Pre‐hospital emergency anaesthesia in awake hypotensive trauma patients: beneficial or detrimental?

Crewdson, Kate; Rehn, Marius; Brohi, Karim; Lockey, David

doi:10.1111/aas.13059

Cited by 24 publications

(25 citation statements)

References 35 publications

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“…Checklists have become particularly popular in pre‐hospital advanced airway management . Tracheal intubation (TI) in the pre‐hospital setting is considered to be a high‐risk intervention with potential serious adverse events such as hypoxia, hypotension, tracheal aspiration as well as difficult or unsuccessful intubation . Complexity is added due to environmental factors, difficult patient positioning, limited airway equipment and limited assistance.…”

Section: Introductionmentioning

confidence: 99%

Checklists in pre‐hospital advanced airway management

Klingberg

Kornhall

Gryth

et al. 2019

Acta Anaesthesiol Scand

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Background In pre‐hospital care, pre‐intubation checklists (PICL) are widely implemented as a safety measure and guidelines support their use. However, the true value of PICL among experienced airway providers is unknown. This study aims to explore possible benefits and disadvantages of PICL in the pre‐hospital setting. Methods We performed a subgroup analysis of a prospective, observational, multicentre study on pre‐hospital advanced airway management in the Nordic countries between May 2015 and November 2016. The original trial was designed to investigate the success rates of pre‐hospital tracheal intubations and the incidence of complications. Our study limited inclusion to drug assisted intubations performed by anaesthesiologists. Intubation success rates and complication rates were plotted against checklist use. Results We analyzed 588 pre‐hospital intubations for medical and traumatic emergencies. Overall, checklists were used in 60.5% of instances. Applying checklists was associated with increased success at first and second intubation attempts. There was no significant difference in the overall success rates (99.4% and 99.1%). Oesophageal misplacement was more common in the No‐PICL group (2.2% vs 0.3%) but otherwise the incidence of airway related complications did not differ between the groups. Scene time was significantly shorter in the No‐PICL group (23.6 vs 27.5 minutes). Conclusion In this retrospective study, checklist use correlated with fewer attempts at intubation when securing the airway. Despite this, we found no association between checklist use and the overall TI success rate or the incidence of serious adverse events. Scene times were shorter without PICL.

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Section: Introductionmentioning

confidence: 99%

Checklists in pre‐hospital advanced airway management

Klingberg

Kornhall

Gryth

et al. 2019

Acta Anaesthesiol Scand

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“…The equal mortality rates between pre-hospital and emergency room intubation, correspond with the results of comparable studies. Crewdson et al found that pre-hospital vs. in-hospital emergency anaesthesia and intubation was associated with a 3-fold higher mortality in awake hypotensive trauma patients [5]. Bochicchio et al reported a significantly increased mortality and morbidity in trauma patients without severe head injury who were intubated in the field compared to those who were intubated immediately after hospital admission [10].…”

Section: Discussionmentioning

confidence: 99%

“…On the other side, there is evidence that patients may be put at risk when airway management is inappropriate and performed by non-skilled operators, thus decreasing the likelihood of survival [3, 4]. Recently, several publications raised the question whether airway management is always mandatory in a wide variety of emergencies such as shock, multiple- or brain trauma [5]. For non-traumatic emergencies, data advocating emergency anaesthesia and tracheal intubation is more than spare.…”

Section: Introductionmentioning

confidence: 99%

Postponing intubation in spontaneously breathing major trauma patients upon emergency room admission does not impair outcome

Schwaiger

Schöchl

Oberladstätter

et al. 2019

Scand J Trauma Resusc Emerg Med

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Background Pre-hospital emergency anaesthesia and tracheal intubation are life-saving interventions in trauma patients. However, there is evidence suggesting that the risks associated with both procedures outweigh the benefits. Thus, we assessed whether induction of anaesthesia and tracheal intubation of trauma patients can be postponed in spontaneously breathing patients until emergency room (ER) admission without increasing mortality. Methods Retrospective analysis of major trauma patients either intubated on-scene by an emergency medical service (EMS) physician (pre-hospital intubation, PHI) or within the first 10 min after admission at a level 1 trauma centre (emergency room intubation, ERI). Data was extracted from the German Trauma Registry, hospital patient data management and electronic clinical information system. Results From a total of 946 major trauma cases documented between 2010 and 2017, 294 patients matched the study inclusion criteria. Mortality rate of PHI ( N = 258) vs. ERI ( N = 36) patients was 26.4% vs. 16.7% ( p = 0.3). After exclusion of patients with severe traumatic brain injury and/or pre-hospital cardiac arrest, mortality rate of PHI ( N = 100) vs. ERI patients ( N = 29) was 6% vs. 17.2%, ( p = 0.07). Median on-scene time was significantly ( p < 0.01) longer in PHI (30 min; IQR: 21–40) vs. ERI patients (20 min; IQR: 15–28). Conclusions There was no statistical difference in mortality rates of spontaneously breathing trauma patients intubated on-scene when compared with patients intubated immediately after hospital admission. Due to the retrospective study design and small case number, further studies evaluating the impact of airway management timing in sufficiently breathing trauma patients are warranted.

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“…There are circumstances in which early intubation may not be in the patient’s best interests. There is data to suggest that patients with significant hypovolaemia following traumatic injury may have a higher mortality if anaesthetised in the pre-hospital setting, and that shorter scene times and waiting until arrival at hospital with direct access to definitive surgical intervention may be preferable for this patient group [ 22 , 23 ].…”

Section: Introductionmentioning

confidence: 99%

Airway management in pre-hospital critical care: a review of the evidence for a ‘top five’ research priority

Crewdson

Rehn

Lockey

2018

Scand J Trauma Resusc Emerg Med

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The conduct and benefit of pre-hospital advanced airway management and pre-hospital emergency anaesthesia have been widely debated for many years. In 2011, prehospital advanced airway management was identified as a ‘top five’ in physician-provided pre-hospital critical care. This article summarises the evidence for and against this intervention since 2011 and attempts to address some of the more controversial areas of this topic.

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Pre‐hospital emergency anaesthesia in awake hypotensive trauma patients: beneficial or detrimental?

Cited by 24 publications

References 35 publications

Checklists in pre‐hospital advanced airway management

Checklists in pre‐hospital advanced airway management

Postponing intubation in spontaneously breathing major trauma patients upon emergency room admission does not impair outcome

Airway management in pre-hospital critical care: a review of the evidence for a ‘top five’ research priority

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