Prehospital Endotracheal Intubation for Trauma Does Not Improve Survival over Bag-Valve-Mask Ventilation

The golden hour of shock - how time is running out: prehospital time intervals in Germany--a multivariate analysis of 15, 103 patients from the TraumaRegister DGU(R)

OBJECTIVES

Although prehospital treatment algorithms have changed over the past years, the prehospital time of multiple trauma patients of some 70 min and the on-scene-treatment time (OST) of some 30 min have not changed since 1993. The aim of this study was to critically assess specific interventions and conditions at the scene in relation to their impact on prehospital rescue intervals.

METHODS

We performed a retrospective data analysis of all multiple injured patients from the TraumaRegister DGU (English: German Trauma Society) from January 1993 to December 2010. Exclusion criteria were missing or implausible data regarding prehospital timelines. With OST as an independent variable, different models of multivariate regression were performed to identify parameters with relevant impact on the OST.

RESULTS

15 103 datasets were included in this study. Based on the mean OST of 32.7 (± 18.6) min and a constant absolute term of 16.2 (± 1.5) min, we identified seven procedures and nine environmental parameters with significant impact on OST. Intubation (9.3 ± 0.8 min) and being a car occupant (8.0 ± 0.8 min) were associated with the most prolonged OSTs. A Glasgow Coma Scale ≤ 8 (-4.5 ± 0.7 min) and cardiopulmonary resuscitation (-2.8 ± 1.7 min) resulted in its most relevant reduction. Admission to a Level III facility led to a reduced overall prehospital time (60.0 ± 24.6 min) compared with Level I (70.0 ± 28.5 min) and II (66.8 ± 27.4 min) trauma centres.

CONCLUSIONS

This study identified characteristic interventions and conditions with significant impact on prehospital treatment times. Current treatment concepts should be re-evaluated with respect to these results.

Still making the case against prehospital intubation: a rat hemorrhagic shock model

BACKGROUND

Prehospital intubation does not appear to result in a survival advantage for patients experiencing penetrating trauma; yet, there is still resistance to the practice of "scoop and run" to speed access to advanced care. An animal model was used to determine whether intubation provides a survival advantage during potentially lethal hemorrhage.

METHODS

The carotid arteries of Sprague-Dawley rats were cannulated, and mean arterial pressure (MAP) was measured. One group of animals (n = 10) was intubated and placed on a ventilator, whereas the other (n = 9) was administered with 100% oxygen via nose cone. Rats were exsanguinated to a MAP of 40 mm Hg and then bled periodically to maintain a MAP between 40 mm Hg and 45 mm Hg. The primary end-point was time until death. Secondary end-points included lactic acid and base excess levels measured in blood collected at 30-minute intervals after inducing shock.

RESULTS

There was no significant difference in time until death between the intubated and nose cone groups (85.5 vs. 93.3 minutes, p = 0.60). Intubated animals had higher lactic acid levels at 90 minutes (6.1 vs. 3.5 mmol/L; p = 0.02) and 120 minutes (7.7 vs. 2.6 mmol/L, p = 0.03) after the initiation of shock. In addition, intubated animals had worse base excess at 90 minutes (-13.5 vs. -7.9 mmol/L, p = 0.04).

CONCLUSION

Intubation does not result in a survival advantage in this rat model of hemorrhagic shock. Positive pressure ventilation may cause decreased venous return and accentuate end-organ hypoperfusion. Large animal studies are needed to further investigate these findings.

Intubation patterns and outcomes in patients with computed tomography-verified traumatic brain injury

BACKGROUND

Studies evaluating traumatic brain injury (TBI) patients have shown an association between prehospital (PH) intubation and worse outcomes. However, previous studies have used surrogates, e.g., Glasgow Coma Scale (GCS) score ≤8 and Abbreviated Injury Severity Scale (AIS) score ≥3, which may overestimate the true presence of TBI. This study evaluated the impact of PH intubation in patients with PH GCS score ≤8 and radiographically proven TBI.

METHODS

Trauma patients routed to a Level I trauma center over a 3-year period with blunt injury and PH GCS score ≤8 were included. PH and in-hospital records were linked and head computed tomography scans were assigned a Marshall Score (MS). Patients with TBI (MS >1) were categorized into groups based on intubation status (PH, emergency department [ED], and no intubation). Comparisons were made using analysis of variance and χ statistics. Mortality differences, crude and adjusted risk ratios (RRs), and 95% confidence intervals (CIs) were calculated using proportions hazards modeling.

RESULTS

Of 334 patients with PH GCS score ≤8, 149 (50%) had TBI by MS. Among the TBI patients, 42.7% of patients were PH intubated, 47.7% were ED intubated, and 9.4% were not intubated during the initial resuscitation. Intubated patients had lower ED GCS score (PH: 4.1 and ED: 5.9 vs. 14.0; p < 0.0001) compared with patients not intubated. Also PH intubated patients had higher mean Injury Severity Score (38.0 vs. 33.7 vs. 23.5, p < 0.001) when compared with ED intubated and nonintubated patients. None of the nonintubated patients had a MS >2. Mortality for TBI patients who required PH intubation was 46.9% and 41.4% among ED-intubated patients. The crude RR of mortality for PH compared with ED intubation was 1.13 (95% CI, 0.68-1.89), and remained nonsignificant (RR, 0.68; 95% CI, 0.36-1.19) when adjusted for key markers of injury severity.

CONCLUSIONS

Patients with PH GCS score ≤8 and proven TBI had a high overall rate of intubation (>90%). PH intubation seems to be a marker for more severe injury and conveyed no increased risk for mortality over ED intubation.

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.

Medical pre-hospital management reduces mortality in severe blunt trauma: a prospective epidemiological study

INTRODUCTION

Severe blunt trauma is a leading cause of premature death and handicap. However, the benefit for the patient of pre-hospital management by emergency physicians remains controversial because it may delay admission to hospital. This study aimed to compare the impact of medical pre-hospital management performed by SMUR (Service Mobile d'Urgences et de Réanimation) with non-medical pre-hospital management provided by fire brigades (non-SMUR) on 30-day mortality.

METHODS

The FIRST (French Intensive care Recorded in Severe Trauma) study is a multicenter cohort study on consecutive patients with severe blunt trauma requiring admission to university hospital intensive care units within the first 72 hours. Initial clinical status, pre-hospital life-sustaining treatments and Injury Severity Scores (ISS) were recorded. The main endpoint was 30-day mortality.

RESULTS

Among 2,703 patients, 2,513 received medical pre-hospital management from SMUR, and 190 received basic pre-hospital management provided by fire brigades. SMUR patients presented a poorer initial clinical status and higher ISS and were admitted to hospital after a longer delay than non-SMUR patients. The crude 30-day mortality rate was comparable for SMUR and non-SMUR patients (17% and 15% respectively; P = 0.61). After adjustment for initial clinical status and ISS, SMUR care significantly reduced the risk of 30-day mortality (odds ratio (OR): 0.55, 95% CI: 0.32 to 0.94, P = 0.03). Further adjustments for the delay to hospital admission only marginally affected these results.

CONCLUSIONS

This study suggests that SMUR management is associated with a significant reduction in 30-day mortality. The role of careful medical assessment and intensive pre-hospital life-sustaining treatments needs to be assessed in further studies.

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.

Prehospital airway and ventilation management: a trauma score and injury severity score-based analysis

BACKGROUND

Emergent endotracheal intubation (ETI) is considered the standard of care for patients with severe traumatic brain injury (TBI). However, recent evidence suggests that the procedure may be associated with increased mortality, possibly reflecting inadequate training, suboptimal patient selection, or inappropriate ventilation.

OBJECTIVE

To explore prehospital ETI in patients with severe TBI using a novel application of Trauma Score and Injury Severity Score methodology.

METHODS

Patients with moderate-to-severe TBI (head Abbreviated Injury Scale score 3+) were identified from our county trauma registry. Demographic information, pre-resuscitation vital signs, and injury severity scores were used to calculate a probability of survival for each patient. The relationship between outcome and prehospital ETI, provider type (air vs. ground), and ventilation status were explored using observed survival-predicted survival and the ratio of unexpected survivors/deaths.

RESULTS

A total of 11,000 patients were identified with complete data for this analysis. Observed and predicted survivals were similar for both intubated and nonintubated patients. The ratio of unexpected survivors/deaths increased and observed survival exceeded predicted survival for intubated patients with lower predicted survival values. Both intubated and nonintubated patients transported by air medical crews had better outcomes than those transported by ground. Both hypo- and hypercapnia were associated with worse outcomes in intubated but not in nonintubated patients.

CONCLUSIONS

Prehospital intubation seems to improve outcomes in more critically injured TBI patients. Air medical outcomes are better than predicted for both intubated and nonintubated TBI patients. Iatrogenic hyper- and hypoventilations are associated with worse outcomes.

End-tidal carbon dioxide monitoring during bag valve ventilation: the use of a new portable device

Background

For healthcare providers in the prehospital setting, bag-valve mask (BVM) ventilation could be as efficacious and safe as endotracheal intubation. To facilitate the evaluation of efficacious ventilation, capnographs have been further developed into small and convenient devices able to provide end- tidal carbon dioxide (ETCO₂). The aim of this study was to investigate whether a new portable device (EMMA™) attached to a ventilation mask would provide ETCO₂ values accurate enough to confirm proper BVM ventilation.

Methods

A prospective observational trial was conducted in a single level-2 centre. Twenty-two patients under general anaesthesia were manually ventilated. ETCO₂ was measured every five minutes with the study device and venous PCO₂ (PvCO₂) was simultaneously measured for comparison. Bland- Altman plots were used to compare ETCO_2, and PvCO₂.

Results

The patients were all hemodynamically and respiratory stable during anaesthesia. End-tidal carbon dioxide values were corresponding to venous gases during BVM ventilation under optimal conditions. The bias, the mean of the differences between the two methods (device versus venous blood gases), for time points 1-4 ranges from -1.37 to -1.62.

Conclusion

The portable device, EMMA™ is suitable for determining carbon dioxide in expired air (kPa) as compared to simultaneous samples of PvCO₂. It could therefore, be a supportive tool to asses the BVM ventilation in the demanding prehospital and emergency setting.

The association between prehospital endotracheal intubation attempts and survival to hospital discharge among out-of-hospital cardiac arrest patients

OBJECTIVES

The benefit of prehospital endotracheal intubation (ETI) among individuals experiencing out-of-hospital cardiac arrest (OOHCA) has not been fully examined. The objective of this study was to determine if prehospital ETI attempts were associated with return of spontaneous circulation (ROSC) and survival to discharge among individuals experiencing OOHCA.

METHODS

This retrospective study included individuals who experienced a medical cardiac arrest between July 2006 and December 2008 and had resuscitation efforts initiated by paramedics from Mecklenburg County, North Carolina. Outcome variables were prehospital ROSC and survival to hospital discharge, while the primary independent variable was the number of prehospital ETI attempts.

RESULTS

There were 1,142 cardiac arrests included in the analytic data set. Prehospital ROSC occurred in 299 individuals (26.2%). When controlling for initial arrest rhythm and other confounding variables, individuals with no ETI attempted were 2.33 (95% confidence interval [CI] = 1.63 to 3.33) times more likely to have ROSC compared to those with one successful ETI attempt. Of the 299 individuals with prehospital ROSC, 118 (39.5%) were subsequently discharged alive from the hospital. Individuals having no ETI were 5.46 (95% CI = 3.36 to 8.90) times more likely to be discharged from the hospital alive compared to individuals with one successful ETI attempt.

CONCLUSIONS

Results from these analyses suggest a negative association between prehospital ETI attempts and survival from OOHCA. In this study, the individuals most likely to have prehospital ROSC and survival to hospital discharge were those who did not have a reported ETI attempt. Further comparative research should assess the potential causes of the demonstrated associations.

Advanced airway management does not improve outcome of out-of-hospital cardiac arrest

BACKGROUND

The goal of out-of-hospital endotracheal intubation (ETI) is to reduce mortality and morbidity for patients with airway and ventilatory compromise. Yet several studies, mostly involving trauma patients, have demonstrated similar or worse neurologic outcomes and survival-to-hospital discharge rates after out-of-hospital ETI. To date, there is no study comparing out-of-hospital ETI to bag-valve-mask (BVM) ventilation for the outcome of survival to hospital discharge among nontraumatic adult out-of-hospital cardiac arrest (OOHCA) patients.

OBJECTIVES

The objective was to compare survival to hospital discharge among adult OOHCA patients receiving ETI to those managed with BVM.

METHODS

In this retrospective cohort study, the records of all OOHCA patients presenting to a municipal teaching hospital from November 1, 1994, through June 30, 2008, were reviewed. The type of field airway provided, age, sex, race, rhythm on paramedic arrival, presence of bystander cardiopulmonary resuscitation (CPR), whether the arrest was witnessed, site of arrest, return of spontaneous circulation (ROSC), survival to hospital admission, comorbid illnesses, and survival to hospital discharge were noted. A univariate odds ratio (OR) was first computed to describe the association between the type of airway and survival to hospital discharge. A multivariable logistic regression analysis was performed, adjusting for rhythm, bystander CPR, and whether the arrest was witnessed.

RESULTS

A cohort of 1,294 arrests was evaluated. A total of 1,027 (79.4%) received ETI, while 131 (10.1%) had BVM, 131 (10.1%) had either a Combitube or an esophageal obturator airway, and five (0.4%) had incomplete prehospital records. Fifty-five of 1,294 (4.3%) survived to hospital discharge; there were no survivors in the Combitube/esophageal obturator airway cohort. Even after multivariable adjustment for age, sex, site of arrest, bystander CPR, witnessed arrest, and rhythm on paramedic arrival, the OR for survival to hospital discharge for BVM versus ETI was 4.5 (95% confidence interval [CI] = 2.3-8.9; p<0.0001).

CONCLUSIONS

In this cohort, when compared to BVM ventilation, advanced airway methods were associated with decreased survival to hospital discharge among adult nontraumatic OOHCA patients.

Better outcome after pediatric resuscitation is still a dilemma

Pediatric cardiac arrest is not a single problem. Although most episodes of pediatric cardiac arrest occur as complications and progression of respiratory failure and shock. Sudden cardiac arrest may result from abrupt and unexpected arrhythmias. With a better-tailored therapy, we can optimize the outcome. In the hospital, cardiac arrest often develops as a progression of respiratory failure and shock. Typically half or more of pediatric victims of in-hospital arrest have pre-existing respiratory failure and one-third or more have shock, although these figures vary somewhat among reporting hospitals. When in-hospital respiratory arrest or failure is treated before the development of cardiac arrest, survival ranges from 60% to 97%. Bradyarrthmia, asystole or pulseless electric activity (PEA) were recorded as an initial rhythm in half or more of the recent reports of in-hospital cardiac arrest, with survival to hospital discharge ranging from 22% to 40%. Data allowing characterization of out of hospital pediatric arrest are limited, although existing data support the long-held belief that as with hospitalized children, cardiac arrest most often occurs as a progression of respiratory failure or shock to cardiac arrest with bradyasystole rhythm. Although VF (Ventricular fibrillation, is a very rapid, uncoordinated, ineffective series of contractions throughout the lower chambers of the heart. Unless stopped, these chaotic impulses are fatal) and VT (Ventricular tachycardia is a rapid heartbeat that originates in one of the ventricles of the heart. To be classified as tachycardia, the heart rate is usually at least 100 beats per minute) are not common out-of-cardiac arrest in children, they are more likely to be present with sudden, witnessed collapse, particularly among adolescents. Pre-hospital care till the late 1980s was mainly concerned with adult care, and the initial focus for pediatric resuscitation was provision of oxygen and ventilation, with initial rhythm at the time of emergency medical services arrival being infrequently recorded. In the 1987 series, pre-hospital pediatric cardiac arrest demonstrated asystole in 80%, PEA in 10.5% and VF or VT in 9.6%. Only 29% arrests were witnessed, however, and death in many victims was caused by sudden infant death syndrome.

[Prognostic factors in chest traumas: a prospective study of 500 patients]

OBJECTIVE

Identify the factors of greatest impact in patients with chest trauma.

PATIENTS AND METHODS

prospective study of 500 patients (425 men and 75 women) with chest trauma treated between January 2006 and December 2008. The parameters assessed include the degree of trauma, the abbreviated injury scale (AIS), the injury severity score (ISS), pre-hospital intubation, duration of mechanical ventilation, stay in the intensive care unit (ICU), number of rib fractures, presence of pulmonary contusion, haemothorax and cardio-pulmonary effects.

RESULTS

The presence of polytrauma, the number of rib fractures, the presence of flail chest, pulmonary contusion, the delay in mechanical ventilation and age were shown to be effective markers of severity.

CONCLUSIONS

Thoracic injuries have a number of indicators of severity. The mortality risk is associated with an ISS >25, the presence of 3 or more rib fractures with flail chest, pulmonary contusion, the development of ARDS, and with an age >55 years.

Variation in the type, rate, and selection of patients for out-of-hospital airway procedures among injured children and adults

OBJECTIVES

The objective was to compare the type, rate, and selection of injured patients for out-of-hospital airway procedures among emergency medical services (EMS) agencies in 10 sites across North America.

METHODS

The authors analyzed a consecutive patient, prospective cohort registry of injured adults and children with an out-of-hospital advanced airway attempt, collected from December 1, 2005, through February 28, 2007, by 181 EMS agencies in 10 sites across the United States and Canada. Advanced airway procedures were defined as orotracheal intubation, nasotracheal intubation, supraglottic airway, or cricothyrotomy. Airway procedure rates were calculated based on age-specific population values for the 10 sites and the number of injured patients with field physiologic abnormality (systolic blood pressure of < or = 90 mm Hg, respiratory rate of <10 or >29 breaths/min, Glasgow Coma Scale [GCS] score of < or = 12). Descriptive measures were used to compare patients between sites.

RESULTS

A total 1,738 patients had at least one advanced airway attempt and were included in the analysis. There was wide variation between sites in the types of airway procedures performed, including orotracheal intubation (63% to 99%), supraglottic airways (0 to 27%), nasotracheal intubation (0 to 21%), and cricothyrotomy (0 to 2%). Use of rapid sequence intubation (RSI) varied from 0% to 65%. The population-adjusted rates of field airway intervention (by site) ranged from 1.2 to 22.8 per 100,000 adults and 0.2 to 4.0 per 100,000 children. Among trauma patients with physiologic abnormality, some sites performed airway procedures in almost 50% of patients, while other sites used these procedures in fewer than 10%. There was also large variation in demographic characteristics, physiologic measures, mechanism of injury, mode of transport, field cardiopulmonary resuscitation, and unadjusted mortality among airway patients.

CONCLUSIONS

Among 10 sites across North America, there was wide variation in the types of out-of-hospital airway procedures performed, population-based rates of airway intervention, and the selection of injured patients for such procedures.

A prospective multicenter evaluation of prehospital airway management performance in a large metropolitan region

OBJECTIVES

To determine 1) the success rate of prehospital endotracheal intubation; 2) the unrecognized tube malposition rate; and 3) predictors of tube malposition upon arrival to the emergency department (ED) in the setting of a large metropolitan area that includes 18 hospitals and 34 transporting emergency medical services (EMS) agencies.

METHODS

Prospective data were collected on patients for whom prehospital intubation was attempted between September 1, 2004, and January 31, 2005. Endotracheal tube (ETT) position upon arrival to the ED was verified by emergency medicine attending physicians. Missing cases were identified by matching prospective data with lists of attempted intubations submitted by EMS agencies, and data were obtained for these cases by retrospective chart review. Successful intubation was defined as an "endotracheal tube balloon below the cords" on arrival to the ED. Patients were the unit of analysis; proportions with 95% confidence intervals were calculated.

RESULTS

Nine hundred twenty-six patients had an attempted intubation. Methods of airway management were determined for 97.5% (825/846) of those transported to a hospital and 33.8% (27/80) of those who died in the field. For transported patients, 74.8% were successfully intubated, 20% had a failed intubation, 5.2% had a malpositioned tube on arrival to the ED, and 0.6% had another method of airway management used. Malpositioned tubes were significantly more common in pediatric patients (13.0%, compared with 4.0% for nonpediatric patients).

CONCLUSIONS

Overall intubation success was low, and consistent with previously published series. The frequency of malpositioned ETT was unacceptably high, and also consistent with prior studies. Our data support the need for ongoing monitoring of EMS providers' practices of endotracheal intubation.

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.

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 Utstein template for uniform reporting of data following major trauma: a joint revision by SCANTEM, TARN, DGU-TR and RITG

BACKGROUND

In 1999, an Utstein Template for Uniform Reporting of Data following Major Trauma was published. Few papers have since been published based on that template, reflecting a lack of international consensus on its feasibility and use. The aim of the present revision was to further develop the Utstein Template, particularly with a major reduction in the number of core data variables and the addition of more precise definitions of data variables. In addition, we wanted to define a set of inclusion and exclusion criteria that will facilitate uniform comparison of trauma cases.

METHODS

Over a ten-month period, selected experts from major European trauma registries and organisations carried out an Utstein consensus process based on a modified nominal group technique.

RESULTS

The expert panel concluded that a New Injury Severity Score > 15 should be used as a single inclusion criterion, and five exclusion criteria were also selected. Thirty-five precisely defined core data variables were agreed upon, with further division into core data for Predictive models, System Characteristic Descriptors and for Process Mapping.

CONCLUSION

Through a structured consensus process, the Utstein Template for Uniform Reporting of Data following Major Trauma has been revised. This revision will enhance national and international comparisons of trauma systems, and will form the basis for improved prediction models in trauma care.

Clinical Experience and Practical Skills: Results from Mexico City's Paramedic Registry

Introduction: Trauma is a leading cause of death and disability in Mexico. Unintentional injuries, along with diabetes and heart disease, contribute to >35% of the country's total mortality. Effective and efficient prehospital care of the conditions may improve outcomes.

Objective: The objective of this paper was to determine if prehospital field experience (PFE) correlated with higher passing rates among candidates for the paramedic registry in Mexico City.

Methods: This was a retrospective, cohort study using data from the Voluntary Registry of Prehospital Care Professionals (VRPHP) in Mexico City.

Results: The mean value for candidate age was 30.6 years and mean value for the years of PFE was 6.8 years (CI = 9–13 years). Most of the applicants were male and almost 90% were basic emergency medical services providers. Sixty-five percent of the candidates were from private, non-profit organizations, 73% were volunteers, and 19% had obtained a university degree. More than 57% had ≥5 years of PFE, but the experience level did not correlate significantly with higher passing rates for the registry evaluation (χ2 = 1.66, p = 0.43).The results differed between the two years that the examination was offered (χ2 = 32.98, df = 1, p <0.001, γ = 0.54), regardless of gender, education, and years of experience.

Conclusions: Previous field experience showed no correlation with passing rates, although the correlations improved between examination periods. The results may be used to support appropriate implementation of future health policies for prehospital emergency services.

Triage Revised Trauma Score change between first assessment and arrival at the hospital to predict mortality

Objective

To assess among seriously injured accident victims whether change of the Triage Revised Trauma Score (T-RTS) between first assessment and arrival at the hospital independently predicts mortality.

Design

Prospective cohort study.

Methods

The study analysed data on 507 trauma patients with multiple injuries and with a Hospital Trauma Index-Injury Severity Score (HTI–ISS) of 16 or higher, who were presented directly by ambulance services to the Accident & Emergency Department of the University Medical Centre Utrecht (the Netherlands) in 1999 and 2000.

Results

Compared to non-intubated patients whose T-RTS remained unchanged (reference category), the mortality risk was 3.1 times higher [95% confidence interval (CI): 1.5–6.3, p=0.001] for patients with deteriorating T-RTS, 2.9 times higher (95% CI: 1.3–6.5, p<0.001) for patients who had an initially good T-RTS but were nevertheless intubated and 5.7 times higher (95% CI: 3.6–9.0, p<0.001) for patients who had an initially poor T-RTS and were intubated. These associations were independent of factors that could be assumed to have a direct effect on T-RTS, that is intravenous therapy, oxygen administration and being attended to by a mobile medical team at the scene of the accident. Along with T-RTS change, more advanced age was associated with a higher mortality risk.

Conclusion

Intubation and a deteriorating T-RTS between the time of the accident and patient’s arrival at the hospital are powerful independent predictors of mortality after hospitalisation. Together with advanced age, a deteriorating T-RTS should be the main aspect guiding the preclinical procedures.

Guidelines for the management of haemodynamically stable patients with stab wounds to the anterior abdomen

Clinical practice guidelines have been shown to improve the delivery of care. Anterior abdominal stab wounds, although uncommon, pose a challenge in both rural and urban trauma care. A multidisciplinary working party was established to assist in the development of evidence-based guidelines to answer three key clinical questions: (i) What is the ideal prehospital management of anterior abdominal stab wounds? (ii) What is the ideal management of anterior abdominal stab wounds in a rural or urban hospital without an on-call surgeon? (iii) What is the ideal emergency management of stable patients with anterior abdominal stab wounds when surgical service is available? A systematic review, using Cochrane method, was undertaken. The data were graded by level of evidence as outlined by the Australian National Health and Medical Research Council. Stable patients with anterior abdominal stab wounds should be transported to the hospital without delay. Any interventions deemed necessary in prehospital care should be undertaken en route to hospital. In rural hospitals with no on-call surgeon, local wound exploration (LWE) may be undertaken by a general practitioner if confident in this procedure. Otherwise or in the presence of obvious fascial penetration, such as evisceration, the patient should be transferred to the nearest main trauma service for further management. In urban hospitals the patient with omental or bowel evisceration or generalized peritonitis should undergo urgent exploratory laparotomy. Stable patients may be screened using LWE. Abdominal computed tomography scan and plain radiographs are not indicated. Obese and/or uncooperative patients require a general anaesthetic for laparoscopy. If there is fascial penetration on LWE or peritoneal penetration on laparoscopy, then an urgent laparotomy should be undertaken. The developed evidence-based guidelines for stable patients with anterior abdominal stab wounds may help minimize unnecessary diagnostic tests and non-therapeutic laparotomy rates.

Alternative airway devices for use in children requiring prehospital airway management: update and case discussion

This manuscript reviews the latest literature on alternative airways for use in children requiring prehospital airway management. Case discussions serve as a springboard for discussion of alternatives to bag-mask ventilation and endotracheal intubation for management of ventilation in infants and children in the prehospital setting. Few airway procedures have been studied with any rigor in this setting, and most of the data that are available are extrapolated from adults. Laryngeal mask airway may be the best alternative airway with the most promise to add to the armamentarium of the prehospital provider, but no controlled trial to date has been conducted.

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.

The International Liaison Committee on Resuscitation (ILCOR) consensus on science with treatment recommendations for pediatric and neonatal patients: pediatric basic and advanced life support

This publication contains the pediatric and neonatal sections of the 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (COSTR). The consensus process that produced this document was sponsored by the International Liaison Committee on Resuscitation (ILCOR). ILCOR was formed in 1993 and consists of representatives of resuscitation councils from all over the world. Its mission is to identify and review international science and knowledge relevant to cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) and to generate consensus on treatment recommendations. ECC includes all responses necessary to treat life-threatening cardiovascular and respiratory events. The COSTR document presents international consensus statements on the science of resuscitation. ILCOR member organizations are each publishing resuscitation guidelines that are consistent with the science in this consensus document, but they also take into consideration geographic, economic, and system differences in practice and the regional availability of medical devices and drugs. The American Heart Association (AHA) pediatric and the American Academy of Pediatrics/AHA neonatal sections of the resuscitation guidelines are reprinted in this issue of Pediatrics (see pages e978-e988). The 2005 evidence evaluation process began shortly after publication of the 2000 International Guidelines for CPR and ECC. The process included topic identification, expert topic review, discussion and debate at 6 international meetings, further review, and debate within ILCOR member organizations and ultimate approval by the member organizations, an Editorial Board, and peer reviewers. The complete COSTR document was published simultaneously in Circulation (International Liaison Committee on Resuscitation. 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2005;112(suppl):73-90) and Resuscitation (International Liaison Committee on Resuscitation. 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation. 2005;67:271-291). Readers are encouraged to review the 2005 COSTR document in its entirety. It can be accessed through the CPR and ECC link at the AHA Web site: www.americanheart.org. The complete publication represents the largest evaluation of resuscitation literature ever published and contains electronic links to more detailed information about the international collaborative process. To organize the evidence evaluation, ILCOR representatives established 6 task forces: basic life support, advanced life support, acute coronary syndromes, pediatric life support, neonatal life support, and an interdisciplinary task force to consider overlapping topics such as educational issues. The AHA established additional task forces on stroke and, in collaboration with the American Red Cross, a task force on first aid. Each task force identified topics requiring evaluation and appointed international experts to review them. A detailed worksheet template was created to help the experts document their literature review, evaluate studies, determine levels of evidence, develop treatment recommendations, and disclose conflicts of interest. Two evidence evaluation experts reviewed all worksheets and assisted the worksheet reviewers to ensure that the worksheets met a consistently high standard. A total of 281 experts completed 403 worksheets on 275 topics, reviewing more than 22000 published studies. In December 2004 the evidence review and summary portions of the evidence evaluation worksheets, with worksheet author conflict of interest statements, were posted on the Internet at www.C2005.org, where readers can continue to access them. Journal advertisements and e-mails invited public comment. Two hundred forty-nine worksheet authors (141 from the United States and 108 from 17 other countries) and additional invited experts and reviewers attended the 2005 International Consensus Conference for presentation, discussion, and debate of the evidence. All 380 participants at the conference received electronic copies of the worksheets. Internet access was available to all conference participants during the conference to facilitate real-time verification of the literature. Expert reviewers presented topics in plenary, concurrent, and poster conference sessions with strict adherence to a novel and rigorous conflict of interest process. Presenters and participants then debated the evidence, conclusions, and draft summary statements. Wording of science statements and treatment recommendations was refined after further review by ILCOR member organizations and the international editorial board. This format ensured that the final document represented a truly international consensus process. The COSTR manuscript was ultimately approved by all ILCOR member organizations and by an international editorial board. The AHA Science Advisory and Coordinating Committee and the editor of Circulation obtained peer reviews of this document before it was accepted for publication. The most important changes in recommendations for pediatric resuscitation since the last ILCOR review in 2000 include: Increased emphasis on performing high quality CPR: "Push hard, push fast, minimize interruptions of chest compression; allow full chest recoil, and don't provide excessive ventilation" Recommended chest compression-ventilation ratio: For lone rescuers with victims of all ages: 30:2 For health care providers performing 2-rescuer CPR for infants and children: 15:2 (except 3:1 for neonates) Either a 2- or 1-hand technique is acceptable for chest compressions in children Use of 1 shock followed by immediate CPR is recommended for each defibrillation attempt, instead of 3 stacked shocks Biphasic shocks with an automated external defibrillator (AED) are acceptable for children 1 year of age. Attenuated shocks using child cables or activation of a key or switch are recommended in children <8 years old. Routine use of high-dose intravenous (IV) epinephrine is no longer recommended. Intravascular (IV and intraosseous) route of drug administration is preferred to the endotracheal route. Cuffed endotracheal tubes can be used in infants and children provided correct tube size and cuff inflation pressure are used. Exhaled CO2 detection is recommended for confirmation of endotracheal tube placement. Consider induced hypothermia for 12 to 24 hours in patients who remain comatose following resuscitation. Some of the most important changes in recommendations for neonatal resuscitation since the last ILCOR review in 2000 include less emphasis on using 100% oxygen when initiating resuscitation, de-emphasis of the need for routine intrapartum oropharyngeal and nasopharyngeal suctioning for infants born to mothers with meconium staining of amniotic fluid, proven value of occlusive wrapping of very low birth weight infants <28 weeks' gestation to reduce heat loss, preference for the IV versus the endotracheal route for epinephrine, and an increased emphasis on parental autonomy at the threshold of viability. The scientific evidence supporting these recommendations is summarized in the neonatal document (see pages e978-e988).

2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of pediatric and neonatal patients: pediatric basic life support

This publication presents the 2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of the pediatric patient and the 2005 American Academy of Pediatrics/AHA guidelines for CPR and ECC of the neonate. The guidelines are based on the evidence evaluation from the 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, hosted by the American Heart Association in Dallas, Texas, January 23-30, 2005. The "2005 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care" contain recommendations designed to improve survival from sudden cardiac arrest and acute life-threatening cardiopulmonary problems. The evidence evaluation process that was the basis for these guidelines was accomplished in collaboration with the International Liaison Committee on Resuscitation (ILCOR). The ILCOR process is described in more detail in the "International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations." The recommendations in the "2005 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care" confirm the safety and effectiveness of many approaches, acknowledge that other approaches may not be optimal, and recommend new treatments that have undergone evidence evaluation. These new recommendations do not imply that care involving the use of earlier guidelines is unsafe. In addition, it is important to note that these guidelines will not apply to all rescuers and all victims in all situations. The leader of a resuscitation attempt may need to adapt application of the guidelines to unique circumstances. The following are the major pediatric advanced life support changes in the 2005 guidelines: There is further caution about the use of endotracheal tubes. Laryngeal mask airways are acceptable when used by experienced providers. Cuffed endotracheal tubes may be used in infants (except newborns) and children in in-hospital settings provided that cuff inflation pressure is kept <20 cm H2O. Confirmation of tube placement requires clinical assessment and assessment of exhaled carbon dioxide (CO2); esophageal detector devices may be considered for use in children weighing >20 kg who have a perfusing rhythm. Correct placement must be verified when the tube is inserted, during transport, and whenever the patient is moved. During CPR with an advanced airway in place, rescuers will no longer perform "cycles" of CPR. Instead, the rescuer performing chest compressions will perform them continuously at a rate of 100/minute without pauses for ventilation. The rescuer providing ventilation will deliver 8 to 10 breaths per minute (1 breath approximately every 6-8 seconds). Timing of 1 shock, CPR, and drug administration during pulseless arrest has changed and now is identical to that for advanced cardiac life support. Routine use of high-dose epinephrine is not recommended. Lidocaine is de-emphasized, but it can be used for treatment of ventricular fibrillation/pulseless ventricular tachycardia if amiodarone is not available. Induced hypothermia (32-34 degrees C for 12-24 hours) may be considered if the child remains comatose after resuscitation. Indications for the use of inodilators are mentioned in the postresuscitation section. Termination of resuscitative efforts is discussed. It is noted that intact survival has been reported following prolonged resuscitation and absence of spontaneous circulation despite 2 doses of epinephrine. The following are the major neonatal resuscitation changes in the 2005 guidelines: Supplementary oxygen is recommended whenever positive-pressure ventilation is indicated for resuscitation; free-flow oxygen should be administered to infants who are breathing but have central cyanosis. Although the standard approach to resuscitation is to use 100% oxygen, it is reasonable to begin resuscitation with an oxygen concentration of less than 100% or to start with no supplementary oxygen (ie, start with room air). If the clinician begins resuscitation with room air, it is recommended that supplementary oxygen be available to use if there is no appreciable improvement within 90 seconds after birth. In situations where supplementary oxygen is not readily available, positive-pressure ventilation should be administered with room air. Current recommendations no longer advise routine intrapartum oropharyngeal and nasopharyngeal suctioning for infants born to mothers with meconium staining of amniotic fluid. Endotracheal suctioning for infants who are not vigorous should be performed immediately after birth. A self-inflating bag, a flow-inflating bag, or a T-piece (a valved mechanical device designed to regulate pressure and limit flow) can be used to ventilate a newborn. An increase in heart rate is the primary sign of improved ventilation during resuscitation. Exhaled CO2 detection is the recommended primary technique to confirm correct endotracheal tube placement when a prompt increase in heart rate does not occur after intubation. The recommended intravenous (IV) epinephrine dose is 0.01 to 0.03 mg/kg per dose. Higher IV doses are not recommended, and IV administration is the preferred route. Although access is being obtained, administration of a higher dose (up to 0.1 mg/kg) through the endotracheal tube may be considered. It is possible to identify conditions associated with high mortality and poor outcome in which withholding resuscitative efforts may be considered reasonable, particularly when there has been the opportunity for parental agreement. The following guidelines must be interpreted according to current regional outcomes: When gestation, birth weight, or congenital anomalies are associated with almost certain early death and when unacceptably high morbidity is likely among the rare survivors, resuscitation is not indicated. Examples are provided in the guidelines. In conditions associated with a high rate of survival and acceptable morbidity, resuscitation is nearly always indicated. In conditions associated with uncertain prognosis in which survival is borderline, the morbidity rate is relatively high, and the anticipated burden to the child is high, parental desires concerning initiation of resuscitation should be supported. Infants without signs of life (no heartbeat and no respiratory effort) after 10 minutes of resuscitation show either a high mortality rate or severe neurodevelopmental disability. After 10 minutes of continuous and adequate resuscitative efforts, discontinuation of resuscitation may be justified if there are no signs of life.