title: Prehospital airway and ventilation management: a trauma score and injury severity score-based analysis.
abstract: BACKGROUND
  Emergent endotracheal intubation (ETI) is considered the standard of care for patients with severe traumatic brain injury (TBI). However, recent evidence suggests that the procedure may be associated with increased mortality, possibly reflecting inadequate training, suboptimal patient selection, or inappropriate ventilation.
  
  
  OBJECTIVE
  To explore prehospital ETI in patients with severe TBI using a novel application of Trauma Score and Injury Severity Score methodology.
  
  
  METHODS
  Patients with moderate-to-severe TBI (head Abbreviated Injury Scale score 3+) were identified from our county trauma registry. Demographic information, pre-resuscitation vital signs, and injury severity scores were used to calculate a probability of survival for each patient. The relationship between outcome and prehospital ETI, provider type (air vs. ground), and ventilation status were explored using observed survival-predicted survival and the ratio of unexpected survivors/deaths.
  
  
  RESULTS
  A total of 11,000 patients were identified with complete data for this analysis. Observed and predicted survivals were similar for both intubated and nonintubated patients. The ratio of unexpected survivors/deaths increased and observed survival exceeded predicted survival for intubated patients with lower predicted survival values. Both intubated and nonintubated patients transported by air medical crews had better outcomes than those transported by ground. Both hypo- and hypercapnia were associated with worse outcomes in intubated but not in nonintubated patients.
  
  
  CONCLUSIONS
  Prehospital intubation seems to improve outcomes in more critically injured TBI patients. Air medical outcomes are better than predicted for both intubated and nonintubated TBI patients. Iatrogenic hyper- and hypoventilations are associated with worse outcomes.
authors.affiliation: Department of Emergency Medicine, UC San Diego, San Diego, California, USA. davismd@cox.net
authors.forename: Daniel P
authors.initials: DP
authors.lastname: Davis
authors.forename: Jeremy
authors.initials: J
authors.lastname: Peay
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Sise
authors.forename: Frank
authors.initials: F
authors.lastname: Kennedy
authors.forename: Fred
authors.initials: F
authors.lastname: Simon
authors.forename: Gail
authors.initials: G
authors.lastname: Tominaga
authors.forename: John
authors.initials: J
authors.lastname: Steele
authors.forename: Raul
authors.initials: R
authors.lastname: Coimbra
mesh_terms: D015998:Abbreviated Injury Scale; D000328:Adult; D001930:Brain Injuries / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy*; D004632:Emergency Medical Services / Q000379:methods* / Q000639:trends; D005260:Female; D005500:Follow-Up Studies; D015600:Glasgow Coma Scale; D006801:Humans; D015601:Injury Severity Score; D007442:Intubation, Intratracheal / Q000009:adverse effects / Q000379:methods*; D008297:Male; D012042:Registries; D012121:Respiration, Artificial / Q000009:adverse effects / Q000379:methods*; D012189:Retrospective Studies; D018570:Risk Assessment; D016019:Survival Analysis; D016896:Treatment Outcome