinical decisions. We aimed to determine early risk factors for prolonged MV among adults suffering from severe blunt thoracic trauma. METHODS This retrospective, single-center, cohort study included all patients admitted between January 2014 and December 2020 due to severe blunt chest trauma. The primary outcome was prolonged MV, defined as invasive MV lasting more than 14 days. Multivariable logistic regression was performed to identify independent risk factors for prolonged MV. RESULTS The final analysis included 378 patients. The median duration of MV was 9.7 (IQR 3.0-18.0) days. 221 (58.5 %) patients required MV for more than 7 days and 143 (37.8 %) for more than 14 days. Male gender (aOR 3.01, 95 % CI 1.63-5.58, p < 0.001), age (aOR 1.40, 95 % CI 1.21-1.63, p < 0.001, for each category above 30 years), presence of severe head trauma (aOR 3.77, 95 % CI 2.23-6.38, p < 0.001), and transfusion of >5 blood units on admission (aOR 2.85, 95 % CI 1.62-5.02, p < 0.001) were independently associated with prolonged MV. The number of fractured ribs and the extent of lung contusions were associated with MV for more than 7 days, but not for 14 days. In the subgroup of 134 patients without concomitant head trauma, age (aOR 1.63, 95 % CI 1.18-2.27, p = 0.004, for each category above 30 years), respiratory comorbidities (aOR 9.70, 95 % CI 1.49-63.01, p = 0.017), worse p/f ratio during the first 24 h (aOR 1.55, 95 % CI 1.15-2.09, p = 0.004), and transfusion of >5 blood units on admission (aOR 5.71 95 % CI 1.84-17.68, p = 0.003) were independently associated with MV for more than 14 days. CONCLUSIONS Several predictors have been identified as independently associated with prolonged MV. Patients who meet these criteria are at high risk for prolonged MV and should be considered for interventions that could potentially shorten MV duration and reduce associated complications. Hemodynamically stable, healthy young patients suffering from severe thoracic trauma but no head injury, including those with extensive lung contusions and rib fractures, have a low risk of prolonged MV.
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Affiliation(s)
- Aran Gilaed
- Department of General Thoracic Surgery, Rambam Health Care Campus, Israel
| | - Nadeem Shorbaji
- Department of Diagnostic Imaging, Rambam Health Care Center, Haifa, Israel
| | - Ori Katzir
- Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Shaked Ankol
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Karawan Badarni
- Critical Care Division, Rambam Health Care Campus, Haifa, Israel
| | - Elias Andrawus
- Critical Care Division, Rambam Health Care Campus, Haifa, Israel
| | - Michael Roimi
- Critical Care Division, Rambam Health Care Campus, Haifa, Israel
| | - Amit Katz
- Department of General Thoracic Surgery, Rambam Health Care Campus, Israel
| | - Yaron Bar-Lavie
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel; Critical Care Division, Rambam Health Care Campus, Haifa, Israel
| | - Aeyal Raz
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel; Department of Anesthesiology, Rambam Health Care Campus, Haifa, Israel
| | - Danny Epstein
- Critical Care Division, Rambam Health Care Campus, Haifa, Israel.
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Lokerman RD, Gulickx M, Waalwijk JF, van Es MA, Tuinema RM, Leenen LPH, van Heijl M, Triage Research Collaborative Pttrc OBOTPHT. Evaluating the influence of alcohol intoxication on the pre-hospital identification of severe head injury: a multi-center, cohort study. Brain Inj 2023; 37:308-316. [PMID: 36573706 DOI: 10.1080/02699052.2022.2158228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To determine the influence of intoxication on the pre-hospital recognition of severely head-injured patients by Emergency Medical Services (EMS) professionals and to investigate the relationship between suspected alcohol intoxication and severe head injury. METHODS This multi-center, retrospective, cohort study included trauma patients, aged ≥ 16 years, transported by an ambulance of the Regional Ambulance Facility Utrecht to any emergency department in the participating trauma regions. RESULTS Between January 1, 2015 and December 31, 2017, 19,206 patients were included, of whom 1167 (6.0%) were suspected to have a severe head injury in the field, and 623 (3.2%) were diagnosed with such an injury at the hospital. These injuries were less frequently recognized in patients with a GCS ≥ 13 than in patients with a GCS < 13 (25.0% vs. 76.2%). Patients suspected to be intoxicated had a higher chance to suffer from severe head injury (OR 1.42, 95%-CI 1.22-1.65) and were recognized slightly more often (45.3% vs. 40.2%). CONCLUSION Severe head injuries are difficult to recognize in the field, especially in patients without a decreased GCS. Suspicion of alcohol intoxication did not seem to influence pre-hospital injury recognition, as it possibly makes a severe head injury harder to recognize and simultaneously raises caution for a severe injury.
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Affiliation(s)
- Robin D Lokerman
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Max Gulickx
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Job F Waalwijk
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Michael A van Es
- Department of Neurology, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rinske M Tuinema
- Management, Regional Ambulance Facilities Utrecht, Bilthoven, The Netherlands.,Department of Emergency Medicine, Diakonessenhuis Utrecht/Zeist/Doorn, Utrecht, The Netherlands
| | - Luke P H Leenen
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.,Management, Trauma Center Utrecht, Utrecht, The Netherlands
| | - Mark van Heijl
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.,Management, Trauma Center Utrecht, Utrecht, The Netherlands.,Department of Surgery, Diakonessenhuis Utrecht/Zeist/Doorn, Utrecht, The Netherlands
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Clinical Indications for Extubation in Coma Patients with Severe Neurological Craniocerebral Injury with Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2022; 2022:8012018. [PMID: 36193306 PMCID: PMC9526588 DOI: 10.1155/2022/8012018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 08/24/2022] [Accepted: 08/31/2022] [Indexed: 11/18/2022]
Abstract
Computer searches of the PubMed, Cochrane Library, and Embase databases for randomized controlled studies on the effects of intensive nutrition on clinical outcomes in patients with severe craniocerebral injury were conducted from the time of database creation to June 11, 2022, along with manual searches of the relevant literature. Two investigators independently screened the literature, extracted data, and evaluated the risk of bias of the included studies before the effect sizes were combined using RevMan 5.3 statistical software provided by the Cochrane Collaboration Network, and publication bias was detected using Stata 12.0 software. Meta-analysis showed that total protein levels were higher in the intensive nutrition group than in the regular nutrition group (WMD = 4.96 g/L (1.57-8.34), P < 0.001); IgA levels were significantly higher in the intensive nutrition group than in the regular nutrition group (SMD = 0.79 (0.51-1.07), P < 0.001; SMD = 0.98 (0.58-1.38), P < 0.001); IgG levels were significantly higher in the fortified group than in the regular group (SMD = 0.98 (0.58-1.38), P < 0.001); CD4/CD8 was significantly higher in the fortified patients than in the regular patients with a combined effect size of WMD = 0.33 (0.18-0.48) (P < RR = 0.45 (0.27-0.75), P = 0.002). The results show that effective support of early enteral nutrition can reduce the occurrence of gastrointestinal complications in patients, give them a better adaptation process to the gastrointestinal tract, and ensure the degree of tolerance of their gastric mucosa, thus absorbing more nutrition. Fortification significantly reduced the incidence of gastric retention in patients with craniocerebral injury (RR = 0.19 (0.07-0.49), P < 0.001). In the subgroup analysis of the three groups, it was shown that, depending on the starting time, the total protein level and IgG level were better in the early nutrition at 24 h than in the late nutrition above 24h and that, depending on the starting dose, the total protein level, IgA, IgG, and CD4/CD8 were better in the intervention at doses above 30 mL/h, using the starting dose of 30 mL/h as the cut-off point. In the subgroup analysis based on different nutrition methods (enteral and parenteral nutrition), IgA levels and the incidence of bloating and diarrhea were better than those of parenteral nutrition in the indicators of enteral nutrition.
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Indications for prehospital intubation among severely injured children and the prevalence of significant traumatic brain injury among those intubated due to impaired level of consciousness. Eur J Trauma Emerg Surg 2022; 49:1217-1225. [PMID: 35524778 DOI: 10.1007/s00068-022-01983-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 04/16/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Prehospital endotracheal intubation (PEI) of head injured children with impaired level of consciousness (LOC) aims to minimize secondary brain injury. However, PEI is controversial in otherwise stable children. We aimed to investigate the indications for PEI among pediatric trauma patients and the prevalence of clinically significant traumatic brain injury (csTBI) among those intubated solely due to impaired consciousness. METHODS This is a multicenter retrospective cohort study of children who underwent PEI in northern Israel between January 2014 and December 2020 by six EMS agencies and were transported to two trauma centers in the area. We extracted data from EMS records and trauma registries. RESULTS PEI was attempted in 179/986 (18.2%) patients and was successful in 92.2% of cases. Common indications for PEI were hypoxemia not corrected by supplemental oxygen (n = 30), traumatic cardiac arrest (n = 16), and facial injury compromising the airway (n = 13). 112 patients (62.6%) were intubated solely due to impaired or deteriorating LOC. Among these patients, 68 (62.4%) suffered csTBI. The prevalence of csTBI among those with field Glasgow Coma Scale (GCS) of 3, 4-8, and > 8 was 81.4%, 55.8%, and 28.6%, respectively (p < 0.001). Among children ≤ 10 years old intubated due to impaired LOC, 50% had csTBI. CONCLUSION Impaired LOC is a major indication for PEI. However, a significant proportion of these patients do not suffer csTBI. Older age and lower pre-intubation GCS are associated with more accurate field classification. Our data indicate that further investigation and better characterization of patients who may benefit from PEI is necessary.
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