A systematic review and meta-analysis comparing mortality in pre-hospital tracheal intubation to emergency department intubation in trauma patients

Abstract

BackgroundPre-hospital endotracheal intubation is frequently used for trauma patients in many emergency medical systems. Despite a wide range of publications in the field, it is debated whether the intervention is associated with a favourable outcome, when compared to more conservative airway measures.MethodsA systematic literature search was conducted to identify interventional and observational studies where the mortality rates of adult trauma patients undergoing pre-hospital endotracheal intubation were compared to those undergoing emergency department intubation.ResultsTwenty-one studies examining 35,838 patients were included. The median mortality rate in patients undergoing pre-hospital intubation was 48% (range 8–94%), compared to 29% (range 6–67%) in patients undergoing intubation in the emergency department. Odds ratios were in favour of emergency department intubation both in crude and adjusted mortality, with 2.56 (95% CI: 2.06, 3.18) and 2.59 (95% CI: 1.97, 3.39), respectively. The overall quality of evidence is very low. Twelve of the twenty-one studies found a significantly higher mortality rate after pre-hospital intubation, seven found no significant differences, one found a positive effect, and for one study an analysis of the mortality rate was beyond the scope of the article.ConclusionsThe rationale for wide and unspecific indications for pre-hospital intubation seems to lack support in the literature, despite several publications involving a relatively large number of patients. Pre-hospital intubation is a complex intervention where guidelines and research findings should be approached cautiously. The association between pre-hospital intubation and a higher mortality rate does not necessarily contradict the importance of the intervention, but it does call for a thorough investigation by clinicians and researchers into possible causes for this finding.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-017-1787-x) contains supplementary material, which is available to authorized users.

Mechanical complications and outcomes following invasive emergency procedures in severely injured trauma patients

“…Data on the process quality of invasive emergency procedures in severely injured patients are available for either out-of-hospital 4 – 7 or resuscitation room settings 8 – 10 , whereas studies elucidating the entire acute care phase including the first 24 hours after injury are scarce 11 . This time period is crucial in the management of severely injured patients since absence, delay, or failure of life-saving procedures may effect patient outcome 12 .…”

Open Penetrating External Laryngotracheal Injury and Abdominal Trauma by Suicide Attempt Successfully Treated With Immediate Intervention: A Case Report

“…However, the decision to intubate or not at the scene needs careful consideration because of the risk of mucosal soft tissue expansion and airway obstruction resulting from blind intubation. In a systematic review and meta-analysis of 21 studies, more than half of the studies showed that pre-hospital intubation was signi cantly associated with a higher mortality rate [11]. Thus, intubating the patient using broncho berscopy, which allows observation of the inner trachea, inserting a thinner endotracheal tube, and inserting a tracheostomy tube from the laceration remain to be much safer options.…”

Deriving Costs and Effectiveness Data for U.S. Army Training-Garrison Pre-Hospital U.S. Army Emergency Medical Services

“…Regardless of how on-site clinical services actually factor into time to arrival, stabilization time, and patient transport time to a hospital/ trauma center, the expectation of an emergency situation is that this will be done with all due speed and with the patient surviving the ride [20]. Another reason is that recent research has revealed that, despite innovations in on-site treatment, the vital contribution of PH-EMS services in terms of improved prognosis and outcomes is rapid stabilization and evacuation to a hospital/trauma center [20,26,32]. Indeed, some research even suggests that delays due to on-site prehospitalization EMS interventions may be related to high mortality rates, though the rate does not necessarily contraindicate the importance of the intervention [33].…”

“…Note that delimiting the time-interval outcome to survival upon arrival at a hospital/trauma center in terms of measuring PH-EMS effectiveness increases the ability to draw conclusions about PH-EMS absent confounding influences from post-acute hospital arrival interventions [32,42]. This prevents complications of erroneously attributing patient survival rates to PH-EMS, when in fact they are due to subsequent hospitalization [20,32,42].…”