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

Intubation and In-Hospital Mortality After Trauma With Glasgow Coma Scale Score Eight or Less-A Cohort Study

INTRODUCTION

Most trauma societies recommend intubating trauma patients with Glasgow Coma Scale (GCS) scores ≤8 without robust supporting evidence. We examined the association between intubation and 30-d in-hospital mortality in trauma patients arriving with a GCS score ≤8 in an Indian trauma registry.

METHODS

Outcomes of patients with a GCS score ≤8 who were intubated within 1 h of arrival (intubation group) were compared with those who were intubated later or not at all (nonintubation group) using various analytical approaches. The association was assessed in various subgroup and sensitivity analyses to identify any variability of the effect.

RESULTS

Of 3476 patients who arrived with a GCS score ≤8, 1671 (48.1%) were intubated within 1 h. Overall, 1957 (56.3%) patients died, 947 (56.7%) in the intubation group and 1010 (56.0%) in the nonintubation group, with no significant difference in mortality (odds ratio = 1.2 [confidence interval, 0.8-1.8], P value = 0.467) in multivariable regression and propensity score-matched analysis. This result persisted across subgroup and sensitivity analyses. Patients intubated within an hour of arrival had longer durations of ventilation, intensive care unit stay, and hospital stay (P < 0.001).

CONCLUSIONS

Intubation within an hour of arrival with a GCS score ≤8 after major trauma was not associated with differences in-hospital mortality. The indications and benefits of early intubation in these severely injured patients should be revisited to promote optimal resource utilization in LMICs.

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.

Effect of prehospital intubation on mortality rates in patients with traumatic brain injury: A systematic review and meta-analysis

OBJECTIVE

It is unclear if prehospital intubation improves survival in patients with traumatic brain injury. We performed a systematic review and meta-analysis to assess the impact of prehospital intubation on mortality rates of traumatic brain injury.

METHODS

PubMed, CENTRAL, Web of Science, and Embase databases were searched without any language restriction up to 20 June 2022 for all types of comparative studies reporting survival of traumatic brain injury patients based on prehospital intubation.

RESULTS

In total, 18 studies with 41,185 patients were eligible for inclusion. Meta-analysis showed that traumatic brain injury patients receiving prehospital intubation had higher odds of mortality as compared to those not receiving prehospital intubation. Meta-analysis of adjusted data also indicated that prehospital intubation was associated with increased odds of mortality in traumatic brain injury patients. The results did not change on sensitivity analysis. Subgroup analysis based on study type, the severity of traumatic brain injury, inclusion of isolated traumatic brain injury, emergency department intubation in the control group, and prehospital intubation group sample size demonstrated variable results.

CONCLUSION

Heterogeneous data from mostly observational studies demonstrates higher mortality rates among traumatic brain injury patients receiving prehospital intubation. The efficacy of prehospital intubation is difficult to judge without taking into account multiple confounding factors.

Prähospitales Atemwegsmanagement in zwei deutschen Städten

Hintergrund und Fragestellung

In der prähospitalen Notfallmedizin ist ein erweitertes Atemwegsmanagement eine wichtige Fähigkeit für Notärzte und Notärztinnen . Sein Erfolg bestimmt die Komplikationen und die Sterblichkeit der Patient(inn)en. Ziel der Studie war es, das prähospitale erweiterte Atemwegsmanagement der bodengebundenen Rettungsdienste in zwei vergleichbaren deutschen Städten zu charakterisieren.

Material und Methoden

Retrospektive Analyse eines prähospitalen Atemwegsmanagementregisters (intubationsregister.de) im Jahr 2018, mit einem Vergleich der Patientenfaktoren, der Intubationssituation, der Charakteristika des Rettungsteams und des Rettungsdiensts in zwei mittelgroßen Städten in Deutschland.

Ergebnisse

Trotz ähnlicher Demografien und vergleichbarer Strukturen der Rettungsdienste fanden sich relevante Unterschiede in der Intubationssituation, dem Ausbildungsgrad der Notärzte und Notärztinnen, der Art der verwendeten Muskelrelaxanzien, der Verfügbarkeit der Videolaryngoskopie, dem Erfolg des ersten Intubationsversuchs und Komplikationen.

Diskussion

Eine strukturierte Erhebung des prähospitalen Atemwegsmanagements und ein Vergleich zwischen den Rettungsdiensten unterschiedlicher Städte können relevante Unterschiede aufzeigen und neue Ansatzpunkte für eine verbesserte Patientenversorgung bieten. Weitere Untersuchungen sind notwendig, um die Ergebnisse zu bestätigen und weitere Fragestellungen anschließen zu können.

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.

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.