Anaesthesiologist-provided prehospital airway management in patients with traumatic brain injury: an observational study

Trauma patient transport to hospital using helicopter emergency medical services or road ambulance in Sweden: a comparison of survival and prehospital time intervals

BACKGROUND

The benefits of helicopter emergency medical services (HEMS) transport of adults following major trauma have been examined with mixed results, with some studies reporting a survival benefit compared to regular emergency medical services (EMS). The benefit of HEMS in the context of the Swedish trauma system remains unclear.

AIM

To investigate differences in survival and prehospital time intervals for trauma patients in Sweden transported by HEMS compared to road ambulance EMS.

METHODS

A total of 74,032 trauma patients treated during 2012-2022 were identified through the Swedish Trauma Registry (SweTrau). The primary outcome was 30-day mortality and Glasgow Outcome Score at discharge from hospital (to home or rehab); secondary outcomes were the proportion of severely injured patients who triggered a trauma team activation (TTA) on arrival to hospital and the proportion of severely injured patients with GCS ≤ 8 who were subject to prehospital endotracheal intubation.

RESULTS

4529 out of 74,032 patients were transported by HEMS during the study period. HEMS patients had significantly lower mortality compared to patients transported by EMS at 1.9% vs 4.3% (ISS 9-15), 5.4% vs 9.4% (ISS 16-24) and 31% vs 42% (ISS ≥ 25) (p < 0.001). Transport by HEMS was also associated with worse neurological outcome at discharge from hospital, as well as a higher rate of in-hospital TTA for severely injured patients and higher rate of prehospital intubation for severely injured patients with GCS ≤ 8. Prehospital time intervals were significantly longer for HEMS patients compared to EMS across all injury severity groups.

CONCLUSION

Trauma patients transported to hospital by HEMS had significantly lower mortality compared to those transported by EMS, despite longer prehospital time intervals and greater injury severity. However, this survival benefit may have been at the expense of a higher degree of adverse neurological outcome. Increasing the availability of HEMS to include all regions should be considered as it may be the preferrable option for transport of severely injured trauma patients in Sweden.

Pre-hospital endotracheal intubation in severe traumatic brain injury: ventilation targets and mortality-a retrospective analysis of 308 patients

BACKGROUND

Traumatic brain injury (TBI) remains one of the main causes of mortality and long-term disability worldwide. Maintaining physiology of brain tissue to the greatest extent possible through optimal management of blood pressure, airway, ventilation, and oxygenation, improves patient outcome. We studied the quality of prehospital care in severe TBI patients by analyzing adherence to recommended target ranges for ventilation and blood pressure, prehospital time expenditure, and their effect on mortality, as well as quality of prehospital ventilation assessed by arterial partial pressure of CO2 (PaCO2) at hospital admission.

METHODS

This is a retrospective cohort study of all TBI patients requiring tracheal intubation on scene who were transported to one of two major level 1 trauma centers in Switzerland between January 2014 and December 2019 by Swiss Air Rescue (Rega). We assessed systolic blood pressure (SBP), end-tidal partial pressure of CO2 (PetCO2), and PaCO2 at hospital admission as well as prehospital and on-scene time. Quality markers of prehospital care (PetCO2, SBP, prehospital times) and prehospital ventilation (PaCO2) are presented as descriptive analysis. Effect on mortality was calculated by multivariable regression analysis and a logistic general additive model.

RESULTS

Of 557 patients after exclusions, 308 were analyzed. Adherence to blood pressure recommendations was 89%. According to PetCO2, 45% were normoventilated, and 29% had a SBP ≥ 90 mm Hg and were normoventilated. Due to the poor correlation between PaCO2 and PetCO2, only 33% were normocapnic at hospital admission. Normocapnia at hospital admission was strongly associated with reduced probability of mortality. Prehospital and on-scene times had no impact on mortality.

CONCLUSIONS

PaCO2 at hospital admission is strongly associated with mortality risk, but normocapnia is achieved only in a minority of patients. Therefore, the time required for placement of an arterial cannula and prehospital blood gas analysis may be warranted in severe TBI patients requiring on-scene tracheal intubation.

[Prehospital emergency anesthesia in adults : Current recommendations for performing prehospital emergency anesthesia based on the recommendations for prehospital emergency anesthesia in adults]

The frequency of prehospital emergency anesthesia in Germany is around 2-3% of all emergency medical missions. The Association of the Scientific Medical Societies of Germany (AWMF) has published guidelines for the implementation of a prehospital emergency anesthesia. The purpose of this article is to highlight important aspects from these guidelines and to present the implementation and special features for specific patient groups. A case study is intended to illustrate that the preclinical setting can provide various facets that make a certain amount of experience and expertise indispensable. The article emphasizes that clear standard situations are not always present and that there are some challenges in the preclinical setting. Therefore, mastering the content of prehospital emergency anesthesia and the manual skills of induction of anesthesia are essential and obligatory for the emergency team.

Association between out-of-hospital cardiac arrest and survival in paediatric traumatic population: results from the French national registry

Trauma is an important cause of paediatric out-of-hospital cardiac arrest (OHCA) with a high mortality rate. The first aim of this study was to compare the survival rate at day 30 and at hospital discharge following paediatric traumatic and medical OHCA. The second aim was to compare the rates of return of spontaneous circulation and survival rates at hospital admission (Day 0). This multicentre comparative post-hoc study was conducted between July 2011 and February 2022 based on the French National Cardiac Arrest Registry data. All patients aged <18 years with OHCA were included in the study. Patients with traumatic aetiology were matched with those with medical aetiology using propensity score matching. Endpoint was the survival rate at day 30. There were 398 traumatic and 1061 medical OHCAs. Matching yielded 227 pairs. In non-adjusted comparisons, days 0 and 30 survival rates were lower in the traumatic aetiology group than in the medical aetiology group [19.1% vs. 24.0%, odds ratio (OR) 0.75, 95% confidence interval (CI) 0.56-0.99, and 2.0% vs. 4.5%, OR 0.43, 95% CI, 0.20-0.92, respectively]. In adjusted comparisons, day 30 survival rate was lower in the traumatic aetiology group than in the medical aetiology group (2.2% vs. 6.2%, OR 0.36, 95% CI, 0.13-0.99). In this post-hoc analysis, paediatric traumatic OHCA was associated with a lower survival rate than medical cardiac arrest.

Haemodynamic effects of a prehospital emergency anaesthesia protocol consisting of fentanyl, ketamine and rocuronium in patients with trauma: a retrospective analysis of data from a Helicopter Emergency Medical Service

OBJECTIVES

Prehospital rapid sequence induction (RSI) of anaesthesia is an intervention with significant associated risk. In this study, we aimed to investigate the haemodynamic response over time of a prehospital RSI protocol of fentanyl, ketamine and rocuronium in a heterogeneous population of trauma patients.

DESIGN, SETTING AND PARTICIPANT

We performed a retrospective study of all trauma patients who received a prehospital RSI for trauma by a physician staffed Helicopter Emergency Medical Service in the UK between 1 June 2018 and 1 February 2020.

PRIMARY OUTCOME MEASURE

Primary outcome was defined as the incidence of clinically relevant hypotensive (systolic blood pressure (SBP) or mean arterial pressure (MAP) >20% below baseline, with an absolute SBP <90 mm Hg or MAP <65 mm Hg) or hypertensive (SBP or MAP >20% above baseline) episodes in the first 10 minutes post-RSI.

RESULTS

In total, 322 patients were included. 204 patients (63%) received a full-dose induction of 3 μg/kg fentanyl, 2 mg/kg ketamine and 1 mg/kg rocuronium, whereas 128 patients (37%) received a reduced-dose induction. Blood pressures decreased on average 12 mm Hg (95% CI 7 to 16) in the full-dose group and 6 mm Hg (95% CI 1 to 11) in the reduced-dose group, p=0.10). A hypotensive episode (mean SBP drop 53 mm Hg) was noted in 29 patients: 17 (8.3%) receiving a full dose and 12 (10.2%) receiving a reduced-dose induction, p=0.69. The blood pressure nadir was recorded on average 6-8 min after RSI. A hypertensive episode was present in 22 patients (6.8%). The highest blood pressures were recorded in the first 3 min after RSI.

CONCLUSION

Prehospital induction of anaesthesia for trauma with fentanyl, ketamine and rocuronium is not related to a significant change in haemodynamics in most patients. However, a (delayed) hypotensive response with a significant drop in SBP should be anticipated in a minority of patients irrespective of the dose regimen chosen.

Adherence to Guidelines in Adult Patients with Traumatic Brain Injury: A Living Systematic Review

Guidelines aim to improve the quality of medical care and reduce treatment variation. The extent to which guidelines are adhered to in the field of traumatic brain injury (TBI) is unknown. The objectives of this systematic review were to (1) quantify adherence to guidelines in adult patients with TBI, (2) examine factors influencing adherence, and (3) study associations of adherence to clinical guidelines and outcome. We searched EMBASE, MEDLINE, Cochrane Central, PubMed, Web of Science, PsycINFO, SCOPUS, CINAHL, and grey literature in October 2014. We included studies of evidence-based (inter)national guidelines that examined the acute treatment of adult patients with TBI. Methodological quality was assessed using the Research Triangle Institute item bank and Quality in Prognostic Studies Risk of Bias Assessment Instrument. Twenty-two retrospective and prospective observational cohort studies, reported in 25 publications, were included, describing adherence to 13 guideline recommendations. Guideline adherence varied considerably between studies (range 18-100%) and was higher in guideline recommendations based on strong evidence compared with those based on lower evidence, and lower in recommendations of relatively more invasive procedures such as craniotomy. A number of patient-related factors, including age, Glasgow Coma Scale, and intracranial pathology, were associated with greater guideline adherence. Guideline adherence to Brain Trauma Foundation guidelines seemed to be associated with lower mortality. Guideline adherence in TBI is suboptimal, and wide variation exists between studies. Guideline adherence may be improved through the development of strong evidence for guidelines. Further research specifying hospital and management characteristics that explain variation in guideline adherence is warranted.

Data quality of Glasgow Coma Scale and Systolic Blood Pressure in scientific studies involving physician-staffed emergency medical services: Systematic review

BACKGROUND

Emergency physicians on-scene provide highly specialized care to severely sick or injured patients. High-quality research relies on the quality of data, but no commonly accepted definition of EMS data quality exits. Glasgow Coma Score (GCS) and Systolic Blood Pressure (SBP) are core physiological variables, but little is known about the quality of these data when reported in p-EMS research. This systematic review aims to describe the quality of pre-hospital reporting of GCS and SBP data in studies where emergency physicians are present on-scene.

METHODS

A systematic literature search was performed using CINAHL, Cochrane, Embase, Medline, Norart, Scopus, SweMed + and Web of Science, in accordance with the PRISMA guidelines. Reported data on accuracy of reporting, completeness and capture were extracted to describe the quality of documentation of GCS and SBP. External and internal validity assessment was performed by extracting a set of predefined variables.

RESULTS

We included 137 articles describing data collection for GCS, SBP or both. Most studies (81%) were conducted in Europe and 59% of studies reported trauma cases. Reporting of GCS and SBP data were not uniform and may be improved to enable comparisons. Of the predefined external and internal validity data items, 26%-45% of data were possible to extract from the included papers.

CONCLUSIONS

Reporting of GCS and SBP is variable in scientific papers. We recommend standardized reporting to enable comparisons of p-EMS.

Computer tomographic assessment of gastric volume in major trauma patients: impact of pre-hospital airway management on gastric air

Background

Gastric dilation is frequently observed in trauma patients. However, little is known about average gastric volumes comprising food, fluids and air. Although literature suggests a relevant risk of gastric insufflation when endotracheal intubation (ETI) is required in the pre-hospital setting, this assumption is still unproven.

Methods

Primary whole body computed tomographic (CT) studies of 315 major trauma patients admitted to our Level 1 Trauma Centre Salzburg during a 7-year period were retrospectively assessed. Gastric volumes were calculated employing a CT volume rendering software. Patients intubated in the pre-hospital setting by emergency physicians (PHI, N = 245) were compared with spontaneously breathing patients requiring ETI immediately after arrival in the emergency room (ERI, N = 70).

Results

The median (range) total gastric content and air volume was 402 (26–2401) and 94 (0–1902) mL in PHI vs. 466 (59–1915) and 120 (1–997) mL in ERI patients (p = .59 and p = .35). PHI patients were more severely injured when compared with the ERI group (injury severity score (ISS) 33 (9–75) vs. 25 (9–75); p = .004). Mortality was higher in the PHI vs. ERI group (26.8% vs. 8.6%, p = .001). When PHI and ERI patients were matched for sex, age, body mass index and ISS (N = 50 per group), total gastric content and air volume was 496 (59–1915) and 119 (0–997) mL in the PHI vs. 429 (36–1726) and 121 (4–1191) mL in the ERI group (p = .85 and p = .98). Radiologic findings indicative for aspiration were observed in 8.1% of PHI vs. 4.3% of ERI patients (p = .31). Gastric air volume in patients who showed signs of aspiration was 194 (0–1355) mL vs. 98 (1–1902) mL in those without pulmonary CT findings (p = .08).

Conclusion

In major trauma patients, overall stomach volume deriving from food, fluids and air must be expected to be around 400–500 mL. Gastric dilation caused by air is common but not typically associated with pre-hospital airway management. The amount of air in the stomach seems to be associated with the risk of aspiration. Further studies, specifically addressing patients after difficult airway management situations are warranted.

Prehospital Airway Management in Severe Traumatic Brain Injury

OBJECTIVE

Traumatic brain injury (TBI) is a leading cause of death and disability among trauma patients. The final outcome of TBI results from a complex interaction between primary and secondary mechanisms of injury that begin immediately after the traumatic event. The aim of this review was to evaluate the latest evidence regarding the impact of prehospital airway management and the outcome after traumatic brain injury.

METHODS

PubMed, Embase, and Cochrane searches were conducted using the MeSH database. Airway management, traumatic brain injury, pneumonia, and the subheadings of these Medical Subject Headings were combined.

RESULTS

The review is structured into 4 major topics: airway management devices, prehospital pharmacologic management, mortality and neurologic outcomes, and early respiratory infections. The available literature shows a shift toward a more comprehensive view of prehospital airway management, taking into account not only the location where airway management is attempted but also the drugs administered, the airway management devices used, and the skills of the main professional figures attending the scene.

CONCLUSIONS

Literature about this topic is still inconclusive; however, new evidence taking into consideration more complex aspects of airway management rather than orotracheal intubation per se shows improved outcomes with aggressive prehospital airway management.

Early-Onset Ventilator-Associated Pneumonia in Severe Traumatic Brain Injury: is There a Relationship with Prehospital Airway Management?

BACKGROUND

Prehospital airway management in severe traumatic brain injury (TBI) is widely recommended by international guidelines for the management of trauma. Early-onset ventilator-associated pneumonia (EOVAP) is a common occurrence in this population and can worsen mortality and functional outcome.

OBJECTIVES

In this retrospective observational study, we aimed to evaluate the association between different prehospital airway management variables and the occurrence of EOVAP. Secondarily we evaluated the correlation between EOVAP and mortality and neurological outcome.

METHODS

The study retrospectively evaluated 223 patients admitted from 2010 to 2017 in our trauma intensive care unit for severe TBI. The population was divided into three groups on the basis of the airway management technique adopted (bag mask ventilation, laryngeal tube, orotracheal intubation). Uni- and multivariate logistic regression analyses were performed using the occurrence of EOVAP as the dependent variable, to investigate potential associations with prehospital airway management.

RESULTS

A total of 131 episodes (58.7%) of EOVAP were registered in the study population (223 patients). Laryngeal tube and orotracheal intubation were used in patients with significantly lower Glasgow Coma Scale score on scene and a higher Face Abbreviated Injury Scale; advanced airway management significantly increased the total rescue time. The prehospital airway management technique adopted, prehospital type of sedation or use of muscle relaxants, type of transport, and rescue times were not associated with the occurrence of EOVAP.

CONCLUSIONS

Prehospital airway management does not have a significant impact on the occurrence of EOVAP in severe TBI patients. Similarly, it does not have a significant impact on mortality or long-term neurological outcome despite increasing duration of mechanical ventilation, intensive care unit, and hospital stay.

Quality measurement in physician-staffed emergency medical services: a systematic literature review

PURPOSE

Quality measurement of physician-staffed emergency medical services (P-EMS) is necessary to improve service quality. Knowledge and consensus on this topic are scarce, making quality measurement of P-EMS a high-priority research area. The aim of this review was to identify, describe and evaluate studies of quality measurement in P-EMS.

DATA SOURCES

The databases of MEDLINE and Embase were searched initially, followed by a search for included article citations in Scopus.

STUDY SELECTION

The study eligibility criteria were: (1) articles describing the use of one quality indicator (QI) or more in P-EMS, (2) original manuscripts, (3) articles published from 1 January 1968 until 5 October 2016. The literature search identified 4699 records. 4543 were excluded after reviewing title and abstract. An additional 129 were excluded based on a full-text review. The remaining 27 papers were included in the analysis. Methodological quality was assessed using an adapted critical appraisal tool.

DATA EXTRACTION

The description of used QIs and methods of quality measurement was extracted. Variables describing the involved P-EMSs were extracted as well.

RESULTS OF DATA SYNTHESIS

In the included papers, a common understanding of which QIs to use in P-EMS did not exist. Fifteen papers used only a single QI. The most widely used QIs were 'Adherence to medical protocols', 'Provision of advanced interventions', 'Response time' and 'Adverse events'.

CONCLUSION

The review demonstrated a lack of shared understanding of which QIs to use in P-EMS. Moreover, papers using only one QI dominated the literature, thus increasing the risk of a narrow perspective in quality measurement. Future quality measurement in P-EMS should rely on a set of consensus-based QIs, ensuring a comprehensive approach to quality measurement.

Observed versus expected mortality in pediatric patients intubated in the field with Glasgow Coma Scale scores < 9

PURPOSE

A Glasgow Coma Scale (GCS) score of 8 or less in patients suffering from severe traumatic brain injury (TBI) represents a decision-making marker in terms of intubation. This study evaluated the impact of prehospital intubation on the mortality of these TBI cases among different age groups.

METHODS

This study included the data from patients predominantly suffering from severe TBI [Abbreviated Injury Scale (AIS) of the head ≥ 3, GCS score < 9, Injury Severity Score (ISS) > 9] who were registered in TraumaRegister DGU^® from 2002 to 2013. An age-related analysis of five subgroups was performed (1-6, 7-15, 16-55, 56-79, and ≥ 80 years old). The observed and expected mortality were matched according to the Revised Injury Severity Classification, version II.

RESULTS

A total of 21,242 patients were included. More often, the intubated patients were severely injured when compared to the non-intubated patients (median ISS 29, IQR 22-41 vs. 24, IQR 16-29, respectively), with an associated higher mortality (42.2% vs. 30.0%, respectively). When compared to the calculated expected mortality, the observed mortality was significantly higher among the intubated patients within the youngest subgroup (42.2% vs. 33.4%, respectively; p = 0.03).

CONCLUSIONS

The observed mortality in the intubated children 1-6 years old suffering from severe TBI seemed to be higher than expected. Whether or not a GCS score of 8 or less is the only reliable criterion for intubation in this age group should be investigated in further trials.

Prehospital treatment of patients with acute intracranial pathology: adherence to guidelines and blood pressure recommendations by the Danish Air Ambulance

Background

Hypoxia and hypotension may be associated with secondary brain injury and negative outcomes in patients with traumatic and non-traumatic intracranial pathology. Guidelines exist only for the prehospital management of patients with severe traumatic brain injury (TBI). In patients with non-traumatic intracranial pathology, TBI guideline recommendations may be applied to assess whether hypoxia and hypotension should be avoided during prehospital treatment. The main study objective was to assess the extent to which Danish Helicopter Emergency Medical Service (HEMS) critical care teams adhere to the prehospital TBI guideline recommendations for the management of patients with a clinical diagnosis of non-traumatic intracranial pathology or isolated TBI. Furthermore, in the same two groups of patients, we evaluated the adherence of the Danish HEMS critical care teams to recommendations aiming to maintain systolic blood pressure (SBP) > 110 mmHg and > 120 mmHg.

Methods

In total, 211 prehospital patient records were studied. All patients were treated for non-traumatic intracranial pathology or isolated TBI by the Danish HEMS critical care teams from October 1, 2014, to January 1, 2017. Adherence to the prehospital TBI guideline recommendations and the SBP recommendations above was assessed in non-TBI and TBI populations.

Results

The adherence rates to TBI guideline recommendations among Danish HEMS critical care teams were 69% (n = 106 [95% CI: 61–77%]) in the non-TBI population and 74% (n = 43 [95% CI: 61–85%]) in the TBI population. SBP > 110 mmHg was observed in 74% (n = 113 [95% CI: 66–81%]) and 69% (n = 40 [95% CI: 56–81%]) of cases in the non-TBI and TBI population, respectively. SBP > 120 mmHg was observed in 55% (n = 84, [95% CI: 47–63%]) of patients in the non-TBI population and 55% (n = 32 [95% CI: 42–68%]) of the patients in the TBI population.

Conclusions

Due to a lack of comparative data, it is difficult to determine the performance quality of the Danish HEMS critical care teams. Our findings may suggest that adherence to TBI guidelines and SBP recommendations needs to be a continuous focal point for the Danish HEMS to avoid secondary brain damage.

Standardised data reporting from pre-hospital advanced airway management - a nominal group technique update of the Utstein-style airway template

Background

Pre-hospital advanced airway management with oxygenation and ventilation may be vital for managing critically ill or injured patients. To improve pre-hospital critical care and develop evidence-based guidelines, research on standardised high-quality data is important. We aimed to identify which airway data were most important to report today and to revise and update a previously reported Utstein-style airway management dataset.

Methods

We recruited sixteen international experts in pre-hospital airway management from Australia, United States of America, and Europe. We used a five-step modified nominal group technique to revise the dataset, and clinical study results from the original template were used to guide the process.

Results

The experts agreed on a key dataset of thirty-two operational variables with six additional system variables, organised in time, patient, airway management and system sections. Of the original variables, one remained unchanged, while nineteen were modified in name, category, definition or value. Sixteen new variables were added. The updated dataset covers risk factors for difficult intubation, checklist and standard operating procedure use, pre-oxygenation strategies, the use of drugs in airway management, airway currency training, developments in airway devices, airway management strategies, and patient safety issues not previously described.

Conclusions

Using a modified nominal group technique with international airway management experts, we have updated the Utstein-style dataset to report standardised data from pre-hospital advanced airway management. The dataset enables future airway management research to produce comparable high-quality data across emergency medical systems. We believe this approach will promote research and improve treatment strategies and outcomes for patients receiving pre-hospital advanced airway management.

Trial registration

The Regional Committee for Medical and Health Research Ethics in Western Norway exempted this study from ethical review (Reference: REK-Vest/2017/260).

Electronic supplementary material

The online version of this article (10.1186/s13049-018-0509-y) contains supplementary material, which is available to authorized users.

Prehospital intubation for isolated severe blunt traumatic brain injury: worse outcomes and higher mortality

PURPOSE

Prehospital endotracheal intubation (ETI) for traumatic brain injury (TBI) is a controversial issue. The aim of this study was to investigate the effect of prehospital ETI in patients with TBI.

METHODS

Cohort-matched study using the US National Trauma Data Bank (NTDB) 2008-2012. Patients with isolated severe blunt TBI (AIS head ≥3, AIS chest/abdomen <3) and a field GCS ≤8 were extracted from NTDB. A 1:1 matching of patients with and without prehospital ETI was performed. Matching criteria were sex, age, exact field GCS, exact AIS head, field hypotension, field cardiac arrest, and the brain injury type (according PREDOT-code). The matched cohorts were compared with univariable and multivariable regression analysis.

RESULTS

A total of 27,714 patients were included. Matching resulted in 8139 cases with and 8139 cases without prehospital ETI. Prehospital ETI was associated with significantly longer scene (median 9 vs. 8 min, p < 0.001) and transport times (median 26 vs. 19 min, p < 0.001), lower Emergency Department (ED) GCS scores (in patients without sedation; mean 3.7 vs. 3.9, p = 0.026), more ventilator days (mean 7.3 vs. 6.9, p = 0.006), longer ICU (median 6.0 vs. 5.0 days, p < 0.001) and total hospital length of stay (median 10.0 vs. 9.0 days, p < 0.001), and higher in-hospital mortality (31.4 vs. 27.5 %, p < 0.001). In regression analysis prehospital ETI was independently associated with lower ED GCS scores (RC -4.213, CI -4.562/-3.864, p < 0.001) and higher in-hospital mortality (OR 1.399, CI 1.205/1.624, p < 0.001).

CONCLUSION

In this large cohort-matched analysis, prehospital ETI in patients with isolated severe blunt TBI was independently associated with lower ED GCS scores and higher mortality.

Isolated blunt severe traumatic brain injury in Bern, Switzerland, and the United States: A matched cohort study

BACKGROUND

The ideal prehospital management of patients with severe traumatic brain injury (TBI) including the impact of endotracheal intubation (ETI) and physicians on scene is unclear. Prehospital management differs substantially in Switzerland and the United States: in Switzerland, there is usually a physician on scene who may provide ETI and other advanced life support procedures, whereas in the United States, prehospital management (including ETI) is performed by paramedics.

METHODS

This is a retrospective cohort-matched study of patients with isolated blunt severe TBI (head Abbreviated Injury Scale [AIS] score, 4-5) and no major extracranial injuries, using Bern University Hospital data from the Swiss PEBITA [Patient-relevant Endpoints after Brain Injury from Traumatic Accidents] (TBI-specific) database and the US National Trauma Data Bank from 2009 to 2010. A 1:4 cohort matching of Bern and US patients was performed. Matching criteria were sex, age (±10 years), exact field Glasgow Coma Scale (GCS) score, exact head AIS score, and injury type (subdural hematoma, epidural hematoma, intraparenchymal hemorrhage, intraventricular hemorrhage, brain edema/swelling, brain stem injury). The matched cohorts were compared with univariable analysis (Fisher's exact test and Mann-Whitney U-test).

RESULTS

Matching of the Bern (n = 128) and US (n = 86,375) cohort resulted in 355 matched cases (71 Bern and 284 US patients). Bern patients had significantly longer scene times (median, 23.0 minutes vs. 9.0 minutes, p < 0.001) and more frequent prehospital ETI (31.0% vs. 18.7%, p = 0.034) and air transportation (39.4% vs. 19.4%, p < 0.001). No significant difference in procedures (craniotomy/craniectomy, intracranial pressure monitoring, tracheotomy), intensive care unit and total hospital lengths of stay, ventilator days, and in-hospital mortality (14.1% vs. 15.8%, p = 0.855) was found between the two cohorts.

CONCLUSION

When taking into account the limitation that patient- and injury-related factors, but not in-hospital treatment variables, were matched, the more frequent prehospital ETI and presence of a physician on scene in the Swiss cohort compared with the US cohort had no significant effect on outcomes, including intensive care unit and total hospital lengths of stay, ventilator days, and in-hospital mortality.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Traumatic brain injury: physiological targets for clinical practice in the prehospital setting and on the Neuro-ICU

PURPOSE OF REVIEW

Over many years, understanding of the pathophysiology in traumatic brain injury (TBI) has resulted in the development of core physiological targets and therapies to preserve cerebral oxygenation, and in doing so prevent secondary insult. The present review revisits the evidence for these targets and therapies.

RECENT FINDINGS

Achieving oxygen, carbon dioxide, blood pressure, temperature and glucose targets remain a key goal of therapy in TBI, as does the role of effective prehospital care. Physician led air ambulance teams reduce mortality. Normobaric hyperoxia is dangerous to the injured brain; as are both high and low carbon dioxide levels. Hypotension is life threatening and higher targets have now been suggested in TBI. Both therapeutic normothermia and hypothermia have a role in specific groups of patients with TBI. Although consensus has not been reached on the optimal intravenous fluid for resuscitation in TBI, vigilant goal-directed fluid administration may improve outcome. Osmotherapeutic agents such as hypertonic sodium lactate solutions may also have a role alongside conventional agents.

SUMMARY

Maintaining physiological targets in several areas remains part of protocol led care in the acute phase of TBI management. As evidence accumulates however, the target values and therefore therapies may be set to change.