Postponing intubation in spontaneously breathing major trauma patients upon emergency room admission does not impair outcome

Philipp Schwaiger,Helmut Trimmel,Wolfgang G Voelckel,Herbert Schöchl,Daniel Oberladstätter

doi:10.1186/s13049-019-0656-9

Abstract

BackgroundPre-hospital emergency anaesthesia and tracheal intubation are life-saving interventions in trauma patients. However, there is evidence suggesting that the risks associated with both procedures outweigh the benefits. Thus, we assessed whether induction of anaesthesia and tracheal intubation of trauma patients can be postponed in spontaneously breathing patients until emergency room (ER) admission without increasing mortality.MethodsRetrospective analysis of major trauma patients either intubated on-scene by an emergency medical service (EMS) physician (pre-hospital intubation, PHI) or within the first 10 min after admission at a level 1 trauma centre (emergency room intubation, ERI). Data was extracted from the German Trauma Registry, hospital patient data management and electronic clinical information system.ResultsFrom a total of 946 major trauma cases documented between 2010 and 2017, 294 patients matched the study inclusion criteria. Mortality rate of PHI (N = 258) vs. ERI (N = 36) patients was 26.4% vs. 16.7% (p = 0.3). After exclusion of patients with severe traumatic brain injury and/or pre-hospital cardiac arrest, mortality rate of PHI (N = 100) vs. ERI patients (N = 29) was 6% vs. 17.2%, (p = 0.07). Median on-scene time was significantly (p < 0.01) longer in PHI (30 min; IQR: 21–40) vs. ERI patients (20 min; IQR: 15–28).ConclusionsThere was no statistical difference in mortality rates of spontaneously breathing trauma patients intubated on-scene when compared with patients intubated immediately after hospital admission. Due to the retrospective study design and small case number, further studies evaluating the impact of airway management timing in sufficiently breathing trauma patients are warranted.

Highlights

Pre-hospital emergency anaesthesia and tracheal intubation are life-saving interventions in trauma patients
Outcome and clinical data for all Pre-Hospital Intubation (PHI) and ETI patients 30-day mortality for the PHI group was 26.4% vs. 16.7% in the emergency room period (ERI) group (p = 0.3)
Median RISC2 score, indicative for mortality, was significantly higher in the PHI group when compared with ERI patients (15.5 (4.2–71.1) % vs. 6.3 (1.2–23.7) %; p = 0.001)

Summary

Introduction

Pre-hospital emergency anaesthesia and tracheal intubation are life-saving interventions in trauma patients. We assessed whether induction of anaesthesia and tracheal intubation of trauma patients can be postponed in spontaneously breathing patients until emergency room (ER) admission without increasing mortality. Emergency physicians must carefully outweigh the risk-benefit ratio of emergency anaesthesia and intubation, and deliberately decide whether airway management should be provided as early as possible in the pre-hospital phase, or postponed until hospital admission. Since current data is inconclusive, we sought to assess whether emergency medical personnel could safely refrain from induction of anaesthesia and intubation of critical, yet spontaneously breathing severe trauma patients, with regard to a higher standard of care that is available within the environment of an emergency room. Our null-hypothesis was that survival rates are comparable between both groups

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Discussion

Conclusion