Prehospital airway and ventilation management: a trauma score and injury severity score-based analysis.
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.
Davis
Daniel P
DP
Department of Emergency Medicine, UC San Diego, San Diego, California, USA. davismd@cox.net
Peay
Jeremy
J
Sise
Michael J
MJ
Kennedy
Frank
F
Simon
Fred
F
Tominaga
Gail
G
Steele
John
J
Coimbra
Raul
R
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