Prehospital endotracheal intubation in adult major trauma patients with head injury

May 8, 2005

May 8, 2005

Ayan Sen, Senior House Officer, Critical Care (Manchester Royal Infirmary)

Raj Nichani, Manchester Royal Infirmary

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]

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.

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]

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

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.

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

1. Wang HE, Peitzman AB, Cassidy LD, Adelson PD, Yealy DM.. Out-of-hospital Endotracheal Intubation and outcome after traumatic brain injury.
2. Stockinger ZT, McSwain NE Jr.. Prehospital Endotracheal intubation for trauma does not improve survival over bag-valve-mask ventilation.
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.
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.
5. Sloane C, Vilke GM, Chan TC, Hayden SR, Hoyt DB, Rosen P.. Rapid Sequence Intubation in the field versus hospital in trauma patients.
6. Eckstein M, Chan L, Schneir A, Palmer R.. Effect of prehospital advanced life support on outcomes of major trauma patients.
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.
8. Winchell RJ, Hoyt DB.. Endotracheal intubation in the field improves survival in patients with severe head injury.
9. Davis DP, Peay J, Sise MJ. et al.. The impact of prehospital endotgracheal intubation on outcome in moderate to severe traumatic brain injury.