End-tidal to arterial carbon dioxide gradient is associated with increased mortality in patients with traumatic brain injury: a retrospective observational study
Abstract:Early definitive airway protection and normoventilation are key principles in the treatment of severe traumatic brain injury. These are currently guided by end tidal CO2 as a proxy for PaCO2. We assessed whether the difference between end tidal CO2 and PaCO2 at hospital admission is associated with in-hospital mortality. We conducted a retrospective observational cohort study of consecutive patients with traumatic brain injury who were intubated and transported by Helicopter Emergency Medical Services to a Lev… Show more
“…Injuries due to trauma seem to be the predominant reason for providing advanced airway management in many HEMS services around the globe [ 15 , 16 ]. Early definitive airway protection as well as normoventilation plays a key role in the recent literature on traumatic brain injury (TBI) [ 16 , 17 ]. This is in accordance with our data showing that TBI was the predominant indication for RSI among all indications.…”
Background
Airway management is a key skill in any helicopter emergency medical service (HEMS). Intubation is successful less often than in the hospital, and alternative forms of airway management are more often needed.
Methods
Retrospective observational cohort study in an anaesthesiologist-staffed HEMS in Switzerland. Patient charts were analysed for all calls to the scene (n = 9,035) taking place between June 2016 and May 2017 (12 months). The primary outcome parameter was intubation success rate. Secondary parameters included the number of alternative techniques that eventually secured the airway, and comparison of patients with and without difficulties in airway management.
Results
A total of 365 patients receiving invasive ventilatory support were identified. Difficulties in airway management occurred in 26 patients (7.1%). Severe traumatic brain injury was the most common indication for out-of-hospital Intubation (n = 130, 36%). Airway management was performed by 129 different Rega physicians and 47 different Rega paramedics. Paramedics were involved in out-of-hospital airway manoeuvres significantly more often than physicians: median 7 (IQR 4 to 9) versus 2 (IQR 1 to 4), p < 0.001.
Conclusion
Despite high overall success rates for endotracheal intubation in the physician-staffed service, individual physicians get only limited real-life experience with advanced airway management in the field. This highlights the importance of solid basic competence in a discipline such as anaesthesiology.
“…Injuries due to trauma seem to be the predominant reason for providing advanced airway management in many HEMS services around the globe [ 15 , 16 ]. Early definitive airway protection as well as normoventilation plays a key role in the recent literature on traumatic brain injury (TBI) [ 16 , 17 ]. This is in accordance with our data showing that TBI was the predominant indication for RSI among all indications.…”
Background
Airway management is a key skill in any helicopter emergency medical service (HEMS). Intubation is successful less often than in the hospital, and alternative forms of airway management are more often needed.
Methods
Retrospective observational cohort study in an anaesthesiologist-staffed HEMS in Switzerland. Patient charts were analysed for all calls to the scene (n = 9,035) taking place between June 2016 and May 2017 (12 months). The primary outcome parameter was intubation success rate. Secondary parameters included the number of alternative techniques that eventually secured the airway, and comparison of patients with and without difficulties in airway management.
Results
A total of 365 patients receiving invasive ventilatory support were identified. Difficulties in airway management occurred in 26 patients (7.1%). Severe traumatic brain injury was the most common indication for out-of-hospital Intubation (n = 130, 36%). Airway management was performed by 129 different Rega physicians and 47 different Rega paramedics. Paramedics were involved in out-of-hospital airway manoeuvres significantly more often than physicians: median 7 (IQR 4 to 9) versus 2 (IQR 1 to 4), p < 0.001.
Conclusion
Despite high overall success rates for endotracheal intubation in the physician-staffed service, individual physicians get only limited real-life experience with advanced airway management in the field. This highlights the importance of solid basic competence in a discipline such as anaesthesiology.
“…14 In one study, prehospital EtCO 2 was a better predictor of mortality than SBP or SI, 14 and in another, initial EtCO 2 effectively predicted poor outcome including when controlling for mechanism and ISS. 15 These associations have been confirmed in traumatic brain injury (TBI), 16 and for nonintubated, non-full trauma activation patients. 17 The physiologic underpinnings of EtCO 2 utility have been confirmed by correlating EtCO 2 in the emergently intubated trauma patient with noninvasive measures of cardiac output, 18 showing that the PaCO 2 -EtCO 2 difference is closely associated with outcome.…”
Damage control resuscitation in the care of critically injured trauma patients aims to limit blood loss and prevent and treat coagulopathy by combining early definitive hemorrhage control, hypotensive resuscitation and early and balanced use of blood products (hemostatic resuscitation) and the use of other hemostatic agents. This clinical protocol has been developed to provide evidence-based recommendations for optimal damage control resuscitation in the care of trauma patients with hemorrhage.
LEVEL OF EVIDENCE
Therapeutic/Care Management; Level V.
TYPE: Algorithms / Guidelines / Clinical Protocol
“…A systematic review examined the association between ventilation strategies during the initial post-injury and resuscitation phase in patients with TBI [54]. Normocapnia (the definition of which varied between the six studies) was associated with a lower mortality, although neurological outcomes were not assessed, and some studies measured endtidal carbon dioxide which may not be reflective of PaCO 2 [55]. However, this suggests that pre-hospital emergency services that can undertake advanced airway interventions (such as tracheal intubation) may improve outcomes for patients with TBI, which is in line with the findings from retrospective analyses of UK trauma registries [56,57].…”
Globally, approximately 70 million people sustain traumatic brain injury each year and this can have significant physical, psychosocial and economic consequences for patients, their families and society. The aim of this review is to provide clinicians with a summary of recent studies of direct relevance to the management of traumatic brain injury in order to promote best clinical practice. The use of tranexamic acid in the management of traumatic brain injury has been the focus of several studies, with one large randomised controlled trial suggesting a reduction in all-cause mortality within 24 h of injury. The use of therapeutic hypothermia does not improve neurological outcomes and maintenance of normothermia remains the optimal management strategy. For seizure management, levetiracetam appears to be as effective as phenytoin, but the optimal dose remains unclear. There has been a lack of clear outcome benefit for any individual osmotherapy agent, with no difference in mortality or neurological recovery. Early tracheostomy (< 7 days from injury) for patients with traumatic brain injury is associated with a reduction in the incidence of ventilator-associated pneumonia and duration of mechanical ventilation, critical care and hospital stay. Further research is needed in order to determine the optimal package of care and interventions. There is a need for research studies to focus on patient-centred outcome measures such as long-term neurological recovery and quality of life.
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