The use of neuromuscular blocking agents to facilitate prehospital intubation does not impair outcome after traumatic brain injury

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.

Evidence-Based Guideline for Prehospital Airway Management

Airway management is a cornerstone of emergency medical care. This project aimed to create evidence-based guidelines based on the systematic review recently conducted by the Agency for Healthcare Research and Quality (AHRQ). A technical expert panel was assembled to review the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The panel made specific recommendations on the different PICO (population, intervention, comparison, outcome) questions reviewed in the AHRQ review and created good practice statements that summarize and operationalize these recommendations. The recommendations address the use of ventilation with bag-valve mask ventilation alone vs. supraglottic airways vs. endotracheal intubation for adults and children with cardiac arrest, medical emergencies, and trauma. Additional recommendations address the use of video laryngoscopy and drug-assisted airway management. These recommendations, and the associated good practice statements, offer EMS agencies and clinicians an opportunity to review the available evidence and incorporate it into their airway management strategies.

Prehospital Drug Assisted Airway Management: An NAEMSP Position Statement and Resource Document

Airway management is a critical intervention for patients with airway compromise, respiratory failure, and cardiac arrest. Many EMS agencies use drug-assisted airway management (DAAM) - the administration of sedatives alone or in combination with neuromuscular blockers - to facilitate advanced airway placement in patients with airway compromise or impending respiratory failure who also have altered mental status, agitation, or intact protective airway reflexes. While DAAM provides several benefits including improving laryngoscopy and making insertion of endotracheal tubes and supraglottic airways easier, DAAM also carries important risks. NAEMSP recommends:DAAM is an appropriate tool for EMS clinicians in systems with clear guidelines, sufficient training, and close EMS physician oversight. DAAM should not be used in settings without adequate resources.EMS physicians should develop clinical guidelines informed by evidence and oversee the training and credentialing for safe and effective DAAM.DAAM programs should include best practices of airway management including patient selection, assessmenct and positioning, preoxygenation strategies including apneic oxygenation, monitoring and management of physiologic abnormalities, selection of medications, post-intubation analgesia and sedation, equipment selection, airway confirmation and monitoring, and rescue airway techniques.Post-DAAM airway placement must be confirmed and continually monitored with waveform capnography.EMS clinicians must have the necessary equipment and training to manage patients with failed DAAM, including bag mask ventilation, supraglottic airway devices and surgical airway approaches.Continuous quality improvement for DAAM must include assessment of individual and aggregate performance metrics. Where available for review, continuous physiologic recordings (vital signs, pulse oximetry, and capnography), audio and video recordings, and assessment of patient outcomes should be part of DAAM continuous quality improvement.

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.

Multiple trauma management in mountain environments - a scoping review : Evidence based guidelines of the International Commission for Mountain Emergency Medicine (ICAR MedCom). Intended for physicians and other advanced life support personnel

Background

Multiple trauma in mountain environments may be associated with increased morbidity and mortality compared to urban environments.

Objective

To provide evidence based guidance to assist rescuers in multiple trauma management in mountain environments.

Eligibility criteria

All articles published on or before September 30th 2019, in all languages, were included. Articles were searched with predefined search terms.

Sources of evidence

PubMed, Cochrane Database of Systematic Reviews and hand searching of relevant studies from the reference list of included articles.

Charting methods

Evidence was searched according to clinically relevant topics and PICO questions.

Results

Two-hundred forty-seven articles met the inclusion criteria. Recommendations were developed and graded according to the evidence-grading system of the American College of Chest Physicians. The manuscript was initially written and discussed by the coauthors. Then it was presented to ICAR MedCom in draft and again in final form for discussion and internal peer review. Finally, in a face-to-face discussion within ICAR MedCom consensus was reached on October 11th 2019, at the ICAR fall meeting in Zakopane, Poland.

Conclusions

Multiple trauma management in mountain environments can be demanding. Safety of the rescuers and the victim has priority. A crABCDE approach, with haemorrhage control first, is central, followed by basic first aid, splinting, immobilisation, analgesia, and insulation. Time for on-site medical treatment must be balanced against the need for rapid transfer to a trauma centre and should be as short as possible. Reduced on-scene times may be achieved with helicopter rescue. Advanced diagnostics (e.g. ultrasound) may be used and treatment continued during transport.

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.

A tale of two cities: prehospital intubation with or without paralysing agents for traumatic brain injury

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.

Environmental Hyperthermia in Prehospital Patients with Major Traumatic Brain Injury

BACKGROUND

Traumatic brain injury (TBI) results in an estimated 1.7 million emergency department visits each year in the United States. These injuries frequently occur outside, leaving injured individuals exposed to environmental temperature extremes before they are transported to a hospital.

OBJECTIVE

Evaluate the existing literature for evidence that exposure to high temperatures immediately after TBI could result in elevated body temperatures (EBTs), and whether or not EBTs affect patient outcomes.

DISCUSSION

It has been clear since the early 1980s that after brain injury, exposure to environmental temperatures can cause hypothermia, and that this represents a significant contributor to increased morbidity and mortality. Less is known about elevated body temperature. Early evidence from the Iraq and Afghanistan wars indicated that exposure to elevated environmental temperatures in the prehospital setting may result in significant EBTs, however, it is unclear what impact these EBTs might have on outcomes in TBI patients. In the hospital, EBT, or neurogenic fever, is thought to be due to the acute-phase reaction that follows critical injury, and these high body temperatures are associated with poor outcomes after TBI.

CONCLUSION

Hospital data suggest that EBTs are associated with poor outcomes, and some preliminary reports suggest that early EBTs are common after TBI in the prehospital setting. However, it remains unclear whether patients with TBI have an increased risk of EBTs after exposure to high environmental temperatures, or if this very early "hyperthermia" might cause secondary injury after TBI.

One-year outcome after prehospital intubation

BACKGROUND

The aim of physician staffed emergency medical services (EMS) is to supplement other EMS units in the care of prehospital patients. The need for advanced airway management in critical prehospital patients can be considered as one indicator of the severity of the patient's condition. Our primary aim was to study the long-term outcome of critically ill patients (excluding cardiac arrest) who were intubated by EMS physicians in the prehospital setting.

METHODS

Data of 845 patients, whose airways were secured by the EMS physicians during a 5-year (2007-2011) period, were retrospectively evaluated. After exclusions, the outcome of 483 patients (8.9% of all patients treated by EMS) was studied. Evaluation was based on hospital patient records 1 year after the incident. For assessment of neurological outcome, a modified Glasgow Outcome Score (GOS) was used. Time and cause of death were recorded.

RESULTS

55.3% of the study patients had a good neurological recovery (GOS 4-5) with independent life 1 year after the event. The overall 1-year mortality (GOS 1) was 35.0%. Poor neurological outcome (GOS 2-3) was found in 9.7% of the patients. Patients with intoxication or convulsions survived best, while those with suspected intracranial pathology had the worst prognosis. Of all survivors, 85% recovered well.

CONCLUSION

The majority of the study patients had a favourable neurological recovery with independent life at 1 year after the incident. More than 80% of all deaths occurred within 30 days of the incident.

The prehospital management of traumatic brain injury

Traumatic brain injury (TBI) is an important cause of death and disability, particularly in younger populations. The prehospital evaluation and management of TBI is a vital link between insult and definitive care and can have dramatic implications for subsequent morbidity. Following a TBI the brain is at high risk for further ischemic injury, with prehospital interventions targeted at reducing this secondary injury while optimizing cerebral physiology. In the following chapter we discuss the prehospital assessment and management of the brain-injured patient. The initial evaluation and physical examination are discussed with a focus on interpretation of specific physical examination findings and interpretation of vital signs. We evaluate patient management strategies including indications for advanced airway management, oxygenation, ventilation, and fluid resuscitation, as well as prehospital strategies for the management of suspected or impending cerebral herniation including hyperventilation and brain-directed hyperosmolar therapy. Transport decisions including the role of triage models and trauma centers are discussed. Finally, future directions in the prehospital management of traumatic brain injury are explored.

Current pre-hospital traumatic brain injury management in China

BACKGROUND

Traumatic brain injury (TBI) is associated with most trauma-related deaths. Secondary brain injury is the leading cause of in-hospital deaths after traumatic brain injury. By early prevention and slowing of the initial pathophysiological mechanism of secondary brain injury, pre-hospital service can significantly reduce case-fatality rates of TBI. In China, the incidence of TBI is increasing and the proportion of severe TBI is much higher than that in other countries. The objective of this paper is to review the pre-hospital management of TBI in China.

DATA SOURCES

A literature search was conducted in January 2014 using the China National Knowledge Infrastructure (CNKI). Articles on the assessment and treatment of TBI in pre-hospital settings practiced by Chinese doctors were identified. The information on the assessment and treatment of hypoxemia, hypotension, and brain herniation was extracted from the identified articles.

RESULTS

Of the 471 articles identified, 65 met the selection criteria. The existing literature indicated that current practices of pre-hospital TBI management in China were sub-optimal and varied considerably across different regions.

CONCLUSION

Since pre-hospital care is the weakest part of Chinese emergency care, appropriate training programs on pre-hospital TBI management are urgently needed in China.

Evaluation of the impact of implementing the emergency medical services traumatic brain injury guidelines in Arizona: the Excellence in Prehospital Injury Care (EPIC) study methodology

Traumatic brain injury (TBI) exacts a great toll on society. Fortunately, there is growing evidence that the management of TBI in the early minutes after injury may significantly reduce morbidity and mortality. In response, evidence-based prehospital and in-hospital TBI treatment guidelines have been established by authoritative bodies. However, no large studies have yet evaluated the effectiveness of implementing these guidelines in the prehospital setting. This article describes the background, design, implementation, emergency medical services (EMS) treatment protocols, and statistical analysis of a prospective, controlled (before/after), statewide study designed to evaluate the effect of implementing the EMS TBI guidelines-the Excellence in Prehospital Injury Care (EPIC) study (NIH/NINDS R01NS071049, "EPIC"; and 3R01NS071049-S1, "EPIC4Kids"). The specific aim of the study is to test the hypothesis that statewide implementation of the international adult and pediatric EMS TBI guidelines will significantly reduce mortality and improve nonmortality outcomes in patients with moderate or severe TBI. Furthermore, it will specifically evaluate the effect of guideline implementation on outcomes in the subgroup of patients who are intubated in the field. Over the course of the entire study (~9 years), it is estimated that approximately 25,000 patients will be enrolled.

Prehospital use of cervical collars in trauma patients: a critical review

The cervical collar has been routinely used for trauma patients for more than 30 years and is a hallmark of state-of-the-art prehospital trauma care. However, the existing evidence for this practice is limited: Randomized, controlled trials are largely missing, and there are uncertain effects on mortality, neurological injury, and spinal stability. Even more concerning, there is a growing body of evidence and opinion against the use of collars. It has been argued that collars cause more harm than good, and that we should simply stop using them. In this critical review, we discuss the pros and cons of collar use in trauma patients and reflect on how we can move our clinical practice forward. Conclusively, we propose a safe, effective strategy for prehospital spinal immobilization that does not include routine use of collars.

Pre-hospital intubation factors and pneumonia in trauma patients

BACKGROUND

We reported similar rates of ventilator-associated pneumonia (VAP) previously in trauma patients intubated either in a pre-hospital (PH) venue or the emergency department. A subset of PH intubations with continuous quality assessment was re-examined to identify the intubation factors associated with VAP.

METHODS

The subgroup was derived from an existing data set of consecutive adult trauma patients intubated prior to Level I trauma center admission July 2007-July 2008. Intubation details recorded included bag-valve mask ventilation (BVM) and the presence of material in the airway. The diagnosis of VAP was made preferentially by quantitative bronchoalveolar lavage (BAL) cultures (≥ 10⁴ colony-forming units indicating infection). Baseline data, injury characteristics, and circumstances of intubation of patients with and without VAP were compared by univariable analysis.

RESULTS

Detailed data were available for 197 patients; 32 (16.2%) developed VAP, on average 6.0±0.7 days after admission. Baseline characteristics were similar in the groups, but diabetes mellitus was more common in the VAP group (4 [12.5%] vs. 5 [3.0%]; p=0.02). There was a higher rate of blunt injury in the VAP patients (28 [87.5%] vs. 106 [64.2%]; p=0.01) and higher injury severity scores (33.1±2.8 vs. 23.0±1.0; p=0.0002) and chest Abbreviated Injury Scores (2.6±0.3 vs. 1.5±0.1; p=0.002). Lower Glasgow Coma Scale scores (7.9±0.9 vs. 9.9±0.4; p=0.04) and greater use of BVM (18 [56.3%] vs. 56 [34.0%]; p=0.02) were observed in patients who developed VAP. Among aspirations, 10 (31.3%) of patients with emesis developed VAP compared with only 4 (12.5%) with blood in the airway (p=0.003).

CONCLUSION

Aspiration, along with depressed consciousness and greater injury severity, may predispose trauma patients to VAP. Prospective studies should focus on the quality and timing of aspiration relative to intubation to determine if novel interventions can prevent aspiration or decrease the risk of VAP after aspiration.

The relationship between out-of-hospital airway management and outcome among trauma patients with Glasgow Coma Scale Scores of 8 or less

BACKGROUND

Airway management remains a fundamental component of optimal care of the severely injured patient, with endotracheal intubation representing the definitive strategy for airway control. However, multiple studies document an association between out-of-hospital intubation and increased mortality for severe traumatic brain injury.

OBJECTIVES

To explore the relationship between out-of-hospital intubation attempts and outcome among trauma patients with Glasgow Coma Scale (GCS) scores ≤ 8 across sites participating in the Resuscitation Outcomes Consortium (ROC).

METHODS

The ROC Epistry-Trauma, an epidemiologic database of prehospital encounters with critically injured trauma victims, was used to identify emergency medical services (EMS)-treated patients with GCS scores ≤ 8. Multiple logistic regression was used to explore the association between intubation attempts and vital status at discharge, adjusting for the following covariates: age, gender, GCS score, hypotension, mechanism of injury, and ROC site. Sites were then stratified by frequency of intubation attempts and chi-square test for trend was used to associate the frequency of intubation attempts with outcome.

RESULTS

A total of 1,555 patients were included in this analysis; intubation was attempted in 758 of these. Patients in whom intubation was attempted had higher mortality (adjusted odds ratio [OR] 2.91, 95% confidence interval [CI] 2.13-3.98, p < 0.01). However, sites with higher rates of attempted intubation had lower mortality across all trauma victims with GCS scores ≤ 8 (OR 1.40, 95% CI 1.15-1.72, p < 0.01).

CONCLUSIONS

Patients in whom intubation is attempted have higher adjusted mortality. However, sites with a higher rate of attempted intubation have lower adjusted mortality across the entire cohort of trauma patients with GCS scores ≤ 8. Coma Scale score.

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.

[Death due to (no) airway. Adverse events by out-of-hospital airway management?]

Securing the airway is a rarely performed procedure in the out-of-hospital setting. In recent years evidence has been accumulated indicating that out-of-hospital airway management is more challenging as compared to elective situations even for experienced health care providers. Furthermore, several authors have questioned the benefit of out-of-hospital tracheal intubation. This review argues the problems regarding out-of-hospital airway management studies and discusses potential solutions which may improve out-of-hospital health care.

Revisiting the value of pre-hospital tracheal intubation: an all time systematic literature review extracting the Utstein airway core variables

Introduction

Although tracheal intubation (TI) in the pre-hospital setting is regularly carried out by emergency medical service (EMS) providers throughout the world, its value is widely debated. Heterogeneity in procedures, providers, patients, systems and stated outcomes, and inconsistency in data reporting make scientific reports difficult to interpret and compare, and the majority are of limited quality. To hunt down what is really known about the value of pre-hospital TI, we determined the rate of reported Utstein airway variables (28 core variables and 12 fixed-system variables) found in current scientific publications on pre-hospital TI.

Methods

We performed an all time systematic search according to the PRISMA guidelines of Medline and EMBASE to identify original research pertaining to pre-hospital TI in adult patients.

Results

From 1,076 identified records, 73 original papers were selected. Information was extracted according to an Utstein template for data reporting from in-the-field advanced airway management. Fifty-nine studies were from North American EMS systems. Of these, 46 (78%) described services in which non-physicians conducted TI. In 12 of the 13 non-North American EMS systems, physicians performed the pre-hospital TI. Overall, two were randomised controlled trials (RCTs), and 65 were observational studies. None of the studies presented the complete set of recommended Utstein airway variables. The median number of core variables reported was 10 (max 21, min 2, IQR 8-12), and the median number of fixed system variables was 5 (max 11, min 0, IQR 4-8). Among the most frequently reported variables were "patient category" and "service mission type", reported in 86% and 71% of the studies, respectively. Among the least-reported variables were "co-morbidity" and "type of available ventilator", both reported in 2% and 1% of the studies, respectively.

Conclusions

Core data required for proper interpretation of results were frequently not recorded and reported in studies investigating TI in adults. This makes it difficult to compare scientific reports, assess their validity, and extrapolate to other EMS systems. Pre-hospital TI is a complex intervention, and terminology and study design must be improved to substantiate future evidence based clinical practice.

Pre-hospital tracheal intubation in patients with traumatic brain injury: systematic review of current evidence

BACKGROUND

We reviewed the current evidence on the benefit and harm of pre-hospital tracheal intubation and mechanical ventilation after traumatic brain injury (TBI).

METHODS

We conducted a systematic literature search up to December 2007 without language restriction to identify interventional and observational studies comparing pre-hospital intubation with other airway management (e.g. bag-valve-mask or oxygen administration) in patients with TBI. Information on study design, population, interventions, and outcomes was abstracted by two investigators and cross-checked by two others. Seventeen studies were included with data for 15,335 patients collected from 1985 to 2004. There were 12 retrospective analyses of trauma registries or hospital databases, three cohort studies, one case-control study, and one controlled trial. Using Brain Trauma Foundation classification of evidence, there were 14 class 3 studies, three class 2 studies, and no class 1 study. Six studies were of adults, five of children, and three of both; age groups were unclear in three studies. Maximum follow-up was up to 6 months or hospital discharge.

RESULTS

In 13 studies, the unadjusted odds ratios (ORs) for an effect of pre-hospital intubation on in-hospital mortality ranged from 0.17 (favouring control interventions) to 2.43 (favouring pre-hospital intubation); adjusted ORs ranged from 0.24 to 1.42. Estimates for functional outcomes after TBI were equivocal. Three studies indicated higher risk of pneumonia associated with pre-hospital (when compared with in-hospital) intubation.

CONCLUSIONS

Overall, the available evidence did not support any benefit from pre-hospital intubation and mechanical ventilation after TBI. Additional arguments need to be taken into account, including medical and procedural aspects.

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.

Emergency airway management in critically injured patients: a survey of U.S. aero-medical transport programs

OBJECTIVE

Pre-hospital airway management represents the intervention most likely to impact outcomes in critically injured patients. As such, airway management issues dominate quality improvement (QI) reviews of aero-medical programs. The purpose of this study was to evaluate current practice patterns of airway management in trauma among U.S. aero-medical service (AMS) programs.

METHODS

The Association of Air Medical Services (AAMS) Resource Guide from 2005 to 2006 was utilized to identify the e-mail addresses of all directors of U.S. aero-medical transport programs. Program directors from 182 U.S. aero-medical programs were asked to participate in an anonymous, web-based survey of emergency airway management protocols and practices. Non-responders to the initial request were contacted a second time by e-mail.

RESULTS

89 programs responded. 98.9% have rapid sequence intubation (RSI) protocols. 90% use succinylcholine, 70% use long-acting neuromuscular blockers (NMB) within their RSI protocol. 77% have protocols for mandatory in-flight sedation but only 13% have similar protocols for maintenance paralytics. 60% administer long-acting NMB immediately after RSI, 13% after confirmation of neurological activity. Given clinical scenarios, however, 97% administer long-acting NMB to patients with scene and in-flight Glasgow Coma Scale (GCS) of 3, even for brief transport times.

CONCLUSIONS

The majority of AMS programs have well defined RSI and in-flight sedation protocols, while protocols for in-flight NMB are uncommon. Despite this, nearly all programs administer long-acting NMB following RSI, irrespective of GCS or flight time. Given the impact of in-flight NMB on initial assessment, early intervention, and injury severity scoring, a critical appraisal of current AMS airway management practices appears warranted.

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.

Survival of trauma patients with coma and bilateral fixed dilated pupils

BACKGROUND

Survival of patients with severe trauma presenting with Glasgow Coma Score (GCS) 3 and bilateral fixed dilated pupils is uncertain. Pre-hospital management of these patients affects the true measurement of the GCS and other factors may affect pupillary status.

PATIENTS AND METHODS

A retrospective review was undertaken of all patients who were classified GCS 3 and had bilateral fixed dilated pupils on admission to a Level 1 Adult Trauma Centre between July 2001 and March 2005. Pre-hospital assessment, hospital interventions and outcomes were determined.

RESULTS

Ninety-three patients fulfilled the criteria for inclusion into the study. There were 6 survivors who were all less than 28 years of age, had at least one GCS score above 3 in the pre-hospital phase and were more likely to have had an evacuable mass lesion on CT brain scan and undergo craniotomy. Of the 6 surviving patients, none had significant thoracoabdominal injuries. Four of the survivors had Glasgow Outcome Score (GOS) of 4 or 5. Time to hospital, mechanism of injury and pre-hospital haemodynamic parameters had no significant effect on survival. Of the 57 patients who were GCS 3 at the scene of the accident, post-basic resuscitation and on admission, none survived.

CONCLUSION

Pre-hospital GCS scores, prior to the effects of intubation, sedation and paralysis should be given more attention when assessing prognosis in patients who are GCS 3 on admission. Trauma patients with GCS 3 persisting from the scene with bilaterally fixed dilated pupils have no appreciable chance of survival. Further interventions such as ICU admission and surgery may not be warranted. Physicians may need to consider stopping treatment and discussing organ donation.

The time cost of prehospital intubation and intravenous access in trauma patients

OBJECTIVES

The prehospital management of trauma patients remains controversial. Little is known about the time each procedure contributes to the on-scene duration, and this information would be helpful in prioritizing which procedures to perform in the prehospital setting. We sought to estimate the contribution of procedures to on-scene duration focusing on intubation and establishment of intravenous (IV) access.

METHODS

Data were provided by the Office of Emergency Planning and Response at the Mississippi Department of Health. Real-time prehospital patient-level data are collected by emergency medical services (EMS) providers for all 9-1-1 calls statewide. Linear regression was performed to determine the overall additional time for an average procedure and to calculate marginal increases in on-scene time associated with the establishment of IV access and with endotracheal intubation. Analyses were performed using Stata 9.

RESULTS

During 2001-2005, 192,055 prehospital runs were made for trauma patients. 121,495 (63%) included prehospital procedures. Average on-scene duration for those runs was 15:24 (minutes:seconds). On average, each procedure was associated with an addition of 1 minute to the on-scene duration (95% confidence interval [CI]: 58-62 seconds). A scene involving the establishment of IV access was 5:04 longer, while one involving tracheal intubation was 2:36 longer.

CONCLUSIONS

We estimate the marginal increase in on-scene duration associated with the performance of an average procedure, establishment of IV access, and endotracheal intubation. There are policy and planning implications for the time trade-off of prehospital procedures, especially discretionary ones.

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.

The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity

BACKGROUND

To date, the benefit of prehospital advanced life-support programs on trauma-related mortality and morbidity has not been established

METHODS

The Ontario Prehospital Advanced Life Support (OPALS) Major Trauma Study was a before-after systemwide controlled clinical trial conducted in 17 cities. We enrolled adult patients who had experienced major trauma in a basic life-support phase and a subsequent advanced life-support phase (during which paramedics were able to perform endotracheal intubation and administer fluids and drugs intravenously). The primary outcome was survival to hospital discharge.

RESULTS

Among the 2867 patients enrolled in the basic life-support (n = 1373) and advanced life-support (n = 1494) phases, characteristics were similar, including mean age (44.8 v. 47.5 years), frequency of blunt injury (92.0% v. 91.4%), median injury severity score (24 v. 22) and percentage of patients with Glasgow Coma Scale score less than 9 (27.2% v. 22.1%). Survival did not differ overall (81.1% among patients in the advanced life-support phase v. 81.8% among those in the basic life-support phase; p = 0.65). Among patients with Glasgow Coma Scale score less than 9, survival was lower among those in the advanced life-support phase (50.9% v. 60.0%; p = 0.02). The adjusted odds of death for the advanced life-support v. basic life-support phases were nonsignificant (1.2, 95% confidence interval 0.9-1.7; p = 0.16).

INTERPRETATION

The OPALS Major Trauma Study showed that systemwide implementation of full advanced life-support programs did not decrease mortality or morbidity for major trauma patients. We also found that during the advanced life-support phase, mortality was greater among patients with Glasgow Coma Scale scores less than 9. We believe that emergency medical services should carefully re-evaluate the indications for and application of prehospital advanced life-support measures for patients who have experienced major trauma.

Does pre-hospital ventilation effect outcome after significant brain injury?

Traumatic brain injury has a devastating impact on society, utilizing many resources and disproportionately affecting the young. Recent evidence demonstrates the early care of the brain injured patient impacts patient outcomes. While prevention of systolic hypotension and hypoxia are mainstays of prehospital management of the injured patient ventilatory management performed in the prehospital environment has recently been shown to impact outcomes. Hypocapnea from hyperventilation has been shown in several trials to cause deleterious effects from cerebral vasoconstriction and ischemia. The importance of balancing the prevention of both hypocapnea and hypercapnea has led to the idea of a target ventilation range for arterial carbon dioxide tension, the ideal way to achieve this balance in the prehospital setting remains elusive. This article reviews the background, physiologic effects, impact on outcomes, and implications for prehospital care of prehospital ventilation.

National Variability in Out-of-Hospital Treatment After Traumatic Injury

STUDY OBJECTIVE

The optimal out-of-hospital treatment for trauma patients remains a subject of national debate. Researchers designing future studies to address these issues must understand the variability in treatment that exists across the United States. We define the variability in the out-of-hospital treatment provided to trauma patients in the United States.

METHODS

This was a retrospective analysis of prospectively collected data for a cohort study of trauma outcomes. The study was conducted at 15 urban or suburban regions across the United States, 18 Level I trauma centers and 51 nontrauma centers. We used a weighted population sample based on data from all hospital trauma deaths and a sample of patients discharged between January 2001 and December 2002. Entry criteria included at least 1 body region with an Abbreviated Injury Score greater than 3 and age between 18 and 84 years. Exclusion criteria were patient age greater than 65 years and isolated hip fractures and patients with burns.

RESULTS

Complete out-of-hospital data were available for 3,357 patients, representing a weighted population sample of 9,929 patients. Out-of-hospital treatment varied substantially among the regions, including out-of-hospital intubation (5% to 48%), use of neuromuscular blocking agents or sedatives to facilitate intubation (0% to 100%), surgical airway access (0.1% to 3.5%), peripheral and central intravenous access (22% to 95%), and needle thoracentesis (0% to 5%).

CONCLUSION

There is considerable national variability in out-of-hospital procedures performed for trauma patients.

Effect of pre-hospital advanced life support with rapid sequence intubation on outcome of severe traumatic brain injury

BACKGROUND

The role of pre-hospital trauma care and the effect of pre-hospital rapid sequence intubation (RSI) on patient outcome are still not clear. This study evaluated the impact of pre-hospital trauma care by emergency physicians (EP) on mortality from severe traumatic brain injury (TBI) and a 180-day Glasgow Outcome Scale (GOS).

METHODS

A 48-month parallel non-controlled cohort study compared a group of 64 patients with severe TBI [Glasgow Coma Scale (GCS) < 9; Injury Severity Score (ISS) > 15] who received pre-hospital advanced life support (ALS) with RSI and were transported to the hospital by EPs (EP group), with a group of 60 patients who did not receive pre-hospital ALS with RSI [emergency medical technicians (EMT) group].

RESULTS

There were no significant statistical differences between the groups in age (P= 0.79), mechanism of injury (P= 0.68), gender (P= 0.82), initial GCS (P= 0.63), initial SaO(2) in the field (P= 0.63), initial systolic blood pressure in the field (P= 0.47) and on-scene time (P= 0.41). In the EP group, there was significantly better first hour survival (97% vs. 79%, P= 0.02), first day survival (90% vs. 72%, P= 0.02), better functional outcome (GOS 4-5: 53% vs. 33%, P < 0.01; GOS 2-3: 8% vs. 20%, P < 0.01) and shortened hospitalization time in intensive care unit (ICU) (P= 0.03) and other departments (P= 0.04). In total hospital mortality, we detected no differences between both groups [EP group: 40% (95% CI: 34-45%) vs. EMT group 42% (95% CI: 36-47%, P= 0.76], except in a subgroup of patients with GCS 6-8 where there was significantly lower total hospital mortality in the EP group (24% vs. 78%, P < 0.01).

CONCLUSION

After starting the trauma care system with emergency physicians in our region, there was a decrease in the number of deaths on hospital admission, a reduction in hospital mortality in the GCS group 6-8, a change in the temporal distribution of deaths, an improvement in functional neurological outcome and shortened hospitalization time.

Paramedic intubation of patients with severe head injury: a review of current Australian practice and recommendations for change

Secondary brain injury may occur early after severe traumatic brain injury due to hypoxia and/or hypotension. Prehospital care by ambulance paramedics has the goal of preventing and treating these complications and, thus, improving outcomes. In Australia, most ambulance services recommend paramedics attempt endotracheal intubation in patients with severe head injury. Even though most patients with severe head injury retain airway reflexes, most states do not allow the use of appropriate drugs to facilitate intubation. In contrast, recent evidence from trauma registries suggests that this approach may be associated with significantly worse outcomes compared with no intubation. Two states allow intubation facilitated by sedative (but not relaxant) drugs, but this has a low success rate and could worsen brain injury because of a decrease in cerebral perfusion pressure. For road-based paramedics, the role of rapid sequence intubation is uncertain. Given the risks of this procedure and the lack of proven benefit, this procedure should not be introduced without supportive evidence from randomised, controlled trials. In contrast, for safety reasons, comatose patients transported by helicopter should undergo rapid sequence intubation prior to flight. However, this is not authorised in most states, despite good supportive evidence that this can be safely and effectively undertaken by paramedics. Finally, there is evidence that inadvertent hyperventilation is associated with adverse outcome, yet only two ambulance services use waveform capnography in head injury patients who are intubated. Overall, current paramedic airway practice in most states of Australia is not supported by the evidence and is probably associated with worse patient outcomes after severe head injury. For road-based paramedics, rapid transport to hospital without intubation should be regarded as the current standard of care. Rapid sequence intubation should be limited to use within appropriate clinical trials, or patients transported by helicopter. For patients who are intubated, waveform capnography is essential to confirm tracheal placement and to prevent inadvertent hyperventilation.

Out-of-hospital endotracheal intubation: where are we?

While remaining prominent in paramedic care and beneficial to some patients, out-of-hospital endotracheal intubation has not clearly improved survival or reduced morbidity from critical illness or injury when studied more broadly. Recent studies identify equivocal or unfavorable clinical effects, adverse events and errors, interaction with other important resuscitation interventions, and challenges in providing and maintaining procedural skill. We provide an overview of current data evaluating the overall effectiveness, safety, and feasibility of paramedic out-of-hospital endotracheal intubation. These studies highlight our limited understanding of out-of-hospital endotracheal intubation and the need for new strategies to improve airway support in the out-of-hospital setting.