Prehospital definitive airway is not associated with improved survival in trauma patients

Abstract

BACKGROUND The American College of Surgeons and the National Association of Emergency Medical Technicians advise securing a definitive airway if there is any doubt about the trauma patient's ability to maintain airway integrity. The objective of this study was to investigate the association between a success in securing a definitive airway in the prehospital setting and survival among trauma patients, in which the provider deemed a definitive airway was necessary. METHODS The study included all trauma patients recorded in the Israel Defense Forces Trauma Registry between the years 2006 and 2018 for whom a prehospital attempt of securing a definitive airway was documented. The successful definitive airway group was defined by explicit documentation of success in either endotracheal intubation or cricothyrotomy. Logistic regression was performed to determine the association between success in securing a definitive airway and survival. RESULTS A total of 566 (3.6%) trauma patients underwent attempts to secure a definitive airway (successful in 425 patients and unsuccessful in 141). Prehospital survival rates were similar (77.6% vs. 78.0%, p = 0.928) between the groups. Whether the definitive airway was successful did not affect the rates of prehospital survival, neither before (odds ratio, 0.98; 95% confidence interval, 0.61–1.54) nor after adjustment for the other factors (odds ratio, 0.91; 95% confidence interval, 0.55–1.46). CONCLUSION This study was unable to find an association between a successful definitive airway in the prehospital setting and survival, even after adjustment for injury characteristics and in multiple models. Furthermore, survival rates were high among trauma patients in which the provider deemed a definitive airway as necessary yet failed in securing one. These results suggest that the liberal use of these invasive airway procedures in the prehospital setting should be reconsidered. LEVEL OF EVIDENCE Retrospective study, lebel III.

Prehospital advanced airway management of emergency medical service‐witnessed traumatic out‐of‐hospital cardiac arrest patients: analysis of nationwide trauma registry

“… 2 , 13 , 18 Tsur et al . 19 showed prehospital definitive airway did not benefit the improvement of survival. However, the survival rates in their series were 77.6% for secured airway patients and 78.0% for failed definitive airway patients.…”

“…We are aware of several studies showing that prehospital AAM is not beneficial for improving mortality in trauma patients. 2,13,18 Tsur et al 19 showed prehospital definitive airway did not benefit the improvement of survival. However, the survival rates in their series were 77.6% for secured airway patients and 78.0% for failed definitive airway patients.…”

“…We are aware of several studies showing that prehospital AAM is not beneficial for improving mortality in trauma patients 2,13,18 . Tsur et al 19 . showed prehospital definitive airway did not benefit the improvement of survival.…”

Trends in combat casualty care following the publication of clinical practice guidelines

“…There is evidence to suggest the benefit of indicated intubations in the hospital scenario 26 . However, multiple studies suggest that the detrimental effect of intubation and positive pressure ventilation on the outcome of patients suffering from hemorrhagic shock 22,23 has led many to call for a much more conservative approach toward advanced airway management in the prehospital settings 24,38 . This is especially true when considering the predominance of hemorrhage in preventable death etiologies.…”

Endotracheal intubation in trauma patients with isolated shock: universally recommended but rarely performed

“…However, a prolonged pre-hospital resuscitation time is associated with increased all-cause mortality [ 11 ]. Even though emergency medical service considered ETI necessary but failed in securing one, there were still good survival rates [ 12 ].…”