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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 2005 USA	patients with moderate to severe TBI (Head/Neck AIS score 3+) from San Diego County Trauma registry	Retrospective Chart Review of 13,625 patients; with controls for mechanism, age, gender, GCS, ISS, hypotension, H/N AIS.	survival benefit from pre-hospital intubation	OR 0.36 increaed mortality with field intubation	Retrospective chart review, aeromedical crews excluded, other advanced training not assesed
Ehrlich PF, Seidman PS Atallah O Sept 2004 USA	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 series	Airway complications and multiple attempts	Airway complications and multiple attempts were associated with transport delay and poorer patient outcomes, with most attempts and complications occurring in the feld	Retrospective nature of study. Level of training of field personnel not distinguished. Small sample size
Arbabi S, Jurkovich GJ, Wahl WL et al May 2004 USA	Trauma registry patients from two academic level one centers from 1994-2001, excluding transfers and burns	retropsective review	ED and field physiologic parameters are eually valid predictors of outcome	Early 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 USA	All trauma patients transported to Level One Trauma Center recieving BVI or ETI over one year period. 316 ETI and 217 BVM patients	retrospective case review	Mortality, corrected for ISS, RTS, and mechanism of injury	ETI was associated with great or similar mortality than BVM and ETI pateints had longer transport times	None
Davis DP, Ochs M, Hoyt DB Oct 2003 USA	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 RSI	Prospective case series, using retrospective cases as controls	Intubation success, stratified by GCS	Percentage of patients intubated without RSI increased and when stratified into GCS 3 and GCS 4-8	Patient 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.
Bochicchio Dec 2003 USA	review article, looking at 16 papers icluding outcomes for TBI and mutliply injured patients	literature review	Multiple studies demostrating poorer outcomes in patients intubated in the field	Patients intubated in the field	It 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 Germany	Matched pair analysis, severe thoracic trauma with and without pre-hospital intubation. Paired with respect to age, injury severity, and prognosis.	retrospective case series	prognosis with rtepsect to organ failure, treatment time, and mortality	Patients 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 France	review article	review article	Outcomes in patients intubated in prehospital setting	Most 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 USA	Pediatric trauma patients receiving CPR over 82 month period	retrospective case series	Survival and functional indepedence	prehospital intubation and penetrating trauma were asssociated with decresed survival	Controls not well matched. Retrospective nature of study.
Cooper A feb 2001 USA	National Pediatric Trauma registry, severely head injured patients	retrospective case review,	Survival, functional outcomes, injurey complications, equpipment failures, procedural complications.	Prehospital intubation offered no survival or functional advantage	Level of training of field intubators not addressed, retropsective nature of study
Murray JA Dec 2000 USA	Severe head injury patients GCS <=8 and Head AIS >=3	retropsective case review	survival in intubated versus non-intubated severly head injured patients	Prehospital intubated patients showed higher RR of mortality campred to nonintubated and even unsuccessfull attepted intubation	Controls not well matched, field intubations by leve of training not addressed
Eckstein M 2000 April USA	Major trauma patients who were transported by paramedics to Level 1 Trauma center	Effect of Pre-hospital ALS on outcomes of major trauma patients	Did not not improve survival	ALS can be performed without pronging scene time	Like many papers in this study, it is a retrospective review. Also included were other procedures such as beginning intravenous fluids.
Winchell RJ 1997 USA	Severely head injured patients, GCS 8 or less	Effect of prehospital intubation	Mortality and functional status sufficient for discharge home	rate of discharge was unaffected by field intubation, however there were decreases in mortality	Again, it is a retrospective review, however, it does control for factors such as injury severity.

Comment(s)

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.

References

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