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Pre-hospital intubation for trauma patients

Three Part Question

How does [pre hospital intubation] affect [survival] in [trauma patients]?

Clinical Scenario

A call comes over your urban emergency department dispatch radio about a 25 year old man involved in a high speed motor vehicle crash, multiple injuries, depressed mental status, and your estimated time from the scene is 6 minutes. The paramedics want to use RSI to intubate, and you say bag-valve-mask, we will intubate in the ED. They arrive with the patient using BVM, angry with you. You want to show them why BVM is better.

Search Strategy

PubMed 1983-09/2005 interface on the world wide web.
(prehospital[All Fields] AND ("intubation"[MeSH Terms] OR intubation[Text Word]) AND ("injuries"[Subheading] OR ("wounds and injuries"[TIAB] NOT Medline[SB]) OR "wounds and injuries"[MeSH Terms] OR trauma[Text Word]) AND ("patients"[MeSH Terms] OR patients[Text Word])) AND English[Lang] AND "humans"[MeSH Terms]

Search Outcome

127 papers, of which 114 were considered either irrelevant or inadequate. The remaining 13 papers are shown in the table.

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Davis DP, Peay J, Sise MJ, et al
patients with moderate to severe TBI (Head/Neck AIS score 3+) from San Diego County Trauma registryRetrospective Chart Review of 13,625 patients; with controls for mechanism, age, gender, GCS, ISS, hypotension, H/N AIS.survival benefit from pre-hospital intubationOR 0.36 increaed mortality with field intubationRetrospective chart review, aeromedical crews excluded, other advanced training not assesed
Ehrlich PF, Seidman PS Atallah O
Sept 2004
Intubated rural pediatric trauma patients less than 19 years old between 1991 and 2000. 105 total patients. Intubation attempts from field, referring hospitaland trauma center were included.Retropsective chart review and case seriesAirway complications and multiple attemptsAirway complications and multiple attempts were associated with transport delay and poorer patient outcomes, with most attempts and complications occurring in the feldRetrospective nature of study. Level of training of field personnel not distinguished. Small sample size
Arbabi S, Jurkovich GJ, Wahl WL et al
May 2004
Trauma registry patients from two academic level one centers from 1994-2001, excluding transfers and burnsretropsective reviewED and field physiologic parameters are eually valid predictors of outcomeEarly field intubation was associated with less risk of fatal outcome.Other outcomes not addressed well in study. training level of field personnel not well distingushed. Morbidity not well examined for field versus ED intubations
Stockinger ZT, McSwain NE Jr
March 2004
All trauma patients transported to Level One Trauma Center recieving BVI or ETI over one year period. 316 ETI and 217 BVM patientsretrospective case reviewMortality, corrected for ISS, RTS, and mechanism of injuryETI was associated with great or similar mortality than BVM and ETI pateints had longer transport timesNone
Davis DP, Ochs M, Hoyt DB
Oct 2003
Adult head injured patients propsectively enrolled over 1 year using inclusion criteria of GCS 3-8, transport time >10 minutes and inability to intubate without RSIProspective case series, using retrospective cases as controlsIntubation success, stratified by GCSPercentage of patients intubated without RSI increased and when stratified into GCS 3 and GCS 4-8Patient outcomes were not examined closely, only intubation success and use of aeromedical transport. Study needs to be prospective with prospective controls as well and cases.
Dec 2003
review article, looking at 16 papers icluding outcomes for TBI and mutliply injured patientsliterature reviewMultiple studies demostrating poorer outcomes in patients intubated in the fieldPatients intubated in the fieldIt is a reveiw article and it does point out that, despite mounting evidence against field intubation by paramendics, we should not discard it.
Ruchholtz S
May 2002
Matched pair analysis, severe thoracic trauma with and without pre-hospital intubation. Paired with respect to age, injury severity, and prognosis.retrospective case seriesprognosis with rtepsect to organ failure, treatment time, and mortalityPatients with severe thoracic trauma without respiratory insuffiency who are not treated with prehospital intubation are not adversely affected.Limited number of patients (44). Some of the significant data was glossed over, large differences in numbers of patients requring more resources in the prehospital intubation group
Adnet F
Dec 2001
review articlereview articleOutcomes in patients intubated in prehospital settingMost studies show that paramedic level and below have more complications related to field intubation and this mnay be related to poorer outcomes.Points out that RSI with manual in-line cervical stabilization is most effective method for establishing airway control but does not address problem of who should do it in the field, when it is performed in field. Suggests that possibly emergency physicians should be performing field intubations.
Perron AD
June 2001
Pediatric trauma patients receiving CPR over 82 month periodretrospective case seriesSurvival and functional indepedenceprehospital intubation and penetrating trauma were asssociated with decresed survivalControls not well matched. Retrospective nature of study.
Cooper A
feb 2001
National Pediatric Trauma registry, severely head injured patientsretrospective case review,Survival, functional outcomes, injurey complications, equpipment failures, procedural complications.Prehospital intubation offered no survival or functional advantageLevel of training of field intubators not addressed, retropsective nature of study
Murray JA
Dec 2000
Severe head injury patients GCS <=8 and Head AIS >=3retropsective case reviewsurvival in intubated versus non-intubated severly head injured patientsPrehospital intubated patients showed higher RR of mortality campred to nonintubated and even unsuccessfull attepted intubationControls not well matched, field intubations by leve of training not addressed
Eckstein M
2000 April
Major trauma patients who were transported by paramedics to Level 1 Trauma centerEffect of Pre-hospital ALS on outcomes of major trauma patientsDid not not improve survivalALS can be performed without pronging scene timeLike many papers in this study, it is a retrospective review. Also included were other procedures such as beginning intravenous fluids.
Winchell RJ
Severely head injured patients, GCS 8 or lessEffect of prehospital intubationMortality and functional status sufficient for discharge homerate of discharge was unaffected by field intubation, however there were decreases in mortalityAgain, it is a retrospective review, however, it does control for factors such as injury severity.


Most of these studies are reviews or retrospective reviews. They all look at paramedic level and below field intubations. Some examine severly head injured patients only. When controlled for injury severity, field intubations by paramedic level and below were associated with worse outcomes in the hospital than intubations performed by MD/DO, flight crews or in the hospital. There is one situation in which outcomes were shown to be improved, which was severly head injured patients, GCS less than 8. Reduced mortality was the improved outcome. A prospective study is needed to fully evaluate changing the current standard, even with mounting evidence against field intubation for trauma patients

Clinical Bottom Line

Field intubations for trauma patients should not be performed by paramedic level and below. In severly head injured patients there may be some exceptions.


  1. Davis, DP The impact of pre-hospital endotracheal intubation on outcome in moderate to severe traumatic brain injury Journal of Trauma 2005 May; 58(5):933-9
  2. Ehrich PF, Seidman PS, et al Endotracheal intubations in rural pediatric trauma patients J Pediatric Surg. 2004 Sept;39(9):1376-80
  3. Arbabi S, et al A comparison of prehospital and hospital data in trauma patients J Trauma May;56(5):1029-32
  4. Stockinger ZT Prehospital endotracheal intubation for trauma does not improve survival over bag-valve-mask ventilation Journal of Trauma March 2004 531-6
  5. Davis DP Paramedic-administered neuromuscular blockade improves prehospital sucess in severely head injured patients Journal of Trauma Oct 2003 713-9
  6. Bochicchio GV Is field intubation useful? Current opinion in Critical care 2003 Dec, 524-9
  7. Ruchholtz S Prehospital intubation in severe thoracic trauma without respiratory insuffiency:a matched pair analysis based on the Trauma Registry of the German Trauma Society J. Trauma May 2002 879-886
  8. Adnet F Intubating trauma patients before reaching hospital- revisited Critical Care Dec 2001
  9. Perron AD Predicting survival in pediatric trauma patients receiving CPR in the prehospital setting Prehosp Emerg Care 2001 6-9
  10. Cooper A Prehospital endotracheal intubation for severe head injury in children: a reappraisal Semin Pediatr Surg. Feb 2001 3-6
  11. Murray JA Prehospital intubation in patients with severe head injury J Trauma Dec 200 1065-1070
  12. Eckstein M, Chan L, Effect of prehospital ALS on outcomes of major trauma pateints J Trauma 200 Apr;48(4):643-8
  13. Winchell RJ Endotracheal intubation in the field improves survival in patients with severe head injury Arch Surg 1997 June;132(6):592-7