title: The use of neuromuscular blocking agents to facilitate prehospital intubation does not impair outcome after traumatic brain injury.
abstract: BACKGROUND
  Several studies have demonstrated that the success rate of prehospital intubation is improved by the use of neuromuscular blocking agents (NMBAs). However, a recent study has reported that prehospital intubation with NMBAs worsens outcome after traumatic brain injury (TBI). We sought to determine the effect of the use of NMBAs to facilitate prehospital intubation on outcome after TBI.
  
  
  METHODS
  All patients admitted to our Level I trauma center with a head Abbreviated Injury Scale score >/= 3 were identified by the trauma registry (January 1998-June 2003). Patient records were matched with prehospital databases. Patients were further stratified on the basis of prehospital Glasgow Coma Scale (GCS) score into mild (GCS score of 14/15), moderate (GCS score of 9-13), and severe (GCS score < 9) TBI. Outcome included mortality and good outcome (survival to discharge with a GCS score of 14/15).
  
  
  RESULTS
  There were 3,052 patients who were identified as having been transported directly from the field. Complete prehospital data were available for 2,012 patients (66%). Of these, 920 were mild TBI (intubation rate, 17.4%), 293 moderate TBI (intubation rate, 57.7%), and 799 severe TBI (intubation rate, 95%). Overall, 72% of intubated patients received NMBAs. There were no significant differences in demographics or injury severity between the groups. Patients not receiving NMBAs were more likely to be hypotensive and have prehospital cardiopulmonary resuscitation (p = 0.001). The unadjusted mortality for the patients intubated with NMBAs was 25% versus 37% for those not receiving NMBAs (p < 0.001). When adjusted for confounding variables, patients intubated with NMBAs were more likely to survive (odds ratio, 0.63; 95% confidence interval, 0.41-0.97; p = 0.04) and have a good outcome (odds ratio, 1.7; 95% confidence interval, 1.2-2.6; p = 0.006) than those in the no-NMBA group.
  
  
  CONCLUSIONS
  The use of NMBAs to facilitate prehospital intubation improves outcome for patients with TBI. The value of prehospital intubation for TBI remains to be determined; however, any trial evaluating nonintubation for TBI must be compared with NMBA-facilitated intubation to be valid.
authors.affiliation: Departments of Surgery, University of Washington, Harborview Medical Center, Seattle, Washington, USA. ebulger@u.washington.edu
authors.forename: Eileen M
authors.initials: EM
authors.lastname: Bulger
authors.forename: Michael K
authors.initials: MK
authors.lastname: Copass
authors.forename: Daniel R
authors.initials: DR
authors.lastname: Sabath
authors.forename: Ronald V
authors.initials: RV
authors.lastname: Maier
authors.forename: Gregory J
authors.initials: GJ
authors.lastname: Jurkovich
mesh_terms: D015998:Abbreviated Injury Scale; D000328:Adult; D001930:Brain Injuries / Q000628:therapy*; D004632:Emergency Medical Services; D005260:Female; D006801:Humans; D007442:Intubation, Intratracheal; D008297:Male; D008875:Middle Aged; D009466:Neuromuscular Blocking Agents / Q000627:therapeutic use*; D017063:Outcome Assessment, Health Care
chemical_list: D009466:Neuromuscular Blocking Agents