Abstract & Commentary
Commentary by Michael Gibbs, MD, FACEP, Chief, Department of Emergency Medicine, Maine Medical Center, Portland, ME. Dr. Gibbs is on the Editorial Board of Emergency Medicine Alert.
Source: Bulger EM. The use of neuromuscular blocking agents to facilitate prehospital intubation does not impair outcome after traumatic brain injury. J Trauma 2005; 58:718-724.
This is a retrospective study of consecutive head injury patients admitted to a single Level 1 trauma center. The authors studied the effect of the use of prehospital neuromuscular blocking agents (NMBAs) on outcome. Intubations were performed by ground paramedics and flight personnel with training and experience in rapid sequence intubation (RSI). Patients were stratified by Glasgow Coma Scale (GCS) score into mild (GCS score 14-15), moderate (GCS score 9-13) and severe (GCS score <9) groups.
Of 2,012 patients with complete records, 920 were classified as mild (intubation rate 17.4%), 293 as moderate (intubation rate 57.7%), and 799 as severe (intubation rate 95%). Overall, 72% of patients received NMBAs. The two groups (those receiving NMBAs and those not) had similar demographics and GCS scores, although hypotension was more common in patients intubated without paralysis. Patients receiving neuromuscular blockade were significantly more likely to survive (odds ratio 0.63; 95% CI, 0.4-0.97) and have a good neurologic outcome (odds ratio 1.7; 95% CI, 1.2-2.6). The authors concluded that, while the fund amental “to intubate-or-not-to-intubate” question requires additional scrutiny, the use of prehospital RSI provided a survival advantage when compared with prehospital intubation without NMBAs
Commentary
During the past two decades, the prehospital airway management pendulum has been swinging violently from side to side. Early studies demonstrating an outcome benefit of prehospital RSI prompted widespread adoption of the technique by air-medicine and a growing appetite for it among ground-based programs.1,2 The scene changed completely in 2003, when Davis reported significantly worse outcomes in head injury patients intubated in the field with RSI.3 A follow-up study of the same patient cohort demonstrated a frightening incidence of hypoxemia.4 Finally, a large review of the Pennsylvania trauma database suggested that prehospital intubation was associated with a higher risk of death.5
Despite some design flaws, Bulger’s study is important, and it pushes the pendulum back a bit toward the “RSI-yes” camp. That being said, the only way we will ever answer this vexing question is by conducting a larger prospective randomized trial.
References
1. Baxt WG, et al. The impact of advanced prehospital emergency care on the mortality of severely brain-injured patients. J Trauma 1987;27:365-369.
2. Winchell RJ, et al. Endotracheal intubation in the field improves survival in patients with severe head injury. Arch Surg 1997;132:592-597.
3. Davis DP, et al. The effect of paramedic rapid sequence intubation on outcome in patients with severe traumatic brain injury. J Trauma 2003;54:444-457.
4. Dunford JV, et al. Incidence of transient hypoxia and pulse rate reactivity during paramedic rapid sequence intubation. Ann Emerg Med 2003;42:721-728.
5. Wang HE et al. Out-of-hospital endotracheal intubation and outcome after traumatic brain injury. Ann Emerg Med 2004;44:439-450.
This is a retrospective study of consecutive head injury patients admitted to a single Level 1 trauma center.
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