Endotracheal Intubation in the Field Does Not Improve Outcome in Trauma Patients Who Present without an Acutely Lethal Traumatic Brain Injury

Bochicchio, Grant V.; Ilahi, Obeid; Joshi, Manjari; Bochicchio, Kelly; Scalea, Thomas M.

doi:10.1097/01.ta.0000046252.97590.be

Cited by 209 publications

(118 citation statements)

References 9 publications

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“…Recent literature has questioned the safety and benefit of out-of-hospital intubation in certain patients, particularly the headinjured trauma patient. 6,7 Two studies also found rates of misplaced ETTs that ranged from unacceptable (25%) 8 to concerning but more in line with earlier literature (5.8%) 9 using hospital rather than field verification of proper placement. Before we determine the true impact of an out-of-hospital intervention on patient outcomes, we need to know whether, and in what settings, the intervention can be performed.…”

supporting

confidence: 67%

“…8 Several studies have also questioned the effect of out-of-hospital intubation on patient outcomes, particularly in the head-injured patient. 6,7,13 Given the discrepancy in the literature and the potential impact on patient care, a clear understanding of success and complication rates related to airway management is crucial to effectively establish protocols for EMS systems. We present the success and complications rates of intubation in a highvolume, urban 9-1-1 system.…”

Section: Discussionmentioning

confidence: 99%

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An Evaluation of Out-of-hospital Advanced Airway Management in an Urban Setting

Colwell

McVaney

Haukoos

et al. 2005

Academic Emergency Medicine

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Objectives: To determine the success and complication rates associated with endotracheal intubation in an urban emergency medical services (EMS) system. Methods: This study evaluated consecutive airway interventions between March 2001 and May 2001 performed by paramedics from the Denver Health Paramedic Division in Denver, Colorado. Patients were identified and enrolled prospectively with the identification of all patients for whom intubation was attempted. A retrospective chart review of the emergency department (ED), intensive care unit, other hospital records, and the coroner's records was then conducted with the intent of identifying all complications related to attempted intubation, including the placement of each endotracheal tube. Results: A total of 278 patients were included in this study. Of these, 154 (55%) had an initial nasal intubation attempt, and 124 (45%) had an initial oral intubation attempt. Of the 278 patients for whom an intubation was attempted, 234 (84%, 95% CI = 77% to 88%) were reported by paramedics to be successfully intubated. Of 114 nasal intubations reported as successful by paramedics, two (2%; 95% CI = 0.2% to 6%) were found to be misplaced. Of the 120 oral intubations reported as successful by paramedics, one (1%; 95% CI = 0.02% to 5%) was found to be misplaced. Of the 278 patients, 22 (8%; 95% CI = 5% to 12%) had complications; three (1%; 95% CI = 0.2% to 3%) endotracheal tubes were incorrectly positioned, two (0.7%; 95% CI = 0.08% to 3%) of which were undetected esophageal intubations and one (0.4%; 95% CI = 0 to 2%) of which was in the posterior pharynx. Conclusions: Reasonable success and complication rates of endotracheal intubation in the outof-hospital setting can be achieved in a busy, urban EMS system without the assistance of medications. Keywords: endotracheal intubation; urban; complications; prehospital care. ACADEMIC EMERGENCY MEDICINE 2005; 12:417-422. There may be no out-of-hospital intervention other than defibrillation that is as critical to a patient's outcome as airway management. Placement of endotracheal tubes (ETTs) by paramedics in the outof-hospital setting has been considered a standard of care for a long time, and a number of studies have shown this airway technique to be safe 1-3 and to improve survival in a variety of clinical settings. 4,5 A relatively recent increase in the attention focused on out-of-hospital interventions and the effect they have on patient outcomes has raised important issues and called into question some practices, such as endotracheal intubation, that many have considered standard out-of-hospital practice. Recent literature has questioned the safety and benefit of out-of-hospital intubation in certain patients, particularly the headinjured trauma patient. 6,7 Two studies also found rates of misplaced ETTs that ranged from unacceptable (25%) 8 to concerning but more in line with earlier literature (5.8%) 9 using hospital rather than field verification of proper placement. Before we determine the true impact of an out...

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supporting

confidence: 67%

Section: Discussionmentioning

confidence: 99%

An Evaluation of Out-of-hospital Advanced Airway Management in an Urban Setting

Colwell

McVaney

Haukoos

et al. 2005

Academic Emergency Medicine

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“…[5][6][7][8][9] EADs are the most common alternative to intubation in the field and likely the most common rescue airway device for failed intubation, other than bag-mask ventilation. The placement of an EAD can occur quickly, provides a means to oxygenate and ventilate a patient, and in many systems falls within the scope of practice for If the EAD does decrease cerebral perfusion-particularly in patients in a low-flow state-then many of these benefits of EAD placement may be outweighed by increased morbidity and mortality, although this has not been definitively demonstrated by research to date.…”

Section: Discussionmentioning

confidence: 99%

Radiographic Evaluation of Carotid Artery Compression in Patients With Extraglottic Airway Devices in Place

White¹,

Braude²,

Lorenzo

et al. 2015

Academic Emergency Medicine

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Objectives: Extraglottic airway devices (EADs) are now commonly placed for airway management of critically ill or injured patients, particularly by emergency medical services providers in the out-ofhospital setting. Recent literature has suggested that EADs may cause decreased cerebral blood flow due to compression of the arteries of the neck by the devices' inflated cuffs. Methods:The authors identified a cohort of 17 patients presumed to be hemodynamically stable with EADs in place who underwent radiographic imaging of the neck. These studies were reviewed by a neuroradiologist to determine if mechanical compression of the carotid arteries was present.Results: None of the 17 cases reviewed had radiographically evident mechanical compression of the carotid artery. Conclusions:Until further studies are performed in which cerebral perfusion is evaluated prospectively in both hemodynamically stable and unstable human subjects, there is insufficicent evidence to recommend against the use of extraglottic airways in the emergency setting on the basis of carotid artery compression.ACADEMIC EMERGENCY MEDICINE 2015;22:636-638 © 2015 by the Society for Academic Emergency Medicine E xtraglottic airway devices (EADs) are commonly placed by emergency medical services (EMS) providers for airway management of critically ill or injured patients in the prehospital setting, and less commonly by physicians in the emergency department (ED). 1 Most EADs use an inflatable cuff in the hypopharynx to prevent airflow into the esophagus and to direct airflow into the trachea and lungs (see Figure 1). There exists a theoretical concern that the inflated cuffs on these devices may cause compression of the arteries in the neck that supply the brain. A recent study by Segal et al. 2 found a decrease in cerebral blood flow when EADs were used in a swine model. Colbert et al. 3 demonstrated that the laryngeal mask airway (LMA) cuff had an effect on the carotid bulb cross-sectional area and blood flow. Nandwani et al. 4 noted no sonographically evident displacement or compression of the internal jugular vein and the carotid artery in human subjects when an LMA was placed. In this study, we took advantage of a common practice at our institution in which well-functioning EADs placed in the field are left in situ for initial resuscitation and imaging in the ED. As a result, we have a number of patients who have undergone cross-sectional computed tomography (CT) studies of the cervical spine with various EADs in place. We examined whether or not mechanical carotid artery compression presumed to be secondary to the presence of the air-filled cuff in the hypopharynx was present in patients who underwent neck imaging studies and had EADs in place. We hypothesized that carotid artery compression would not be identified. METHODS Study DesignThis was a retrospective study of images acquired during usual care in our ED. This study received an exemption from our institutional review board.

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“…5). Three studies 7 30 36 reported on pneumonia after pre-hospital or in-hospital intubation; it was the primary study outcome in In-hospital mortality Suominen and colleagues 29 Sloane and colleagues 30 Winchell and colleagues 31 Gausche and colleagues 32 Murray and colleagues 33 Cooper and colleagues 34 Davis and colleagues 35 Bochicchio and colleagues 36 DiRusso and colleagues 37 Wang and colleagues 38 Davis and colleagues 39 Davis and colleagues 28 Klemen and Grmec 40 1 h mortality von Elm et al …”

Section: Harm Outcomesmentioning

confidence: 99%

“…Sloane and colleagues 30 Bochicchio and colleagues 36 Eckert and colleagues 7 Inadvertent hyperventilation…”

Section: Pneumoniamentioning

confidence: 99%

Pre-hospital tracheal intubation in patients with traumatic brain injury: systematic review of current evidence

Elm

Schoettker

Henzi

et al. 2009

British Journal of Anaesthesia

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Endotracheal Intubation in the Field Does Not Improve Outcome in Trauma Patients Who Present without an Acutely Lethal Traumatic Brain Injury

Abstract: Prehospital intubation is associated with a significant increase in morbidity and mortality in trauma patients with traumatic brain injury who are admitted to the hospital without an acutely lethal injury. A randomized, prospective study is warranted to confirm these results.

Cited by 209 publications

References 9 publications

An Evaluation of Out-of-hospital Advanced Airway Management in an Urban Setting

An Evaluation of Out-of-hospital Advanced Airway Management in an Urban Setting

Radiographic Evaluation of Carotid Artery Compression in Patients With Extraglottic Airway Devices in Place

Pre-hospital tracheal intubation in patients with traumatic brain injury: systematic review of current evidence

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