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 ( ). Ventilator days and hospital length of stay ( 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%, ). 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. 1. Introduction Prehospital intubation (PHI) is a standard approach for early critical care management among severe trauma patients. In particular, establishment of definitive airway is an integral part in the optimal care and management of severe traumatic brain injury (STBI) patients [1]. Several data showed that early prevention of hypoxia at the scene has favorable effect on the survival in patients with STBI [2–5]. An earlier study demonstrated that PHI in isolated STBI patients significantly reduced the mortality from 50% to 23%, with an absolute survival benefit of 27% [6]. However, other data found PHI in head injury patients to be associated with worse outcomes [7–10], even with the use of Rapid Sequence Intubation (RSI) [11]. Many factors have been postulated to be responsible for such adverse outcome. These factors include higher risk of aspiration pneumonia, the effect of laryngoscopy on raising the intracranial pressure, the deleterious effect of hyperventilation and hypocapnia, and the potentially harmful effect of supra normal oxygen tension (hyperoxia) on the injured brain [12–15]. Helm et al. [16], in a prospective study, evaluated the effect of quality of controlled ventilation and airway protection in head injury patients. The authors did not find PHI effective for maintaining optimal oxygenation and ventilation in these patients. Despite high incidence of head
References
[1]
D. P. Davis, K. M. Koprowicz, C. D. Newgard et al., “The relationship between out-of-hospital airway management and outcome among trauma patients with glasgow coma scale scores of 8 or less,” Prehospital Emergency Care, vol. 15, no. 2, pp. 184–192, 2011.
[2]
R. M. Chesnut, L. F. Marshall, M. R. Klauber et al., “The role of secondary brain injury in determining outcome from severe head injury,” Journal of Trauma, vol. 34, no. 2, pp. 216–222, 1993.
[3]
F. A. Pigula, S. L. Wald, S. R. Shackford, and D. W. Vane, “The effect of hypotension and hypoxia on children with severe head injuries,” Journal of Pediatric Surgery, vol. 28, no. 3, pp. 310–316, 1993.
[4]
N. Stocchetti, A. Furlan, and F. Volta, “Hypoxemia and arterial hypotension at the accident scene in head injury,” Journal of Trauma—Injury, Infection and Critical Care, vol. 40, no. 5, pp. 764–767, 1996.
[5]
E. R. Kokoska, G. S. Smith, T. Pittman, and T. R. Weber, “Early hypotension worsens neurological outcome in pediatric patients with moderately severe head trauma,” Journal of Pediatric Surgery, vol. 33, no. 2, pp. 333–338, 1998.
[6]
R. J. Winchell and D. B. Hoyt, “Endotracheal intubation in the field improves survival in patients with severe head injury,” Archives of Surgery, vol. 132, no. 6, pp. 592–597, 1997.
[7]
J. A. Murray, D. Demetriades, T. V. Berne et al., “Prehospital intubation in patients with severe head injury,” Journal of Trauma—Injury, Infection and Critical Care, vol. 49, no. 6, pp. 1065–1070, 2000.
[8]
Z. T. Stockinger and N. E. McSwain Jr., “Prehospital endotracheal intubation for trauma does not improve survival over bag-valve-mask ventilation,” Journal of Trauma—Injury, Infection and Critical Care, vol. 56, no. 3, pp. 531–536, 2004.
[9]
G. V. Bochicchio, O. Ilahi, M. Joshi, K. Bochicchio, and T. M. Scalea, “Endotracheal intubation in the field does not improve outcome in trauma patients who present without an acutely lethal traumatic brain injury,” Journal of Trauma—Injury, Infection and Critical Care, vol. 54, no. 2, pp. 307–311, 2003.
[10]
M. Eckstein, L. Chan, A. Schneir, and R. Palmer, “Effect of prehospital advanced life support on outcomes of major trauma patients,” Journal of Trauma—Injury, Infection and Critical Care, vol. 48, no. 4, pp. 643–648, 2000.
[11]
D. P. Davis, D. B. Hoyt, M. Ochs et al., “The effect of paramedic rapid sequence intubation on outcome in patients with severe traumatic brain injury,” Journal of Trauma—Injury, Infection and Critical Care, vol. 54, no. 3, pp. 444–453, 2003.
[12]
T. F. Vadeboncoeur, D. P. Davis, M. Ochs, J. C. Poste, D. B. Hoyt, and G. M. Vilke, “The ability of paramedics to predict aspiration in patients undergoing prehospital rapid sequence intubation,” Journal of Emergency Medicine, vol. 30, no. 2, pp. 131–136, 2006.
[13]
W. P. Bozeman and A. H. Idris, “Intracranial pressure changes during rapid sequence intubation: a swine model,” Journal of Trauma—Injury, Infection and Critical Care, vol. 58, no. 2, pp. 278–283, 2005.
[14]
D. P. Davis, A. H. Idris, M. J. Sise et al., “Early ventilation and outcome in patients with moderate to severe traumatic brain injury,” Critical Care Medicine, vol. 34, no. 4, pp. 1202–1208, 2006.
[15]
D. P. Davis, W. Meade Jr., M. J. Sise et al., “Both hypoxemia and extreme hyperoxemia may be detrimental in patients with severe traumatic brain injury,” Journal of Neurotrauma, vol. 26, no. 12, pp. 2217–2223, 2009.
[16]
M. Helm, J. Hauke, and L. Lampl, “A prospective study of the quality of pre-hospital emergency ventilation in patients with severe head injury,” British Journal of Anaesthesia, vol. 88, no. 3, pp. 345–349, 2002.
[17]
C. Healey, T. M. Osler, F. B. Rogers et al., “Improving the Glasgow Coma Scale score: motor score alone is a better predictor,” Journal of Trauma—Injury, Infection and Critical Care, vol. 54, no. 4, pp. 671–680, 2003.
[18]
“Guidelines for the management of severe traumatic brain injury, 3rd edition,” Journal of Neurotrauma, vol. 24, supplement 1, 2007.
[19]
H. E. Wang, A. B. Peitzman, L. D. Cassidy, P. D. Adelson, and D. M. Yealy, “Out-of-hospital endotracheal intubation and outcome after traumatic brain injury,” Annals of Emergency Medicine, vol. 44, no. 5, pp. 439–450, 2004.
[20]
M. J. Vandromme, S. M. Melton, R. Griffin et al., “Intubation patterns and outcomes in patients with computed tomography-verified traumatic brain injury,” Journal of Trauma—Injury, Infection and Critical Care, vol. 71, no. 6, pp. 1615–1619, 2011.
[21]
K. J. Warner, J. Cuschieri, M. K. Copass, G. J. Jurkovich, and E. M. Bulger, “The impact of prehospital ventilation on outcome after severe traumatic brain injury,” Journal of Trauma—Injury, Infection and Critical Care, vol. 62, no. 6, pp. 1330–1338, 2007.
[22]
D. P. Davis, J. Peay, M. J. Sise et al., “The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injury,” Journal of Trauma—Injury, Infection and Critical Care, vol. 58, no. 5, pp. 933–939, 2005.
[23]
E. M. Bulger, A. B. Nathens, F. P. Rivara, M. Moore, E. J. MacKenzie, and G. J. Jurkovich, “Management of severe head injury: institutional variations in care and effect on outcome,” Critical Care Medicine, vol. 30, no. 8, pp. 1870–1876, 2002.
[24]
E. M. Bulger, D. Guffey, F. X. Guyette, et al., “Resuscitation outcomes consortium investigators. Impact of prehospital mode of transport after severe injury: a multicenter evaluation from the resuscitation outcomes consortium,” Journal of Trauma and Acute Care Surgery, vol. 72, no. 3, pp. 567–573, 2012.
[25]
L. Raatiniemi, S. L？nkim？ki, and M. Martikainen, “Pre-hospital airway management by non-physicians in Northern Finland—a cross-sectional survey,” Acta Anaesthesiologica Scandinavica, vol. 57, no. 5, pp. 654–659, 2013.
[26]
M. Helm, G. Kremers, L. Lampl, and B. Hossfeld, “Incidence of transient hypoxia during pre-hospital rapid sequence intubation by anaesthesiologists,” Acta Anaesthesiologica Scandinavica, vol. 57, no. 2, pp. 199–205, 2013.
[27]
H. M. Lossius, J. R？islien, and D. J. Lockey, “Patient safety in pre-hospital emergency tracheal intubation: a comprehensive meta-analysis of the intubation success rates of EMS providers,” Critical Care, vol. 16, no. 1, article R24, 2012.
