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Should Trauma Patients with a Glasgow Coma Scale Score of 3 Be Intubated Prior to Hospital Arrival?

  • Charlene B. Irvin (a1), Susan Szpunar (a1), Lauren A. Cindrich (a2), Justin Walters (a1) and Robert Sills (a1)...

Abstract

Introduction:

Previous studies of heterogeneous populations (Glasgow Coma Scale (GCS) scores <9) suggest that endotracheal intubaton of trauma patients prior to hospital arrival (i.e., prehospital intubated) is associated with an increased mortality compared to those patients not intubated in the pre-hospital setting. Deeply comatose patients (GCS = 3) represent a unique population of severely traumatized patients and may benefit from intubation in the prehospital setting. The objective of this study was to compare mortality rates of severely comatose patients (scene GCS = 3) with prehospital endotracheal intubation to those intubated at the hospital.

Methods:

Using the National Trauma Data Bank (V. 6.2), the following variables were analyzed retrospectively: (1) age; (2) injury type (blunt or penetrating); (3) Injury Severity Score (ISS); (4) scene GCS = 3 (scored prior to intubation/without sedation); (5) emergency department GCS score; (6) arrival emergency department intubation status; (7) first systolic blood pressure in the emergency department (>0); (8) discharge status (alive or dead); (9) Abbreviated Injury Scale Score (AIS); and (10) AIS body region.

Results:

Of the 10,948 patients analyzed, 23% (2,491/10,948) were endotracheally intubated in a prehospital setting. Mortality rate for those hospital intubated was 35% vs. 62% for those with prehospital intubation (p <0.0001); mean ISS scores 24.2 ±16.0 vs. 31.6 ±16.2, respectively (p <0.0001). Using logistic regression, controlling for first systolic blood pressure, ISS, emergency department GCS, age, and type of trauma, those with prehospital intubation were more likely to die (OR = 1.9, 95% CI = 1.7−2.2). For patients with only head AIS scores (no other body region injury, n = 1,504), logistic regression (controlling for all other variables) indicated that those with prehospital intubation were still more likely to die (OR = 2.0. 95% CI = 1.4−2.9).

Conclusions:

Prehospital endotracheal intubation is associated with an increased mortality in completely comatose trauma patients (GCS = 3). Although the exact reasons for this remain unclear, these results support other studies and suggest the need for future research and re-appraisal of current policies for prehospital intubation in these severely traumatized patients.

Copyright

Corresponding author

50572 Jefferson Avenue, New Baltimore, Michigan 48047, USA E-mail: cbi@123.net

References

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1.Pepe, PE, Stewart, RD, Copass, MK: Prehospital management of trauma: A tale of three cities. Ann Emerg Med 1986;15(12):14841490.
2.Pepe, PE, Copass, MK, Joyce, TH: Prehospital endotracheal intubation: Rationale for training emergency medical personnel. Ann Emerg Med 1985;14(11):10851092.
3.Frankel, H, Rozycki, G, Champion, H, Harviel, JD, Bass, R: The use of TRISS methodology to validate prehospital intubation by urban EMS providers. Am J Emerg Med 1997;15(7):630632.
4.Quintans-Rodríquez, A, Turégano-Fuentes, F, Hernández-Granados, P, Pérez-Díaz, MD, Fuenmayor-Valera, ML, Fernández-Moreira, C: Survival after prehospital advanced life support in severe trauma. Eur J Emerg Med 1995;2(4):224226.
5.Winchell, RJ, Hoyt, DB: Endotracheal intubation in the pre-hospital improves survival in patients with severe head injury. Arch Surg 1997;132(6):592597.
6.Stockinger, ZT, McSwain, NE Jr : Prehospital endotracheal intubation for trauma does not improve survival over bag-valve-mask ventilation. J Trauma 2004;56(3):531536.
7.Cooper, A, DiScala, C, Foltin, G, Tunik, M, Markenson, D, Welborn, C: Prehospital endotracheal intubation for severe head injury in children: A reappraisal. Semin Pediatr Surg 2001;10(1):36.
8.Cudnik, MT, Newgard, CD, Wang, H, Bangs, C, Herrington R 4th: Distance impacts mortality in trauma patients with an intubation attempt. Prehosp Emerg Care 2008;12(4):459466.
9.Eckstein, M, Chan, L, Schneir, A, Palmer, R: Effect of prehospital advanced life support on outcomes of major trauma patients. J Trauma 2000;48(4):643648.
10.Murray, JA, Demetriades, D, Berne, TV, Stratton, SJ, Cryer, HG, Bongard, F, Fleming, A, Gaspard, D: Prehospital intubation in patients with severe head injury. J Trauma 2000;49(6):10651070.
11.Davis, DP, Peay, J, Sise, MJ, Vilke, GM, Kennedy, F, Eastman, AB, Velky, T, Hoyt, DB: The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injury. J Trauma 2005;58(5):933939.
12.Wang, HE, Peitzman, AB, Cassidy, LD, Adelson, PD, Yealy, DM: Out-of-hospital endotracheal intubation and outcome after traumatic brain injury. Ann Emerg Med 2004;44(5):439450.
13.DiRusso, SM, Sullivan, T, Risucci, D, Nealon, P, Slim, M: Intubation of pediatric trauma patients in the pre-hospital: Predictor of negative outcome despite risk stratification. J Trauma 2005;59(1):8490; discussion 90-91. Comment in: J Trauma Nurs 2006;13(3):151-153.
14.Bochicchio, GV, Ilahi, O, Joshi, M, Bochicchio, K, Scalea, TM: Endotracheal intubation in the pre-hospital does not improve outcome in trauma patients who present without an acutely lethal traumatic brain injury. J Trauma 2003;54:307311.
15.Lee, A, Garner, A, Fearnside, M, Harrison, K: Level of prehospital care and risk of mortality in patients with and without severe blunt head injury. Injury 2003;34(11):815819.
16.Stiell, IG, Nesbitt, LP, Pickett, W, Munkley, D, Spaite, DW, Banek, J, Pre-hospital, B, Luinstra-Toohey, L, Maloney, J, Dreyer, J, Lyver, M, Campeau, T, Wells, GA, OPALS Study Group: Collaborators (18) The OPALS Major Trauma Study: Impact of advanced life-support on survival and morbidity. CMAJ 2008;178(9):11411152;1171-1173, CMAJ 2008;179(1):56.
17.Polk-Williams, A, Carr, BG, Blinman, TA, Masiakos, PT, Wiebe, DJ, Nance, ML: Cervical spine injury in young children: A National Trauma Data Bank Review. J Pediatr Surg 2008;43(9):17181721.
18.Flagel, BT, Luchette, FA, Reed, RL, Esposito, TJ, Davis, KA, Santaniello, JM, Gamelli, RL: Half-a-dozen ribs: The breakpoint for mortality. Surgery 2005;138(4):717723.
19.Sen, A: Prehospital endotracheal intubation in adult major trauma patients with head injury. Available at http://bstbets.org. Accessed May 2005.
20.Lecky, F, Bryden, D, Little, R, Tong, N, Moulton, C: Emergency intubation for acutely ill and injured patients. Cochrane Database Syst Rev 2008;(2):CD001429.
21.Gausche, M, Lewis, RJ, Stratton, SJ, et al: Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome. JAMA 2000;283:783790.
22.von Elm, E, Schoettker, P, Henzi, I, Osterwalder, J, Walder, B: Pre-hospital tracheal intubation in patients with traumatic brain injury: Systematic review of the current evidence. Br J Anaesth 2009;103(3):371386
23.Suominen, P, Baillie, C, Kivioja, A, Ohman, J, Olkkola, KT: Intubation and survival in severe paediatric blunt head injury. Eur J Emerg Med 2000;7(1):37.
24.Davis, DP: Prehospital intubation of brain-injured patients. Curr Opin Crit Care 2008;14(2):142148.
25.Carr, BG, Brachet, T, David, G, Duseja, R, Branas, CC: The time cost of pre-hospital intubation and intravenous access in trauma patients. Prehosp Emerg Care 2008;12(3):327332.
26.Cudnik, MT, Newgard, CD, Wang, H, Bangs, C, Herringtion R 4th: Endotracheal intubation increases out-of-hospital time in trauma patients. Prehosp Emerg Care 2007;11(2):224229.
27.Karch, SB, Lewis, T, Young, S, Hales, D, Ho, CH: Pre-hospital intubation of trauma patients: Complications, indications, and outcomes. Am J Emerg Med 1996;14(7):617619.
33.Cudnik, MT, Newgard, CD, Daya, M, Jui, J: The impact of Rapid Sequence Intubation on trauma patient mortality in attempted prehospital intubation. J Emerg Med 2008 [Epub ahead of print].
34.Sloane, C, Vilke, GM, Chan, TC, Hayden, SR, Hoyt, DB, Rosen, P: Rapid sequence intubation in the pre-hospital versus hospital in trauma patients. J Emerg Med 2000;19(3):259264.
35.Bulger, EM, Copass, MK, Sabath, DR, Maier, RV, Jurkovich, GJ: The use of neuromuscular blocking agents to facilitate prehospital intubation does not impair outcome after traumatic brain injury. J Trauma 2005;58(4);718723.
36.Davis, DP, Peay, J, Serano, JA, Buono, C, Vilke, GM, Sise, MJ, Kennedy, F, Eastman, AB, Velky, T, Hoyt, DB: The impact of aeromedical response to patients with moderate to severe traumatic brain injury. Ann Emerg Med 2005;46(2):115122.
37.Bulger, EM, Nathens, AB, Rivara, FP, MacKenzie, E, Sabath, DR, Jurkovich, GJ: National variability in out-of-hospital treatment after traumatic injury. Ann Emerg Med 2007;49(3):293301.
38.Floccare, DJ: Letter to Editor. J Trauma 2003;11841185.
28.Eckert, MJ, Davis, KA, Reed, RL 2nd, Santaniello, JM, Poulakidas, S, Esposito, TJ, Luchette, FA: Urgent airways after trauma: who gets pneumonia? J Trauma 2004;57(4):750755.
29.Davis, DP, Dunford, JV, Poste, JC, Ochs, M, Holbrook, T, Fortlage, D, Size, MJ, Kennedy, F, Hoyt, DB: The impact of hypoxia and hyperventilation on outcome after paramedic rapid sequence intubation of severely head-injured patients. J Trauma 2004;57(1):18; discussion 8-10.
30.Davis, DP, Stern, J, Sise, MJ, Hoyt, DB: A follow-up analysis of factors associated with head-injury mortality after paramedic rapid sequence intubation. J Trauma 2005;59(2):486490.
31.Helm, M, Hauke, J, Lampl, L: A prospective study of the quality of pre-hospital emergency ventilation in patients with severe head injury. Br J Anaesth 2002;88(3):345349. Comment in: Br J Anaesth 2002;89(6):936; author reply 936.
32.Nakayama, DK, Gardner, MJ, Rowe, MI: Emergency endotracheal intubation in pediatric trauma. Ann Surg 1990;211(2):218223.

Keywords

Should Trauma Patients with a Glasgow Coma Scale Score of 3 Be Intubated Prior to Hospital Arrival?

  • Charlene B. Irvin (a1), Susan Szpunar (a1), Lauren A. Cindrich (a2), Justin Walters (a1) and Robert Sills (a1)...

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