Emergency medicine researchers at the University of Pittsburgh School of Medicine have found that patients with similar traumatic brain injuries who receive an emergency breathing tube at the scene of an accident fare worse than those intubated after arrival to the hospital. The researchers also found that these patients’ neurologic and functional outcome was nearly twice as bad.
From University of Pittsburgh :
Patients who are intubated prior to hospital arrival fare worse find Pitt researchers
Emergency medicine researchers at the University of Pittsburgh School of Medicine have found that patients with similar traumatic brain injuries who receive an emergency breathing tube at the scene of an accident fare worse than those intubated after arrival to the hospital. The researchers also found that these patients’ neurologic and functional outcome was nearly twice as bad. These findings are reported in the lead article in the November issue of Annals of Emergency Medicine.
Endotracheal intubation is an emergency medical procedure whereby trained medical personnel place a flexible, clear, plastic breathing tube down into the trachea to help air pass freely to and from the lungs. Often patients with traumatic brain injury need help to breathe to prevent further injury.
While out-of-hospital intubation is a valuable interventional tool in helping to save patients’ lives, earlier studies had suggested that this rapid intervention may be more harmful than helpful.
The Pitt researchers conducted a retrospective analysis using data obtained from the Pennsylvania Trauma Outcome Study between 2000 and 2002 and studied adult patients with severe head injuries. The primary outcome for most of these patients was death, with secondary outcomes being various types of neurologic and functional impairment. Among the 4,098 patients who were intubated, odds of death were about four times greater if they were intubated out of the hospital. Neurologic and overall functional impairment was also greater.
”These findings present important challenges to the emergency medicine profession and EMS communities,” stated Donald M. Yealy, M.D., professor and vice chairman of the department of emergency medicine at the University of Pittsburgh School of Medicine and one of the study authors. ”Paramedics, while very well trained, don’t often have opportunity to perform this procedure, and must attempt it in a difficult environment and without many of the aids available in the hospital. Perhaps these findings indicate that we need to reassess how we manage these cases,” he added.
The researchers note that additional studies are needed to determine if out-of-hospital intubation is the optimal treatment for patients with severe head injury and to determine the root cause of why patients who receive out-of-hospital intubation fare worse than those who receive intubation at the hospital.
Collaborating with lead authors Henry Wang, M.D., M.P.H., and Dr. Yealy were Andrew B. Peitzman, M.D.; P. David Adelson, M.D.; and Laura D. Cassidy, Ph.D.; all from Pitt.
From reading this article, it is easy to assume that intubation in the field is harmful to patients. It is not made clear in this article that this research DOES NOT make or prove that claim. There are two specific points which are not addressed and are extremely important to the future use of this article in policy-making.
1. There is no mention of how severely injured those patients needing field intubation are compared to those who do not need intubation until hospital arrival. If a person is not breathing or protecting their airway immediately after an accident they are likely more severely injured than those who are able to do so for a time. Needless to say, those people who are more severly injured are going to have worse outcomes, but it doesn’t follow that a paramedic caused their poor outcome. Without addressing that, the data are relatively meaningless for policy purposes.
2. This is a retrospective study, which means it is based on past records, many of which are notoriously unreliable. Having a full record of what actually happens during a trauma resuscitation is nearly impossible without several simultaneous video cameras. Although there may be truth in the assumption that field intubation is harmful, until a randomized controlled study is performed and equally injured patients who are intubated do worse than those who are not will it is unlikely to change our care. Until then, we have no definitive evidence that we wouldn’t be harming people more by allowing them to aspirate and hypoventilate during their ride to the hospital.