Prehospital advanced trauma life support: how should we manage the airway, and who should do it?

The British Medical Journal recently published a report by Christensen and Hoyer [1] on prehospital tracheal intubation in severely injured patients. This retrospective observational study identified 220 severely injured patients (injury severity score > 15), who were treated by the anaesthesiologist staffed mobile emergency care unit in Aarhus (Denmark) over a period of 3 years (1998–2000). A total of 172 patients were taken to the hospital, and 41% (74/172) of these were intubated before arrival. The majority (84% [62/74]) of intubations were facilitated by anaesthesia (hypnotics, analgesics and muscle relaxants), and 58% (36/62) of patients intubated in this manner survived for at least 6 months. This contrasted with only 8% (1/12) survivors among those patients who were intubated without administration of anaesthetics. The authors concluded the following from their data: endotracheal intubation in traumatized patients who do not require the use of anaesthetics should not be considered hopeless; and ambulance personnel may be unable to master administration of anaesthesia and intubation in the prehospital setting (a corresponding paper was published previously elsewhere by the same group [2]).The work reported by Christensen and Hoyer [1] lacks substantial supplemental information, making it difficult to appreciate how the authors drew their conclusions from the actual data presented in the article. The group of patients who received anaesthetics for intubation appears very heterogeneous, exhibiting large variations in Glasgow Coma Scale and Injury Severity Scores. No details are provided on the respective injury patterns and the organ systems involved. Therefore, differences in injury characteristics between the groups might have contributed, at least in part, to the differences in survival rates (see the report by Eckstein and coworkers [3] for comments on the limitations of the Injury Severity Score for characterizing a group of severely injured patients).Addi