Prehospital intubation in patients with severe head injury

EMS Treatment Guidelines in Major Traumatic Brain Injury With Positive Pressure Ventilation

Importance

The Excellence in Prehospital Injury Care (EPIC) study demonstrated improved survival in patients with severe traumatic brain injury (TBI) following implementation of the prehospital treatment guidelines. The impact of implementing these guidelines in the subgroup of patients who received positive pressure ventilation (PPV) is unknown.

Objective

To evaluate the association of implementation of prehospital TBI evidence-based guidelines with survival among patients with prehospital PPV.

Design, Setting, and Participants

The EPIC study was a multisystem, intention-to-treat study using a before/after controlled design. Evidence-based guidelines were implemented by emergency medical service agencies across Arizona. This subanalysis was planned a priori and included participants who received prehospital PPV. Outcomes were compared between the preimplementation and postimplementation cohorts using logistic regression, stratified by predetermined TBI severity categories (moderate, severe, or critical). Data were collected from January 2007 to June 2017, and data were analyzed from January to February 2023.

Exposure

Implementation of the evidence-based guidelines for the prehospital care of patient with TBI.

Main Outcomes and Measures

The primary outcome was survival to hospital discharge, and the secondary outcome was survival to admission.

Results

Among the 21 852 participants in the main study, 5022 received prehospital PPV (preimplementation, 3531 participants; postimplementation, 1491 participants). Of 5022 included participants, 3720 (74.1%) were male, and the median (IQR) age was 36 (22-54) years. Across all severities combined, survival to admission improved (adjusted odds ratio [aOR], 1.59; 95% CI, 1.28-1.97), while survival to discharge did not (aOR, 0.94; 95% CI, 0.78-1.13). Within the cohort with severe TBI but not in the moderate or critical subgroups, survival to hospital admission increased (aOR, 6.44; 95% CI, 2.39-22.00), as did survival to discharge (aOR, 3.52; 95% CI, 1.96-6.34).

Conclusions and Relevance

Among patients with severe TBI who received active airway interventions in the field, guideline implementation was independently associated with improved survival to hospital admission and discharge. This was true whether they received basic airway interventions or advanced airways. These findings support the current guideline recommendations for aggressive prevention/correction of hypoxia and hyperventilation in patients with severe TBI, regardless of which airway type is used.

Prioritizing Circulation to Improve Outcomes for Patients with Exsanguinating Injury: A Literature Review and Techniques to Help Clinicians Achieve Bleeding Control

Prioritizing circulation in trauma care and delaying intubation in noncompressible cases improve outcomes. By prioritizing circulation, patient survival significantly improves, advocating evidence-based shifts in trauma care.

A systematic review of the timing of intubation in patients with traumatic brain injury: pre-hospital versus in-hospital intubation

PURPOSE

The objective of this systematic review was to examine current evidence on the risks versus benefit of pre-hospital intubation when compared with in-hospital intubation in adult patients with traumatic brain injuries.

METHODS

We conducted electronic searches of PubMed, Medline, Embase, CIANHL and the Cochrane library up to March 2021. Data extracted compared mortality, length of hospital and intensive care stay, pneumonia and functional outcomes in traumatic brain injured patients undergoing pre-hospital intubation versus in-hospital intubation. The risk of bias was assessed using the Grading of Recommendations Assessment, Development and Evaluation.

RESULTS

Ten studies including 25,766 patients were analysed. Seven were retrospective studies, two prospective cohort studies and one randomised control study. The mean mortality rate in patients who underwent pre-hospital intubation was 44.5% and 31.98% for in-hospital intubation. The odds ratio for an effect of pre-hospital intubation on mortality ranged from 0.31 (favouring in-hospital intubation) to 3.99 (favouring pre-hospital). The overall quality of evidence is low; however, the only randomised control study showed an improved functional outcome for pre-hospital intubation at 6 months.

CONCLUSIONS

The existing evidence does not support widespread pre-hospital intubation in all traumatic brain injured patients. This does not, however, contradict the need for the intervention when there is severe airway compromise; instead, it must be assessed by experienced personnel if a time critical transfer to hospital is more advantageous. Favourable neurological outcomes highlighted by the randomised control trial favours pre-hospital intubation, but further research is required in this field.

Paramedic Endotracheal Intubation Success Rates Before and After an Intensive Airway Management Education Session

Introduction

Advanced airway management by paramedics is potentially life-saving, but carries a significant risk to patient safety and can be associated with poor clinical outcome if performed incorrectly. Previously, our team had found that an intensive education intervention demonstrated an improvement in paramedic performance on a written exam and increased confidence in airway skills. This study measured intubation success and the number of attempts per patient before and after intensive paramedic airway management education intervention.

Methods

A 10-hour mandatory course was taken by all advanced life support (ALS) paramedics in a provincial system (2009/04-07, n=~395). The course was done during semi-annual continuing education Emergency Health Services (EHS) in-services. These day-long courses were held in person over four months. The electronic charting database was queried for intubation attempts and successful placements 12 months before the training, during the four months of training, and 12 months post-training. The primary outcome is the difference in success rates between the before (pre-intervention) and after (post-intervention) periods. The secondary outcome is the number of attempts per patient. Stationarity of success in pre- and post-periods was tested. The model was fit tested using Maximum Likelihood regression, and variables were tested using the Wald test.

Results

A sample size of 476 intubation attempts in each of the pre- and post-periods was required to detect a 10% improvement with the pre-intervention success of 60%. A total of 1421 intubation attempts occurred; 674 pre-intervention, 604 post-intervention, and 143 during teaching. Seven attempts were excluded (success unknown). Intubation success rates improved, from 0.68 (95% CI 0.64-0.71) to 0.75 (95% CI 0.72-0.78); a difference of 0.076 (95% CI 0.03-0.12) (p = 0.001). Intubation success rates in the pre-intervention and post-intervention periods were found to be static. A significant decrease was found in the number of attempts per patient in the post-period (p = 0.005).

Conclusion

Intubation success increased from 68% to 75% and was maintained over the 12-month post-period. There is a potential that judgment may also have improved, based on the decreased number of attempts per patient. Limitations include missing values, paramedics’ self-reported number of attempts, and the definition of what is considered to be an attempt. In addition to previously demonstrated improvements in paramedic exam and scenario performance, this airway education intervention appears to have made a significant improvement to patient outcomes. These findings support the value of such education interventions to improve performance.

Anesthesiology in Times of Physical Disasters-Earthquakes and Typhoons

Nepal and Hong Kong both are susceptible to natural disasters due to their geographic locations. Nepal suffers from frequent earthquakes, and Hong Kong regularly experiences typhoons of varying severity. Natural disasters may present acutely or with some advance warning. In either case, it is critical that disaster response plans are well established in advance of any incident. This article discusses the anesthetic and critical care implications of such natural disasters, using Nepal and Hong Kong as case studies.

Mechanical Ventilation of Severe Traumatic Brain Injury Patients in the Prehospital Setting

OBJECTIVE

Suboptimal ventilation may impact outcomes in patients with traumatic brain injury (TBI). This study compares the incidence of eucapnia between manually and mechanically ventilated patients with severe TBI during helicopter transport.

METHODS

This retrospective chart review included consecutive intubated adults with severe TBI (Glasgow Coma Scale score < 9) transported by helicopter from the scene of injury to a level 1 trauma center between 2009 and 2015. The primary outcome was the first venous partial pressure of carbon dioxide obtained in the emergency department. Hypocapnia, eucapnia, and hypercapnia were defined based on the normal range for the testing instrument. The Fisher exact test was used to compare groups.

RESULTS

Of 1,070 trauma patients intubated and transported, 93 met the inclusion criteria with full data. The mean age was 43 years, 81 of 93 were white, and 70 of 93 were men. The mean Injury Severity Score was 29, and 26 of 93 were mechanically ventilated. Hypocapnia occurred in 4 of 93 and hypercapnia in 56 of 93. There was no difference in the rate of eucapnia in manually ventilated compared with mechanically ventilated patients (36% vs. 35%, P = 1.00).

CONCLUSION

Eucapnia at emergency department arrival occurred in 36% of patients and was unaffected by whether ventilation was manually or mechanically controlled. Few patients were hypocapnic, indicating a low incidence of hyperventilation during helicopter transport.

Influence of prehospital physician presence on survival after severe trauma: Systematic review and meta-analysis

BACKGROUND

As trauma is one of the leading causes of death worldwide, there is great potential for reducing mortality in trauma patients. However, there is continuing controversy over the benefit of deploying emergency medical systems (EMS) physicians in the prehospital setting. The objective of this systematic review and meta-analysis is to assess how out-of-hospital hospital management of severely injured patients by EMS teams with and without physicians affects mortality.

METHODS

PubMed and Google Scholar were searched for relevant articles, and the search was supplemented by a hand search. Injury severity in the group of patients treated by an EMS team including a physician had to be comparable to the group treated without a physician. Primary outcome parameter was mortality. Helicopter transport as a confounder was accounted for by subgroup analyses including only the studies with comparable modes of transport. Quality of all included studies was assessed according to the Cochrane handbook.

RESULTS

There were 2,249 publications found, 71 full-text articles assessed, and 22 studies included. Nine of these studies were matched or adjusted for injury severity. The odds ratio (OR) of mortality was significantly lower in the EMS physician-treated group of patients: 0.81; 95% confidence interval (CI): 0.71-0.92. When analysis was limited to the studies that were adjusted or matched for injury severity, the OR was 0.86 (95% CI, 0.73-1.01). Analyzing only studies published after 2005 yielded an OR for mortality of 0.75 (95% CI, 0.64-0.88) in the overall analysis and 0.81 (95% CI, 0.67-0.97) in the analysis of adjusted or matched studies. The OR was 0.80 (95% CI, 0.65-1.00) in the subgroup of studies with comparable modes of transport and 0.74 (95% CI, 0.53-1.03) in the more recent studies.

CONCLUSION

Prehospital management of severely injured patients by EMS teams including a physician seems to be associated with lower mortality. After excluding the confounder of helicopter transport we have shown a nonsignificant trend toward lower mortality.

LEVEL OF EVIDENCE

Systematic review and meta-analysis, level III.

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.

Meta-Analysis of Post-Intubation Hypotension: A Plea to Consider Circulation First in Hypovolemic Patients

Hypovolemic patients can develop postintubation hypotension (PIH). Our objective is to review the literature regarding PIH and the association with mortality. We searched MEDLINE from inception to February 2018. A meta-analysis was performed to assess the effect of PIH on mortality. The results of the meta-analysis were reported in forest plots of the estimated effects of the included studies with a 95 per cent confidence interval. Heterogeneity was evaluated using the I2 test, which corresponded to low (I2 < 25%), medium (I2 = 25–75%), and high (I2 > 75%) heterogeneity. We identified 243 records. Four studies were included in the meta-analysis. The studies reported 2044 patients with 36.8 per cent (n = 753) developing PIH. Data indirectly reflecting the hemodynamic status were available in three studies (n = 1117 patients). Overall mortality was 24.6 per cent (n = 503) and was significantly higher in patients that developed PIH [mortality, n (%): PIH = 250/753 (33.2%) vs 253/1291 (19.6%), P < 0.001]. Patients that develop PIH have an increased mortality. Considering a targeted resuscitation in hypovolemic patients is pivotal to minimize PIH.

Prehospital on-scene anaesthetist treating severe traumatic brain injury patients is associated with lower mortality and better neurological outcome

BACKGROUND

Patients with isolated traumatic brain injury (TBI) are likely to benefit from effective prehospital care to prevent secondary brain injury. Only a few studies have focused on the impact of advanced interventions in TBI patients by prehospital physicians. The primary end-point of this study was to assess the possible effect of an on-scene anaesthetist on mortality of TBI patients. A secondary end-point was the neurological outcome of these patients.

METHODS

Patients with severe TBI (defined as a head injury resulting in a Glasgow Coma Score of ≤8) from 2005 to 2010 and 2012-2015 in two study locations were determined. Isolated TBI patients transported directly from the accident scene to the university hospital were included. A modified six-month Glasgow Outcome Score (GOS) was defined as death, unfavourable outcome (GOS 2-3) and favourable outcome (GOS 4-5) and used to assess the neurological outcomes. Binary logistic regression analysis was used to predict mortality and good neurological outcome. The following prognostic variables for TBI were available in the prehospital setting: age, on-scene GCS, hypoxia and hypotension. As per the hypothesis that treatment provided by an on-scene anaesthetist would be beneficial to TBI outcomes, physician was added as a potential predictive factor with regard to the prognosis.

RESULTS

The mortality data for 651 patients and neurological outcome data for 634 patients were available for primary and secondary analysis. In the primary analysis higher age (OR 1.06 CI 1.05-1.07), lower on-scene GCS (OR 0.85 CI 0.79-0.92) and the unavailability of an on-scene anaesthetist (OR 1.89 CI 1.20-2.94) were associated with higher mortality together with hypotension (OR 3.92 CI 1.08-14.23). In the secondary analysis lower age (OR 0.95 CI 0.94-0.96), a higher on-scene GCS (OR 1.21 CI 1.20-1.30) and the presence of an on-scene anaesthetist (OR 1.75 CI 1.09-2.80) were demonstrated to be associated with good patient outcomes while hypotension (OR 0.19 CI 0.04-0.82) was associated with poor outcome.

CONCLUSION

Prehospital on-scene anaesthetist treating severe TBI patients is associated with lower mortality and better neurological outcome.

History and significance of the trauma resuscitation flow sheet

There is little to no written information in the literature regarding the origin of the trauma flow sheet. This vital document allows programs to evaluate initial processes of trauma care. This information populates the trauma registry and is reviewed in nearly every Trauma Process Improvement and Patient Safety conference when discerning the course of patient care. It is so vital, a scribe is assigned to complete this documentation task for all trauma resuscitations, and there are continual process improvement efforts in trauma centers across the nation to ensure complete and accurate data collection. Indeed, it is the single most important document reviewed by the verification committee when evaluating processes of care at site visits. Trauma surgeons often overlook its importance during resuscitation, as recording remains the domain of the trauma scribe. Yet it is the first document scrutinized when the outcome is less than what is expected. The development of the flow sheet is not a result of any consensus statement, expert work group, or mandate, but a result of organic evolution due to the need for relevant and better data. The purpose of this review is to outline the origin, importance, and critical utility of the trauma flow sheet.

Circulation first - the time has come to question the sequencing of care in the ABCs of trauma; an American Association for the Surgery of Trauma multicenter trial

Background

The traditional sequence of trauma care: Airway, Breathing, Circulation (ABC) has been practiced for many years. It became the standard of care despite the lack of scientific evidence. We hypothesized that patients in hypovolemic shock would have comparable outcomes with initiation of bleeding treatment (transfusion) prior to intubation (CAB), compared to those patients treated with the traditional ABC sequence.

Methods

This study was sponsored by the American Association for the Surgery of Trauma multicenter trials committee. We performed a retrospective analysis of all patients that presented to trauma centers with presumptive hypovolemic shock indicated by pre-hospital or emergency department hypotension and need for intubation from January 1, 2014 to July 1, 2016. Data collected included demographics, timing of intubation, vital signs before and after intubation, timing of the blood transfusion initiation related to intubation, and outcomes.

Results

From 440 patients that met inclusion criteria, 245 (55.7%) received intravenous blood product resuscitation first (CAB), and 195 (44.3%) were intubated before any resuscitation was started (ABC). There was no difference in ISS, mechanism, or comorbidities. Those intubated prior to receiving transfusion had a lower GCS than those with transfusion initiation prior to intubation (ABC: 4, CAB:9, p = 0.005). Although mortality was high in both groups, there was no statistically significant difference (CAB 47% and ABC 50%). In multivariate analysis, initial SBP and initial GCS were the only independent predictors of death.

Conclusion

The current study highlights that many trauma centers are already initiating circulation first prior to intubation when treating hypovolemic shock (CAB), even in patients with a low GCS. This practice was not associated with an increased mortality. Further prospective investigation is warranted.

Trial registration

IRB approval number: HM20006627. Retrospective trial not registered.

Physician-staffed helicopter emergency medical service has a beneficial impact on the incidence of prehospital hypoxia and secured airways on patients with severe traumatic brain injury

BACKGROUND

After traumatic brain injury (TBI), hypotension, hypoxia and hypercapnia have been shown to result in secondary brain injury that can lead to increased mortality and disability. Effective prehospital assessment and treatment by emergency medical service (EMS) is considered essential for favourable outcome. The aim of this study was to evaluate the effect of a physician-staffed helicopter emergency medical service (HEMS) in the treatment of TBI patients.

METHODS

This was a retrospective cohort study. Prehospital data from two periods were collected: before (EMS group) and after (HEMS group) the implementation of a physician-staffed HEMS. Unconscious prehospital patients due to severe TBI were included in the study. Unconsciousness was defined as a Glasgow coma scale (GCS) score ≤ 8 and was documented either on-scene, during transportation or by an on-call neurosurgeon on hospital admission. Modified Glasgow Outcome Score (GOS) was used for assessment of six-month neurological outcome and good neurological outcome was defined as GOS 4-5.

RESULTS

Data from 181 patients in the EMS group and 85 patients in the HEMS group were available for neurological outcome analyses. The baseline characteristics and the first recorded vital signs of the two cohorts were similar. Good neurological outcome was more frequent in the HEMS group; 42% of the HEMS managed patients and 28% (p = 0.022) of the EMS managed patients had a good neurological recovery. The airway was more frequently secured in the HEMS group (p < 0.001). On arrival at the emergency department, the patients in the HEMS group were less often hypoxic (p = 0.024). In univariate analysis HEMS period, lower age and secured airway were associated with good neurological outcome.

CONCLUSION

The introduction of a physician-staffed HEMS unit resulted in decreased incidence of prehospital hypoxia and increased the number of secured airways. This may have contributed to the observed improved neurological outcome during the HEMS period.

TRIAL REGISTRATION

ClinicalTrials.gov IDNCT02659046. Registered January 15th, 2016.

Prehospital Intubation is Associated with Favorable Outcomes and Lower Mortality in ProTECT III

OBJECTIVE

Traumatic brain injury (TBI) causes more than 2.5 million emergency department visits, hospitalizations, or deaths annually. Prehospital endotracheal intubation has been associated with poor outcomes in patients with TBI in several retrospective observational studies. We evaluated the relationship between prehospital intubation, functional outcomes, and mortality using high quality data on clinical practice collected prospectively during a randomized multicenter clinical trial.

METHODS

ProTECT III was a multicenter randomized, double-blind, placebo-controlled trial of early administration of progesterone in 882 patients with acute moderate to severe nonpenetrating TBI. Patients were excluded if they had an index GCS of 3 and nonreactive pupils, those with withdrawal of life support on arrival, and if they had documented prolonged hypotension and/or hypoxia. Prehospital intubation was performed as per local clinical protocol in each participating EMS system. Models for favorable outcome and mortality included prehospital intubation, method of transport, index GCS, age, race, and ethnicity as independent variables. Significance was set at α = 0.05. Favorable outcome was defined by a stratified dichotomy of the GOS-E scores in which the definition of favorable outcome depended on the severity of the initial injury.

RESULTS

Favorable outcome was more frequent in the 349 subjects with prehospital intubation (57.3%) than in the other 533 patients (46.0%, p = 0.003). Mortality was also lower in the prehospital intubation group (13.8% v. 19.5%, p = 0.03). Logistic regression analysis of prehospital intubation and mortality, adjusted for index GCS, showed that odds of dying for those with prehospital intubation were 47% lower than for those that were not intubated (OR = 0.53, 95% CI = 0.36-0.78). 279 patients with prehospital intubation were transported by air. Modeling transport method and mortality, adjusted for index GCS, showed increased odds of dying in those transported by ground compared to those transported by air (OR = 2.10, 95% CI = 1.40-3.15). Decreased odds of dying trended among those with prehospital intubation adjusted for transport method, index GCS score at randomization, age, and race/ethnicity (OR = 0.70, 95% CI = 0.37-1.31).

CONCLUSIONS

In this study that excluded moribund patients, prehospital intubation was performed primarily in patients transported by air. Prehospital intubation and air medical transport together were associated with favorable outcomes and lower mortality. Prehospital intubation was not associated with increased morbidity or mortality regardless of transport method or severity of injury.

Hypoxia and hypotension in patients intubated by physician staffed helicopter emergency medical services - a prospective observational multi-centre study

BACKGROUND

The effective treatment of airway compromise in trauma and non-trauma patients is important. Hypoxia and hypotension are predictors of negative patient outcomes and increased mortality, and may be important quality indicators of care provided by emergency medical services. Excluding cardiac arrests, critical trauma and non-trauma patients remain the two major groups to which helicopter emergency medical services (HEMS) are dispatched. Several studies describe the impact of pre-hospital hypoxia or hypotension on trauma patients, but few studies compare this in trauma and non-trauma patients. The primary aim was to describe the incidence of pre-hospital hypoxia and hypotension in the two groups receiving pre-hospital tracheal intubation (TI) by physician-staffed HEMS.

METHODS

Data were collected prospectively over a 12-month period, using a uniform Utstein-style airway template. Twenty-one physician-staffed HEMS in Europe and Australia participated. We compared peripheral oxygen saturation and systolic blood pressure before and after definitive airway management. Data were analysed using Cochran-Mantel-Haenszel methods and mixed-effects models.

RESULTS

Eight hundred forty three trauma patients and 422 non-trauma patients receiving pre-hospital TI were included. Non-trauma patients had significantly lower predicted mean pre-intervention SpO₂ compared to trauma patients. Post-intervention and admission SpO₂ for the two groups were comparable. However, 3% in both groups were still hypoxic at admission. For hypotension, the differences between the groups were less prominent. However, 9% of trauma and 10% of non-trauma patients were still hypotensive at admission. There was no difference in short-term survival between trauma (97%) and non-trauma patients (95%). Decreased level of consciousness was the most frequent indication for TI, and was associated with increased survival to hospital (cOR 2.8; 95% CI: 1.4-5.4).

CONCLUSIONS

Our results showed that non-trauma patients had a higher incidence of hypoxia before TI than trauma patients, but few were hypoxic at admission. The difference for hypotension was less prominent, but one in ten patients were still hypotensive at admission. Further investigations are needed to identify reversible causes that may be corrected to improve haemodynamics in the pre-hospital setting. We found high survival rates to hospital in both groups, suggesting that physician-staffed HEMS provide high-quality emergency airway management in trauma and non-trauma patients.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT01502111 . Registered 22 Desember 2011.

Does the presence of an emergency physician influence pre-hospital time, pre-hospital interventions and the mortality of severely injured patients? A matched-pair analysis based on the trauma registry of the German Trauma Society (TraumaRegister DGU®)

PURPOSE

The role of emergency physicians in the pre-hospital management of severely injured patients remains controversial. In Germany and Austria, an emergency physician is present at the scene of an emergency situation or is called to such a scene in order to provide pre-hospital care to severely injured patients in approximately 95% of all cases. By contrast, in the United States and the United Kingdom, paramedics, i.e. non-physician teams, usually provide care to an injured person both at the scene of an incident and en route to an appropriate hospital. We investigated whether physician or non-physician care offers more benefits and what type of on-site care improves outcome.

MATERIAL AND METHODS

In a matched-pair analysis using data from the trauma registry of the German Trauma Society, we retrospectively (2002-2011) analysed the pre-hospital management of severely injured patients (ISS ≥16) by physician and non-physician teams. Matching criteria were age, overall injury severity, the presence of relevant injuries to the head, chest, abdomen or extremities, the cause of trauma, the level of consciousness, and the presence of shock.

RESULTS

Each of the two groups, i.e. patients who were attended by an emergency physician and those who received non-physician care, consisted of 1235 subjects. There was no significant difference between the two groups in pre-hospital time (61.1 [SD 28.9] minutes for the physician group and 61.9 [SD 30.9] minutes for non-physician group). Significant differences were found in the number of pre-hospital procedures such as fluid administration, analgosedation and intubation. There was a highly significant difference (p<0.001) in the number of patients who received no intervention at all applying to 348 patients (28.2%) treated by non-physician teams and to only 31 patients (2.5%) in the physician-treated group. By contrast, there was no significant difference in mortality within the first 24h and in mortality during hospitalisation.

CONCLUSION

This retrospective analysis does not allow definitive conclusions to be drawn about the optimal model of pre-hospital care. It shows, however, that there was no significant difference in mortality although patients who were attended by non-physician teams received fewer pre-hospital interventions with similar scene times.

Traumatic brain injury: It is all about definition

BACKGROUND

TBI may be defined by different methods. Some may be most useful for immediate clinical purposes, however less optimal for epidemiologic research. Other methods, such as the Abbreviated Injury Score (AIS), may prove more beneficial for this task, if the cut-off-points for their categories are defined correctly.

OBJECTIVE

To reveal the optimal cut-off-points for AIS in definition of severity of TBI in order to ensure uniformity between future studies of TBI.

RESULTS

Mortality of patients with TBI AIS 3, 4 was 1.9% and 2.9% respectively, comparing with 31.1% among TBI AIS 5+. Predictive discrimination ability of the model with cut-off-points of 5+ for TBI AIS (in comparison with other cut-off-points) was better. Patients with missing Glasgow Coma Scale (GCS) in the ED had an in-hospital mortality rate of 11.5%. In this group, 25% had critical TBI according to AIS. Normal GCS didn't indicate an absence of head injury, as, among patients with GCS 15 in the ED, 26% had serious/critical TBI injury. Moreover, 7% of patients with multiple injury and GCS 3-8 had another reason than head injury for unconsciousness.

CONCLUSIONS

This study recommends the adoption of an AIS cut-off ≥ 5 as a valid definition of severe TBI in epidemiological studies, while AIS 3-4 may be defined as 'moderate' TBI and AIS 1-2 as 'mild'.

Pre-hospital severe traumatic brain injury - comparison of outcome in paramedic versus physician staffed emergency medical services

Background

Traumatic brain injury (TBI) is one of the leading causes of death and permanent disability. Emergency Medical Services (EMS) personnel are often the first healthcare providers attending patients with TBI. The level of available care varies, which may have an impact on the patient’s outcome. The aim of this study was to evaluate mortality and neurological outcome of TBI patients in two regions with differently structured EMS systems.

Methods

A 6-year period (2005 – 2010) observational data on pre-hospital TBI management in paramedic-staffed EMS and physician-staffed EMS systems were retrospectively analysed. Inclusion criteria for the study were severe isolated TBI presenting with unconsciousness defined as Glasgow coma scale (GCS) score ≤ 8 occurring either on-scene, during transportation or verified by an on-call neurosurgeon at admission to the hospital. For assessment of one-year neurological outcome, a modified Glasgow Outcome Score (GOS) was used.

Results

During the 6-year study period a total of 458 patients met the inclusion criteria. One-year mortality was higher in the paramedic-staffed EMS group: 57 % vs. 42 %. Also good neurological outcome was less common in patients treated in the paramedic-staffed EMS group.

Discussion

We found no significant difference between the study groups when considering the secondary brain injury associated vital signs on-scene. Also on arrival to ED, the proportion of hypotensive patients was similar in both groups. However, hypoxia was common in the patients treated by the paramedic-staffed EMS on arrival to the ED, while in the physician-staffed EMS almost none of the patients were hypoxic. Pre-hospital intubation by EMS physicians probably explains this finding.

Conclusion

The results suggest to an outcome benefit from physician-staffed EMS treating TBI patients.

Trial registration

ClinicalTrials.gov ID NCT01454648

Predictors of mortality in patients with isolated severe traumatic brain injury

BACKGROUND

Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. Many prognostic models predicting mortality in patients with TBI were developed, which also include patients with mild or moderate TBI and patients who suffered major extracranial injuries.

METHODS

From a prospective database, we conducted a retrospective medical chart review covering the period between January 2000 and December 2012 of patients with isolated severe TBI (Abbreviated Injury Score for head, AIS_H ≥ 3) without extracranial injuries, who were intubated in the field using the rapid sequence intubation method and were of age 16 or more. Prehospital vital signs, Injury Severity Score (ISS) and laboratory tests were compared in two study groups: survivors (n = 25) and non-survivors (n = 27). Selected variables identified during univariate analysis (p < 0.1) were then subjected to multivariate analysis logistic regression model.

RESULTS

Univariate analysis showed that in-hospital mortality was statistically significantly associated with male sex (p = 0.040), ISS (p = 0.005) and mydriasis (p = 0.012). For predicting mortality, area under the curve (AUC) was calculated: for ISS 0.76 (95 % confidence interval, CI; 0.63-0.90; p < 0.001) and for initial Glasgow Coma Scale (GCS) 0.64 (95 % CI, 0.49-0.80, p = 0.079). In the multivariate analysis, ISS (odds ratio, OR; 1.19, 95 % CI, 1.06-1.35; p = 0.004) and mydriasis (OR, 5.73; 95 % CI, 1.06-30.88; p = 0.042) were identified as independent risk factors for in-hospital mortality. The AUC for the regression model was 0.83 (95 % CI, 0.71-0.94; p < 0.001).

CONCLUSIONS

In prehospital intubated patients with isolated severe TBI only ISS and mydriasis were found to be independent predictors of in-hospital mortality.

A New Injury Severity Score for Predicting the Length of Hospital Stay in Multiple Trauma Patients

Background:

Trauma is a leading cause of morbidity and mortality among individuals under 40 and is the third main cause for death throughout the world.

Objectives:

This study was designed to compare our modified injury scoring systems with the current injury severity score (ISS) from the viewpoint of its predictive value to estimate the duration of hospitalization in trauma patients.

Patients and Methods:

This analytical cross-sectional study was performed at the general referral trauma center of Bandar-Abbas in southern Iran from March 2009 to March 2010. The study population consisted of all the trauma patients referred to the emergency department (ED). Demographic data, type and severity of injury, duration of admission, Glasgow coma scale (GCS), and revised trauma score (RTS) were recorded. The injury severity score (ISS) and NISS were calculated. The length of hospital stay was recorded during the patients follow-up and compared with ISS, NISS and modified injury scoring systems.

Results:

Five hundred eleven patients (446 males (87.3%) and 65 females (12.7%)) were enrolled in the study. The mean age was 22 ± 4.2 for males and 29.15 ± 3.8 for females. The modified NISS had a relatively strong correlation with the length of hospitalization (r = 0.79). The formula below explains the length of hospitalization according to MNISS score. Duration of hospitalization was 0.415 + (2.991) MNISS. Duration of hospitalization had a strong correlation with MISS (r = 0.805, R2: 0.65). Duration of hospitalization was 0.113 + (7.915) MISS.

Conclusions:

This new suggested scale shows a better value to predict patients’ length of hospital stay compared to ISS and NISS. However, future studies with larger sample sizes and more confounding factors such as prehospital procedures, intubation and other procedures during admission, should be designed to examine these scoring systems and confirm the results of our study.

4,871 Emergency airway encounters by air medical providers: a report of the air transport emergency airway management (NEAR VI: "A-TEAM") project

INTRODUCTION

Pre-hospital airway management is a key component of resuscitation although the benefit of pre-hospital intubation has been widely debated. We report a large series of pre-hospital emergency airway encounters performed by air-transport providers in a large, multi-state system.

METHODS

We retrospectively reviewed electronic intubation flight records from an 89 rotorcraft air medical system from January 01, 2007, through December 31, 2009. We report patient characteristics, intubation methods, success rates, and rescue techniques with descriptive statistics. We report proportions with 95% confidence intervals and binary comparisons using chi square test with p-values <0.05 considered significant.

RESULTS

4,871 patients had active airway management, including 2,186 (44.9%) medical and 2,685 (55.1%) trauma cases. There were 4,390 (90.1%) adult and 256 (5.3%) pediatric (age ≤ 14) intubations; 225 (4.6%) did not have an age recorded. 4,703 (96.6%) had at least one intubation attempt. Intubation was successful on first attempt in 3,710 (78.9%) and was ultimately successful in 4,313 (91.7%). Intubation success was higher for medical than trauma patients (93.4% versus 90.3%, p=0.0001 JT test). 168 encounters were managed primarily with an extraglottic device (EGD). Cricothyrotomy was performed 35 times (0.7%) and was successful in 33. Patients were successfully oxygenated and ventilated with an endotracheal tube, EGD, or surgical airway in 4809 (98.7%) encounters. There were no reported deaths from a failed airway.

CONCLUSION

Airway management, predominantly using rapid sequence intubation protocols, is successful within this high-volume, multi-state air-transport system.

Experience in Prehospital Endotracheal Intubation Significantly Influences Mortality of Patients with Severe Traumatic Brain Injury: A Systematic Review and Meta-Analysis

Background

Patients with severe traumatic brain injury (TBI) are at high risk for airway obstruction and hypoxia at the accident scene, and routine prehospital endotracheal intubation has been widely advocated. However, the effects on outcome are unclear. We therefore aim to determine effects of prehospital intubation on mortality and hypothesize that such effects may depend on the emergency medical service providers’ skill and experience in performing this intervention.

Methods and Findings

PubMed, Embase and Web of Science were searched without restrictions up to July 2015. Studies comparing effects of prehospital intubation versus non-invasive airway management on mortality in non-paediatric patients with severe TBI were selected for the systematic review. Results were pooled across a subset of studies that met predefined quality criteria. Random effects meta-analysis, stratified by experience, was used to obtain pooled estimates of the effect of prehospital intubation on mortality. Meta-regression was used to formally assess differences between experience groups. Mortality was the main outcome measure, and odds ratios refer to the odds of mortality in patients undergoing prehospital intubation versus odds of mortality in patients who are not intubated in the field. The study was registered at the International Prospective Register of Systematic Reviews (PROSPERO) with number CRD42014015506. The search provided 733 studies, of which 6 studies including data from 4772 patients met inclusion and quality criteria for the meta-analysis. Prehospital intubation by providers with limited experience was associated with an approximately twofold increase in the odds of mortality (OR 2.33, 95% CI 1.61 to 3.38, p<0.001). In contrast, there was no evidence for higher mortality in patients who were intubated by providers with extended level of training (OR 0.75, 95% CI 0.52 to 1.08, p = 0.126). Meta-regression confirmed that experience is a significant predictor of mortality (p = 0.009).

Conclusions

Effects of prehospital endotracheal intubation depend on the experience of prehospital healthcare providers. Intubation by paramedics who are not well skilled to do so markedly increases mortality, suggesting that routine prehospital intubation of TBI patients should be abandoned in emergency medical services in which providers do not have ample training, skill and experience in performing this intervention.

Decreased mortality after prehospital interventions in severely injured trauma patients

BACKGROUND

We test the hypothesis that prehospital interventions (PHIs) performed by skilled emergency medical service providers during ground or air transport adversely affect outcome in severely injured trauma patients.

METHODS

Consecutive trauma activations (March 2012 to June 2013) transported from the scene by air or ground emergency medical service providers were reviewed. PHI was defined as intubation, needle decompression, tourniquet, cricothyroidotomy, or advanced cardiac life support.

RESULTS

In 3,733 consecutive trauma activations (71% blunt, 25% penetrating, 4% burns), age was 39 years, 74% were male, Injury Severity Score (ISS) was 5, and Glasgow Coma Score (GCS) was 15, with 32% traumatic brain injury (TBI) and 7% overall mortality. Those who received PHI (n = 130, 3.5% of the trauma activations) were more severely injured: ISS (26 vs. 5), GCS (3 vs. 15), TBI (57% vs. 31%), Revised Trauma Score (RTS, 5.45 vs. 7.84), Trauma and Injury Severity Score (TRISS, 1.32 vs. 4.89), and mortality (56% vs. 5%) were different (all p < 0.05) than those who received no PHI. Air crews transported 22% of the patients; more had TBI, blunt injury, high ISS, and long prehospital times (all p < 0.05), but mortality was similar to those transported by ground. In the most severely injured patients with signs of life who received a PHI, the ISS, prehospital times, and proportions of TBI, blunt trauma, and air transport were similar, but mortality was significantly lower (43% vs. 23%, p= 0.021).

CONCLUSION

In our urban trauma system, PHIs are associated with a lower incidence of mortality in severely injured trauma patients and do not delay transport to definitive care.

LEVEL OF EVIDENCE

Prognostic/epidemiologic study, level III; therapeutic study, level IV.

Environmental Hyperthermia in Prehospital Patients with Major Traumatic Brain Injury

BACKGROUND

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

OBJECTIVE

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

DISCUSSION

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

CONCLUSION

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

Comparison of tracheal intubation and alternative airway techniques performed in the prehospital setting by paramedics: a systematic review

This systematic review included controlled clinical trials comparing tracheal intubation (TI) with alternative airway techniques (AAT) (bag-mask ventilation and use of extraglottic devices) performed by paramedics in the prehospital setting. A priori outcomes to be assessed were survival, neurologic outcome, airway management success rates and complications. We identified trials using EMBASE, MEDLINE, CINAHL, The Cochrane Library, Web of Science, author contacts and hand searching. We included 5 trials enrolling a total of 1559 patients. No individual study showed any statistical difference in outcomes between the TI and AAT groups. Because of study heterogeneity, we did not pool the data. This is the most comprehensive review to date on paramedic trials. Owing to the heterogeneity of prehospital systems, administrators of each system must individually consider their airway management protocols.

Radiographic evaluation of carotid artery compression in patients with extraglottic airway devices in place

OBJECTIVES

Extraglottic airway devices (EADs) are now commonly placed for airway management of critically ill or injured patients, particularly by emergency medical services providers in the out-of-hospital setting. Recent literature has suggested that EADs may cause decreased cerebral blood flow due to compression of the arteries of the neck by the devices' inflated cuffs.

METHODS

The authors identified a cohort of 17 patients presumed to be hemodynamically stable with EADs in place who underwent radiographic imaging of the neck. These studies were reviewed by a neuroradiologist to determine if mechanical compression of the carotid arteries was present.

RESULTS

None of the 17 cases reviewed had radiographically evident mechanical compression of the carotid artery.

CONCLUSIONS

Until further studies are performed in which cerebral perfusion is evaluated prospectively in both hemodynamically stable and unstable human subjects, there is insufficicent evidence to recommend against the use of extraglottic airways in the emergency setting on the basis of carotid artery compression.

Pre-hospital anaesthesia: the same but different

Advanced airway management is one of the most controversial areas of pre-hospital trauma care and is carried out by different providers using different techniques in different Emergency Medical Services systems. Pre-hospital anaesthesia is the standard of care for trauma patients arriving in the emergency department with airway compromise. A small proportion of severely injured patients who cannot be managed with basic airway management require pre-hospital anaesthesia to avoid death or hypoxic brain injury. The evidence base for advanced airway management is inconsistent, contradictory and rarely reports all key data. There is evidence that poorly performed advanced airway management is harmful and that less-experienced providers have higher intubation failure rates and complication rates. International guidelines carry many common messages about the system requirements for the practice of advanced airway management. Pre-hospital rapid sequence induction (RSI) should be practiced to the same standard as emergency department RSI. Many in-hospital standards such as monitoring, equipment, and provider competence can be achieved. Pre-hospital and emergency in-hospital RSI has been modified from standard RSI techniques to improve patient safety, physiological disturbance, and practicality. Examples include the use of opioids and long-acting neuromuscular blocking agents, ventilation before intubation, and the early release of cricoid pressure to improve laryngoscopic view. Pre-hospital RSI is indicated in a small proportion of trauma patients. Where pre-hospital anaesthesia cannot be carried out to a high standard by competent providers, excellent quality basic airway management should be the mainstay of management.

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

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

Prehospital intubation in patients with isolated severe traumatic brain injury: a 4-year observational study

Objectives. To study the effect of prehospital intubation (PHI) on survival of patients with isolated severe traumatic brain injury (ISTBI). Method. Retrospective analyses of all intubated patients with ISTBI between 2008 and 2011 were studied. Comparison was made between those who were intubated in the PHI versus in the trauma resuscitation unit (TRU). Results. Among 1665 TBI patients, 160 met the inclusion criteria (105 underwent PHI, and 55 patients were intubated in TRU). PHI group was younger in age and had lower median scene motor GCS (P = 0.001). Ventilator days and hospital length of stay (P = 0.01 and 0.006, resp.) were higher in TRUI group. Mean ISS, length of stay, initial blood pressure, pneumonia, and ARDS were comparable among the two groups. Mortality rate was higher in the PHI group (54% versus 31%, P = 0.005). On multivariate regression analysis, scene motor GCS (OR 0.55; 95% CI 0.41-0.73) was an independent predictor for mortality. Conclusion. PHI did not offer survival benefit in our group of patients with ISTBI based on the head AIS and the scene motor GCS. However, more studies are warranted to prove this finding and identify patients who may benefit from this intervention.

Is prehospital endotracheal intubation associated with improved outcomes in isolated severe head injury? A matched cohort analysis

INTRODUCTION

Prehospital endotracheal intubation (ETI) following traumatic brain injury in urban settings is controversial. Studies investigating admission arterial blood gas (ABG) patterns in these instances are scant.

HYPOTHESIS

Outcomes in patients subjected to divergent prehospital airway management options following severe head injury were studied.

METHODS

This was a retrospective propensity-matched study in patients with isolated TBI (head Abbreviated Injury Scale (AIS) ≥ 3) and Glasgow Coma Scale (GCS) score of ≤ 8 admitted to a Level 1 urban trauma center from January 1, 2003 through October 31, 2011. Cases that had prehospital ETI were compared to controls subjected to oxygen by mask in a one to three ratio for demographics, mechanism of injury, tachycardia/hypotension, Injury Severity Score, type of intracranial lesion, and all major surgical interventions. Primary outcome was mortality and secondary outcomes included admission gas profile, in-hospital morbidity, ICU length of stay (ICU LOS) and hospital length of stay (HLOS).

RESULTS

Cases (n = 55) and controls (n = 165) had statistically similar prehospital and in-hospital variables after propensity matching. Mortality was significantly higher for the ETI group (69.1% vs 55.2% respectively, P = .011). There was no difference in pH, base deficit, and pCO2 on admission blood gases; however the ETI group had significantly lower pO2 (187 (SD = 14) vs 213 (SD = 13), P = .034). There was a significantly increased incidence of septic shock in the ETI group. Patients subjected to prehospital ETI had a longer HLOS and ICU LOS.

CONCLUSION

In isolated severe traumatic brain injury, prehospital endotracheal intubation was associated with significantly higher adjusted mortality rate and worsened admission oxygenation. Further prospective validation of these findings is warranted.

Effect of video laryngoscopy on trauma patient survival: a randomized controlled trial

BACKGROUND

Many resuscitation scenarios include the use of emergency intubation to support injured patients. New video-guided airway management technology is available, which may minimize the risk to patients from this procedure.

METHODS

This was a controlled clinical trial conducted in the trauma receiving unit in a university-affiliated urban hospital in which 623 consecutive adult patients requiring emergency airway management were prospectively randomized to intubation with either the direct laryngoscope (DL) or the GlideScope video laryngoscope (GVL) device.

RESULTS

The primary outcome was survival to hospital discharge. There was no significant difference in mortality between the GVL group (28 [9%] of 303) and the DL group (24 [8%] of 320) (p = 0.43) for all patients. Within a smaller cohort identified retrospectively, there was a higher mortality rate seen in the subgroup of patients with severe head injuries (head Abbreviated Injury Scale [AIS] score > 3) who were randomized to intubation with GVL (22 [30%] of 73) versus DL (16 [14%] of 112) (p = 0.047). Among all patients, median intubation duration in seconds was significantly higher for the GVL group (median, 56; interquartile range, 40-81) than for the DL group (median, 40; interquartile range, 24-68) (p < 0.001). Among those with severe head injuries, median intubation duration in seconds was also significantly higher for the GVL group (median, 74) than for the DL group (median, 65) (p < 0.003). Correspondingly, this group also experienced a greater incidence of low oxygen saturations of 80% or less (27 [50%] of 54 for the GVL group and 15 [24%] of 63 for the DL group; p = 0.004). There were no significant differences between the two groups in first-pass success (80% for GVL and 81% for DL, p = 0.46).

CONCLUSION

Use of the GlideScope did not influence survival to hospital discharge among all patients and was associated with longer intubation times than direct laryngoscopy. Among the video laryngoscope cohort, a smaller subgroup of severe head injury trauma patients identified retrospectively seemed to be associated with a greater incidence of hypoxia of 80% or less and mortality.

Two hundred sixty pediatric emergency airway encounters by air transport personnel: a report of the air transport emergency airway management (NEAR VI: "A-TEAM") project

BACKGROUND

Effective airway management is the cornerstone of resuscitative efforts for any critically ill or injured patient. The role and safety of pediatric prehospital intubation is controversial, particularly after prior research has shown varying degrees of intubation success. We report a series of consecutive prehospital pediatric intubations performed by air-transport providers.

METHODS

We retrospectively reviewed intubation flight records from an 89-rotorcraft, multistate emergency flight service during the time period from January 1, 2007, to December 31, 2009. All patients younger than 15 years were included in our analysis. We characterized patient, flight, and operator demographics; intubation methods; success rates; rescue techniques; and adverse events with descriptive statistics. We report proportions with 95% confidence intervals and differences between groups with Fisher exact and χ tests; P < 0.05 was considered significant.

RESULTS

Two hundred sixty pediatric intubations were performed consisting of 88 medical (33.8%) and 172 trauma (66.2%) cases; 98.8% (n = 257) underwent an orotracheal intubation attempt as the first method. First-pass intubation success was 78.6% (n = 202), and intubation was ultimately successful in 95.7% (n = 246) of cases. Medical and trauma intubations had similar success rates (98% vs 95%, Fisher exact test P = 0.3412). There was no difference in intubation success between age groups (χ = 0.26, P = 0.88). Three patients were managed primarily with an extraglottic device. Rescue techniques were used in 11 encounters (4.2%), all of which were successful. Cricothyrotomy was performed twice, both successful.

CONCLUSIONS

Prehospital pediatric intubation performed by air-transport providers, using rapid sequence intubation protocols, is highly successful. This effect on patient outcome requires further study.

Association of out-of-hospital advanced airway management with outcomes after traumatic brain injury and hemorrhagic shock in the ROC hypertonic saline trial

OBJECTIVE

Prior studies suggest adverse associations between out-of-hospital advanced airway management (AAM) and patient outcomes after major trauma. This secondary analysis of data from the Resuscitation Outcomes Consortium Hypertonic Saline Trial evaluated associations between out-of-hospital AAM and outcomes in patients suffering isolated severe traumatic brain injury (TBI) or haemorrhagic shock.

METHODS

This multicentre study included adults with severe TBI (GCS ≤8) or haemorrhagic shock (SBP ≤70 mm Hg, or (SBP 71-90 mm Hg and heart rate ≥108 bpm)). We compared patients receiving out-of-hospital AAM with those receiving emergency department AAM. We evaluated the associations between airway strategy and patient outcomes (28-day mortality, and 6-month poor neurologic or functional outcome) and airway strategy, adjusting for confounders. Analysis was stratified by (1) patients with isolated severe TBI and (2) patients with haemorrhagic shock with or without severe TBI.

RESULTS

Of 2135 patients, we studied 1116 TBI and 528 shock; excluding 491 who died in the field, did not receive AAM or had missing data. In the shock cohort, out-of-hospital AAM was associated with increased 28-day mortality (adjusted OR 5.14; 95% CI 2.42 to 10.90). In TBI, out-of-hospital AAM showed a tendency towards increased 28-day mortality (adjusted OR 1.57; 95% CI 0.93 to 2.64) and 6-month poor functional outcome (1.63; 1.00 to 2.68), but these differences were not statistically significant. Out-of-hospital AAM was associated with poorer 6-month TBI neurologic outcome (1.80; 1.09 to 2.96).

CONCLUSIONS

Out-of-hospital AAM was associated with increased mortality after haemorrhagic shock. The adverse association between out-of-hospital AAM and injury outcome is most pronounced in patients with haemorrhagic shock.

Evaluation of the clinical usefulness of critical patient severity classification system and glasgow coma scale for neurological patients in intensive care units

PURPOSE

The purpose of this study was to evaluate the clinical usefulness of the Critical Patient Severity Classification System (CPSCS) and Glasgow Coma Scale (GCS) for critically ill neurological patients and to determine the applicability of CPSCS and GCS in predicting their mortality.

METHODS

Data were collected from the medical records of 187 neurological patients who were admitted to the intensive care unit of C university hospital. The data were analyzed through chi-square test, t test, Mann-Whitney, Kruskal-Wallis, goodness-of-fit test, and receiver operating characteristic curve.

RESULTS

In accordance with patients' general and clinical characteristics, patient mortality turned out to be significantly different depending on intensive care unit stay, endotracheal intubation, central venous catheter, and severity by CPSCS. Hosmer-Lemeshow goodness-of-fit tests were applied to CPSCS and GCS. The results of the discrimination test using the receiver operating characteristic curve were CPSCS0, .743, GCS0 .583, CPSCS24, .734, GCS24 .612, CPSCS48, .591, GCS48 .646, CPSCS72, .622, and GCS72 .623. Logistic regression analysis showed that each point on the CPSCS score signifies a 1.034 higher likelihood of dying.

CONCLUSION

Applied to neurologically ill patients, early CPSCS scores can be regarded as a useful tool.

Pediatric traumatic brain injury in 2012: the year with new guidelines and common data elements

Traumatic brain injury (TBI) remains the leading cause of death of children in the developing world. In 2012, several international efforts were completed to aid clinicians and researchers in advancing the field of pediatric TBI. The second edition of the Guidelines for the Medical Management of Traumatic Brain Injury in Infants, Children and Adolescents updated those published in 2003. This article highlights the processes involved in developing the Guidelines, contrasts the new guidelines with the previous edition, and delineates new research efforts needed to advance knowledge. The impact of common data elements within these potential new research fields is reviewed.

Prehospital airway management: high tech meets trauma: an air medical perspective

Trauma is the leading cause of death in the United States for those younger than 35 years and injuries sustained from trauma are a significant source of moderate to severe disability. The inability to establish, secure, or maintain a definitive airway is a major cause of preventable death and secondary injury due to inadequate oxygenation and ventilation. Prehospital airway management is an essential skill of any prehospital care provider. A critical component to providing excellent airway management is the ability of the provider to quickly establish endotracheal intubation without complications such as hypoxia, hyper/hypocapnea, or hypotension. These complications have been shown to cause increased morbidity and mortality, especially in patients suffering from traumatic brain injury. This article presents some of the challenges faced by flight nurses in the air medical environment and how Airlift Northwest has developed a structured, standardized approach to airway management both in training and it the prehospital setting. We will discuss the process improvements that lead to the implementation of video laryngoscopy as our first-line intubation tool. The ultimate goal of any air medical or prehospital emergency medical services program is to manage 100% of airways without complications, which will decrease morbidity and mortality, ultimately improving patient outcomes.

Prehospital care in patients with severe traumatic brain injury: does the level of prehospital care influence mortality?

INTRODUCTION AND PURPOSE

The controversy between the "scoop and run" versus the "stay and play" approach in severely injured trauma patients has been an ongoing issue for decades. The present study was undertaken to investigate whether changes in prehospital care for patients with severe traumatic brain injury in the Netherlands have improved outcome.

METHODS

In this retrospective study, files (n = 60) were analyzed from a prospectively collected database including all patients admitted to one of six hospitals in the Limburg region in the Netherlands with a Glasgow Coma Scale (GCS) score ≤8 on admittance over the period from January 2006 to December 2008. All patients had traumatic brain damage proven on computed tomography (CT) or magnetic resonance imaging (MRI). Relevant prehospital and clinical data from the present cohort were compared to data from a similar study (n = 30) conducted 20 years ago. The primary outcome assessed was mortality.

RESULTS

The two study groups had similar characteristics with regard to the GCS score. In the historic cohort, Basic Life Support (BLS) and the "scoop and run" approach in patients with major traumatic brain injury was common, with an average time on scene of 7.5 min. Currently, prehospital care is performed mainly on the level of prehospital Advanced Life Support (ALS), with the average time on scene being about four times as long as in the historic cohort. However, the overall mortality rate for the current cohort compared to the historic cohort has not changed.

CONCLUSION

Despite more on-site ALS in severely head injured patients nowadays compared to the historic cohort, there was no reduction in mortality.

[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.

Anglo-American vs. Franco-German Emergency Medical Services System

It has been stated that the Franco-German Emergency Medical Services System (FGS) has considerable drawbacks compared to the Anglo-American Emergency Medical Services System (AAS):

1. The key differences between the AAS and the FGS are that in the AAS, the patients is brought to the doctor, while in the FGS, the doctor is brought to the patient.

2. In the FGS, patients with urgent conditions usually are evaluated and treated by general practitioners in their offices or at the patient`s home; initially, very few approach an emergency department.

3. Emergency patients with life-threatening trauma or disease are treated by emergency physicians at the scene and during transport. Paramedics often are first to arrive at the scene, and until the emergency physician arrives at the scene, are allowed to defibrillate, to intubate endotracheal-ly, and to administer life-saving drugs (epinephrine endotracheally, glucose intravenously, etc.).

4. Prehospital emergency physicians treat patients at the scene and during transport.

5. Emergency patients are guaranteed to be reached by an appropriate emergency vehicle and a respective crew within 10 minutes in 80% of the responses and within 15 minutes in 95% of cases.

6. The FGS deploys qualified emergency physicians assisted by qualified paramedics as prehospital intensive care providers; extended immediate care is standard. Total Prehospital Times (TPT) and scene times only are minimally longer than in the AAS.

7. Emergency Medicine is recognized as a supra-specialty to the base specialties. Specific training programs exist for emergency physicians, medical directors of emergency medical services systems (EMSS), and chief emergency physicians (CEP).

8. Resuscitation attempts are carried out not only by anesthesiologists, but also by internists, surgeons, pediatricians, etc. Emergency medicine encompasses cardiopulmonary resuscitation (CPR) and shock cases, and patients with an acute myocardial infarction, stroke, poly-trauma, status asthmaticus, etc. Emergency patients are admitted directly to emergency departments of the hospitals, which, depending upon the size of the hospital.

9. The incidence of life-threatening trauma victims has decreased to <10% in the FGS. Of a total of 830,000 deaths/year, fatal trauma cases ranked the lowest at 4%.

10. Survival figures on cardiac arrest (asystole, ventricular fibrillation/ventricular tachycardia (VF/VT), pulseless electrical activity (PEA), etc.) reported in the German EMSS correspond to those in Europe and the United States.

11. Paramedic training is characterized by a two-year program followed by a theoretical and a practical examination.

12. Paramedics and emergency physicians-in-training are supervised at the scene and during transport. Quality assurance (Q/A) constitutes an integral and legally compulsory part of the EMSS.

13. In the majority of cases, the emergency patients are evaluated and treated by the respective specialties without delays caused by patient transfer to other hospitals.

14. The FGS does not require a greater number of ambulances and/or personnel than does the AAS.

15. The German healthcare system creates less expenses/ capita than the does the U.S. system at a similar level of quality of care.

16. Emergency procedures are carried out by anesthesiologists, emergency physicians, surgeons, internists, and other specialists.

Intraparenchymal vs extracranial ventricular drain intracranial pressure monitors in traumatic brain injury: less is more?

BACKGROUND

Management of severe traumatic brain injury has centered on continuous intracranial pressure (ICP) monitoring with intraparenchymal ICP monitors (IPM) or extracranial ventricular drains (EVD). Our hypothesis was that neurologic outcomes are unaffected by the type of ICP monitoring device.

STUDY DESIGN

We reviewed 377 adult patients with traumatic brain injury requiring ICP monitoring. Primary outcome was Glasgow Outcome Score (GOS) 1 month after injury. Secondary outcomes included mortality, monitoring-related complications, and length of ICU and hospital stay.

RESULTS

There were 253 patients managed with an IPM and 124 with an EVD. There was no difference in Glasgow Outcome Score (2.7 ± 1.3 vs 2.5 ± 1.3, p = 0.45), mortality (30.9% vs 32.2%, p = 0.82), and hospital length of stay (LOS) (15.6 ± 12.4 days vs 16.4 ± 10.7 days, p = 0.57). Device-related complications (11.9% vs 31.1%, p < 0.001), duration of ICP monitoring (3.8 ± 2.6 days vs 7.3 ± 5.6 days, p < 0.001), and ICU LOS (7.6 ± 5.6 days vs 9.5 ± 6.2 days, p = 0.004) were longer in the EVD group. Age, opening ICP, and size of midline shift were independent predictors for neurologic outcomes and mortality, when type and severity of brain injury, as well as overall injury severity were controlled for. Duration of ICP monitoring and opening ICP were independent predictors for hospital LOS and the former predicted prolonged ICU stay. Device-related complications were affected by type of device.

CONCLUSIONS

Use of EVDs in adult traumatic brain injury patients is associated with prolonged ICP monitoring, ICU LOS, and more frequent device-related complications.

[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.

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.

Patient safety in pre-hospital emergency tracheal intubation: a comprehensive meta-analysis of the intubation success rates of EMS providers

Introduction

Pre-hospital airway management is a controversial subject, but there is general agreement that a small number of seriously ill or injured patients require urgent emergency tracheal intubation (ETI) and ventilation. Many European emergency medical services (EMS) systems provide physicians to care for these patients while other systems rely on paramedics (or, rarely, nurses). The ETI success rate is an important measure of provider and EMS system success and a marker of patient safety.

Methods

We conducted a systematic search of Medline and EMBASE to identify all of the published original English-language articles reporting pre-hospital ETI in adult patients. We selected all of the studies that reported ETI success rates and extracted information on the number of attempted and successful ETIs, type of provider, level of ETI training and the availability of drugs on scene. We calculated the overall success rate using meta-analysis and assessed the relationships between the ETI success rate and type of provider and between the ETI success rate and the types of drugs available on the scene.

Results

From 1,070 studies initially retrieved, we identified 58 original studies meeting the selection criteria. Sixty-four per cent of the non-physician-manned services and 54% of the physician-manned services reported ETI success rates but the success rate reporting was incomplete in three studies from non-physician-manned services. Median success rate was 0.905 (0.491, 1.000). In a weighted linear regression analysis, physicians as providers were significantly associated with increased success rates, 0.092 (P = 0.0345). In the non-physician group, the use of drug-assisted intubation significantly increased the success rates. All physicians had access to traditional rapid sequence induction (RSI) and, comparing these to non-physicians using muscle paralytics or a traditional RSI, there still was a significant difference in success rate in favour of physicians, 0.991 and 0.955, respectively (P = 0.047).

Conclusions

This comprehensive meta-analysis suggests that physicians have significantly fewer pre-hospital ETI failures overall than non-physicians. This finding, which remains true when the non-physicians administer muscle paralytics or RSI, raises significant patient safety issues. In the absence of pre-hospital physicians, conducting basic or advanced airway techniques other than ETI should be strongly considered.