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Prehospital endotracheal intubation in adult major trauma patients with head injury

Three Part Question

In [patients with major trauma and head injury needing airway management in prehospital setting] is [endotracheal intubation better than bag and mask ventilation] for [improved outcomes]

Clinical Scenario

A 41 year old car driver was involved in a major road traffic accident, sustaining injuries to his head, a fracture of his right femur and multiple bruises on his chest. On scene he had altered sensorium and his GCS was estimated to be 5. He was intubated by the paramedics and brought to the Emergency Department. You wonder about the evidence in favour of endotracheal intubation as compared to bag and mask ventilation in trauma patients.

Search Strategy

Medline 1966-Week 4 August 2005 using the OVID interface
Embase 1980-2005 week 37
The Cochrane Library Issue 3 2005
Medline 1966-Week 4 August 2005 using the OVID interface, {Cochrane Prehospital Search filter} AND {exp Intubation, Intratracheal/ or endotracheal intubation.mp. OR ETI.mp. OR RSI.mp OR rapid sequence intubation.mp}
Embase 1980-2005 week 37, [exp Emergency Health Service/ OR exp Rescue Personnel/ OR exp Emergency Treatment/ OR exp Emergency Medicine/ OR exp Ambulance/ OR exp First Aid/ OR exp Military Medicine/] AND [intratracheal intubation.mp. OR exp Endotracheal Intubation/ OR ETI.mp. OR RSI.mp. OR rapid sequence intubation.mp. OR rapid sequence induction.mp.] LIMIT to Human, English Language, Abstracts, (adult <18 to 64 years> or aged <65+ years>) and Clinical Queries Prognosis filter sensitive
The Cochrane Library Issue 3 2005, exp intubation, intratracheal [MeSH] AND exp Emergency Medical Services [ MeSH]

Search Outcome

4360 papers found, of which nine were relevant and of sufficient quality for inclusion. These are summarised in the table:

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Wang et al
Nov 2004
USA
All trauma patients > 18 years sustaining severe traumatic brain injury who were intubated in prehospital or hospital settingRetrospective cohort studyPrehospital versus hospital intubation mortalityOR of 3.99 (CI 3.21 to 4.93)Non-randomised study, use of pre-existing and unvalidated registry, unvalidated functional impairment score, adjustment not done for some factors that could affect prehospital intubation, no information of course of ED airway care, Could not identify failed prehospital intubation efforts and analysis, propensity score used but matching techniques not used
Prehospital versus hospital intubation poor neurologic outcomesOR of 1.61 ( CI 1.15 to 2.26)
Prehospital versus hospital intubation functional impairmentOR of 1.92 (CI 1.40 to 2.64) for moderate or severe
Stockinger ZT, McSwain NE
2004
USA
Review of records from Dec 1999 to sept 2002 who met level 1 trauma criteria and who received ETI or BVM ventilationRetrospective cohort studyOverall mortality65.3%Retrospective design, record review, not controlled, small number of ETI survivors to compare functional outcomes or prehospital transit time, inadequately matched groups
Penetrating injury mortalityOR 1.78 (CI 1.54 to 2.05)
Patients receiving ETI mortalityOR 2.88 (CI 2.36 to 3.54)
Penetrating injury and ETI mortality versus blunt injury and ETI mortality95.8% and 78.4%, p<0.0001
Penetrating injury and BVM mortality53.5% p<0.0001
Different ISS,ETI versus BVMETI worse than BVM p<0.0001
Prehospital time ETI versus BVMLonger time on ETI but only by 1.9 minutes
Increasing RTS ETI versus BVM mortalityMortality worse in ETI patients p>0.05
TRISS model actual deaths vs predicted deathsETI mortality worse than BVM p<0.05
Davis et al
2003
USA
Adult major Trauma victims with severe head injuries >18 yrs, suspected head injury by mechanism or physical findings, GCS 3-8, estimated time for transport >10 minutes, exclusion if unable to achieve IV access or needed PR before RSIProspective cohort study 209 patients who received ETI matched to 627 historical controls who did notMortality in ETI versus BVM ventilation33% VERSUS 24.2%, OR 1.6(CI 1.1 to 2.2)Cohort sudy with historical controls though matched well, GCS not used for matching as they were not consistently calculated pre-trial cohort and omitted from trial cohort as they were paralysed and intubated, higher mortality in RSI cohorts who had low pCO2, possibility of hyperventilation contributing to increased mortality, other parameters may have been present which were unmatched in the two groups
Good outcome ETI versus BVM45.5% versus 57.9% OR 1.6(1.2-2.3 CI)
Total days in ICU ETI versus BVM7.1% versus 6%, non-significant
Total days in hospital ETI versus BVM12.2% versus 14.5% non-significant
Bochichhio et al
2003
USA
Data collected on 191 patients admitted to a trauma centre with field GCS <=8, head Abbreviated Injury Scale >=3 who were intubated (78) in the field or intubated on arrival to hospital (113), patients who died within 48 hrs excludedProspective cohort studyDispatch time field ETI versus hospital ETIp<0.05Cohort study, death within 48 hrs excluded, individual paramedic bais in intubation, difference between ground and state patrol flight paramedics, lack of longterm data or functional outcomes, bias on the practice of neurosurgeon
Field ETI versus hospital ETI23% versus 12.4% (p=0.05), OR 1.85
Field ETI versus hospital ETI respiratory complications61% versus 29%, p<0.05
Field ETI versus hospital ETI ICU stayLonger in field ETI p<0.005
Sloane et al
2000
USA
All adult trauma patients who underwent prehospital RSI 1988 to 1995 (47 patients) compared with those who had RSI upon arrival to trauma resuscitation suite 1992-1995 (537 patients) as per RSI protocolRetrospective studyField intubation versus hospital intubation success rates97.9% versus 98.5%Retrospective study, small sample of field intubation, matching not adequate esp. related to age, retrospective definition of number of attempts at intubation and record review, field patients had worse trauma severity scores, no blinding of data collector
Attempts to reach successful intubationNo significant difference
Field intubation time versus hospital intubation time in transit25.7 mins versus 14.2 mins, p<0.01
Field and hospital intubation immediate and long term complicationNo difference
Field and hospital intubation pneumonia28% versus 6% p<0.001
Length of stay ICU and hospital field and hospital intubationNo significant difference
Mortality in field and hospital intubations in head injured subgroups14% in field and 22% in hospital subgroups p=0.54
Eckstein et al
2000
USA
All adult patients from 1993 to 1995 who met trauma centre criteria, had airway intervention performed by paramedics and transprted to medical centre, ETI or BVM done as per hospital policy, 93 patients had ETI and 403 BVMRetrospective cohort studyPrehospital transit time for ETI versus BVM12.8 mins versus 11 mins p=0.09Data obtained from paramedic field reports, retrospective study, groups compared by covariates and not true controls, effect of hyperventilation not studied, small number of patients with ETI, despite adjustment for ISS through logistic regression, ETI group had a very high mortality based on ISS, limitations of ISS, RSI not used
Mortality in ETI versus BVM after adjustment for sex, mechanism and ISS,93% versus 67%, OR 5.3 (CI 2.3 to 14.2)
Patients not receiving IV fluids mortalityOR 3.9 (CI 1.0 to 26.7)
Murray et al
2000
USA
All adult patients with severe head injury GCS <=8, head AIS score >=3 over a 3 yr period 1995-1997 who were intubated (81) in the field or non-intubated (714) or unsuccessfully intubated (57)Retrospective study, review of trauma registryCrude mortality figures in intubated versus non-intubated group82% versus 43%, OR 1.88 (CI 1.65 to 2.15)Retrospective design, matching done but certain critical parameters missed out, selection bias, only patients with more severe injuries selected for intubation
Mortality in matched groups intubated in field or non-intubatedOR 1.74 (CI 1.41-2.00)
Adjusted unsuccessful intubation vs nonintubated patientsOR 1.53 (CI 1.15 to 1.86)
Winchell RJ, Hoyt DB
1997
USA
All trauma patients admitted to trauma centres in San Diego county from 1991-1995 who underwent field intubation when GCS <=8(565 were intubated and 527 were not intubated in field)Retrospective registry based reviewScene GCS scores in intubated and non-intubated groupsNo differenceRetrospective design, matching may have have left out several critical parameters, multivariate analysis not done, functional outcomes not compared
Mortality in patients who were not intubated for whole group36% versus 26% OR 1.6
Mortality in patients not intubated with isolated severe head injruy49.6% versus 22.8% OR 3
Davis DP et al,
2005
USA
13, 625 patients with moderate to severe traumatic brain injury included on a country trauma registry of whom 19.3% were intubated in the prehospital environmentObservationalMortalityIncreased with prehospital intubation (OR 0.36 p<0.001)

Comment(s)

Quite a few studies have been conducted to address the question of prehospital endotracheal intubation in major trauma victims needing airway management. All of them are of retrospective design and most of them show that there is increased mortality, longer transit times with prehospital endotracheal intubation. The reasons could be difficulty in ascertaining tube position, paramedic experience, hyperventilation, transient hypoxia, or lack of sufficient pre-oxygenation prior to RSI. Prospective multi-centre randomised trials are needed to avoid the inherent problems associated with the study designs.

Clinical Bottom Line

Prehospital endotracheal intubation is associated with increased mortality in patients with moderate to severe traumatic brain injury

References

  1. Wang HE, Peitzman AB, Cassidy LD, Adelson PD, Yealy DM. Out-of-hospital Endotracheal Intubation and outcome after traumatic brain injury. Annals of Emergency Medicine 44(5):439-50, 2004 Nov.
  2. Stockinger ZT, McSwain NE Jr. Prehospital Endotracheal intubation for trauma does not improve survival over bag-valve-mask ventilation. Journal of Trauma, Injury Infection & Critical Care 56(3):531-6, 2004 Mar.
  3. Davis DP, Hoyt DB, Ochs M, Fortlage D, Holbrook T, Marshall LK, Rosen P. The effect of paramedic rapid sequence intubation on outcome in patients with severe traumatic head injury. Journal of Trauma, Injury, Infection and Critical Care 54(3):444-53, 2003 Mar.
  4. Bochichhio GV, Ilahi O, Joshi M, Bochicchio K, Scalea TM. 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 2003;54:307-311.
  5. Sloane C, Vilke GM, Chan TC, Hayden SR, Hoyt DB, Rosen P. Rapid Sequence Intubation in the field versus hospital in trauma patients. Journal of Emergency Medicine 2000:vol 19;3:259-264.
  6. Eckstein M, Chan L, Schneir A, Palmer R. Effect of prehospital advanced life support on outcomes of major trauma patients. Journal of Trauma, Injury, Infection and Critical Care 48(4):643-8, 2000 Apr.
  7. Murray JA, Demetriades D, Berne TV, Stratton Sj, Cryer HG, Bongard F, Fleming A, Gaspard D. Prehospital intubation in patients with severe head injury. Journal of Trauma,Injury,Infection and Critical Care 2000;49:1065-1070.
  8. Winchell RJ, Hoyt DB. Endotracheal intubation in the field improves survival in patients with severe head injury. Archives of Surgery 1997;132:592-597.
  9. Davis DP, Peay J, Sise MJ. et al. The impact of prehospital endotgracheal intubation on outcome in moderate to severe traumatic brain injury. J Trauma Infect Crit Care 2005;58:9339.