Top

European Journal of Trauma and Emergency Surgery

Published in:

Open Access 12-05-2022 | Shock | Original Article

Endotracheal intubation in trauma patients with isolated shock: universally recommended but rarely performed

Authors: Timo Stausberg, Tobias Ahnert, Ben Thouet, Rolf Lefering, Andreas Böhmer, Thomas Brockamp, Arasch Wafaisade, Matthias Fröhlich, the TraumaRegister DGU

Published in: European Journal of Trauma and Emergency Surgery | Issue 6/2022

Abstract

Purpose

The indication for pre-hospital endotracheal intubation (ETI) must be well considered as it is associated with several risks and complications. The current guidelines recommend, among other things, ETI in case of shock (systolic blood pressure < 90 mmHg). This study aims to investigate whether isolated hypotension without loss of consciousness is a useful criterion for ETI.

Methods

The data of 37,369 patients taken from the TraumaRegister DGU® were evaluated in a retrospective study with regard to pre-hospital ETI and the underlying indications. Inclusion criteria were the presence of any relevant injuries (Abbreviated Injury Scale [AIS] ≥ 3) and complete pre-hospital management information.

Results

In our cohort, 29.6% of the patients were intubated. The rate of pre-hospital ETI increased with the number of indications. If only one criterion according to current guidelines was present, ETI was often omitted. In 582 patients with shock as the only indication for pre-hospital ETI, only 114 patients (19.6%) were intubated. Comparing these subgroups, the intervention was associated with longer time on scene (25.3 min vs. 41.6 min; p < 0.001), higher rate of coagulopathy (31.8% vs. 17.2%), an increased mortality (8.2% vs. 11.5%) and higher standard mortality ratio (1.17 vs. 1.35). If another intubation criterion was present in addition to shock, intubation was performed more frequently.

Conclusion

Decision making for pre-hospital intubation in trauma patients is challenging in front of a variety of factors. Despite the presence of a guideline recommendation, ETI is not always executed. Patients presenting with shock as remaining indication and subsequent intubation showed a decreased outcome. Thus, isolated shock does not appear to be an appropriate indication for pre-hospital ETI, but clearly remains an important surrogate of trauma severity and the need for trauma team activation.

Sektion Notfall IUS. Jahresbericht 2020 - TraumaRegister DGU®. 2020, Sektion Notfall- and Intensivmedizin and Schwerverletztenversorgung der Deutschen Gesellschaft für Unfallchirurgie e.V.; AUC - Akademie der Unfallchirurgie GmbH.

Cook TM, MacDougall-Davis SR. Complications and failure of airway management. Br J Anaesth. 2012. https://doi.org/10.1093/bja/aes393.CrossRefPubMed

Ko BS, et al. Prevalence and outcomes of endotracheal intubation-related cardiac arrest in the ED. Am J Emerg Med. 2015. https://doi.org/10.1016/j.ajem.2015.07.083.CrossRefPubMed

Hussmann B, et al. Prehospital intubation of the moderately injured patient: a cause of morbidity? A matched-pairs analysis of 1200 patients from the DGU trauma registry. Crit Care. 2011. https://doi.org/10.1186/cc10442.CrossRefPubMedPubMedCentral

Unfallchirurgie, D.G.f.r., S3 – Leitlinie Polytrauma / Schwerverletzten-Behandlung. 2019.

Rehn M, et al. Scandinavian SSAI clinical practice guideline on pre-hospital airway management. Acta Anaesthesiol Scand. 2016. https://doi.org/10.1111/aas.12746.CrossRefPubMedPubMedCentral

Mayglothling J, et al. Emergency tracheal intubation immediately following traumatic injury: an eastern association for the surgery of trauma practice management guideline. J Trauma Acute Care Surg. 2012. https://doi.org/10.1097/TA.0b013e31827018a5.CrossRefPubMed

Cannon JW. Hemorrhagic shock. N Engl J Med. 2018. https://doi.org/10.1056/NEJMra1705649.CrossRefPubMed

Surgeons, A.C.o. ATLS, advanced trauma life support for doctors. American College of Surgeons; 2008. p. 366.

10.

Kulla M, et al. Prehospital endotracheal intubation and chest tubing does not prolong the overall resuscitation time of severely injured patients: a retrospective, multicentre study of the trauma registry of the German society of trauma surgery. Emerg Med J. 2012. https://doi.org/10.1136/emj.2010.107391.CrossRefPubMed

11.

Gauss T, et al. Association of prehospital time to in-hospital trauma mortality in a physician-staffed emergency medicine system. JAMA Surg. 2019. https://doi.org/10.1001/jamasurg.2019.3475.CrossRefPubMedPubMedCentral

12.

Tsur AM, et al. Prehospital definitive airway is not associated with improved survival in trauma patients. J Trauma Acute Care Surg. 2020. https://doi.org/10.1097/ta.0000000000002722.CrossRefPubMed

13.

Lefering R, et al. Update of the trauma risk adjustment model of the TraumaRegister DGU™: the revised injury severity classification, version II. Crit Care. 2014. https://doi.org/10.1186/s13054-014-0476-2.CrossRefPubMedPubMedCentral

14.

Lefering R. Strategies for comparative analyses of registry data. Injury. 2014. https://doi.org/10.1016/j.injury.2014.08.023.CrossRefPubMed

15.

Bukur M, et al. Pre-hospital intubation is associated with increased mortality after traumatic brain injury. J Surg Res. 2011. https://doi.org/10.1016/j.jss.2011.04.005.CrossRefPubMed

16.

Wang HE, et al. Association of out-of-hospital advanced airway management with outcomes after traumatic brain injury and hemorrhagic shock in the ROC hypertonic saline trial. Emerg Med J. 2014. https://doi.org/10.1136/emermed-2012-202101.CrossRefPubMed

17.

Lockey DJ, et al. Advanced airway management is necessary in prehospital trauma patients. Br J Anaesth. 2015. https://doi.org/10.1093/bja/aeu412.CrossRefPubMed

18.

Crewdson K, et al. The success of pre-hospital tracheal intubation by different pre-hospital providers: a systematic literature review and meta-analysis. Crit Care. 2017. https://doi.org/10.1186/s13054-017-1603-7.CrossRefPubMedPubMedCentral

19.

Spahn DR, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care. 2019. https://doi.org/10.1186/s13054-019-2347-3.CrossRefPubMedPubMedCentral

20.

Bieler D, et al. Why do some trauma patients die while others survive? A matched-pair analysis based on data from trauma register DGU®. Chin J Traumatol. 2020. https://doi.org/10.1016/j.cjtee.2020.05.001.CrossRefPubMedPubMedCentral

21.

Zafar SN, et al. Increased mortality associated with EMS transport of gunshot wound victims when compared to private vehicle transport. Injury. 2014. https://doi.org/10.1016/j.injury.2014.05.032.CrossRefPubMed

22.

Seamon MJ, et al. Prehospital interventions for penetrating trauma victims: a prospective comparison between advanced life support and basic life support. Injury. 2013. https://doi.org/10.1016/j.injury.2012.12.020.CrossRefPubMed

23.

Hussmann B, Lendemans S. Pre-hospital and early in-hospital management of severe injuries: changes and trends. Injury. 2014. https://doi.org/10.1016/j.injury.2014.08.016.CrossRefPubMed

24.

Fröhlich M, et al. Do elderly trauma patients receive the required treatment? Epidemiology and outcome of geriatric trauma patients treated at different levels of trauma care. Eur J Trauma Emerg Surg. 2020. https://doi.org/10.1007/s00068-019-01285-0.CrossRefPubMedPubMedCentral

25.

Bridges LC, Waibel BH, Newell MA. Permissive hypotension: potentially harmful in the elderly? A national trauma data bank analysis. Am Surg. 2015. https://doi.org/10.1177/000313481508100814.CrossRefPubMed

26.

Shafi S, Gentilello L. Pre-hospital endotracheal intubation and positive pressure ventilation is associated with hypotension and decreased survival in hypovolemic trauma patients: an analysis of the national trauma data bank. J Trauma. 2005. https://doi.org/10.1097/01.ta.0000196434.88182.77.CrossRefPubMed

27.

Heffner AC, et al. The frequency and significance of postintubation hypotension during emergency airway management. J Crit Care. 2012. https://doi.org/10.1016/j.jcrc.2011.08.011.CrossRefPubMed

Title: Endotracheal intubation in trauma patients with isolated shock: universally recommended but rarely performed
Authors: Timo Stausberg
Tobias Ahnert
Ben Thouet
Rolf Lefering
Andreas Böhmer
Thomas Brockamp
Arasch Wafaisade
Matthias Fröhlich
the TraumaRegister DGU
Publication date: 12-05-2022
Publisher: Springer Berlin Heidelberg
Keywords: Shock
Shock
Airway Management
Published in: European Journal of Trauma and Emergency Surgery / Issue 6/2022
Print ISSN: 1863-9933
Electronic ISSN: 1863-9941
DOI: https://doi.org/10.1007/s00068-022-01988-x

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Endotracheal intubation in trauma patients with isolated shock: universally recommended but rarely performed

Abstract

Purpose

Methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 6/2022

A retrospective comparison of clinical and radiological outcomes using palmar or dorsal plating to treat complex intraarticular distal radius fractures (AO 2R3 C3)

Traumatic brain injury with concomitant injury to the spleen: characteristics and mortality of a high-risk trauma cohort from the TraumaRegister DGU®

Outcomes of plate osteosynthesis for displaced 3-part and 4-part proximal humerus fractures with deltopectoral vs. deltoid split approach

Trauma-Angio score as a predictor of urgent angioembolization for blunt trauma: development and validation using independent cohorts

The fragility and reverse fragility indices of proximal humerus fracture randomized controlled trials: a systematic review

Proximal humeral fracture osteosynthesis in Belgium: a retrospective population-based epidemiologic study