A Follow-Up Analysis of Factors Associated with Head-Injury Mortality After Paramedic Rapid Sequence Intubation

EMS Treatment Guidelines in Major Traumatic Brain Injury With Positive Pressure Ventilation

Importance

The Excellence in Prehospital Injury Care (EPIC) study demonstrated improved survival in patients with severe traumatic brain injury (TBI) following implementation of the prehospital treatment guidelines. The impact of implementing these guidelines in the subgroup of patients who received positive pressure ventilation (PPV) is unknown.

Objective

To evaluate the association of implementation of prehospital TBI evidence-based guidelines with survival among patients with prehospital PPV.

Design, Setting, and Participants

The EPIC study was a multisystem, intention-to-treat study using a before/after controlled design. Evidence-based guidelines were implemented by emergency medical service agencies across Arizona. This subanalysis was planned a priori and included participants who received prehospital PPV. Outcomes were compared between the preimplementation and postimplementation cohorts using logistic regression, stratified by predetermined TBI severity categories (moderate, severe, or critical). Data were collected from January 2007 to June 2017, and data were analyzed from January to February 2023.

Exposure

Implementation of the evidence-based guidelines for the prehospital care of patient with TBI.

Main Outcomes and Measures

The primary outcome was survival to hospital discharge, and the secondary outcome was survival to admission.

Results

Among the 21 852 participants in the main study, 5022 received prehospital PPV (preimplementation, 3531 participants; postimplementation, 1491 participants). Of 5022 included participants, 3720 (74.1%) were male, and the median (IQR) age was 36 (22-54) years. Across all severities combined, survival to admission improved (adjusted odds ratio [aOR], 1.59; 95% CI, 1.28-1.97), while survival to discharge did not (aOR, 0.94; 95% CI, 0.78-1.13). Within the cohort with severe TBI but not in the moderate or critical subgroups, survival to hospital admission increased (aOR, 6.44; 95% CI, 2.39-22.00), as did survival to discharge (aOR, 3.52; 95% CI, 1.96-6.34).

Conclusions and Relevance

Among patients with severe TBI who received active airway interventions in the field, guideline implementation was independently associated with improved survival to hospital admission and discharge. This was true whether they received basic airway interventions or advanced airways. These findings support the current guideline recommendations for aggressive prevention/correction of hypoxia and hyperventilation in patients with severe TBI, regardless of which airway type is used.

Survival benefit of helicopter scene response for patients with an Injury Severity Score of at least nine: A systematic review and meta-analysis

Background and AimHelicopter EMS (HEMS) is a well-established mode of rapid transportation for patients with need for time-sensitive interventions, especially in patients with significant traumatic injuries. Traditionally in the setting of trauma, HEMS is often considered appropriate when used for patients with "severe" injury as defined by Injury Severity Score (ISS) >15. This may be overly conservative, and patients with a lower ISS may benefit from HEMS-associated speed or care quality. Our objective was to perform a meta-analysis of trauma HEMS transports to evaluate for possible mortality benefit in injured cases defined by an ISS score >8, lower than the customary ISS cutoff of >15.MethodsA broad search of the literature was performed including PubMed, EMBASE, SCOPUS, Cochrane Central Register of Controlled Trials, and Google Scholar from the years 1970 to 2022. The gray literature and reference lists of included publications were also examined. We included studies with the outcome of mortality in HEMS vs control in trauma transports from scene of injury for patients (adult or pediatric) with ISS > 8.ResultsNine eligible studies were used in the final analysis: six in the primary analysis and three in sensitivity analysis due to patient overlap. All studies reported statistically significant survival benefit in HEMS compared to control group. The minimum survival odds ratio (OR) benefit observed was OR 1.15 (95% CI 1.06-1.25) and maximum was OR 2.04 (95% CI 1.18-3.57). Risk of bias tool (ROBINS-I) application yielded moderate to low risk of bias, mainly due to the observational nature of the studies included.ConclusionsThere was a statistically significant survival benefit in patients with ISS > 8 when HEMS was used over traditional ground ambulance transportation, although novel and more inclusive trauma triage criteria may be more appropriate in the future to guide HEMS utilization decision-making. Restricting HEMS to trauma patients with ISS >15 likely misses survival benefit that could be afforded to the subset of trauma patients with serious injury.

Pre-hospital tracheal intubation in severe traumatic brain injury: a systematic review and meta-analysis

BACKGROUND

Severe traumatic brain injury (TBI) continues to be a leading cause of death, particularly in young adults. Severe TBI contributes to significant socioeconomic burden secondary to the long-term disability, impacting the individual and their family, and wider society. The aim of this study was to determine whether establishing a pre-hospital definitive airway was beneficial to mortality and morbidity when compared with no pre-hospital airway.

METHODS

A literature search for all relevant studies was performed in Medline, Embase, Cochrane, EBSCO, and Emcare databases, with studies comparing effects of pre-hospital tracheal intubation vs noninvasive airway management on mortality in non-paediatric patients with severe TBI. There were 1025 studies that had abstracts screened from this search. This study was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

We identified 19 studies that met inclusion criteria. The included studies identified no significant difference in mortality between pre-hospital and no pre-hospital tracheal intubation, with an odds ratio of 1.07 (95% CI, 0.72-1.57; P<0.001). The meta-analysis identified a trend favouring pre-hospital tracheal intubation with respect to long-term morbidity, with an odds ratio of 0.92 (95% CI, 0.51-1.67; P<0.001).

CONCLUSIONS

Management of traumatic brain injuries is a constantly evolving field, with ever-changing target parameters regarding management. There is growing evidence, based on the RCTs and recent studies, that pre-hospital tracheal intubation in patients with severe TBI is beneficial if performed by well-trained, experienced practitioners in accordance with current TBI guidelines.

PROSPERO REGISTRATION

CRD42021234439.

Face-to-Face Versus Telephonic Extended Glasgow Outcome Score Testing After Traumatic Brain Injury

OBJECTIVE

The Extended Glasgow Outcome Scale (GOS-E) is used for objective assessment of functional outcome in traumatic brain injury (TBI). In situations where face-to-face contact is not feasible, telephonic assessment of the GOS-E might be desirable. The aim of this study is to assess the level of agreement between face-to-face and telephonic assessment of the GOS-E.

SETTING

Multicenter study in 2 Dutch University Medical Centers. Inclusion was performed in the outpatient clinic (face-to-face assessment, by experienced neurologist), followed by assessment via telephone of the GOS-E after ±2 weeks (by trained researcher).

PARTICIPANTS

Patients ±6 months after TBI.

DESIGN

Prospective validation study.

MAIN MEASURES

Interrater agreement of the GOS-E was assessed with Cohen's weighted κ.

RESULTS

From May 2014 until March 2018, 50 patients were enrolled; 54% were male (mean age 49.1 years). Median time between trauma and in-person GOS-E examination was 158 days and median time between face-to-face and telephonic GOS-E was 15 days. The quadratic weighted κ was 0.79. Sensitivity analysis revealed a quadratic weighted κ of 0.77, 0.78, and 0.70 for moderate-severe, complicated mild, and uncomplicated mild TBI, respectively.

CONCLUSION

No disagreements of more than 1 point on the GOS-E were observed, with the κ value representing good or substantial agreement. Assessment of the GOS-E via telephone is a valid alternative to the face-to-face interview when in-person contact is not feasible.

Effect of Implementing the Out-of-Hospital Traumatic Brain Injury Treatment Guidelines: The Excellence in Prehospital Injury Care for Children Study (EPIC4Kids)

STUDY OBJECTIVE

We evaluate the effect of implementing the out-of-hospital pediatric traumatic brain injury guidelines on outcomes in children with major traumatic brain injury.

METHODS

The Excellence in Prehospital Injury Care for Children study is the preplanned secondary analysis of the Excellence in Prehospital Injury Care study, a multisystem, intention-to-treat study using a before-after controlled design. This subanalysis included children younger than 18 years who were transported to Level I trauma centers by participating out-of-hospital agencies between January 1, 2007, and June 30, 2015, throughout Arizona. The primary and secondary outcomes were survival to hospital discharge or admission for children with major traumatic brain injury and in 3 subgroups, defined a priori as those with moderate, severe, and critical traumatic brain injury. Outcomes in the preimplementation and postimplementation cohorts were compared with logistic regression, adjusting for risk factors and confounders.

RESULTS

There were 2,801 subjects, 2,041 in preimplementation and 760 in postimplementation. The primary analysis (postimplementation versus preimplementation) yielded an adjusted odds ratio of 1.16 (95% confidence interval 0.70 to 1.92) for survival to hospital discharge and 2.41 (95% confidence interval 1.17 to 5.21) for survival to hospital admission. In the severe traumatic brain injury cohort (Regional Severity Score-Head 3 or 4), but not the moderate or critical subgroups, survival to discharge significantly improved after guideline implementation (adjusted odds ratio = 8.42; 95% confidence interval 1.01 to 100+). The improvement in survival to discharge among patients with severe traumatic brain injury who received positive-pressure ventilation did not reach significance (adjusted odds ratio = 9.13; 95% confidence interval 0.79 to 100+).

CONCLUSION

Implementation of the pediatric out-of-hospital traumatic brain injury guidelines was not associated with improved survival when the entire spectrum of severity was analyzed as a whole (moderate, severe, and critical). However, both adjusted survival to hospital admission and discharge improved in children with severe traumatic brain injury, indicating a potential severity-based interventional opportunity for guideline effectiveness. These findings support the widespread implementation of the out-of-hospital pediatric traumatic brain injury guidelines.

Patient Contact Time and Prehospital Interventions in Hypotensive Trauma Patients: Should We Reconsider the "ABC" Algorithm When Time Is of the Essence?

INTRODUCTION

There is disagreement in the trauma community concerning the extent to which emergency medical services (EMS) should perform on-scene interventions. Additionally, in recent years the "ABC" algorithm has been questioned in hypotensive patients. The objective of this study was to quantify the delay introduced by different on-scene interventions.

METHODS

A retrospective analysis of hypotensive trauma patients brought to an urban level 1 trauma center by EMS from 2007 to 2018 was performed, and patients were stratified by mechanism of injury and new injury severity score (NISS). Independent samples median tests were used to compare median on-scene times.

RESULTS

Among 982 trauma patients, median on-scene time was 5 minutes (interquartile range 3-8). In penetrating trauma patients (n = 488) with NISS of 16-25, intubation significantly increased scene time from 4 to 6 minutes (P < .05). In penetrating trauma patients with NISS of 10-15, wound care significantly increased scene time from 3 to 6 minutes (P < .05). Tourniquet use, interosseous (IO) access, intravenous (IV) access, and needle decompression did not significantly increase scene time.

CONCLUSION

Understanding that intubation increases scene time in penetrating trauma, while IV and IO access do not, alterations to the traditional "ABC" algorithm may be warranted. Further investigation of prehospital interventions is needed to determine which are appropriate on-scene.

Brief Research Report: Prehospital Rapid Sequence Airway

BACKGROUND

Rapid Sequence Airway (RSA) describes the administration of an induction agent and paralytic followed by the intended primary placement of an extraglottic airway device rather than an endotracheal tube. The purpose of this study was to determine the success rates for prehospital RSA. The secondary goal was to determine aspiration rates among patients managed with RSA.

METHODS

Adult and pediatric prehospital RSA cases between 2005 and 2017 reported to an airway quality assurance registry from one ground and one air agency were reviewed. Success was defined as the ability to adequately ventilate patients after extraglottic device placement. Aspiration was defined as radiologic evidence (chest x-ray or CT scan) within 48 hours of hospital presentation.

RESULTS

68 patients underwent RSA with a King LTS-D (n = 24), LMA-Supreme (n = 28), Combitube (n = 2), LMA-Unique (n = 8) and iGel (n = 6). Age ranged from 1 year to 73 years with 10 patients less than 18. RSA was successful in 64 (94%) cases; 56 (88%) were successful on first pass and 63 (98%) within 2 attempts. The RSA procedure occurred in an aircraft in 14 (21%) of cases and 71% of patients were in cervical precautions. Duration of EGD insertion prior to hospital arrival ranged from 5 to 102 minutes with an average of 34.5 minutes. Aspiration data was available for 46 patients of whom 4 (8.7%) were found to have evidence of aspiration.

CONCLUSION

Overall and first pass RSA success rates were high and aspiration rates were low in this quality assurance registry despite predictors of airway difficulty. RSA may be a reasonable alternative to RSI for prehospital airway management that merits further research.

Identifying patients with time-sensitive injuries: Association of mortality with increasing prehospital time

BACKGROUND

Trauma is a time-sensitive disease. However, recognizing which patients have time-critical injuries in the field is challenging. Many studies failed to identify an association between increasing prehospital time (PHT) and mortality due to evaluation of heterogenous trauma patients, as well as inherent survival bias from missed deaths in patients with long PHT. Our objective was to determine if a subset of existing trauma triage criteria can identify patients in whom mortality is associated with PHT.

METHODS

Trauma patients 16 years or older transported from the scene in the National Trauma Databank 2007 to 2015 were included. Cubic spline analysis used to identify an inflection where mortality increases to identify a marginal population in which PHT is more likely associated with mortality and exclude biased patients with long PHT. Logistic regression determined the association between mortality and PHT, adjusting for demographics, transport mode, vital signs, operative interventions, and complications. Interaction terms between existing trauma triage criteria and PHT were tested, with model stratification across triage criteria with a significant interaction to determine which criteria identify patients that have increased risk of mortality associated with increasing PHT.

RESULTS

Mortality risk increased in patients with total PHT of 30 minutes or less, comprising a study population of 517,863 patients. Median total PHT was 26 minutes (interquartile range, 22-28 minutes) with median Injury Severity Score of 9 (interquartile range, 4-14) and 7.4% mortality. Overall, PHT was not associated with mortality (adjusted odd ratio [AOR], 0.984 per 5-minute increase; 95% confidence interval [CI], 0.960-1.009; p = 0.20). Interaction analysis demonstrated increased mortality associated with increasing PHT for patients with systolic blood pressure less than 90 mm Hg (AOR, 1.039; 95% CI, 1.003-1.078, p = 0.04), Glasgow Coma Scale score of 8 or less (AOR, 1.047; 95% CI, 1.018-1.076; p < 0.01), or nonextremity firearm injury (AOR, 1.049; 95% CI, 1.010-1.089; p < 0.01).

CONCLUSION

Patients with prehospital hypotension, Glasgow Coma Scale score of 8 or less, and nonextremity firearm injury have higher mortality with increasing PHT. These patients may have time-sensitive injuries and benefit from rapid transport to definitive care.

LEVEL OF EVIDENCE

Prognostic/Epidemiologic III; Therapeutic/Care Management IV.

Association of Statewide Implementation of the Prehospital Traumatic Brain Injury Treatment Guidelines With Patient Survival Following Traumatic Brain Injury: The Excellence in Prehospital Injury Care (EPIC) Study

Importance

Traumatic brain injury (TBI) is a massive public health problem. While evidence-based guidelines directing the prehospital treatment of TBI have been promulgated, to our knowledge, no studies have assessed their association with survival.

Objective

To evaluate the association of implementing the nationally vetted, evidence-based, prehospital treatment guidelines with outcomes in moderate, severe, and critical TBI.

Design, Setting, and Participants

The Excellence in Prehospital Injury Care (EPIC) Study included more than 130 emergency medical services systems/agencies throughout Arizona. This was a statewide, multisystem, intention-to-treat study using a before/after controlled design with patients with moderate to critically severe TBI (US Centers for Disease Control and Prevention Barell Matrix-Type 1 and/or Abbreviated Injury Scale Head region severity ≥3) transported to trauma centers between January 1, 2007, and June 30, 2015. Data were analyzed between October 25, 2017, and February 22, 2019.

Interventions

Implementation of the prehospital TBI guidelines emphasizing avoidance/treatment of hypoxia, prevention/correction of hyperventilation, and avoidance/treatment of hypotension.

Main Outcomes and Measures

Primary: survival to hospital discharge; secondary: survival to hospital admission.

Results

Of the included patients, the median age was 45 years, 14 666 (67.1%) were men, 7181 (32.9%) were women; 16 408 (75.1% ) were white, 1400 (6.4%) were Native American, 743 (3.4% ) were Black, 237 (1.1%) were Asian, and 2791 (12.8%) were other race/ethnicity. Of the included patients, 21 852 met inclusion criteria for analysis (preimplementation phase [P1]: 15 228; postimplementation [P3]: 6624). The primary analysis (P3 vs P1) revealed an adjusted odds ratio (aOR) of 1.06 (95% CI, 0.93-1.21; P = .40) for survival to hospital discharge. The aOR was 1.70 (95% CI, 1.38-2.09; P < .001) for survival to hospital admission. Among the severe injury cohorts (but not moderate or critical), guideline implementation was significantly associated with survival to discharge (Regional Severity Score-Head 3-4: aOR, 2.03; 95% CI, 1.52-2.72; P < .001; Injury Severity Score 16-24: aOR, 1.61; 95% CI, 1.07-2.48; P = .02). This was also true for survival to discharge among the severe, intubated subgroups (Regional Severity Score-Head 3-4: aOR, 3.14; 95% CI, 1.65-5.98; P < .001; Injury Severity Score 16-24: aOR, 3.28; 95% CI, 1.19-11.34; P = .02).

Conclusions and Relevance

Statewide implementation of the prehospital TBI guidelines was not associated with significant improvement in overall survival to hospital discharge (across the entire, combined moderate to critical injury spectrum). However, adjusted survival doubled among patients with severe TBI and tripled in the severe, intubated cohort. Furthermore, guideline implementation was significantly associated with survival to hospital admission. These findings support the widespread implementation of the prehospital TBI treatment guidelines.

Trial Registration

ClinicalTrials.gov identifier: NCT01339702.

Use of Polarized Sunglasses During Video Laryngoscopy: A Cause of Difficult Prehospital Intubation

BACKGROUND

In the prehospital setting, many providers advocate for video laryngoscopy as the initial method of intubation to improve the likelihood of a successful first attempt. However, bright ambient light can worsen visualization of the video laryngoscope liquid crystal display (LCD).

CASE REPORT

A patient involved in a motor vehicle accident was evaluated by an Emergency Medical Services (EMS) crew. Initial endotracheal intubation attempt using video laryngoscopy was aborted after the patient desaturated. The primary reason for the failure was poor visualization of the video laryngoscope LCD, despite attempts to block direct sunlight. Debriefing revealed that the intubating provider was wearing polarized sunglasses.

DISCUSSION

Because LCDs emit polarized light, use of polarized sunglasses may cause the display to appear dark. Thus, the purpose of this Case Report is to raise awareness of a potential safety issue that is likely under-recognized by prehospital providers but can be easily avoided.SmithAJ, JackimczykK, HorwoodB, ChristensonD. Use of polarized sunglasses during video laryngoscopy: a cause of difficult prehospital intubation.Prehosp Disaster Med. 2019;34(1):104-107.

Emergency Neurological Life Support: Airway, Ventilation, and Sedation

Airway management and ventilation are central to the resuscitation of the neurologically ill. These patients often have evolving processes that threaten the airway and adequate ventilation. Furthermore, intubation, ventilation, and sedative choices directly affect brain perfusion. Therefore, Airway, Ventilation, and Sedation was chosen as an Emergency Neurological Life Support protocol. Topics include airway management, when and how to intubate with special attention to hemodynamics and preservation of cerebral blood flow, mechanical ventilation settings and the use of sedative agents based on the patient's neurological status.

Airway management and mechanical ventilation in acute brain injury

Patients with acute neurologic disease often develop respiratory failure, the management of which profoundly affects brain physiology and long-term functional outcomes. This chapter reviews airway management and mechanical ventilation of patients with acute brain injury, offering practical strategies to optimize treatment of respiratory failure and minimize secondary brain injury. Specific concerns that are addressed include physiologic changes during intubation and ventilation such as the effects on intracranial pressure and brain perfusion; cervical spine management during endotracheal intubation; the role of tracheostomy; and how ventilation and oxygenation are utilized to minimize ischemia-reperfusion injury and cerebral metabolic distress.

Early neurological wake-up test in intubated brain-injured patients: A long-term, single-centre experience

BACKGROUND

In prehospital setting, a severe traumatic brain injury (TBI) requires tracheal intubation, sedation and mechanical ventilation pending the initial imagery. An early neurological wake-up test (ENWT), soon after the initial imaging assessment, allows a rapid neurological reassessment. This strategy authorises an initial clinical examination of reference with which will be compared the later examinations. The main objective of this study was to describe the characteristics of the patients who underwent an ENWT, and to determine its causes of failure.

METHODS

We conducted a retrospective, observational, single-centre study including all intubated TBI admitted in the trauma centre. An ENWT was defined as cessation of sedation within 24h after TBI. Data concerning patient characteristics, CT-scan results, and outcomes were extracted from a prospective register of all intubated TBI admitted in the ICU. Characteristic of ENWT and causes of failure were retrieved from patient files. A multivariate logistic regression model was developed to determine the risk factors of ENWT failure.

RESULTS

During 7 years, 242 patients with intubated TBI were included. An ENWT was started in 96 patients, for an overall rate at 40%. The ENWT was stopped in 38 patients (39.5%), mostly due to neurological deterioration in 27 cases (71%) or respiratory distress in 10 cases (26%). Significant predictors of ENWT failure were: the presence of subdural hematoma with a thickness >5mm on first imagery (OR=3.2; 95%CI [1.01-10.28]), and an initial GCS score <5 (OR=7.4; 95%CI [1.92-28.43]). Prevalence of poor outcome at 1year was lesser in patients with successful ENWT compared to those with failure or absence of ENWT: 4% vs. 48% and 49% (p<0.0001).

CONCLUSIONS

The ENWT is achieved in 40% of patients, with a success rate of 60.5%. In presence of a subdural hematoma with a thickness >5mm or an initial GCS score <5, an ENWT failure may be expected.

Apneic oxygenation is associated with a reduction in the incidence of hypoxemia during the RSI of patients with intracranial hemorrhage in the emergency department

Critically ill patients undergoing emergent intubation are at risk of oxygen desaturation during the management of their airway. Patients with intracranial hemorrhage (ICH) are particularly susceptible to the detrimental effects of hypoxemia. Apneic oxygenation (AP OX) may be able to reduce the occurrence of oxygen desaturation during the emergent intubation of these patients. We sought to assess the effect AP OX on oxygen desaturation during the rapid sequence intubation (RSI) of patients with ICH in the emergency department (ED). We prospectively collected data on all patients intubated in an urban academic ED over the 2-year period from July 1, 2013 to June 30, 2015. Following each intubation, the operator completed a standardized continuous quality improvement (CQI) data form, which included information on patient, operator and intubation characteristics. Operators recorded data on the use of AP OX, the oxygen flow rate used for AP OX, and the starting and lowest saturations during intubation. Adult patients with ICH who underwent RSI by emergency medicine (EM) residents were included in the analyses. The primary outcome variable was any oxygen saturation <90 % during the intubation. We performed a backward stepwise multivariate logistic regression analysis to identify variables associated with oxygen desaturation. The primary independent variable of interest was the use of AP OX during the intubation. Inclusion criteria for the study was met by 127 patients. AP OX was used in 72 patients (AP OX group) and was not used in 55 patients (NO AP OX group). The incidence of desaturation was 5/72 (7 %) in the AP OX group and was 16/55 (29 %) in the NO AP OX group. In the multivariate logistic regression analysis the use of AP OX was associated with a reduced odds of desaturation (aOR 0.13; 95 % CI 0.03-0.53). Patients with ICH who received AP OX during RSI in the ED were seven times less likely to have an oxygen saturation of <90 % during the intubation compared to patients who did not receive AP OX. AP OX is a simple intervention that may minimize the risk of oxygen desaturation during the RSI of patients with ICH.

Emergency Neurological Life Support: Airway, Ventilation, and Sedation

Airway management and ventilation are central to the resuscitation of the neurologically ill. These patients often have evolving processes that threaten the airway and adequate ventilation. Furthermore, intubation, ventilation, and sedative choices directly affect brain perfusion. Therefore, airway, ventilation, and sedation was chosen as an emergency neurological life support protocol. Topics include airway management, when and how to intubate with special attention to hemodynamics and preservation of cerebral blood flow, mechanical ventilation settings, and the use of sedative agents based on the patient's neurological status.

Early in-theater management of combat-related traumatic brain injury: A prospective, observational study to identify opportunities for performance improvement

BACKGROUND

Combat-related moderate-to-severe traumatic brain injury (CRTBI) is a significant cause of wartime morbidity and mortality. As of August 2014, moderate-to-severe traumatic brain injuries sustained by members of the Department of Defense worldwide since 2000 totaled 32,996 cases. Previously published epidemiologic reviews describe CRTBI management at a "strategic" level, but they lack "tactical" patient-specific data required for performance improvement. In addition, scarce data exist regarding prehospital CRTBI care.

METHODS

This is a prospective observational study of consecutive CRTBI casualties presenting to US Role 3 medical facilities. Admission variables including demographics, initial clinical findings, and laboratory results were collected. Head computed tomographic scan findings were noted. Interventions in the first 72 postinjury hours were recorded. Early in-theater mortality was noted, but longer-term outcomes were not.

RESULTS

Casualties were predominately injured by explosive blasts (78.6%). Penetrating injuries occurred in 42.9%. On arrival, Glasgow Coma Scale (GCS) score was less than 8 for 47.7%. Hypothermia (temperature < 95.0°F) was present in 4.5%, and hypotension (systolic blood pressure < 90 mm Hg) in 21.1%. Hypoxia (O2 saturation < 90%) was observed in 52.5%. Both hypercarbia (Paco2 > 45 mm Hg, 50%) and hypocarbia (Paco2 < 36 mm Hg, 20.3%) were common on presentation. Head computed tomographic scan most commonly found skull fracture (68.9%), subdural hematoma (54.1%), and cerebral contusion (51.4%). Hypertonic saline was administered to 69.7% and factor VIIa to 11.1%. Early in-theater mortality at Role 3 was 19.4%.

CONCLUSION

Avoidance of secondary brain injury by optimizing oxygenation, ventilation, and cerebral perfusion is the primary goal in the contemporary care of moderate-to-severe CRTBI. Ideally, this crucial care must begin as early as possible after injury. Given the frequency of hypotension, hypoxia, and both hypercarbia and hypocarbia upon Role 3 arrival, increased emphasis on prehospital management is indicated.

LEVEL OF EVIDENCE

Therapeutic study, level IV; epidemiologic study, level III.

4,871 Emergency airway encounters by air medical providers: a report of the air transport emergency airway management (NEAR VI: "A-TEAM") project

INTRODUCTION

Pre-hospital airway management is a key component of resuscitation although the benefit of pre-hospital intubation has been widely debated. We report a large series of pre-hospital emergency airway encounters performed by air-transport providers in a large, multi-state system.

METHODS

We retrospectively reviewed electronic intubation flight records from an 89 rotorcraft air medical system from January 01, 2007, through December 31, 2009. We report patient characteristics, intubation methods, success rates, and rescue techniques with descriptive statistics. We report proportions with 95% confidence intervals and binary comparisons using chi square test with p-values <0.05 considered significant.

RESULTS

4,871 patients had active airway management, including 2,186 (44.9%) medical and 2,685 (55.1%) trauma cases. There were 4,390 (90.1%) adult and 256 (5.3%) pediatric (age ≤ 14) intubations; 225 (4.6%) did not have an age recorded. 4,703 (96.6%) had at least one intubation attempt. Intubation was successful on first attempt in 3,710 (78.9%) and was ultimately successful in 4,313 (91.7%). Intubation success was higher for medical than trauma patients (93.4% versus 90.3%, p=0.0001 JT test). 168 encounters were managed primarily with an extraglottic device (EGD). Cricothyrotomy was performed 35 times (0.7%) and was successful in 33. Patients were successfully oxygenated and ventilated with an endotracheal tube, EGD, or surgical airway in 4809 (98.7%) encounters. There were no reported deaths from a failed airway.

CONCLUSION

Airway management, predominantly using rapid sequence intubation protocols, is successful within this high-volume, multi-state air-transport system.

Experience in Prehospital Endotracheal Intubation Significantly Influences Mortality of Patients with Severe Traumatic Brain Injury: A Systematic Review and Meta-Analysis

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.

Prehospital versus Emergency Room Intubation of Trauma Patients in Qatar: A-2-year Observational Study

Background:

The impact of prehospital intubation (PHI) in improving outcome of trauma patients has not been adequately evaluated in the developing countries.

Aims:

The present study analyzed the outcome of PHI versus emergency room intubation (ERI) among trauma patients in Qatar.

Materials and Methods:

Data were retrospectively reviewed for all intubated trauma patients between 2010 and 2011. Patients were classified according to location of intubation (PHI: Group-1 versus ERI: Group-2). Data were analyzed and compared.

Results:

Out of 570 intubated patients; 482 patients (239 in group-1 and 243 in group-2) met the inclusion criteria with a mean age of 32 ΁ 14.6 years Head injury (P = 0.003) and multiple trauma (P = 0.004) were more prevalent in group-1, whereas solid organ injury predominated in group-2 (P = 0.02). Group-1 had significantly higher mean injury severity scoring (ISS), lower Glasgow coma scale (GCS), greater head abbreviated injury score and longer activation, response, scene and total emergency medical services times. The mortality was higher in group-1 (53% vs. 18.5%; P = 0.001). Multivariate analysis showed that GCS [odds ratio (OR) 0.78, P = 0.005) and ISS (OR 1.12, P = 0.001) were independent predictors of mortality.

Conclusions:

PHI is associated with high mortality when compared with ERI. However, selection bias cannot be ruled out and therefore, PHI needs further critical assessment in Qatar.

Two hundred sixty pediatric emergency airway encounters by air transport personnel: a report of the air transport emergency airway management (NEAR VI: "A-TEAM") project

BACKGROUND

Effective airway management is the cornerstone of resuscitative efforts for any critically ill or injured patient. The role and safety of pediatric prehospital intubation is controversial, particularly after prior research has shown varying degrees of intubation success. We report a series of consecutive prehospital pediatric intubations performed by air-transport providers.

METHODS

We retrospectively reviewed intubation flight records from an 89-rotorcraft, multistate emergency flight service during the time period from January 1, 2007, to December 31, 2009. All patients younger than 15 years were included in our analysis. We characterized patient, flight, and operator demographics; intubation methods; success rates; rescue techniques; and adverse events with descriptive statistics. We report proportions with 95% confidence intervals and differences between groups with Fisher exact and χ tests; P < 0.05 was considered significant.

RESULTS

Two hundred sixty pediatric intubations were performed consisting of 88 medical (33.8%) and 172 trauma (66.2%) cases; 98.8% (n = 257) underwent an orotracheal intubation attempt as the first method. First-pass intubation success was 78.6% (n = 202), and intubation was ultimately successful in 95.7% (n = 246) of cases. Medical and trauma intubations had similar success rates (98% vs 95%, Fisher exact test P = 0.3412). There was no difference in intubation success between age groups (χ = 0.26, P = 0.88). Three patients were managed primarily with an extraglottic device. Rescue techniques were used in 11 encounters (4.2%), all of which were successful. Cricothyrotomy was performed twice, both successful.

CONCLUSIONS

Prehospital pediatric intubation performed by air-transport providers, using rapid sequence intubation protocols, is highly successful. This effect on patient outcome requires further study.

Does helicopter transport impact outcome following trauma?

Helicopter transport (HT) has evolved from military roots into a critical component of trauma systems throughout the world. Concerns over cost and safety continue to challenge the role of HT in the civilian setting. Despite this, recent evidence has demonstrated a survival advantage for trauma patients undergoing HT. For patients transported from the scene of injury, improved survival has been shown in several multicenter studies as well as evaluation of large national databases. Issues of overtriage, however, remain problematic for scene HT and represent a prime area for future research in helicopter emergency medical systems (EMS). Patients undergoing inter-facility transfer have also been shown to have improved outcomes over ground transport in terms of shorter transfer times and increased survival particularly in more severely injured patients. The benefits seen are likely a result of a combination of rapid transport, advanced medical capabilities, and accessibility to remote terrain. Several subgroups of patients undergoing HT have been the subject of study as well. Patients with severe head injury have consistently been shown to have superior outcomes over ground ambulance, attributable to improvements in airway management early in the course of their injury. Conversely, HT for urban and penetrating injury has not seen similar benefits, likely due to proximity of trauma centers and recent advancements in urban EMS systems. The benefits of including physicians in helicopter crews are less clear and vary by region and system. Helicopter transport for trauma does appear to improve outcomes for trauma patients, and optimizing utilization of this valuable resource will be key as the role of helicopter EMS continues to develop within trauma systems.

Emergency neurological life support: airway, ventilation, and sedation

Airway management is central to the resuscitation of the neurologically ill. These patients often have evolving processes that threaten the airway and adequate ventilation. Therefore, airway, ventilation, and sedation were chosen as an Emergency Neurological Life Support (ENLS) protocol. Reviewed topics include airway management; the decision to intubate; when and how to intubate with attention to cardiovascular status; mechanical ventilation settings; and the use of sedation, including how to select sedative agents based on the patient's neurological status.

En-route care capability from point of injury impacts mortality after severe wartime injury

OBJECTIVE

The objective of this study is to characterize modern point-of-injury (POI) en-route care platforms and to compare mortality among casualties evacuated with conventional military retrieval (CMR) methods to those evacuated with an advanced medical retrieval (AMR) capability.

BACKGROUND

Following a decade of war in Afghanistan, the impact of en-route care capabilities from the POI on mortality is unknown.

METHODS

Casualties evacuated from POI to one level III facility in Afghanistan (July 2008-March 2012) were identified from UK and US trauma registries. Groups comprised those evacuated by a medically qualified provider-led, AMR and those by a medic-led CMR capability. Outcomes were compared per incremental Injury Severity Score (ISS) bins.

RESULTS

Most casualties (n = 1054; 61.2%) were in the low-ISS (1-15) bracket in which there was no difference in en-route care time or mortality between AMR and CMR. Casualties in the mid-ISS bracket (16-50) (n = 583; 33.4%) experienced the same median en-route care time (minutes) on AMR and CMR platforms [78 (58) vs 75 (93); P = 0.542] although those on AMR had shorter time to operation [110 (95) vs 117 (126); P < 0.001]. In this mid-ISS bracket, mortality was lower in the AMR than in the CMR group (12.2% vs 18.2%; P = 0.035). In the high-ISS category (51-75) (n = 75; 4.6%), time to operation was lower in the AMR than the CMR group (66 ± 77 vs 113 ± 122; P = 0.013) but there was no difference in mortality.

CONCLUSIONS

This study characterizes en-route care capabilities from POI in modern combat. Conventional platforms are effective in most casualties with low injury severity. However, a definable injury severity exists for which evacuation with an AMR capability is associated with improved survival.

Impact of critical care-trained flight paramedics on casualty survival during helicopter evacuation in the current war in Afghanistan

BACKGROUND

The US Army pioneered medical evacuation (MEDEVAC) by helicopter, yet its system remains essentially unchanged since the Vietnam era. Care is provided by a single combat medic credentialed at the Emergency Medical Technician - Basic level. Treatment protocols, documentation, medical direction, and quality improvement processes are not standardized and vary significantly across US Army helicopter evacuation units. This is in contrast to helicopter emergency medical services that operate within the United States. Current civilian helicopter evacuation platforms are routinely staffed by critical care-trained flight paramedics (CCFP) or comparably trained flight nurses who operate under trained EMS physician medical direction using formalized protocols, standardized patient care documentation, and rigorous quality improvement processes. This study compares mortality of patients with injury from trauma between the US Army's standard helicopter evacuation system staffed with medics at the Emergency Medical Technician - Basic level (standard MEDEVAC) and one staffed with experienced CCFP using adopted civilian helicopter emergency medical services practices.

METHODS

This is a retrospective study of a natural experiment. Using data from the Joint Theater Trauma Registry, 48-hour mortality for severely injured patients (injury severity score ≥ 16) was compared between patients transported by standard MEDEVAC units and CCFP air ambulance units.

RESULTS

The 48-hour mortality for the CCFP-treated patients was 8% compared to 15% for the standard MEDEVAC patients. After adjustment for covariates, the CCFP system was associated with a 66% lower estimated risk of 48-hour mortality compared to the standard MEDEVAC system.

CONCLUSIONS

These findings demonstrate that using an air ambulance system based on modern civilian helicopter EMS practice was associated with a lower estimated risk of 48-hour mortality among severely injured patients in a combat setting.

Helicopter EMS: Research Endpoints and Potential Benefits

Patients, EMS systems, and healthcare regions benefit from Helicopter EMS (HEMS) utilization. This article discusses these benefits in terms of specific endpoints utilized in research projects. The endpoint of interest, be it primary, secondary, or surrogate, is important to understand in the deployment of HEMS resources or in planning further HEMS outcomes research. The most important outcomes are those which show potential benefits to the patients, such as functional survival, pain relief, and earlier ALS care. Case reports are also important "outcomes" publications. The benefits of HEMS in the rural setting is the ability to provide timely access to Level I or Level II trauma centers and in nontrauma, interfacility transport of cardiac, stroke, and even sepsis patients. Many HEMS crews have pharmacologic and procedural capabilities that bring a different level of care to a trauma scene or small referring hospital, especially in the rural setting. Regional healthcare and EMS system's benefit from HEMS by their capability to extend the advanced level of care throughout a region, provide a "backup" for areas with limited ALS coverage, minimize transport times, make available direct transport to specialized centers, and offer flexibility of transport in overloaded hospital systems.

Effect of secondary prehospital risk factors on outcome in severe traumatic brain injury in the context of fast access to trauma care

BACKGROUND

Prevention of secondary prehospital risk factors such as hypoxia and hypotension is likely to improve patient prognosis in severe traumatic brain injury (TBI). Because the Dutch trauma care organization is characterized by fast access to specialized trauma care due to the geographical situation, we investigated whether and to what extend secondary risk factors, such as hypoxia and hypotension, and measures, such as endotracheal intubation, affect outcome in severe TBI in the context of a region with fast access to trauma care.

METHODS

The medical records of 339 subsequent computed tomography-confirmed patients with TBI with a Glasgow coma scale (GCS) score≤8 who were primarily referred to a Level I trauma center in Amsterdam or Nijmegen in the Netherlands were retrospectively analyzed.

RESULTS

Multinomial logistic regression revealed that the strongest outcome predictors in our population were a disturbed pupillary reflex (odds ratio [OR], 5.8), a GCS score of 3 (OR, 4.9), and arterial hypotension (OR, 3.5). Interestingly, we observed no differences between intubated and nonintubated patients with respect to metabolic and respiratory parameters or mortality whereby the injury severity score was slightly higher in endotracheally intubated patients (32 [25-41]) versus nonintubated patients (25 [22-29]).

CONCLUSION

In agreement with others, GCS, a disturbed pupil reflex, and arterial hypotension were predictive for the prognosis of primarily referred patients with severe TBI in the Netherlands. In contrast, in the perspective of slightly higher injury scores in intubated patients, prehospital endotracheal intubation was not predictive for patient outcome.

150 years of treating severe traumatic brain injury: a systematic review of progress in mortality

Considerable effort and resources have been devoted to preserving life in patients with severe closed traumatic brain injury (TBI). We sought to identify temporal trends in mortality rates of these patients from the late 1800s to the present. We searched the literature for articles on severe TBI, abstracting numbers of patients studied, numbers of deaths, and years of patient entry. Mortality rates were calculated for each study, and meta-regression was used to pool data and to test for significant temporal trends. We reviewed 207 case series comprising more than 140,000 cases of severe closed TBI admitted to hospital over a span of almost 150 years. Since the late 1800s mortality has fallen by almost 50%. However, the rate has varied considerably among the four epochs chosen. Between 1885 and 1930, mortality decreased at a rate of 3% per decade. From 1970 to 1990, mortality declined at a rate of 9% per decade. Both changes are significant. There was no observed improvement in mortality between 1930 and 1970, nor is progress evident since 1990. The authors discuss possible reasons for the apparently intermittent progress in TBI survival over time.

Should trauma patients with a Glasgow Coma Scale score of 3 be intubated prior to hospital arrival?

INTRODUCTION

Previous studies of heterogeneous populations (Glasgow Coma Scale (GCS) scores<9) suggest that endotracheal intubation of trauma patients prior to hospital arrival (i.e., prehospital intubated) is associated with an increased mortality compared to those patients not intubated in the prehospital setting. Deeply comatose patients (GCS=3) represent a unique population of severely traumatized patients and may benefit from intubation in the prehospital setting. The objective of this study was to compare mortality rates of severely comatose patients (scene GCS=3) with prehospital endotracheal intubation to those intubated at the hospital.

METHODS

Using the National Trauma Data Bank (V. 6.2), the following variables were analyzed retrospectively: (1) age; (2) injury type (blunt or penetrating); (3) Injury Severity Score (ISS); (4) scene GCS=3 (scored prior to intubation/without sedation); (5) emergency department GCS score; (6) arrival emergency department intubation status; (7) first systolic blood pressure in the emergency department (>0); (8) discharge status (alive or dead); (9) Abbreviated Injury Scale Score (AIS); and (10) AIS body region.

RESULTS

Of the 10,948 patients analyzed, 23% (2,491/10,948) were endotracheally intubated in a prehospital setting. Mortality rate for those hospital intubated was 35% vs. 62% for those with prehospital intubation (p<0.0001); mean ISS scores 24.2±16.0 vs. 31.6±16.2, respectively (p<0.0001). Using logistic regression, controlling for first systolic blood pressure, ISS, emergency department GCS, age, and type of trauma, those with prehospital intubation were more likely to die (OR=1.9, 95% CI=1.7-2.2). For patients with only head AIS scores (no other body region injury, n=1,504), logistic regression (controlling for all other variables) indicated that those with prehospital intubation were still more likely to die (OR=2.0. 95% CI=1.4-2.9).

CONCLUSIONS

Prehospital endotracheal intubation is associated with an increased mortality in completely comatose trauma patients (GCS = 3). Although the exact reasons for this remain unclear, these results support other studies and suggest the need for future research and re-appraisal of current policies for prehospital intubation in these severely traumatized patients.

Minimal illumination for direct laryngoscopy and intubation in different ambient light settings

OBJECTIVES

This study sought to investigate the minimal laryngoscope illumination required for proper laryngoscopy and intubation in different ambient light settings as determined by paramedics.

METHODS

Paramedics qualified to intubate patients in the field were recruited to intubate a cadaver embalmed with a minimal fixation technique designed to maintain tissue integrity. All paramedic participants intubated the cadaver under three different ambient light settings representing possible out-of-hospital settings: an outdoor night setting, an indoor setting, and an outdoor day setting. Paramedics were asked to determine the minimal illumination required for intubation of the cadaver under each of these settings.

RESULTS

Twenty-three paramedics participated in the study. The mean (+/-SD) minimal illumination required for intubation was 39.1 (+/-35.4) lux at the night setting, 92.5 (+/-57.3) lux at the indoor setting, and 209.7 (+/-117.4) lux at the day setting. There was a statistically significant difference in minimal illumination required between each of the three light settings (p < 0.0001).

CONCLUSIONS

Minimal illumination requirements in the out-of-hospital setting may be lower than previously recommended. Ambient light intensity affects this minimal illumination requirement, with brighter ambient light conditions necessitating more laryngoscope light output. Further studies assessing out-of-hospital laryngoscope illumination should consider ambient light conditions.

Paramedic Rapid Sequence Intubation for Severe Traumatic Brain Injury: Perspectives from an Expert Panel

Although early intubation has become standard practice in the prehospital management of severe traumatic brain injury (TBI), many patients cannot be intubated without neuromuscular blockade. Several emergency medical services (EMS) systems have implemented paramedic rapid sequence intubation (RSI) protocols, with published reports documenting apparently conflicting outcomes effects. In response, the Brain Trauma Foundation assembled a panel of experts to interpret the existing literature regarding paramedic RSI for severe TBI and offer guidance for EMS systems considering adding this skill to the paramedic scope of practice. The interpretation of this panel can be summarized as follows: (1) the existing literature regarding paramedic RSI is inconclusive, and apparent differences in outcome can be explained by use of different methodologies and variability in comparison groups; (2) the use of Glasgow Coma Scale score alone to identify TBI patients requiring RSI is limited, with additional research needed to refine our screening criteria; (3) suboptimal RSI technique as well as subsequent hyperventilation may account for some of the mortality increase reported with the procedure; (4) initial and ongoing training as well as experience with RSI appear to affect performance; and (5) the success of a paramedic RSI program is dependent on particular EMS and trauma system characteristics.

Prehospital management of traumatic brain injury

The aim of this study was to review the current protocols of prehospital practice and their impact on outcome in the management of traumatic brain injury. A literature review of the National Library of Medicine encompassing the years 1980 to May 2008 was performed. The primary impact of a head injury sets in motion a cascade of secondary events that can worsen neurological injury and outcome. The goals of care during prehospital triage, stabilization, and transport are to recognize life-threatening raised intracranial pressure and to circumvent cerebral herniation. In that process, prevention of secondary injury and secondary insults is a major determinant of both short- and longterm outcome. Management of brain oxygenation, blood pressure, cerebral perfusion pressure, and raised intracranial pressure in the prehospital setting are discussed. Patient outcomes are dependent upon an organized trauma response system. Dispatch and transport timing, field stabilization, modes of transport, and destination levels of care are addressed. In addition, special considerations for mass casualty and disaster planning are outlined and recommendations are made regarding early response efforts and the ethical impact of aggressive prehospital resuscitation. The most sophisticated of emergency, operative, or intensive care units cannot reverse damage that has been set in motion by suboptimal protocols of triage and resuscitation, either at the injury scene or en route to the hospital. The quality of prehospital care is a major determinant of long-term outcome for patients with traumatic brain injury.

Distance impacts mortality in trauma patients with an intubation attempt

OBJECTIVE

Out-of-hospital endotracheal intubation (OOH-ETI) has been associated with adverse outcomes; whether transport distance changes this relationship is unclear. We sought to determine whether patients injured farther from the hospital benefit more from OOH-ETI than those injured closer.

METHODS

We performed a retrospective cohort analysis of trauma patients > 14 years old transported to two Level 1 trauma centers and surviving to admission from 2000 to 2003. We used probabilistically linked geographic data to calculate transport distance. To adjust for the nonrandom selection of patients for OOH-ETI, we used a propensity score based on clinical variables: prehospital physiology, demographics, transport mode, mechanism, comorbidities, Abbreviated Injury Scale head injury score >or= 3, Injury Severity Score, blood transfusion, and major surgery. Propensity-adjusted multivariable logistic regression with mode of transport was used to test the interaction between distance and OOH-ETI.

RESULTS

8,786 patients were included, 534 with OOH-ETI. Patients with OOH-ETI had higher adjusted mortality (odds ratio [OR] 2.06, 95% confidence interval [CI] 1.33-3.18), and there was a significant interaction between distance and OOH-ETI (p = 0.02). Patients with shortest distances had the highest mortality (OR 3.98, 95% CI 2.08-7.60). Probability of mortality was higher with OOH-ETI across all distances and increased for patients closest to the hospital. Helicopter transport was associated with improved survival.

CONCLUSIONS

Prehospital intubation is associated with increased mortality among trauma patients at all distances from the hospital. Patients with the shortest transport distances had the greatest mortality associated with OOH-ETI, whereas helicopter transport was associated with improved survival. The event location and ensuing distance to the hospital are another factor to consider when instituting and modifying OOH airway protocols.

Pro/con debate: is the scoop and run approach the best approach to trauma services organization?

You are asked to be involved in organizing a trauma service for a major urban center. You are asked to make a decision on whether the services general approach to trauma in the city (which does have a well-established trauma center) will be scoop and run (minimal resuscitation at the scene with a goal to getting the patient to a trauma center as quickly as possible) or on-the-scene resuscitation with transfer following some degree of stabilization.

Air medical response to traumatic brain injury: a computer learning algorithm analysis

BACKGROUND

The role of air medicine in traumatic brain injury (TBI) has been studied extensively using trauma registries but remains unclear. Learning algorithms, such as artificial neural networks (ANN), support vector machines (SVM), and decision trees, can identify relationships between data set variables but are not empirically useful for hypothesis testing.

OBJECTIVE

To use ANN, SVM, and decision trees to explore the role of air medicine in TBI.

METHODS

Patients with Head Abbreviated Injury Score 3+ were identified from our county trauma registry. Predictive models were generated using ANN, SVM, and decision trees. The three best-performing ANN models were used to calculate differential survival values (actual and predicted outcome) for each patient. In addition, predicted survival values with transport mode artificially input as "air" or "ground" were calculated for each patient to identify those who benefit from air transport. For SVM analysis, chi was used to compare the ratio of unexpected survivors to unexpected deaths for air- and ground-transported patients. Finally, decision tree analysis was used to explore the indications for various transport modes in optimized survival algorithms.

RESULTS

A total of 11,961 patients were included. All three learning algorithms predicted a survival benefit with air transport across all patients, especially those with higher Head Abbreviated Injury Score or Injury Severity Score values, lower Glasgow Coma Scale scores, or hypotension.

CONCLUSION

Air medical response in TBI seems to confer a survival advantage, especially in more critically injured patients.

Emergency department ventilation effects outcome in severe traumatic brain injury

BACKGROUND

Recently, we have demonstrated that patients with traumatic brain injury (TBI) with an arrival PaCo2 30 to 35 mm Hg have improved outcome compared with those outside this target range. We sought to determine whether achieving ventilation into a target range would translate into better outcomes in patients with TBI.

METHODS

Data were retrospectively reviewed for all trauma prehospital intubations during a period of 24 months (n = 851). Targeted ventilation was defined as a PaCo2 between 30 and 39 mm Hg. Arterial blood gases collected within 15 minutes of patient arrival were assessed and compared with subsequent arterial blood gases to determine patient's ventilation status over time.

RESULTS

There was no difference in patient demographics between various ventilation groups. Patients with TBI who achieved the target range had a mortality of 21.2% compared with 33.7% for those who persistently remained outside this range (p = 0.03). Logistic regression demonstrated a trend toward lower mortality for those TBI patients who achieved the target range while in the emergency department (odds ratio 0.33, 95% confidence interval 0.15-0.75).

CONCLUSION

Optimal outcome is achieved when the patient is in the target ventilation range on arrival and remains within it. Ventilation status in trauma patients should be closely monitored after intubation to develop an optimal ventilation strategy for patients with severe TBI.

Early ventilation in traumatic brain injury

While airway and ventilatory compromise are significant concerns following traumatic brain injury (TBI), there is little data supporting an aggressive approach to airway management by prehospital personnel, and a growing number of reports suggesting an association between early intubation and increased mortality. Recent clinical and experimental data suggest that hyperventilation is an important contributor to these adverse outcomes in TBI patients. Various mechanisms appear to be responsible for the worsened outcomes, including hemodynamic, cerebrovascular, immunologic and cellular effects. Here, relevant experimental and clinical data regarding the impact of ventilation on TBI are reviewed. In addition, experimental data regarding potential mechanisms for the adverse effects of hyperventilation and hypocapnia on the injured brain are presented. Finally, the limited data regarding the impact of hypoventilation and hypercapnia on outcome from TBI are discussed.

Resuscitation of patients after traumatic brain injury

Traumatic brain injury (TBI) is the commonest worldwide cause of death and disability in people under 45 years of age. Following an injury of this nature, physiological derangements, both systemic and within the brain, rapidly progress and have a deleterious effect on outcome. There is a lack of brain specific treatments that significantly improve outcome and management must therefore be best care of appropriate physiology, along the familiar ABC lines. There are international guidelines that describe targets to be achieved. Methods to do this plus the rationale for doing so are discussed in this article.

Traumatic brain injury

Traumatic brain injury (TBI) is a significant source of morbidity and mortality throughout the world. This article discusses the epidemiology, pathophysiology, and clinical presentations of minor, moderate, and severe TBI. Controversial topics, such as hypertonic saline for increased intracranial pressure, prehospital intubation of patients who have experienced TBI, and the use of recombinant factor VIIa, are addressed.