Pre-hospital intubation for trauma patients

Date First Published:
September 22, 2005
Last Updated:
April 7, 2006
Report by:
Cyril Morello, M.D., Senior Emergency Medicine Resident (University of South Florida/Tampa General Hospital)
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.
Search Details:
(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]
Outcome:
127 papers, of which 114 were considered either irrelevant or inadequate. The remaining 13 papers are shown in the table.
Relevant Paper(s):
Study Title Patient Group Study type (level of evidence) Outcomes Key results Study Weaknesses
The impact of pre-hospital endotracheal intubation on outcome in moderate to severe traumatic brain injury Davis, DP 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
Endotracheal intubations in rural pediatric trauma patients Ehrich PF, Seidman PS, et al Sep-04 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
A comparison of prehospital and hospital data in trauma patients Arbabi S, et al May-04 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
Prehospital endotracheal intubation for trauma does not improve survival over bag-valve-mask ventilation Stockinger ZT Mar-04 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
Paramedic-administered neuromuscular blockade improves prehospital sucess in severely head injured patients Davis DP Oct-03 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.
Is field intubation useful? Bochicchio GV Dec-03 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.
Prehospital intubation in severe thoracic trauma without respiratory insuffiency:a matched pair analysis based on the Trauma Registry of the German Trauma Society Ruchholtz S May-02 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
Intubating trauma patients before reaching hospital- revisited Adnet F Dec-01 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.
Predicting survival in pediatric trauma patients receiving CPR in the prehospital setting Perron AD Jun-01 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.
Prehospital endotracheal intubation for severe head injury in children: a reappraisal Cooper A Feb-01 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
Prehospital intubation in patients with severe head injury Murray JA Dec-00 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
Effect of prehospital ALS on outcomes of major trauma pateints Eckstein M, Chan L, 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.
Endotracheal intubation in the field improves survival in patients with severe head injury 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.
Author Commentary:
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
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
  2. Ehrich PF, Seidman PS, et al. Endotracheal intubations in rural pediatric trauma patients
  3. Arbabi S, et al. A comparison of prehospital and hospital data in trauma patients
  4. Stockinger ZT. Prehospital endotracheal intubation for trauma does not improve survival over bag-valve-mask ventilation
  5. Davis DP. Paramedic-administered neuromuscular blockade improves prehospital sucess in severely head injured patients
  6. Bochicchio GV. Is field intubation useful?
  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
  8. Adnet F. Intubating trauma patients before reaching hospital- revisited
  9. Perron AD. Predicting survival in pediatric trauma patients receiving CPR in the prehospital setting
  10. Cooper A. Prehospital endotracheal intubation for severe head injury in children: a reappraisal
  11. Murray JA. Prehospital intubation in patients with severe head injury
  12. Eckstein M, Chan L,. Effect of prehospital ALS on outcomes of major trauma pateints
  13. Winchell RJ. Endotracheal intubation in the field improves survival in patients with severe head injury