Guidelines for Emergency Tracheal Intubation Immediately after Traumatic Injury

Dunham, C. Michael; Barraco, Robert D.; Clark, David E.; Daley, Brian; Davis, Frank E.; Gibbs, Michael; Knuth, Thomas E.; Letarte, Peter B.; Luchette, Fred A.; Omert, Laurel; Weireter, Leonard J.; Wiles, Charles E.

doi:10.1097/01.ta.0000083335.93868.2c

Cited by 146 publications

(84 citation statements)

References 237 publications

(457 reference statements)

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“…For example, in national guidelines for trauma patient management, a below-normal prehospital GCS is one criterion for emergency medical service (EMS) transport from the field directly to a level 1 trauma center 3 and for emergency tracheal intubation after traumatic injury. 4 In addition, the GCS is often relied upon in prehospital research to help control for degree of TBI (for example, see Davis and colleagues 5 ), even though it was not originally intended, nor validated, for this clinical context. Indeed, the GCS is currently being used for non-TBI patients, for instance, to measure brain function in meningitis 6 and hypothyroidism 7 cases.…”

Section: Introductionmentioning

confidence: 99%

Prehospital Heart Rate and Blood Pressure Increase the Positive Predictive Value of the Glasgow Coma Scale for High-Mortality Traumatic Brain Injury

Reisner

Chen

Kumar

et al. 2014

Journal of Neurotrauma

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We hypothesized that vital signs could be used to improve the association between a trauma patient's prehospital Glasgow Coma Scale (GCS) score and his or her clinical condition. Previously, abnormally low and high blood pressures have both been associated with higher mortality for patients with traumatic brain injury (TBI). We undertook a retrospective analysis of 1384 adult prehospital trauma patients. Vital-sign data were electronically archived and analyzed. We examined the relative risk of severe head Abbreviated Injury Scale (AIS) 5-6 as a function of the GCS, systolic blood pressure (SBP), heart rate (HR), and respiratory rate (RR). We created multi-variate logistic regression models and, using DeLong's test, compared their area under receiver operating characteristic curves (ROC AUCs) for three outcomes: head AIS 5-6, all-cause mortality, and either head AIS 5-6 or neurosurgical procedure. We found significant bimodal relationships between head AIS 5-6 versus SBP and HR, but not RR. When the GCS was < 15, ROC AUCs were significantly higher for a multi-variate regression model (GCS, SBP, and HR) versus GCS alone. In particular, patients with abnormalities in all parameters (GCS, SBP, and HR) were significantly more likely to have high-mortality TBI versus those with abnormalities in GCS alone. This could be useful for mobilizing resources (e.g., neurosurgeons and operating rooms at the receiving hospital) and might enable new prehospital management protocols where therapies are selected based on TBI mortality risk.

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Section: Introductionmentioning

confidence: 99%

Prehospital Heart Rate and Blood Pressure Increase the Positive Predictive Value of the Glasgow Coma Scale for High-Mortality Traumatic Brain Injury

Reisner

Chen

Kumar

et al. 2014

Journal of Neurotrauma

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“…Im Rahmen dieser Schädigungs-kaskade kommt der Gewebeoxygenierung eine besondere Bedeutung zu, und diese kann nur aufrechterhalten werden, wenn Sauerstoffaufnahme, -transport und -abgabe gewährleistet werden. Die Sauerstoffaufnahme ist nur bei Sicherung des Atemwegs möglich, und die ETI hat dabei gemäß den aktuell bestehenden europäischen und nichteuropäischen Leitlinien den Stellenwert des Goldstandards [27,31,73]. In den prä-und innerhospitalen Handlungsalgorithmen unterschiedlicher Ausbildungsformate [z.…”

Section: Grundlagen Des Atemwegsmanagementsunclassified

“…In der Leitlinien der "Eastern Association for the Surgery of Trauma" (EAST, [31]) zur ETI nach Trauma wurde konstatiert, dass keinerlei kontrollierte, randomisierte Studien zu der Fragestellung "Apnoe und Schnappatmung" existieren. Im Umkehrschluss fanden die Autoren der EASTGuideline jedoch auch keine Studien, die eine alternative Therapiestrategie als nachweislich effektiv darstellen konnten [31].…”

Section: Apnoe Und Schnappatmungunclassified

“…Im Umkehrschluss fanden die Autoren der EASTGuideline jedoch auch keine Studien, die eine alternative Therapiestrategie als nachweislich effektiv darstellen konnten [31]. Die ETI wird als insgesamt so etabliertes Verfahren bei Hypoxie/Apnoe bewertet, dass trotz fehlender wissenschaftlicher Evidenz diesbezüglich eine Grad-AEmpfehlung formuliert wurde ("Pragmatismus-Upgrade", [31]).…”

Section: Apnoe Und Schnappatmungunclassified

“…Im Rahmen des SHT wird eine schwere Bewusstseinsstörung mit einem GCS < 9 als Indikation zur ETI angesehen [4,7,31]. Insbesondere die medikamentengestützte Narkoseeinleitung, adäquate Oxygenierung und Kreislauftherapie reduzieren bei bewusstseinsgetrübten Patienten (GCS 6-8) die Letalität [9,55].…”

Section: Schweres Schädel-hirn-traumaunclassified

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Notfallnarkose, Atemwegsmanagement und Beatmung beim Polytrauma

et al. 2011

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Patients with multiple trauma presenting with apnea or a gasping breathing pattern (respiratory rate <6/min) require prehospital endotracheal intubation (ETI) and ventilation. Additional indications are hypoxia (S(p)O(2)<90% despite oxygen insufflation and after exclusion of tension pneumothorax), severe traumatic brain injury [Glasgow Coma Scale (GCS)<9], trauma-associated hemodynamic instability [systolic blood pressure (SBP)<90 mmHg] and severe chest trauma with respiratory insufficiency (respiratory rate >29/min). The induction of anesthesia after preoxygenation is conducted as rapid sequence induction (analgesic, hypnotic drug, neuromuscular blocking agent). With the availability of ketamine as a viable alternative, the use of etomidate is not encouraged due to its side effects on adrenal function. An electrocardiogram (ECG), blood pressure measurement and pulse oximetry are needed to monitor the emergency anesthesia and the secured airway. Capnography is absolutely mandatory to confirm correct placement of the endotracheal tube and to monitor tube dislocations as well as ventilation and oxygenation in the prehospital and hospital setting. Because airway management is often complicated in trauma patients, alternative devices and a fiber-optic endoscope need to be available within the hospital. Use of these alternative measures for airway management and ventilation should be considered at the latest after a maximum of three unsuccessful intubation attempts. Emergency medical service (EMS) physicians should to be trained in emergency anesthesia, ETI and alternative methods of airway management on a regular basis. Within hospitals ETI, emergency anesthesia and ventilation are to be conducted by trained and experienced anesthesiologists. When a difficult airway or induction of anesthesia is expected, endotracheal intubation should be supervised or conducted by an anesthesiologist. Normoventilation should be the goal of mechanical ventilation. After arrival in the resuscitation room the ventilation will be controlled and guided with the help of arterial blood gas analyses. After temporary removal of a cervical collar, the cervical spine needs to be immobilized by means of manual in-line stabilization when securing the airway.

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Guidelines for Emergency Tracheal Intubation Immediately after Traumatic Injury

Cited by 146 publications

References 237 publications

Prehospital Heart Rate and Blood Pressure Increase the Positive Predictive Value of the Glasgow Coma Scale for High-Mortality Traumatic Brain Injury

Prehospital Heart Rate and Blood Pressure Increase the Positive Predictive Value of the Glasgow Coma Scale for High-Mortality Traumatic Brain Injury

Notfallnarkose, Atemwegsmanagement und Beatmung beim Polytrauma

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