Air medical transport of severely head-injured patients undergoing paramedic rapid sequence intubation

Abstract

Introduction The San Diego Paramedic Rapid Sequence Intubation (RSI) Trial documented an increase in mortality with paramedic RSI of patients with severe traumatic brain injury. This analysis explores the impact of air medical transport of trial patients on outcome. Methods Adult trauma victims with severe traumatic brain injury (Glasgow Coma Scale score of 3 to 8) were prospectively enrolled. Paramedics performed RSI using midazolam and succinylcholine; air medical crews could be called at the discretion of ground paramedics, generally for anticipated prolonged transports. Patients were matched to historical controls using the following parameters: age, gender, mechanism, injury of severity score, and abbreviated injury scale scores for each body system. Patients transported by air and ground were compared with regard to demographics, clinical parameters, vital signs, arterial blood gas data, and outcome. Results A total of 336 patients were included (79 air medical and 257 ground transports). No significant differences arose between the groups with regard to demographic, clinical, vital sign, and arterial blood gas data. Air medical patients had decreased mortality (28% vs 31%, OR 0.9), and ground patients had increased mortality versus matched controls (33% vs 22%, OR 1.8). Discordant groups analysis revealed a statistically significant effect of transport personnel on outcome ( P= .009). Neither advanced procedures nor the use of mannitol accounted for the improved outcomes; air medical crews used capnometry to guide ventilation on all study patients. Conclusion Air medical transport of severely head-injured patients undergoing paramedic RSI was associated with improved outcomes. Improved ventilation by capnometry may account for part of these improvements.