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Wahlster S, Johnson NJ. The Neurocritical Care Examination and Workup. Continuum (Minneap Minn) 2024; 30:556-587. [PMID: 38830063 DOI: 10.1212/con.0000000000001438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE This article provides an overview of the evaluation of patients in neurocritical care settings and a structured approach to recognizing and localizing acute neurologic emergencies, performing a focused examination, and pursuing workup to identify critical findings requiring urgent management. LATEST DEVELOPMENTS After identifying and stabilizing imminent threats to survival, including respiratory and hemodynamic compromise, the initial differential diagnosis for patients in neurocritical care is built on a focused history and clinical examination, always keeping in mind critical "must-not-miss" pathologies. A key priority is to identify processes warranting time-sensitive therapeutic interventions, including signs of elevated intracranial pressure and herniation, acute neurovascular emergencies, clinical or subclinical seizures, infections of the central nervous system, spinal cord compression, and acute neuromuscular respiratory failure. Prompt neuroimaging to identify structural abnormalities should be obtained, complemented by laboratory findings to assess for underlying systemic causes. The indication for EEG and lumbar puncture should be considered early based on clinical suspicion. ESSENTIAL POINTS In neurocritical care, the initial evaluation is often fast paced, requiring assessment and management to happen in parallel. History, clinical examination, and workup should be obtained while considering therapeutic implications and the need for lifesaving interventions.
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Robateau Z, Lin V, Wahlster S. Acute Respiratory Failure in Severe Acute Brain Injury. Crit Care Clin 2024; 40:367-390. [PMID: 38432701 DOI: 10.1016/j.ccc.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Acute respiratory failure is commonly encountered in severe acute brain injury due to a multitude of factors related to the sequelae of the primary injury. The interaction between pulmonary and neurologic systems in this population is complex, often with competing priorities. Many treatment modalities for acute respiratory failure can result in deleterious effects on cerebral physiology, and secondary brain injury due to elevations in intracranial pressure or impaired cerebral perfusion. High-quality literature is lacking to guide clinical decision-making in this population, and deliberate considerations of individual patient factors must be considered to optimize each patient's care.
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Affiliation(s)
- Zachary Robateau
- Department of Neurology, University of Washington, Seattle, USA.
| | - Victor Lin
- Department of Neurology, University of Washington, Seattle, USA
| | - Sarah Wahlster
- Department of Neurology, University of Washington, Seattle, USA; Department of Neurological Surgery, University of Washington, Seattle, USA; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA
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Shafique MA, Haseeb A, Asghar B, Kumar A, Chaudhry ER, Mustafa MS. Assessing the impact of pre-hospital airway management on severe traumatic Brain injury: A systematic review and Meta-analysis. Am J Emerg Med 2024; 78:188-195. [PMID: 38301369 DOI: 10.1016/j.ajem.2024.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 01/05/2024] [Accepted: 01/15/2024] [Indexed: 02/03/2024] Open
Abstract
OBJECTIVE This study aimed to assess the impact of establishing a pre-hospital definitive airway on mortality and morbidity compared with no prehospital airway in cases of severe traumatic brain injury (TBI). BACKGROUND Traumatic brain injury (TBI) is a global health concern that is associated with substantial morbidity and mortality. Prehospital intubation (PHI) has been proposed as a potential life-saving intervention for patients with severe TBI to mitigate secondary insults, such as hypoxemia and hypercapnia. However, their impact on patient outcomes remains controversial. METHODS A systematic review and meta-analysis were conducted to assess the effects of prehospital intubation versus no prehospital intubation on morbidity and mortality in patients with severe TBI, adhering to the PRISMA guidelines. RESULTS 24 studies, comprising 56,543 patients, indicated no significant difference in mortality between pre-hospital and In-hospital Intubation (OR 0.89, 95% CI 0.65-1.23, p = 0.48), although substantial heterogeneity was noted. Morbidity analysis also showed no significant difference (OR 0.83, 95% CI 0.43-1.63, p = 0.59). These findings underscore the need for cautious interpretation due to heterogeneity and the influence of specific studies on the results. CONCLUSION In summary, an initial assessment did not reveal any apparent disparity in mortality rates between individuals who received prehospital intubation and those who did not. However, subsequent analyses and randomized controlled trials (RCTs) demonstrated that patients who underwent prehospital intubation had a reduced risk of death and morbidity. The dependence on biased observational studies and the need for further replicated RCTs to validate these findings are evident. Despite the intricacy of the matter, it is crucial to intervene during severe airway impairment.
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Affiliation(s)
| | - Abdul Haseeb
- Department of Medicine, Jinnah Sindh Medical University, Karachi, Pakistan
| | - Bushra Asghar
- Department of Medicine, Jinnah Sindh Medical University, Karachi, Pakistan
| | - Aashish Kumar
- Department of Medicine, Shaheed Mohtarma Benazir Bhutto Medical College, Karachi, Pakistan
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Ji F, Zhou X. Effect of prehospital intubation on mortality rates in patients with traumatic brain injury: A systematic review and meta-analysis. Scott Med J 2023; 68:80-90. [PMID: 37499223 DOI: 10.1177/00369330231189886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
OBJECTIVE It is unclear if prehospital intubation improves survival in patients with traumatic brain injury. We performed a systematic review and meta-analysis to assess the impact of prehospital intubation on mortality rates of traumatic brain injury. METHODS PubMed, CENTRAL, Web of Science, and Embase databases were searched without any language restriction up to 20 June 2022 for all types of comparative studies reporting survival of traumatic brain injury patients based on prehospital intubation. RESULTS In total, 18 studies with 41,185 patients were eligible for inclusion. Meta-analysis showed that traumatic brain injury patients receiving prehospital intubation had higher odds of mortality as compared to those not receiving prehospital intubation. Meta-analysis of adjusted data also indicated that prehospital intubation was associated with increased odds of mortality in traumatic brain injury patients. The results did not change on sensitivity analysis. Subgroup analysis based on study type, the severity of traumatic brain injury, inclusion of isolated traumatic brain injury, emergency department intubation in the control group, and prehospital intubation group sample size demonstrated variable results. CONCLUSION Heterogeneous data from mostly observational studies demonstrates higher mortality rates among traumatic brain injury patients receiving prehospital intubation. The efficacy of prehospital intubation is difficult to judge without taking into account multiple confounding factors.
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Affiliation(s)
- Fang Ji
- Department of Emergency, Lishui People's Hospital, Lishui City, Zhejiang Province, China
| | - Xiaohui Zhou
- Department of Emergency, Lishui People's Hospital, Lishui City, Zhejiang Province, China
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Radhakrishnan A, McCahill C, Atwal RS, Lahiri S. A systematic review of the timing of intubation in patients with traumatic brain injury: pre-hospital versus in-hospital intubation. Eur J Trauma Emerg Surg 2022; 49:1199-1215. [PMID: 35962218 DOI: 10.1007/s00068-022-02048-0] [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: 01/07/2022] [Accepted: 06/30/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE The objective of this systematic review was to examine current evidence on the risks versus benefit of pre-hospital intubation when compared with in-hospital intubation in adult patients with traumatic brain injuries. METHODS We conducted electronic searches of PubMed, Medline, Embase, CIANHL and the Cochrane library up to March 2021. Data extracted compared mortality, length of hospital and intensive care stay, pneumonia and functional outcomes in traumatic brain injured patients undergoing pre-hospital intubation versus in-hospital intubation. The risk of bias was assessed using the Grading of Recommendations Assessment, Development and Evaluation. RESULTS Ten studies including 25,766 patients were analysed. Seven were retrospective studies, two prospective cohort studies and one randomised control study. The mean mortality rate in patients who underwent pre-hospital intubation was 44.5% and 31.98% for in-hospital intubation. The odds ratio for an effect of pre-hospital intubation on mortality ranged from 0.31 (favouring in-hospital intubation) to 3.99 (favouring pre-hospital). The overall quality of evidence is low; however, the only randomised control study showed an improved functional outcome for pre-hospital intubation at 6 months. CONCLUSIONS The existing evidence does not support widespread pre-hospital intubation in all traumatic brain injured patients. This does not, however, contradict the need for the intervention when there is severe airway compromise; instead, it must be assessed by experienced personnel if a time critical transfer to hospital is more advantageous. Favourable neurological outcomes highlighted by the randomised control trial favours pre-hospital intubation, but further research is required in this field.
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Affiliation(s)
| | - Claire McCahill
- Anaesthetic Department, Great Ormond Street Hospital, London, WC1N 3JH, UK
| | | | - Sumitra Lahiri
- Anaesthetic Department, The Royal London Hospital, London, E1 1FR, UK
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6
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Epstein D, Rakedzon S, Kaplan B, Ben Lulu H, Chen J, Samuel N, Lipsky AM, Miller A, Bahouth H, Raz A. Prevalence of significant traumatic brain injury among patients intubated in the field due to impaired level of consciousness. Am J Emerg Med 2021; 52:159-165. [PMID: 34922237 DOI: 10.1016/j.ajem.2021.12.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/10/2021] [Accepted: 12/08/2021] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE Current guidelines advocate prehospital endotracheal intubation (ETI) in patients with suspected severe head injury and impaired level of consciousness. However, the ability to identify patients with traumatic brain injury (TBI) in the prehospital setting is limited and prehospital ETI carries a high complication rate. We investigated the prevalence of significant TBI among patients intubated in the field for that reason. METHODS Data were retrospectively collected from emergency medical services and hospital records of trauma patients for whom prehospital ETI was attempted and who were transferred to Rambam Health Care Campus, Israel. The indication for ETI was extracted. The primary outcome was significant TBI (clinical or radiographic) among patients intubated due to suspected severe head trauma. RESULTS In 57.3% (379/662) of the trauma patients, ETI was attempted due to impaired consciousness. 349 patients were included in the final analysis: 82.8% were male, the median age was 34 years (IQR 23.0-57.3), and 95.7% suffered blunt trauma. 253 patients (72.5%) had significant TBI. In a multivariable analysis, Glasgow Coma Scale>8 and alcohol intoxication were associated with a lower risk of TBI with OR of 0.26 (95% CI 0.13-0.51, p < 0.001) and 0.16 (95% CI 0.06-0.46, p < 0.001), respectively. CONCLUSION Altered mental status in the setting of trauma is a major reason for prehospital ETI. Although most of these patients had TBI, one in four of them did not suffer a significant TBI. Patients with a higher field GCS and those suffering from intoxication have a higher risk of misdiagnosis. Future studies should explore better tools for prehospital assessment of TBI and ways to better define and characterize patients who may benefit from early ETI.
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Affiliation(s)
- Danny Epstein
- Critical Care Division, Rambam Health Care Campus, HaAliya HaShniya St 8, Haifa 3109601, Israel.
| | - Stav Rakedzon
- Department of Internal Medicine B, Rambam Health Care Campus, HaAliya HaShniya St 8, Haifa 3109601, Israel
| | - Ben Kaplan
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Efron St 1, Haifa 3109601, Israel
| | - Hen Ben Lulu
- Trauma and Emergency Surgery, Rambam Health Care Campus, HaAliya HaShniya St 8, Haifa 3109601, Israel
| | - Jacob Chen
- Hospital Management, Meir Medical Center, Tchernichovsky St 59, Kefar Saba 4428164, Israel; Sackler Faculty of Medicine, Tel Aviv University, Klachkin St 35, Tel Aviv 6997801, Israel
| | - Nir Samuel
- Pediatric Emergency Department, Schneider Children's Medical Center, Kaplan St 14, Petah Tikva 4920235, Israel
| | - Ari M Lipsky
- Emergency Department, Emek Medical Center, Yitshak Rabin Boulevard 21, Afula 1834111, Israel
| | - Asaf Miller
- Medical Intensive Care Unit, Rambam Health Care Campus, HaAliya HaShniya St 8, Haifa 3109601, Israel
| | - Hany Bahouth
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Efron St 1, Haifa 3109601, Israel; Trauma and Emergency Surgery, Rambam Health Care Campus, HaAliya HaShniya St 8, Haifa 3109601, Israel
| | - Aeyal Raz
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Efron St 1, Haifa 3109601, Israel; Department of Anesthesiology, Rambam Health Care Campus, HaAliya HaShniya St 8, Haifa 3109601, Israel
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Orso D, Vetrugno L, Federici N, D'Andrea N, Bove T. Endotracheal intubation to reduce aspiration events in acutely comatose patients: a systematic review. Scand J Trauma Resusc Emerg Med 2020; 28:116. [PMID: 33303004 PMCID: PMC7726605 DOI: 10.1186/s13049-020-00814-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 11/24/2020] [Indexed: 01/08/2023] Open
Abstract
Background It is customary to believe that a patient with a Glasgow Coma Scale (GCS) score less than or equal to 8 should be intubated to avoid aspiration. We conducted a systematic review to establish if patients with GCS ≤ 8 for trauma or non-traumatic emergencies and treated in the acute care setting (e.g., Emergency Department or Pre-hospital environment) should be intubated to avoid aspiration or aspiration pneumonia/pneumonitis, and consequently, reduce mortality. Methods We searched six databases, Pubmed, Embase, Scopus, SpringerLink, Cochrane Library, and Ovid Emcare, from April 15th to October 14th, 2020, for studies involving low GCS score patients of whom the risk of aspiration and related complications was assessed. Results Thirteen studies were included in the final analysis (7 on non-traumatic population, 4 on trauma population, 1 pediatric and 1 adult mixed case studies). For the non-traumatic cases, two prospective studies and one retrospective study found no difference in aspiration risk between intubated and non-intubated patients. Two retrospective studies reported a reduction in the risk of aspiration in the intubated patient group. For traumatic cases, the study that considered the risk of aspiration did not show any differences between the two groups. A study on adult mixed cases found no difference in the incidence of aspiration among intubated and non-intubated patients. A study on pediatric patients found increased mortality for intubated versus non-intubated non-traumatic patients with a low GCS score. Conclusion Whether intubation results in a reduction in the incidence of aspiration events and whether these are more frequent in patients with low GCS scores are not yet established. The paucity of evidence on this topic makes clinical trials justifiable and necessary. Trial registration Prospero registration number: CRD42020136987. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-020-00814-w.
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Affiliation(s)
- Daniele Orso
- Department of Medicine, University of Udine, P.le S. Maria della Misericordia 15, 33100, Udine, Italy
| | - Luigi Vetrugno
- Department of Medicine, University of Udine, P.le S. Maria della Misericordia 15, 33100, Udine, Italy. .,Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital "Santa Maria della Misericordia" of Udine, Udine, Italy.
| | - Nicola Federici
- Department of Medicine, University of Udine, P.le S. Maria della Misericordia 15, 33100, Udine, Italy
| | - Natascia D'Andrea
- Department of Medicine, University of Udine, P.le S. Maria della Misericordia 15, 33100, Udine, Italy
| | - Tiziana Bove
- Department of Medicine, University of Udine, P.le S. Maria della Misericordia 15, 33100, Udine, Italy.,Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital "Santa Maria della Misericordia" of Udine, Udine, Italy
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8
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Bendinelli C, Ku D, Nebauer S, King KL, Howard T, Gruen R, Evans T, Fitzgerald M, Balogh ZJ. A tale of two cities: prehospital intubation with or without paralysing agents for traumatic brain injury. ANZ J Surg 2018; 88:455-459. [PMID: 29573111 DOI: 10.1111/ans.14479] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 02/17/2018] [Accepted: 02/20/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND The role of prehospital endotracheal intubation (PETI) for traumatic brain injury is unclear. In Victoria, paramedics use rapid sequence induction (RSI) drugs to facilitate PETI, while in New South Wales (NSW) they do not have access to paralysing agents. We hypothesized that RSI would both increase PETI rates and improve mortality. METHODS Retrospective comparison of adult primary admissions (Glasgow Coma Scale <9 and abbreviated injury scale head and neck >2) to either Victorian or NSW trauma centre, which were compared with univariate and logistic regression analysis to estimate odds ratio for mortality and intensive care unit (ICU) length of stay. RESULTS One hundred and ninety-two Victorian and 91 NSW patients did not differ in: demographics (males: 77% versus 79%; P = 0.7 and age: 34 (18-88) versus 33 (18-85); P = 0.7), Glasgow Coma Scale (3 (3-8) versus 5 (3-8); P = 0.07), and injury severity score (38 (26-75) versus 35 (18-75); P = 0.09), prehospital hypotension (15.4% versus 11.7%; P = 0.5) and desaturation (14.6% versus 17.5%; P = 0.5). Victorians had higher abbreviated injury scale head and neck (5 (4-5) versus 5 (3-6); P = 0.04) and more often successful PETI (85% versus 22%; P < 0.05). On logistic regression analysis, mortality did not differ among groups (31.7% versus 26.3%; P = 0.34; OR = 0.84; 95% CI: 0.38-1.86; P = 0.67). Among survivors, Victorians had longer stay in ICU (364 (231-486) versus 144 (60-336) h), a difference that persisted on gamma regression (effect = 1.58; 95% CI: 1.30-1.92; P < 0.05). CONCLUSION Paramedics using RSI to obtain PETI in patients with traumatic brain injury had a higher success rate. This increase in successful PETI rate was not associated with an improvement in either mortality rate or ICU length of stay.
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Affiliation(s)
- Cino Bendinelli
- John Hunter Hospital, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Dominic Ku
- John Hunter Hospital, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Shane Nebauer
- John Hunter Hospital, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Kate L King
- John Hunter Hospital, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Teresa Howard
- The Alfred Hospital, Monash University, Melbourne, Victoria, Australia
| | - Russel Gruen
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Tiffany Evans
- Clinical Research Design, Information Technology and Statistical Support, Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Mark Fitzgerald
- The Alfred Hospital, Monash University, Melbourne, Victoria, Australia
| | - Zsolt J Balogh
- John Hunter Hospital, The University of Newcastle, Newcastle, New South Wales, Australia
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Fedor PJ, Burns B, Lauria M, Richmond C. Major Trauma Outside a Trauma Center: Prehospital, Emergency Department, and Retrieval Considerations. Emerg Med Clin North Am 2017; 36:203-218. [PMID: 29132578 DOI: 10.1016/j.emc.2017.08.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Care of the critically injured begins well before the patient arrives at a large academic trauma center. It is important to understand the continuum of care from the point of injury in the prehospital environment, through the local hospital and retrieval, until arrival at a trauma center capable of definitive care. This article highlights the important aspects of trauma assessment and management outside of tertiary or quaternary care hospitals. Key elements of each phase of care are reviewed, including management pearls and institutional strategies to facilitate effective and efficient treatment of trauma patients from the point of injury forward.
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Affiliation(s)
- Preston J Fedor
- Department of Emergency Medicine, Division of Prehospital, Austere and Disaster Medicine, University of New Mexico, 1 University of New Mexico, MSC11 6025, Albuquerque, NM 87131-0001, USA.
| | - Brian Burns
- Greater Sydney Area HEMS, NSW Ambulance, NSW 2200, Australia; Sydney University, Sydney, NSW, Australia
| | - Michael Lauria
- Dartmouth-Hitchcock Advanced Response Team (DHART), Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Clare Richmond
- Greater Sydney Area HEMS, NSW Ambulance, NSW 2200, Australia; Royal Prince Alfred Hospital, Sydney, Australia
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Abstract
The organization of prehospital care for trauma patients began in the military arena. At the urging of multiple stakeholders and providers, these lessons were applied to the civilian setting and emergency medical services were created across the nation. Advances have taken place in the triage, transport, and management of severely injured patients. Many issues remain in the care of trauma patients in the prehospital environment. Collaboration between stakeholders and providers, regionalization of trauma care, and protocol-driven care may be solutions to some of these issues. Further research is necessary to dictate standard of care in this early phase after injury.
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Affiliation(s)
- Joshua Brown
- Department of Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Nitin Sajankila
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, 2500 MetroHealth Drive, Cleveland, OH 44109, USA
| | - Jeffrey A Claridge
- Division of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, 2500 Metrohealth Drive, Cleveland, OH 44109, USA.
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Fevang E, Perkins Z, Lockey D, Jeppesen E, Lossius HM. A systematic review and meta-analysis comparing mortality in pre-hospital tracheal intubation to emergency department intubation in trauma patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:192. [PMID: 28756778 PMCID: PMC5535283 DOI: 10.1186/s13054-017-1787-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 07/05/2017] [Indexed: 11/17/2022]
Abstract
Background Pre-hospital endotracheal intubation is frequently used for trauma patients in many emergency medical systems. Despite a wide range of publications in the field, it is debated whether the intervention is associated with a favourable outcome, when compared to more conservative airway measures. Methods A systematic literature search was conducted to identify interventional and observational studies where the mortality rates of adult trauma patients undergoing pre-hospital endotracheal intubation were compared to those undergoing emergency department intubation. Results Twenty-one studies examining 35,838 patients were included. The median mortality rate in patients undergoing pre-hospital intubation was 48% (range 8–94%), compared to 29% (range 6–67%) in patients undergoing intubation in the emergency department. Odds ratios were in favour of emergency department intubation both in crude and adjusted mortality, with 2.56 (95% CI: 2.06, 3.18) and 2.59 (95% CI: 1.97, 3.39), respectively. The overall quality of evidence is very low. Twelve of the twenty-one studies found a significantly higher mortality rate after pre-hospital intubation, seven found no significant differences, one found a positive effect, and for one study an analysis of the mortality rate was beyond the scope of the article. Conclusions The rationale for wide and unspecific indications for pre-hospital intubation seems to lack support in the literature, despite several publications involving a relatively large number of patients. Pre-hospital intubation is a complex intervention where guidelines and research findings should be approached cautiously. The association between pre-hospital intubation and a higher mortality rate does not necessarily contradict the importance of the intervention, but it does call for a thorough investigation by clinicians and researchers into possible causes for this finding. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1787-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Espen Fevang
- Department of Research and Development, Norwegian Air Ambulance Foundation, Drøbak, Norway. .,Department of Anaesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway.
| | - Zane Perkins
- Blizard Institute, Centre for Trauma Sciences, Queen Mary University, London, UK.,London's Air Ambulance, The Royal London Hospital, London, UK
| | - David Lockey
- Blizard Institute, Centre for Trauma Sciences, Queen Mary University, London, UK.,London's Air Ambulance, The Royal London Hospital, London, UK.,Department of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Elisabeth Jeppesen
- Department of Research and Development, Norwegian Air Ambulance Foundation, Drøbak, Norway.,Department of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Hans Morten Lossius
- Department of Research and Development, Norwegian Air Ambulance Foundation, Drøbak, Norway.,Department of Health Sciences, University of Stavanger, Stavanger, Norway
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12
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Abstract
BACKGROUND Trauma is time sensitive, and minimizing prehospital (PH) time is appealing. However, most studies have not linked increasing PH time with worse outcomes because raw PH times are highly variable. It is unclear whether specific PH time patterns affect outcomes. Our objective was to evaluate the association of PH time interval distribution with mortality. METHODS Patients transported by emergency medical services in the Pennsylvania trauma registry from 2000 to 2013 with a total PH time (TPT) of 20 minutes or longer were included. TPT was divided into three PH time intervals: response, scene, and transport time. The number of minutes in each PH time interval was divided by TPT to determine the relative proportion each interval contributed to TPT. A prolonged interval was defined as any one PH interval contributing equal to or greater than 50% of TPT. Patients were classified by prolonged PH interval or no prolonged PH interval (all intervals < 50% of TPT). Patients were matched for TPT, and conditional logistic regression determined the association of mortality with PH time pattern, controlling for confounders. PH interventions were explored as potential mediators, and PH triage criteria used identify patients with time-sensitive injuries. RESULTS There were 164,471 patients included. Patients with prolonged scene time had increased odds of mortality (odds ratio, 1.21; 95% confidence interval, 1.02-1.44; p = 0.03). Prolonged response, transport, and no prolonged interval were not associated with mortality. When adjusting for mediators including extrication and PH intubation, prolonged scene time was no longer associated with mortality (odds ratio, 1.06; 95% confidence interval, 0.90-1.25; p = 0.50). Together, these factors mediated 61% of the effect between prolonged scene time and mortality. Mortality remained associated with prolonged scene time in patients with hypotension, penetrating injury, and flail chest. CONCLUSION Prolonged scene time is associated with increased mortality. PH interventions partially mediate this association. Further study should evaluate whether these interventions drive increased mortality because they prolong scene time or by another mechanism, as reducing scene time may be a target for intervention. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.
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13
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Salottolo K, Carrick M, Stewart Levy A, Morgan BC, Slone DS, Bar-Or D. The epidemiology, prognosis, and trends of severe traumatic brain injury with presenting Glasgow Coma Scale of 3. J Crit Care 2016; 38:197-201. [PMID: 27940095 DOI: 10.1016/j.jcrc.2016.11.034] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 11/08/2016] [Accepted: 11/23/2016] [Indexed: 11/17/2022]
Abstract
PURPOSE To characterize trends and prognosis of severe traumatic brain injury (TBI). METHODS This 5-year multicenter retrospective study included patients with TBI and Glasgow Coma Scale of 3. We analyzed demographic and clinical characteristics and mortality using Pearson χ2 tests, Cochran-Armitage trend tests, and stepwise logistic regression. Analyses were stratified by vehicular and fall etiologies; other etiologies were excluded (24%). RESULTS Included were 481 patients. Fall-related injuries increased 58% (P=.001) but vehicular etiology did not change (P=.63). The characteristics of the populations changed over time; with falls, the population became older and increasingly presented with normal vital signs, whereas with vehicular etiology, the population became younger, with more alcohol-related injury (P<.05 for all). Mortality from falls increased substantially from 25% to 63% (P<.001), whereas death from vehicular injures remained statistically unchanged but with a downward trend (50%-38%, P=.28). Predictors of mortality included injury severity and age at least 65 years for both groups. Additional variables that were prognostic were abnormal vital signs and subdural hematoma for vehicular injuries, and sex for fall injuries. CONCLUSIONS The epidemiology of severe TBI is changing. These epidemiologic data may be used for management and resource decisions, monitoring, and directing injury prevention measures.
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Affiliation(s)
- Kristin Salottolo
- Department of Trauma Research, Medical Center of Plano, 3901 West 15th Street, Plano, TX 75075; Department of Trauma Research, Swedish Medical Center, 501 E. Hampden Ave, Englewood, CO 80113; Department of Trauma Research, St Anthony Hospital, 11600 W. 2nd Place, Lakewood, CO 80228; Department of Trauma Research, Penrose Hospital, 2222 N Nevada Ave, Colorado Springs, CO 80907.
| | - Matthew Carrick
- Department of Trauma Research, Medical Center of Plano, 3901 West 15th Street, Plano, TX 75075; Trauma Services Department, Medical Center of Plano, 3901 W 15th St, Plano, TX 75075.
| | - A Stewart Levy
- Intermountain Neurosurgery, 11700 W. 2nd Place, Lakewood, CO 80228; Trauma Services Department, St Anthony Hospital, 11600 West 2nd Place, Lakewood, CO 80228.
| | - Brent C Morgan
- Trauma Services Department, Medical Center of Plano, 3901 W 15th St, Plano, TX 75075.
| | - Denetta S Slone
- Department of Trauma Research, Swedish Medical Center, 501 E. Hampden Ave, Englewood, CO 80113; Trauma Services Department, Swedish Medical Center, 499 E. Hampden Ave, Englewood, CO 80113.
| | - David Bar-Or
- Department of Trauma Research, Medical Center of Plano, 3901 West 15th Street, Plano, TX 75075; Department of Trauma Research, Swedish Medical Center, 501 E. Hampden Ave, Englewood, CO 80113; Department of Trauma Research, St Anthony Hospital, 11600 W. 2nd Place, Lakewood, CO 80228; Department of Trauma Research, Penrose Hospital, 2222 N Nevada Ave, Colorado Springs, CO 80907.
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Salottolo K, Carrick M, Levy AS, Morgan BC, Mains CW, Slone DS, Bar-Or D. Aggressive operative neurosurgical management in patients with extra-axial mass lesion and Glasgow Coma Scale of 3 is associated with survival benefit: A propensity matched analysis. Injury 2016; 47:70-6. [PMID: 26499227 DOI: 10.1016/j.injury.2015.10.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 10/01/2015] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Prognosis in patients with traumatic brain injury (TBI) and Glasgow Coma Scale (GCS) score of 3 is poor, raising concern regarding the utility of aggressive operative neurosurgical management. Our purpose was to describe outcomes in a propensity matched population with TBI and GCS3 treated with operative neurosurgical procedures of craniotomy or craniectomy (CRANI). METHODS We conducted a five-year, multicenter retrospective cohort study of patients with an ED GCS 3 and a positive head CT identified by ICD-9CM diagnosis codes. Two populations were examined: (1) patients with extra-axial mass lesion (subdural or epidural haematoma), (2) patients without mass lesion (subarachnoid and intraparenchymal haemorrhage including contusion, other intracerebral haemorrhage or intracranial injury including diffuse axonal injury). In patients with extra-axial mass lesion, propensity score techniques were used to match patients 1:1 by CRANI, and the following outcomes were analysed with conditional logistic regression: survival, favourable hospital disposition to home or rehabilitation, and development of complications. RESULTS There were 541 patients with TBI and GCS3; 19% had a CRANI, 83% were initiated within 4h. In those with mass lesion, 27% (91/338) had a CRANI; after matching, a significant survival benefit was observed with CRANI vs. without CRANI (65% vs. 34% survival, OR: 3.9 (1.6-10.5) p<0.001). There was borderline increased odds of favourable disposition (43% vs. 26%, OR: 2.4 (0.99-6.3, p=0.052) with CRANI vs. without CRANI, and no difference in developing a complication (58% vs. 48%, OR: 1.5 (0.7-3.4), p=0.30). CONCLUSIONS Survival was achieved in 65% of patients that underwent surgical intervention for subdural and epidural haematoma, despite a presenting GCS of 3. These results demonstrate prompt operative neurosurgical management of mass lesion is warranted for selected patients with a GCS of 3, contributing to a significant 4-fold survival benefit. In the absence of mass lesion the effect of immediate neurosurgery on outcomes is inconclusive.
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Affiliation(s)
- Kristin Salottolo
- Department of Trauma Research, Medical Center of Plano, 3901 West 15th Street, Plano, TX 75075, United States; Department of Trauma Research, Swedish Medical Center, 501 E. Hampden Ave, Englewood, CO 80113, United States; Department of Trauma Research, St. Anthony Hospital, 11600 W. 2nd Place, Lakewood, CO 80228, United States.
| | - Matthew Carrick
- Department of Trauma Research, Medical Center of Plano, 3901 West 15th Street, Plano, TX 75075, United States; Trauma Services Department, Medical Center of Plano, 3901 W. 15th St, Plano, TX 75075, United States.
| | - A Stewart Levy
- Trauma Services Department, St. Anthony Hospital, 11600 West 2nd Place, Lakewood, CO 80228, United States; Trauma Services Department, Intermountain Neurosurgery, 11700 W. 2nd Place, Lakewood, CO 80228, United States.
| | - Brent C Morgan
- Trauma Services Department, Medical Center of Plano, 3901 W. 15th St, Plano, TX 75075, United States.
| | - Charles W Mains
- Trauma Services Department, St. Anthony Hospital, 11600 West 2nd Place, Lakewood, CO 80228, United States.
| | - Denetta S Slone
- Department of Trauma Research, St. Anthony Hospital, 11600 W. 2nd Place, Lakewood, CO 80228, United States; Trauma Services Department, Swedish Medical Center, 499 E. Hampden Ave, Englewood, CO 80113, United States; Trauma Services Department, Rocky Vista University, 8401 S. Chambers Rd, Parker, CO 80134, United States.
| | - David Bar-Or
- Department of Trauma Research, Medical Center of Plano, 3901 West 15th Street, Plano, TX 75075, United States; Department of Trauma Research, Swedish Medical Center, 501 E. Hampden Ave, Englewood, CO 80113, United States; Department of Trauma Research, St. Anthony Hospital, 11600 W. 2nd Place, Lakewood, CO 80228, United States; Trauma Services Department, Rocky Vista University, 8401 S. Chambers Rd, Parker, CO 80134, United States.
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15
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Experience in Prehospital Endotracheal Intubation Significantly Influences Mortality of Patients with Severe Traumatic Brain Injury: A Systematic Review and Meta-Analysis. PLoS One 2015; 10:e0141034. [PMID: 26496440 PMCID: PMC4619807 DOI: 10.1371/journal.pone.0141034] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 10/02/2015] [Indexed: 11/19/2022] Open
Abstract
Background Patients with severe traumatic brain injury (TBI) are at high risk for airway obstruction and hypoxia at the accident scene, and routine prehospital endotracheal intubation has been widely advocated. However, the effects on outcome are unclear. We therefore aim to determine effects of prehospital intubation on mortality and hypothesize that such effects may depend on the emergency medical service providers’ skill and experience in performing this intervention. Methods and Findings PubMed, Embase and Web of Science were searched without restrictions up to July 2015. Studies comparing effects of prehospital intubation versus non-invasive airway management on mortality in non-paediatric patients with severe TBI were selected for the systematic review. Results were pooled across a subset of studies that met predefined quality criteria. Random effects meta-analysis, stratified by experience, was used to obtain pooled estimates of the effect of prehospital intubation on mortality. Meta-regression was used to formally assess differences between experience groups. Mortality was the main outcome measure, and odds ratios refer to the odds of mortality in patients undergoing prehospital intubation versus odds of mortality in patients who are not intubated in the field. The study was registered at the International Prospective Register of Systematic Reviews (PROSPERO) with number CRD42014015506. The search provided 733 studies, of which 6 studies including data from 4772 patients met inclusion and quality criteria for the meta-analysis. Prehospital intubation by providers with limited experience was associated with an approximately twofold increase in the odds of mortality (OR 2.33, 95% CI 1.61 to 3.38, p<0.001). In contrast, there was no evidence for higher mortality in patients who were intubated by providers with extended level of training (OR 0.75, 95% CI 0.52 to 1.08, p = 0.126). Meta-regression confirmed that experience is a significant predictor of mortality (p = 0.009). Conclusions Effects of prehospital endotracheal intubation depend on the experience of prehospital healthcare providers. Intubation by paramedics who are not well skilled to do so markedly increases mortality, suggesting that routine prehospital intubation of TBI patients should be abandoned in emergency medical services in which providers do not have ample training, skill and experience in performing this intervention.
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Haider AH, Saleem T, Leow JJ, Villegas CV, Kisat M, Schneider EB, Haut ER, Stevens KA, Cornwell EE, MacKenzie EJ, Efron DT. Influence of the National Trauma Data Bank on the study of trauma outcomes: is it time to set research best practices to further enhance its impact? J Am Coll Surg 2012; 214:756-68. [PMID: 22321521 PMCID: PMC3334459 DOI: 10.1016/j.jamcollsurg.2011.12.013] [Citation(s) in RCA: 188] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Revised: 12/08/2011] [Accepted: 12/08/2011] [Indexed: 11/18/2022]
Abstract
BACKGROUND Risk-adjusted analyses are critical in evaluating trauma outcomes. The National Trauma Data Bank (NTDB) is a statistically robust registry that allows such analyses; however, analytical techniques are not yet standardized. In this study, we examined peer-reviewed manuscripts published using NTDB data, with particular attention to characteristics strongly associated with trauma outcomes. Our objective was to determine if there are substantial variations in the methodology and quality of risk-adjusted analyses and therefore, whether development of best practices for risk-adjusted analyses is warranted. STUDY DESIGN A database of all studies using NTDB data published through December 2010 was created by searching PubMed and Embase. Studies with multivariate risk-adjusted analyses were examined for their central question, main outcomes measures, analytical techniques, covariates in adjusted analyses, and handling of missing data. RESULTS Of 286 NTDB publications, 122 performed a multivariable adjusted analysis. These studies focused on clinical outcomes (51 studies), public health policy or injury prevention (30), quality (16), disparities (15), trauma center designation (6), or scoring systems (4). Mortality was the main outcome in 98 of these studies. There were considerable differences in the covariates used for case adjustment. The 3 covariates most frequently controlled for were age (95%), Injury Severity Score (85%), and sex (78%). Up to 43% of studies did not control for the 5 basic covariates necessary to conduct a risk-adjusted analysis of trauma mortality. Less than 10% of studies used clustering to adjust for facility differences or imputation to handle missing data. CONCLUSIONS There is significant variability in how risk-adjusted analyses using data from the NTDB are performed. Best practices are needed to further improve the quality of research from the NTDB.
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Affiliation(s)
- Adil H Haider
- Center for Surgery Trials and Outcomes Research, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD 21212, USA.
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Abstract
Head injury is one of the major causes of trauma-related morbidity and mortality in all age groups in the United Kingdom, and anaesthetists encounter this problem in many areas of their work. Despite a better understanding of the pathophysiological processes following traumatic brain injury and a wealth of research, there is currently no specific treatment. Outcome remains dependant on basic clinical care: management of the patient's airway with particular attention to preventing hypoxia; avoidance of the extremes of lung ventilation; and the maintenance of adequate cerebral perfusion, in an attempt to avoid exacerbating any secondary injury. Hypertonic fluids show promise in the management of patients with raised intracranial pressure. Computed tomography scanning has had a major impact on the early identification of lesions amenable to surgery, and recent guidelines have rationalised its use in those with less severe injuries. Within critical care, the importance of controlling blood glucose is becoming clearer, along with the potential beneficial effects of hyperoxia. The major improvement in outcome reflects the use of protocols to guide resuscitation, investigation and treatment and the role of specialist neurosciences centres in caring for these patients. Finally, certain groups are now recognised as being at greater risk, in particular the elderly, anticoagulated patient.
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