Prehospital Airway Management in Head Injury—Friend or Foe?
Abstract & Commentary
Source: Murray JA. Prehospital intubation in patients with severe head injury. J Trauma 2000;49:1065-1070.
The authors of this retrospective, registry-based review of 13 Los Angeles trauma centers assessed the outcome of patients with severe head injury to determine whether prehospital intubation was associated with an improved outcome. The Los Angeles County Department of Health Services Trauma Registry was used to identify all patients with a Glasgow Coma Scale (GCS) score of 8 or less over a three-year period. Multiple demographic variables were included in the analysis. Patients were stratified into three groups by type of airway management: intubated; attempted intubation, unsuccessful; and non-intubated. Mortality was determined for each group.
A total of 894 patients met the criteria; 714 (84%) were in the non-intubated group, 81 (10%) were in the intubated group, and 57 (6%) were in the unsuccessfully intubated group. Patients requiring prehospital intubation or in whom intubation was attempted had an increased mortality (81% and 77%, respectively) compared with non-intubated patients (43%). The mortality for patients who had prehospital intubation performed did not demonstrate an improved survival using a matched cohort of patients. The authors concluded that prehospital intubation did not demonstrate an improvement in survival, and recommended "further prospective randomized trials."
Comment by Michael A. Gibbs, MD, FACEP
While at first glance these results may call into question the proven benefit of early airway control and optimized oxygenation in severe head injury,1 a closer, more critical look is revealing. First, the three treatment groups were dissimilar. The injury severity score, GCS score, and maximal oxygen intake were significantly less severe in the non-intubated group. Using a "matched" group unfortunately does not overcome this fundamental difference, and comparing the outcome of these very different groups of patients is hazardous. Second, other than "being trained in oral endotracheal intubation," there is no information on the training and skill of the paramedics providing care. The 61% overall success rate for intubation is telling. Third, intubation was performed without the aid of neuromuscular blockade. While this is the reality of most prehospital systems, there are abundant data demonstrating the poor success rate of this mode of airway control, and theoretical data suggesting that this technique may worsen outcome in head injury. Fourth, there were no data describing the number of intubation attempts, the reason for failed endotracheal intubation, or the incidence of airway-related complications.
Despite the best effort of the authors, the data do not answer the research question put forth. In fact, all that can be said about the results of this study is that patients with "really bad" head injuries die more often than do patients with injuries that are not as severe. Period.
References
1. Chesnut RM, et al. The role of secondary brain injury in determining outcome from severe head injury. J Trauma 1993;34:216-222.
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