1. #1
    Join Date
    Jun 2004

    Default A positive study re: prehospital RSI?

    J Trauma. 2005 Apr;58(4):718-23
    The use of neuromuscular blocking agents to facilitate prehospital intubation does not impair outcome after traumatic brain injury.

    Bulger EM, Copass MK, Sabath DR, Maier RV, Jurkovich GJ.

    Departments of Surgery, University of Washington, Harborview Medical Center, Seattle, Washington, USA. ebulger@u.washington.edu

    BACKGROUND: Several studies have demonstrated that the success rate of prehospital intubation is improved by the use of neuromuscular blocking agents (NMBAs). However, a recent study has reported that prehospital intubation with NMBAs worsens outcome after traumatic brain injury (TBI). We sought to determine the effect of the use of NMBAs to facilitate prehospital intubation on outcome after TBI. METHODS: All patients admitted to our Level I trauma center with a head Abbreviated Injury Scale score >/= 3 were identified by the trauma registry (January 1998-June 2003). Patient records were matched with prehospital databases. Patients were further stratified on the basis of prehospital Glasgow Coma Scale (GCS) score into mild (GCS score of 14/15), moderate (GCS score of 9-13), and severe (GCS score < 9) TBI. Outcome included mortality and good outcome (survival to discharge with a GCS score of 14/15). RESULTS: There were 3,052 patients who were identified as having been transported directly from the field. Complete prehospital data were available for 2,012 patients (66%). Of these, 920 were mild TBI (intubation rate, 17.4%), 293 moderate TBI (intubation rate, 57.7%), and 799 severe TBI (intubation rate, 95%). Overall, 72% of intubated patients received NMBAs. There were no significant differences in demographics or injury severity between the groups. Patients not receiving NMBAs were more likely to be hypotensive and have prehospital cardiopulmonary resuscitation (p = 0.001). The unadjusted mortality for the patients intubated with NMBAs was 25% versus 37% for those not receiving NMBAs (p < 0.001). When adjusted for confounding variables, patients intubated with NMBAs were more likely to survive (odds ratio, 0.63; 95% confidence interval, 0.41-0.97; p = 0.04) and have a good outcome (odds ratio, 1.7; 95% confidence interval, 1.2-2.6; p = 0.006) than those in the no-NMBA group. CONCLUSION: The use of NMBAs to facilitate prehospital intubation improves outcome for patients with TBI. The value of prehospital intubation for TBI remains to be determined; however, any trial evaluating nonintubation for TBI must be compared with NMBA-facilitated intubation to be valid.


    Mittlesmertz - your comments? (I assume this was an analysis of patients which your service treated prehospital)

  2. #2
    Join Date
    Apr 2004


    This is not a new study and was conducted, if you read between the lines, to contraindicate the study done in San Diego that showed negative results.

    The differences in how the studies were conducted is the reason for the difference in results.

    1. The medics performing the RSIs were already trained and very proficient to begin with. Some of these medics are geting around 40 tubes per year (Mittle, correct me if I am mistaken) so the chances are much better of getting the first attempt with very little difficulty and in a very short time frame, keeping complications to a minnimum.

    2. There were no limitations on GCS. Like Mittle has stated in another thread for their requirements for RSI: If they need an airway they get one. If a patient has a GCS of 15 and is suspected of having a closed head injuty, or there is either a airway problem, or one is expected to develop, RSI is indicated. So the positive outcomes were apparent in the GCS of 9-13 range. A survivable range where a patient has a good chance of recovering.

  3. #3
    Join Date
    Jul 2005


    -Montet- yes your numbers are about right- some more, some less.
    -Scotttttt- This is the type of study most EMT-Ps would expect to see, based on our own experiences. Providing a patent airway for a pt with a decreased/altered LOC is a good idea. I agree it sounds like they were taking a rather thinly-veiled shot at San Diego. I have heard that Dr Copass has a rather abrupt demeanor...
    -I think a better measure would be a comparison of outcomes between pts receiving ET vs OPA vs Combitube/LMA. Using a standardized ISS, I would find it very interesting to see if there was any difference in overall outcome.
    -Finally, when you think of your altered pts, I can remember many scenes that became alot more calm the second I pushed the succ. All the yelling/crying/screamin is gone, replaced by the calm voices of the providers caring for the pt. Perhaps this is an understudied benefit of RSI...

  4. #4
    Join Date
    Mar 2002


    With all the controversy surrounding prehospital RSI, many questions have been raised. There is one factor that I have not seen addressed that I feel is key in RSI. This may seem too simple, but has anyone studied the actual ventilation that the patients receive, ie overventilation blowing off CO2 resulting in vasoconstriction and decreased cerebral perfusion?
    We few, we happy few, we band of brothers.--W Shakespeare

    ***The opinions and beliefs expressed above are mine and mine alone based on my education, training, and personal experiences. In no way do they reflect those of my employer(s), their affiliates, or any professional organiztaions that I belong to.***

  5. #5
    Join Date
    Jun 2004


    There was, recently, a study published examining EtCO2 concentration upon ED arrival and coorelating EtCO2 w/ patient outcome. If I remember correctly, the patients with EtCo2 between 25 & 50 torr had the most favorable outcomes. I think the the 35-40 was found to be the most optimal.

    I don't have time right now to find the abstract, I'll post it later.

  6. #6
    Join Date
    Jun 2004


    Ok, I found time. Note: This study was performed in San Diego, CA.

    Early ventilation and outcome in patients with moderate to severe
    traumatic brain injury*
    Daniel P. Davis, MD; Ahamed H. Idris, MD; Michael J. Sise, MD; Frank Kennedy, MD;
    A. Brent Eastman, MD; Thomas Velky, MD; Gary M. Vilke, MD; David B. Hoyt, MD

    Objectives: An increase in mortality has been reported with
    early intubation in severe traumatic brain injury, possibly due to
    suboptimal ventilation. This analysis explores the impact of early
    ventilation on outcome in moderate to severe traumatic brain

    Design: Retrospective, registry-based analysis.

    Setting: This study was conducted in a large county trauma
    system that includes urban, suburban, and rural jurisdictions.
    Patients: Nonarrest trauma victims with a Head Abbreviated
    Injury Score of >3 were identified from our county trauma registry.
    Interventions: Intubated patients were stratified into 5 mm Hg
    arrival PCO2 increments. Logistic regression was used to calculate
    odds ratios for each increment, adjusting for age, gender, mechanism
    of injury, year of injury, preadmission Glasgow Coma Scale
    score, hypotension, Head Abbreviated Injury Score, Injury Severity
    Score, PO2, and base deficit. Increments with the highest relative
    survival were used to define the optimal PCO2 range. Outcomes for
    patients with arrival PCO2 values inside and outside this optimal
    range were then explored for both intubated and nonintubated
    patients, adjusting for the same factors as defined previously. In
    addition, the independent outcome effect of hyperventilation and
    hypoventilation was assessed.

    Measurements and Main Results: A total of 890 intubated and
    2,914 nonintubated patients were included. Improved survival
    was observed for the arrival PCO2 range 3049 mm Hg. Patients
    with arrival PCO2 values inside this optimal range had improved
    survival and a higher incidence of good outcomes. Conversely,
    there was no improvement in outcomes for patients within this
    optimal PCO2 range for nonintubated patients after adjusting for all
    of the factors defined previously. Both hyperventilation and hypoventilation
    were associated with worse outcomes in intubated
    but not nonintubated patients. The proportion of arrival PCO2
    values within the optimal range was lower for intubated vs.
    nonintubated patients.

    Conclusions: Arrival hypercapnia and hypocapnia are common
    and associated with worse outcomes in intubated but not spontaneously
    breathing patients with traumatic brain injury. (Crit
    Care Med 2006; 34:12021208)

    KEY WORDS: traumatic brain injury; ventilation; intubation; resuscitation;
    head trauma; hyperventilation

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