Aggressive out-of-hospital treatment regimen for severe closed head injury in patients undergoing air medical transport

doi:10.1016/S1067-991X(98)90102-X

Air Medical Journal

Volume 17, Issue 3, July–September 1998, Pages 94-100

https://doi.org/10.1016/S1067-991X(98)90102-X Get rights and content

Abstract

The impact of aggressive out-of-hospital management on disposition for 1286 patients with closed head injuries in ground advanced life support (ALS) and helicopter services was evaluated over 60 months in San Diego County. The case group included 196 air medical patients with, a scene Glascow coma scale (GCS) < 9 who were treated according to a standard head injury protocol. The frequency matched control group included 1090 ground ALS patients receiving airway management with hyperventilation but neither induction agents nor mannitol. The trauma registry provided admission and discharge dates, neurosurgical interventions, and disposition. Patient age, scene GCS, head and neck abbreviated injury scale (HNAIS), and injury severity score (ISS) served to stratify study groups.

Case-control distribution of mortality was compared with the two-tailed Mantel-Haenszel weighted odds ratio (OR) and chi-squared test; significance at P ≤ 0.05. The case group displayed an 11% decreased mortality (P < 0.01), remaining significant after adjusting for age (P = 0.05) and scene GCS (P = 0.06). The case group displayed 10% (P < 0.01) greater survivor discharges to rehabilitation and 6% (P < 0.05) fewer discharges to extended care facilities.

This study's data indicate a strong possibility for improved patient morbidity and mortality in severe closed head injuries treated with an aggressive treatment protocol and rapid air medical transport.

References (18)

C Borel et al.
Intensive management of severe head injury
Chest
(1990)
WG Baxt et al.
Hospital-based rotorcraft aeromedical emergency care services and trauma mortality: a multicenter study
Ann Emerg Med
(1985)
DM Sosin et al.
Head injury associated deaths in the United States from 1979 to 1986
JAMA
(1989)
B Jennett et al.
Preventable mortality and morbidity after head injury
Injury
(1978)
DP Becker et al.
Textbook of head injury
(1989)
AT Walder et al.
The abbreviated injury scale as a predictor of outcome of severe head injury
Intensive Care Med
(1995)
HA Kahn et al.
Statistical methods in epidemiology
(1989)
JD Miller et al.
Further experiences in the management of severe head injury
J Neurosurg
(1981)

There are more references available in the full text version of this article.

Cited by (17)

Anesthesiology in Times of Physical Disasters—Earthquakes and Typhoons
2021, Anesthesiology Clinics
Citation Excerpt :
Several studies have shown prehospital tracheal intubation of severely injured patients to be potentially unsafe if delivered without appropriate drugs, monitoring, equipment, training, and clinical guidance.11–14 Utilizing anesthesiologists in prehospital care can lead to a survival benefit.15–19 Traumatic injuries frequently require surgical intervention, and intraoperative anesthetic technique is important to optimize patient outcomes.
Development of trauma systems and effect on outcomes after injury
2004, Lancet
Citation Excerpt :
However, paramedics are not permitted to administer paralytic agents in many emergency medical service (EMS) regions across the USA. As a result, there is a tendency for only those patients who are in extremis or comatose to be intubated, thus producing a significant bias against the intervention.20–22 By contrast, there appears to be a survival advantage to prehospital intubation in patients with head injury receiving care in environments where paralytic agents can be administered.20
The ideal system for management of trauma remains controversial, especially in respect of prehospital care and regionalisation of trauma-care delivery. To explore these issues, we compare two differing trauma systems—in the USA the focus is on the trauma centre, with a lesser emphasis on prehospital care, whereas in France there is more emphasis on prehospital care coordinated by the Service d'Aide Médicale Urgente. We describe the historical developments, current structure, and major controversies with regard to trauma-care delivery in the two countries. Comparative evidence on the effectiveness of the two systems was obtained through a structured review of databases, but very little evidence permits direct comparison of outcomes across the two systems. Crude injury mortality rates and fatality rates from motor-vehicle accidents (crashes in US usage) are higher in France than in the USA, although adjustment for potential confounders is difficult. Adjusted mortality rates suggest equivalent outcomes among patients who survive to hospital, although these data are confounded by the lack of a contemporaneous comparator population. There are differences in the American and French trauma systems that might translate into measurable differences in trauma-related mortality. However, the lack of data to allow comparison of outcomes between countries significantly impedes the identification and implementation of components of a trauma system that are effective and the discarding of those that offer little benefit.
Level of prehospital care and risk of mortality in patients with and without severe blunt head injury
2003, Injury
Objectives: To determine the association between mortality and the level of prehospital care in severely injured blunt trauma patients with or without severe head injury.
Method: Retrospective review of 2010 severe blunt trauma patients (injury severity score (ISS) >15) with or without severe head injury in a tiered trauma system involving ambulance officers (basic life support (BLS) and advanced life support (ALS)) and physicians, and a Level 1 trauma centre.
Results: After adjusting for age, type of head injury, glasgow coma scale score (GCS), systolic blood pressure, ISS and prehospital time, intensive care unit (ICU) admission modified the association between level of prehospital care and mortality. In those patients without ICU admission, patients in the paramedic and physician-staffed emergency services group were more likely to die than patients in the BLS ambulance group (odds ratio (OR) 2.18, 95% confidence intervals (CI): 1.05–4.55; 4.27, 95% CI: 1.46–12.45, respectively). Among patients who survived to ICU treatment, however, there was no association between level of prehospital care and risk of mortality. Presence or absence of a head injury did not modify the risk of mortality.
Conclusions: The level of prehospital care was associated with the risk of mortality. This was modified by whether the patient survived long enough to be admitted to the ICU.
Efficacy of pre-hospital interventions for the management of severe blunt head injury
2002, Injury
Efficacy of prehospital critical care teams for severe blunt head injury in the Australian setting
2001, Injury
Objective: To determine whether prehospital critical care teams (CCT) would result in improved functional outcomes for road trauma related severe head injury in the Australian setting, when compared with standard advanced life support measures provided by paramedics.
Methods: Retrospective review of 250 patients treated by paramedics and 46 patients treated by CCT transported directly from the accident scene, with a prehospital Glasgow coma scale (GCS)≤8.
Results: CCT-treated patients had longer median prehospital times (113 versus 45 min, P<0.001), and a higher prehospital intubation rate (100% versus 36%, P<0.001) than paramedic-treated patients. On multivariate analysis, revised trauma score≥4.45 (odds ratio [OR] 2.31, 95% CI: 1.15–4.65), lower injury severity score (OR 1.04, 95% CI: 1.02–1.06), age≤25 years (OR 1.76, 95% CI: 1.13–2.75), absence of an acute subdural haematoma (OR 3.36, 95% CI: 1.89–5.95) and prehospital treatment by a CCT (OR 2.70, 95% CI: 1.48–4.95) independently predicted better outcome.
Conclusion: The range of advanced interventions provided by the CCT were associated with improved functional outcome. Further studies are required to determine the individual factors responsible.
Primary aeromedical retrieval crew composition: Do different teams impact clinical outcomes? A descriptive systematic review
2020, Canadian Journal of Emergency Medicine

View all citing articles on Scopus

View full text

Original researchAggressive out-of-hospital treatment regimen for severe closed head injury in patients undergoing air medical transport

Abstract

Chest

Ann Emerg Med

Head injury associated deaths in the United States from 1979 to 1986

JAMA

Preventable mortality and morbidity after head injury

Injury

Textbook of head injury

The abbreviated injury scale as a predictor of outcome of severe head injury

Intensive Care Med

Statistical methods in epidemiology

Further experiences in the management of severe head injury

J Neurosurg

Original research
Aggressive out-of-hospital treatment regimen for severe closed head injury in patients undergoing air medical transport