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Abstract
A short cut review was carried out to establish whether prehospital intubation was of benefit to patients with moderate to severe head injury. 4630 papers were found using the reported searches, of which 9 presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated. It is concluded that prehospital intubation is associated with increased mortality in these patients.
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Report by Ayan Sen, Senior House Officer, Critical Care Search checked by Raj Nichani, Specialist Registrar, Anaesthesia and Critical Care Manchester Royal Infirmary, Manchester, UK
Clinical scenario
A 41 year old car driver was involved in a major road traffic accident, sustaining injuries to his head, a fracture of his right femur and multiple bruises on his chest. On scene he had altered sensorium and his GCS was estimated to be 5. He was intubated by the paramedics and brought to the Emergency Department. You wonder about the evidence in favour of endotracheal intubation as compared to bag and mask ventilation in trauma patients.
Three part question
In [patients with major trauma and head injury needing airway management in prehospital setting] is [endotracheal intubation better than bag and mask ventilation] for [improved outcomes]
Search strategies
Medline 1966-Week 4 August 2005 using the OVID interface, {Cochrane Prehospital Search filter} AND {exp Intubation, Intratracheal/ or endotracheal intubation.mp. OR ETI.mp. OR RSI.mp OR rapid sequence intubation.mp}, Embase 1980-2005 week 37, [exp Emergency Health Service/ OR exp Rescue Personnel/ OR exp Emergency Treatment/ OR exp Emergency Medicine/ OR exp Ambulance/ OR exp First Aid/ OR exp Military Medicine/] AND [intratracheal intubation.mp. OR exp Endotracheal Intubation/ OR ETI.mp. OR RSI.mp. OR rapid sequence intubation.mp. OR rapid sequence induction.mp.] LIMIT to Human, English Language, Abstracts, (adult <18 to 64 years> or aged <65+ years>) and Clinical Queries Prognosis filter – sensitive, The Cochrane Library Issue 3 2005, exp intubation, intratracheal [MeSH] AND exp Emergency Medical Services [ MeSH]
Search outcome
4360 papers found, of which nine were relevant and of sufficient quality for inclusion. These are summarised in the table:
Comments
Quite a few studies have been conducted to address the question of prehospital endotracheal intubation in major trauma victims needing airway management. All of them are of retrospective design and most of them show that there is increased mortality, longer transit times with prehospital endotracheal intubation. The reasons could be difficulty in ascertaining tube position, paramedic experience, hyperventilation, transient hypoxia, or lack of sufficient pre-oxygenation prior to RSI. Prospective multi-centre randomised trials are needed to avoid the inherent problems associated with the study designs.
CLINICAL BOTTOM LINE
Prehospital endotracheal intubation is associated with increased mortality in patients with moderate to severe traumatic brain injury
Report by Ayan Sen, Senior House Officer, Critical Care Search checked by Raj Nichani, Specialist Registrar, Anaesthesia and Critical Care Manchester Royal Infirmary, Manchester, UK