Hospital Outcomes and Disposition of Trauma Patients Who Are Intubated Because of Combativeness

Adolescent Trauma Patients With Isolated Head Trauma and Glasgow Coma Scale 6-8: Routine Intubation?

BACKGROUND

Recent evidence suggests that routine intubation upon arrival for adults with isolated head trauma and a depressed Glasgow Coma Scale (GCS) score is associated with increased risk of morbidity and mortality. Whether these outcomes are similar within an adolescent trauma population has not been previously investigated. We hypothesized intubation upon arrival for adolescent trauma patients with isolated head trauma to be associated with a higher risk of death and prolonged length of stay (LOS).

METHODS

The 2017-2019 TQIP was queried for adolescents (age 12-16) presenting after isolated blunt head trauma (abbreviated injury scale [AIS] <1 spine/chest/abdomen/upper-extremity/lower-extremity) and GCS 6-8 on arrival. Transferred patients, dead-on-arrival, and those undergoing emergent operation from the emergency department were excluded. Patients intubated within one-hour were compared to patients not intubated within one-hour. A multivariable logistic regression analysis was performed adjusting for age, sex, GCS, and AIS-grade for the head.

RESULTS

From 141 patients, 73 (51.8%) were intubated upon arrival. Intubated patients had a low complication rate (5.6%). Intubated and non-intubated patients had a similar rate and mortality risk (6.8% vs 1.5%, P = .11) (OR 1.84, CI .08-43.69, P = .71) and median length of stay (LOS) (2 days vs 2 days, P = .13).

DISCUSSION

Unlike adult patients, adolescents with isolated head trauma and a depressed GCS have similar outcomes if they are intubated upon arrival. Utilizing initial GCS score to determine which adolescent trauma patients with isolated head trauma should be intubated appears to be a safe practice.

Prevalence of significant traumatic brain injury among patients intubated in the field due to impaired level of consciousness

OBJECTIVE

Current guidelines advocate prehospital endotracheal intubation (ETI) in patients with suspected severe head injury and impaired level of consciousness. However, the ability to identify patients with traumatic brain injury (TBI) in the prehospital setting is limited and prehospital ETI carries a high complication rate. We investigated the prevalence of significant TBI among patients intubated in the field for that reason.

METHODS

Data were retrospectively collected from emergency medical services and hospital records of trauma patients for whom prehospital ETI was attempted and who were transferred to Rambam Health Care Campus, Israel. The indication for ETI was extracted. The primary outcome was significant TBI (clinical or radiographic) among patients intubated due to suspected severe head trauma.

RESULTS

In 57.3% (379/662) of the trauma patients, ETI was attempted due to impaired consciousness. 349 patients were included in the final analysis: 82.8% were male, the median age was 34 years (IQR 23.0-57.3), and 95.7% suffered blunt trauma. 253 patients (72.5%) had significant TBI. In a multivariable analysis, Glasgow Coma Scale>8 and alcohol intoxication were associated with a lower risk of TBI with OR of 0.26 (95% CI 0.13-0.51, p < 0.001) and 0.16 (95% CI 0.06-0.46, p < 0.001), respectively.

CONCLUSION

Altered mental status in the setting of trauma is a major reason for prehospital ETI. Although most of these patients had TBI, one in four of them did not suffer a significant TBI. Patients with a higher field GCS and those suffering from intoxication have a higher risk of misdiagnosis. Future studies should explore better tools for prehospital assessment of TBI and ways to better define and characterize patients who may benefit from early ETI.

Questioning dogma: does a GCS of 8 require intubation?

Background

There is no evidence supporting intubation for a Glasgow Coma Scale (GCS) of 8. We investigated the effect of intubation in trauma patients with a GCS 6–8, with the hypothesis that intubation would increase mortality and length of stay.

Methods

We studied adult patients with GCS 6–8 from the 2016 National Trauma Data Bank. Intubated and non-intubated patients were compared using inverse probability weighted regression adjustment (IPWRA) to control for injury severity and patient characteristics. Outcomes were mortality, intensive care unit length of stay (ICU LOS), and total LOS. Stratified analysis was performed to investigate the effect in patients with and without head injuries.

Results

Among 6676 patients with a GCS between 6 and 84,078 were intubated within 1 h of arrival to the emergency department. The overall mortality rate was 15.1%. IPWRA revealed an increase in mortality associated with intubation (OR 1.05, 95% CI 1.03, 1.06). The results were similar in patients with head injuries (OR 1.04, 95% CI 1.02, 1.06) and without (OR 1.06, 95% CI 1.03, 1.10). Among the 5,742 patients admitted to the ICU, intubation was associated with a 14% increase in ICU LOS (95% CI 8–20%; 5.5 vs. 4.8 days; p < 0.001). The overall length of stay was 27% longer (95% CI 19.8–34.3%) among intubated patients (mean 7.7 vs 6.0 days; p < 0.001).

Conclusion

Among patients with GCS of 6 to 8, intubation on arrival was associated with an increase in mortality and with longer ICU and overall length of stay. The use of a strict threshold GCS to mandate intubation should be revisited.

Is Prehospital Time Important for the Treatment of Severely Injured Patients? A Matched-Triplet Analysis of 13,851 Patients from the TraumaRegister DGU®

Background

The impact of time (the golden period of trauma) on the outcome of severely injured patients has been well known for a long time. While the duration of the prehospital phase has changed only slightly (average time: ~66 min) since the TraumaRegister DGU® (TR-DGU®) was implemented, mortality rates have decreased within the last 20 years. This study analyzed the influence of prehospital time on the outcome of trauma patients in a matched-triplet analysis.

Material and Methods

A total of 93,024 patients from the TraumaRegister DGU® were selected based on the following inclusion criteria: ISS ≥ 16, primary admission, age ≥ 16 years, and data were available for the following variables: prehospital intubation, blood pressure, mode of transportation, and age. The patients were assigned to one of three groups: group 1: 10-50 min (short emergency treatment time); group 2: 51-75 min (intermediate emergency treatment time); group 3: >75 min (long emergency treatment time). A matched-triplet analysis was conducted; matching was based on the following criteria: intubation at the accident site, rescue resources, Abbreviated Injury Scale (AIS) of the body regions, systolic blood pressure, year of the accident, and age.

Results

A total of 4,617 patients per group could be matched. The number of patients with a GCS score ≤8 was significantly higher in the first group (group 1: 36.6%, group 2: 33.5%, group 3: 30.3%; p < 0.001). Moreover, the number of patients who had to be resuscitated during the prehospital phase and/or upon arrival at the hospital was higher in group 1 (p = 0.010); these patients also had a significantly higher mortality (group 1: 20.4%, group 2: 18.1%, group 3: 15.9%; p ≤ 0.001). The number of measures performed during the prehospital phase (e.g., chest tube insertion) increased with treatment time.

Conclusions

The results suggest that survival after severe trauma is not only a matter of short rescue time but more a matter of well-used rescue time including performance of vital measures already in the prehospital setting. This also includes that rescue teams identify the severity of injuries more rapidly in the most-severely injured patients in critical condition than in less-severely injured patients and plan their interventions accordingly.

Air medical retrieval of acute psychiatric patients

BACKGROUND

The aim of this study is to review the characteristics of acute psychiatric patients requiring air medical retrieval across the Northern Territory (NT) of Australia, to assess the sedation requirements and incidence of in-flight complications when retrieving such patients, and to review the optimal flight crew composition required for safe retrieval.

METHODS

Retrospective data were collected for all psychiatric patients retrieved by an air medical retrieval service of the NT of Australia over a 12-month period between February 1, 2012, and January 31, 2013.

RESULTS

Two hundred sixty-two patients were retrieved using fixed wing transport; 90% were indigenous. Eighty-one percent of retrievals occurred during the day, averaging approximately 4.5 hours. A flight doctor was tasked with a nurse to retrieve 79% of patients. Eighty-nine percent of patients received sedation in the health care center before flight, whereas 39% of total patients required further in-flight sedation. Only 8 patients required intubation before transport. The only in-flight complication was hypotension occurring in 6% of patients; these cases predominantly involved the use of propofol, and the hypotension was rapidly corrected without further incident.

CONCLUSIONS

This review highlights the characteristics of psychiatric patients retrieved by an air medical retrieval service in the NT of Australia. The majority of patients retrieved had a background psychiatric history and also a history of violence. Given the nature of the retrieval and the risk to crew and aircraft, a flight doctor was tasked on a high number of cases. The complication rate was negligible. Further analysis of patient history and characteristics of violence could lead to a risk assessment tool for the retrieval of such patients.

Pre-hospital and early in-hospital management of severe injuries: changes and trends

The pre-hospital and early in-hospital management of most severely injured patients has dramatically changed over the last 20 years. In this context, the factor time has gained more and more attention, particularly in German-speaking countries. While the management in the early 1990s aimed at comprehensive and complete therapy at the accident site, the premise today is to stabilise trauma patients at the accident site and transfer them into the hospital rapidly. In addition, the introduction of training and education programmes such as Pre-hospital Trauma Life Support (PHTLS(®)), Advanced Trauma Life Support (ATLS(®)) concept or the TEAM(®) concept has increased the quality of treatment of most severely injured trauma patients both in the preclinical field and in the emergency trauma room. Today, all emergency surgical procedures in severely injured patients are generally performed in accordance with the Damage Control Orthopaedics (DCO) principle. The advancements described in this article provide examples for the improved quality of the management of severely injured patients in the preclinical field and during the initial in-hospital treatment phase. The implementation of trauma networks, the release of the S3 polytrauma guidelines, and the DGU "Weißbuch" have contributed to a more structured management of most severely injured patients.

Should Uncooperative Trauma Patients with Suspected Head Injury be Intubated?

In trauma patients with a suspicion for traumatic brain injury (TBI), a head computed tomography (CT) scan is imperative. However, uncooperative patients often cannot undergo imaging without sedation and may need to be intubated. Our hypothesis was that among mildly injured trauma patients, in whom there is a suspicion of a head injury, uncooperative patients have higher rates of TBI and intubation should be considered to obtain a CT scan. We found that uncooperative patients intubated for diagnostic purposes were more likely to have moderate to severe TBI than nonintubated patients (21.4 vs 8.4%, P < 0.0001) and uncooperative behavior leading to intubation was an independent predictor of TBI (odds ratio, 2.5; 95% confidence interval, 1.5 to 4.5). Of patients with brain injury, intubated patients more often had a head Abbreviated Injury Scale score of 4 (20.8 vs 7.9%, P = 0.04). Uncooperative intubated patients had longer hospital stays (3.6 vs 2.6 days, P = 0.003) and higher mortality (0.9 vs 0.2%, P = 0.02) than nonintubated patients. Uncooperative behavior may be an early warning sign of TBI and the trauma surgeon should consider intubating uncooperative trauma patients if there is suspicion for brain injury based on the mechanism of their trauma.

[Emergency anesthesia, airway management and ventilation in major trauma. Background and key messages of the interdisciplinary S3 guidelines for major trauma patients]

Patients with multiple trauma presenting with apnea or a gasping breathing pattern (respiratory rate  < 6/min) require prehospital endotracheal intubation (ETI) and ventilation. Additional indications are hypoxia (S(p)O(2)  < 90% despite oxygen insufflation and after exclusion of tension pneumothorax), severe traumatic brain injury [Glasgow Coma Scale (GCS)  < 9], trauma-associated hemodynamic instability [systolic blood pressure (SBP)  < 90 mmHg] and severe chest trauma with respiratory insufficiency (respiratory rate  > 29/min). The induction of anesthesia after preoxygenation is conducted as rapid sequence induction (analgesic, hypnotic drug, neuromuscular blocking agent). With the availability of ketamine as a viable alternative, the use of etomidate is not encouraged due to its side effects on adrenal function. An electrocardiogram (ECG), blood pressure measurement and pulse oximetry are needed to monitor the emergency anesthesia and the secured airway. Capnography is absolutely mandatory to confirm correct placement of the endotracheal tube and to monitor tube dislocations as well as ventilation in the prehospital and hospital setting. Because airway management is often complicated in trauma patients, alternative devices need to be available preclinical and a fiber-optic endoscope should be available within the hospital. Use of these alternative measures for airway management and ventilation should be considered at the latest after a maximum of three unsuccessful endotracheal intubation attempts. Emergency medical service (EMS) physicians should to be trained in emergency anesthesia, ETI and alternative methods of airway management on a regular basis. Within hospitals ETI, emergency anesthesia and ventilation are to be conducted by trained and experienced anesthesiologists. When a difficult airway or induction of anesthesia is expected, endotracheal intubation should be supervised or conducted by an anesthesiologist. Normoventilation should be the goal of mechanical ventilation. After arrival in the resuscitation room the ventilation will be controlled and guided with the help of arterial blood gas analyses. After temporary removal of a cervical collar, the cervical spine needs to be immobilized by means of manual in-line stabilization when securing the airway.

[Preclinical management of multiples injuries: S3 guideline]

The guidelines follow the priorities established by the A-B-C-D-E scheme. They focus on the treatment of actual disturbances of vital functions and not so much on their anticipated development. Important recommendations with regard to the indication for intubation and ventilation, fluid therapy, diagnosis and treatment of severe chest injuries (tension pneumothorax in particular), management of severe traumatic brain injury, pelvic and vertebral injuries, priorities in the management of extremity fractures as well as indications for the choice of the receiving hospital are given. The recommendations are discussed in view of future concerns and developments.

Propofol infusion for the retrieval of the acutely psychotic patient

Transporting acutely psychotic patients is hazardous because of the risks they present to themselves, escorting staff, and aircraft. Various strategies have been proposed, usually involving combinations of sedating drugs and physical restraint. Thus far, none guarantees safe retrieval while completely mitigating risks. This case proposes the use of propofol as an alternative to more traditionally used agents. An infusion facilitated the uneventful and safe retrieval of a patient who had demonstrated resistance and tolerance to other drugs. Discussion is also presented on the potential utility of propofol for the retrieval of acutely psychotic patients.

Predictors of new findings on repeat head CT scan in blunt trauma patients with an initially negative head CT scan

BACKGROUND

Our goal was to determine the need for a repeat head CT scan when the initial CT was negative.

STUDY DESIGN

Data were collected from January 1, 2002 to December 31, 2008. There were 281 patients admitted to the trauma center with an initial negative head CT, who had a repeat CT during the same hospitalization. Repeat CTs were categorized into negative/negative (NNG) and negative/positive (NPG) groups.

RESULTS

There were 281 patients who underwent a repeat head CT for changes in neurologic status, persistent symptoms, follow-up, decreased mental status, or suspected bleed. Of these, 241 patients remained negative (NNG) and new abnormal findings were noted in 40 patients (NPG). There were no differences in sex (NNG, 63% males vs NPG, 75% females; p = 0.14) or average age (NNG, 51.6 ± 22.5 years vs NPG, 45.2 ± 24.6 years; p = 0.07). There was no difference in positive toxicology (NNG, 29% vs NPG, 30%; p = 0.94) or mechanism of injury (NNG, 51% motor vehicle crash [MVC] vs NPG, 62% MVC; p = 0.18). There was a significant difference in Injury Severity Score (ISS) (NNG, 10.7 ± 8.1 vs NPG, 17.9 ± 11.0; p = 0.0002) and initial Glasgow Coma Scale (GCS) (NNG, 12.7 ± 3.5 vs NPG, 10.9 ± 4.2; p = 0.006). Patients with an ISS > 15 and who were intubated were associated with an increased odds of having a positive repeat CT scan (odds ratio [OR] 2.6; 95%CI 1.2, 5.5 and OR 3.5; 95% CI, 1.7, 7.3, respectively).

CONCLUSIONS

Patients with a high ISS score and/or those who are intubated have significantly higher odds of having a positive repeat head CT when repeated for follow-up or when clinically warranted.

[Emergency anesthesia, airway management and ventilation in major trauma. Background and key messages of the interdisciplinary S3 guidelines for major trauma patients]

Patients with multiple trauma presenting with apnea or a gasping breathing pattern (respiratory rate <6/min) require prehospital endotracheal intubation (ETI) and ventilation. Additional indications are hypoxia (S(p)O(2)<90% despite oxygen insufflation and after exclusion of tension pneumothorax), severe traumatic brain injury [Glasgow Coma Scale (GCS)<9], trauma-associated hemodynamic instability [systolic blood pressure (SBP)<90 mmHg] and severe chest trauma with respiratory insufficiency (respiratory rate >29/min). The induction of anesthesia after preoxygenation is conducted as rapid sequence induction (analgesic, hypnotic drug, neuromuscular blocking agent). With the availability of ketamine as a viable alternative, the use of etomidate is not encouraged due to its side effects on adrenal function. An electrocardiogram (ECG), blood pressure measurement and pulse oximetry are needed to monitor the emergency anesthesia and the secured airway. Capnography is absolutely mandatory to confirm correct placement of the endotracheal tube and to monitor tube dislocations as well as ventilation and oxygenation in the prehospital and hospital setting. Because airway management is often complicated in trauma patients, alternative devices and a fiber-optic endoscope need to be available within the hospital. Use of these alternative measures for airway management and ventilation should be considered at the latest after a maximum of three unsuccessful intubation attempts. Emergency medical service (EMS) physicians should to be trained in emergency anesthesia, ETI and alternative methods of airway management on a regular basis. Within hospitals ETI, emergency anesthesia and ventilation are to be conducted by trained and experienced anesthesiologists. When a difficult airway or induction of anesthesia is expected, endotracheal intubation should be supervised or conducted by an anesthesiologist. Normoventilation should be the goal of mechanical ventilation. After arrival in the resuscitation room the ventilation will be controlled and guided with the help of arterial blood gas analyses. After temporary removal of a cervical collar, the cervical spine needs to be immobilized by means of manual in-line stabilization when securing the airway.

Prehospital intubation of the moderately injured patient: a cause of morbidity? A matched-pairs analysis of 1,200 patients from the DGU Trauma Registry

INTRODUCTION

Hypoxia and hypoxemia can lead to an unfavorable outcome after severe trauma, by both direct and delayed mechanisms. Prehospital intubation is meant to ensure pulmonary gas exchange. Limited evidence exists regarding indications for intubation after trauma. The aim of this study was to analyze prehospital intubation as an independent risk factor for the posttraumatic course of moderately injured patients. Therefore, only patients who, in retrospect, would not have required intubation were included in the matched-pairs analysis to evaluate the risks related to intubation.

METHODS

The data of 42,248 patients taken from the trauma registry of the German Association for Trauma Surgery (Deutsche Gesellschaft für Unfallchirurgie (DGU)) were analyzed. Patients who met the following criteria were included: primary admission to a hospital; Glasgow Coma Scale (GCS) of 13 to 15; age 16 years or older; maximum injury severity per body region (AIS) ≤ 3; no administration of packed red blood cell units in the emergency trauma room; admission between 2005 and 2008; and documented data regarding intubation. The intubated patients were then matched with not-intubated patients.

RESULTS

The study population included 600 matched pairs that met the inclusion criteria. The results indicated that prehospital intubation was associated with a prolonged rescue time (not intubated, 64.8 minutes; intubated, 82.3 minutes; P ≤ 0.001) and a higher volume replacement (not intubated, 911.3 ml; intubated, 1,573.8 ml; P ≤ 0.001). In the intubated patients, coagulation parameters, such as the prothrombin time ratio (PT) and platelet count, declined, as did the hemoglobin value (PT not intubated: 92.3%; intubated, 85.7%; P ≤ 0.001; hemoglobin not intubated, 13.4 mg/dl; intubated, 12.2 mg/dl; P ≤ 0.001). Intubation at the scene resulted in an elevated sepsis rate (not intubated, 1.5%; intubated, 3.7%; P ≤ 0.02) and an elevated prevalence of multiorgan failure (MOF) and organ failure (OF) (OF not intubated, 9.1%; intubated, 23.4%; P ≤ 0.001).

CONCLUSIONS

Prehospital intubation in trauma patients is associated with a number of risks and should be critically weighed, except in cases with clear indicators, such as posttraumatic apnea.