RE: Does Prehospital Intubation Worsen Severe TBI Pt Outcome?

[Guest guest]

2 thoughts on this- Perhaps the patients who appeared

worse off are the ones who got intubated prehospital

and they would have had a higher mortality either way.

Secondly, why did the research exclude patients

intubated by aeromedical crews? What were they doing

different?

Thanks,

Andy W

Paramedic

--- wrote:

> Journal of Trauma May 2005 Volume 58 Issue 5

>

> Abstract:

> Background: Although early intubation to prevent the

> mortality that

> accompanies hypoxia is considered the standard of

> care for severe traumatic

> brain injury (TBI), the efficacy of this approach

> remains unproven.

>

> Methods: Patients with moderate to severe TBI

> (Head/Neck Abbreviated Injury

> Scale [AIS] score 3+) were identified from our

> county trauma registry.

> Logistic regression was used to explore the impact

> of prehospital intubation

> on outcome, controlling for age, gender, mechanism,

> Glasgow Coma Scale

> score, Head/Neck AIS score, Injury Severity Score,

> and hypotension. Neural

> network analysis was performed to identify patients

> predicted to benefit

> from prehospital intubation.

>

> Results: A total of 13,625 patients from five trauma

> centers were included;

> overall mortality was 22.9%, and 19.3% underwent

> prehospital intubation.

> Logistic regression revealed an increase in

> mortality with prehospital

> intubation (odds ratio, 0.36; 95% confidence

> interval, 0.32-0.42; p <

> 0.001). This was true for all patients, for those

> with severe TBI (Head/Neck

> AIS score 4+ and/or Glasgow Coma Scale score of

> 3-8), and with exclusion of

> patients transported by aeromedical crews. Patients

> intubated in the field

> versus the emergency department had worse outcomes.

> Neural network analysis

> identified a subgroup of patients with more

> significant injuries as

> potentially benefiting from prehospital intubation.

>

> Conclusion: Prehospital intubation is associated

> with a decrease in survival

> among patients with moderate-to-severe TBI. More

> critically injured patients

> may benefit from prehospital intubation but may be

> difficult to identify

> prospectively.

>

>

>

> Article in pdf format attached.

>

>

>

> Jim<

>

>

>

>

>

> [Non-text portions of this message have been

> removed]

>

>

__________________________________________________

[Guest guest]

2 thoughts on this- Perhaps the patients who appeared

worse off are the ones who got intubated prehospital

and they would have had a higher mortality either way.

Secondly, why did the research exclude patients

intubated by aeromedical crews? What were they doing

different?

Thanks,

Andy W

Paramedic

--- wrote:

> Journal of Trauma May 2005 Volume 58 Issue 5

>

> Abstract:

> Background: Although early intubation to prevent the

> mortality that

> accompanies hypoxia is considered the standard of

> care for severe traumatic

> brain injury (TBI), the efficacy of this approach

> remains unproven.

>

> Methods: Patients with moderate to severe TBI

> (Head/Neck Abbreviated Injury

> Scale [AIS] score 3+) were identified from our

> county trauma registry.

> Logistic regression was used to explore the impact

> of prehospital intubation

> on outcome, controlling for age, gender, mechanism,

> Glasgow Coma Scale

> score, Head/Neck AIS score, Injury Severity Score,

> and hypotension. Neural

> network analysis was performed to identify patients

> predicted to benefit

> from prehospital intubation.

>

> Results: A total of 13,625 patients from five trauma

> centers were included;

> overall mortality was 22.9%, and 19.3% underwent

> prehospital intubation.

> Logistic regression revealed an increase in

> mortality with prehospital

> intubation (odds ratio, 0.36; 95% confidence

> interval, 0.32-0.42; p <

> 0.001). This was true for all patients, for those

> with severe TBI (Head/Neck

> AIS score 4+ and/or Glasgow Coma Scale score of

> 3-8), and with exclusion of

> patients transported by aeromedical crews. Patients

> intubated in the field

> versus the emergency department had worse outcomes.

> Neural network analysis

> identified a subgroup of patients with more

> significant injuries as

> potentially benefiting from prehospital intubation.

>

> Conclusion: Prehospital intubation is associated

> with a decrease in survival

> among patients with moderate-to-severe TBI. More

> critically injured patients

> may benefit from prehospital intubation but may be

> difficult to identify

> prospectively.

>

>

>

> Article in pdf format attached.

>

>

>

> Jim<

>

>

>

>

>

> [Non-text portions of this message have been

> removed]

>

>

__________________________________________________

[Guest guest]

2 thoughts on this- Perhaps the patients who appeared

worse off are the ones who got intubated prehospital

and they would have had a higher mortality either way.

Secondly, why did the research exclude patients

intubated by aeromedical crews? What were they doing

different?

Thanks,

Andy W

Paramedic

--- wrote:

> Journal of Trauma May 2005 Volume 58 Issue 5

>

> Abstract:

> Background: Although early intubation to prevent the

> mortality that

> accompanies hypoxia is considered the standard of

> care for severe traumatic

> brain injury (TBI), the efficacy of this approach

> remains unproven.

>

> Methods: Patients with moderate to severe TBI

> (Head/Neck Abbreviated Injury

> Scale [AIS] score 3+) were identified from our

> county trauma registry.

> Logistic regression was used to explore the impact

> of prehospital intubation

> on outcome, controlling for age, gender, mechanism,

> Glasgow Coma Scale

> score, Head/Neck AIS score, Injury Severity Score,

> and hypotension. Neural

> network analysis was performed to identify patients

> predicted to benefit

> from prehospital intubation.

>

> Results: A total of 13,625 patients from five trauma

> centers were included;

> overall mortality was 22.9%, and 19.3% underwent

> prehospital intubation.

> Logistic regression revealed an increase in

> mortality with prehospital

> intubation (odds ratio, 0.36; 95% confidence

> interval, 0.32-0.42; p <

> 0.001). This was true for all patients, for those

> with severe TBI (Head/Neck

> AIS score 4+ and/or Glasgow Coma Scale score of

> 3-8), and with exclusion of

> patients transported by aeromedical crews. Patients

> intubated in the field

> versus the emergency department had worse outcomes.

> Neural network analysis

> identified a subgroup of patients with more

> significant injuries as

> potentially benefiting from prehospital intubation.

>

> Conclusion: Prehospital intubation is associated

> with a decrease in survival

> among patients with moderate-to-severe TBI. More

> critically injured patients

> may benefit from prehospital intubation but may be

> difficult to identify

> prospectively.

>

>

>

> Article in pdf format attached.

>

>

>

> Jim<

>

>

>

>

>

> [Non-text portions of this message have been

> removed]

>

>

__________________________________________________

[Guest guest]

Probably RSI.

Jim<

_____

From: [mailto: ] On

Behalf Of Andy Wheeler

Sent: Saturday, May 28, 2005 7:52 AM

To:

Subject: Re: Does Prehospital Intubation Worsen Severe TBI Pt

Outcome?

2 thoughts on this- Perhaps the patients who appeared

worse off are the ones who got intubated prehospital

and they would have had a higher mortality either way.

Secondly, why did the research exclude patients

intubated by aeromedical crews? What were they doing

different?

Thanks,

Andy W

Paramedic

--- wrote:

> Journal of Trauma May 2005 Volume 58 Issue 5

>

> Abstract:

> Background: Although early intubation to prevent the

> mortality that

> accompanies hypoxia is considered the standard of

> care for severe traumatic

> brain injury (TBI), the efficacy of this approach

> remains unproven.

>

> Methods: Patients with moderate to severe TBI

> (Head/Neck Abbreviated Injury

> Scale [AIS] score 3+) were identified from our

> county trauma registry.

> Logistic regression was used to explore the impact

> of prehospital intubation

> on outcome, controlling for age, gender, mechanism,

> Glasgow Coma Scale

> score, Head/Neck AIS score, Injury Severity Score,

> and hypotension. Neural

> network analysis was performed to identify patients

> predicted to benefit

> from prehospital intubation.

>

> Results: A total of 13,625 patients from five trauma

> centers were included;

> overall mortality was 22.9%, and 19.3% underwent

> prehospital intubation.

> Logistic regression revealed an increase in

> mortality with prehospital

> intubation (odds ratio, 0.36; 95% confidence

> interval, 0.32-0.42; p <

> 0.001). This was true for all patients, for those

> with severe TBI (Head/Neck

> AIS score 4+ and/or Glasgow Coma Scale score of

> 3-8), and with exclusion of

> patients transported by aeromedical crews. Patients

> intubated in the field

> versus the emergency department had worse outcomes.

> Neural network analysis

> identified a subgroup of patients with more

> significant injuries as

> potentially benefiting from prehospital intubation.

>

> Conclusion: Prehospital intubation is associated

> with a decrease in survival

> among patients with moderate-to-severe TBI. More

> critically injured patients

> may benefit from prehospital intubation but may be

> difficult to identify

> prospectively.

>

>

>

> Article in pdf format attached.

>

>

>

> Jim<

>

>

>

>

>

> [Non-text portions of this message have been

> removed]

>

>

__________________________________________________

[Guest guest]

Intubation increases mortality REALLY?

If you don¹t take your next breath nothing else matters.

This is a perfect example of junk science.

Inclusion and exclusion bias made this study worthless.

Of course, patients that were intubated were by far the most seriously

injured. They are going to have a much higher death rate. Despite claiming

logistic regression controlling for age, gender, mechanism, Glasgow Coma

Scale score, Head/Neck AIS score, Injury Severity Score, and hypotension.

Neural network analysis etc.--- nothing comes close to the triage that

occurred in the field by paramedics knowing which patients really needed

airway control and which ones did not.

The only way to prove the benefit or detriment of prehospital intubation is

to conduct a prospective randomized trial where on one day all patients get

intubated and on the next day none get intubated. Then, and only then, can

you eliminate this inclusion bias and draw conclusions about outcome.

Don¹t let the size of the sample or the people conducting the study confuse

you or deceive you. We must demand unbiased trials or else we will continue

to be victims of myths and EMS legends.

Larry MD

>

>

> From: [mailto: ] On

> Behalf Of Andy Wheeler

> Sent: Saturday, May 28, 2005 7:52 AM

> To:

> Subject: Re: Does Prehospital Intubation Worsen Severe TBI Pt

> Outcome?

>

>

>

> 2 thoughts on this- Perhaps the patients who appeared

> worse off are the ones who got intubated prehospital

> and they would have had a higher mortality either way.

> Secondly, why did the research exclude patients

> intubated by aeromedical crews? What were they doing

> different?

>

> Thanks,

>

> Andy W

> Paramedic

> --- wrote:

>> > Journal of Trauma May 2005 Volume 58 Issue 5

>> >

>> > Abstract:

>> > Background: Although early intubation to prevent the

>> > mortality that

>> > accompanies hypoxia is considered the standard of

>> > care for severe traumatic

>> > brain injury (TBI), the efficacy of this approach

>> > remains unproven.

>> >

>> > Methods: Patients with moderate to severe TBI

>> > (Head/Neck Abbreviated Injury

>> > Scale [AIS] score 3+) were identified from our

>> > county trauma registry.

>> > Logistic regression was used to explore the impact

>> > of prehospital intubation

>> > on outcome, controlling for age, gender, mechanism,

>> > Glasgow Coma Scale

>> > score, Head/Neck AIS score, Injury Severity Score,

>> > and hypotension. Neural

>> > network analysis was performed to identify patients

>> > predicted to benefit

>> > from prehospital intubation.

>> >

>> > Results: A total of 13,625 patients from five trauma

>> > centers were included;

>> > overall mortality was 22.9%, and 19.3% underwent

>> > prehospital intubation.

>> > Logistic regression revealed an increase in

>> > mortality with prehospital

>> > intubation (odds ratio, 0.36; 95% confidence

>> > interval, 0.32-0.42; p <

>> > 0.001). This was true for all patients, for those

>> > with severe TBI (Head/Neck

>> > AIS score 4+ and/or Glasgow Coma Scale score of

>> > 3-8), and with exclusion of

>> > patients transported by aeromedical crews. Patients

>> > intubated in the field

>> > versus the emergency department had worse outcomes.

>> > Neural network analysis

>> > identified a subgroup of patients with more

>> > significant injuries as

>> > potentially benefiting from prehospital intubation.

>> >

>> > Conclusion: Prehospital intubation is associated

>> > with a decrease in survival

>> > among patients with moderate-to-severe TBI. More

>> > critically injured patients

>> > may benefit from prehospital intubation but may be

>> > difficult to identify

>> > prospectively.

>> >

>> >

>> >

>> > Article in pdf format attached.

>> >

>> >

>> >

>> > Jim<

>> >

>> >

>

[Guest guest]

Intubation increases mortality REALLY?

If you don¹t take your next breath nothing else matters.

This is a perfect example of junk science.

Inclusion and exclusion bias made this study worthless.

Of course, patients that were intubated were by far the most seriously

injured. They are going to have a much higher death rate. Despite claiming

logistic regression controlling for age, gender, mechanism, Glasgow Coma

Scale score, Head/Neck AIS score, Injury Severity Score, and hypotension.

Neural network analysis etc.--- nothing comes close to the triage that

occurred in the field by paramedics knowing which patients really needed

airway control and which ones did not.

The only way to prove the benefit or detriment of prehospital intubation is

to conduct a prospective randomized trial where on one day all patients get

intubated and on the next day none get intubated. Then, and only then, can

you eliminate this inclusion bias and draw conclusions about outcome.

Don¹t let the size of the sample or the people conducting the study confuse

you or deceive you. We must demand unbiased trials or else we will continue

to be victims of myths and EMS legends.

Larry MD

>

>

> From: [mailto: ] On

> Behalf Of Andy Wheeler

> Sent: Saturday, May 28, 2005 7:52 AM

> To:

> Subject: Re: Does Prehospital Intubation Worsen Severe TBI Pt

> Outcome?

>

>

>

> 2 thoughts on this- Perhaps the patients who appeared

> worse off are the ones who got intubated prehospital

> and they would have had a higher mortality either way.

> Secondly, why did the research exclude patients

> intubated by aeromedical crews? What were they doing

> different?

>

> Thanks,

>

> Andy W

> Paramedic

> --- wrote:

>> > Journal of Trauma May 2005 Volume 58 Issue 5

>> >

>> > Abstract:

>> > Background: Although early intubation to prevent the

>> > mortality that

>> > accompanies hypoxia is considered the standard of

>> > care for severe traumatic

>> > brain injury (TBI), the efficacy of this approach

>> > remains unproven.

>> >

>> > Methods: Patients with moderate to severe TBI

>> > (Head/Neck Abbreviated Injury

>> > Scale [AIS] score 3+) were identified from our

>> > county trauma registry.

>> > Logistic regression was used to explore the impact

>> > of prehospital intubation

>> > on outcome, controlling for age, gender, mechanism,

>> > Glasgow Coma Scale

>> > score, Head/Neck AIS score, Injury Severity Score,

>> > and hypotension. Neural

>> > network analysis was performed to identify patients

>> > predicted to benefit

>> > from prehospital intubation.

>> >

>> > Results: A total of 13,625 patients from five trauma

>> > centers were included;

>> > overall mortality was 22.9%, and 19.3% underwent

>> > prehospital intubation.

>> > Logistic regression revealed an increase in

>> > mortality with prehospital

>> > intubation (odds ratio, 0.36; 95% confidence

>> > interval, 0.32-0.42; p <

>> > 0.001). This was true for all patients, for those

>> > with severe TBI (Head/Neck

>> > AIS score 4+ and/or Glasgow Coma Scale score of

>> > 3-8), and with exclusion of

>> > patients transported by aeromedical crews. Patients

>> > intubated in the field

>> > versus the emergency department had worse outcomes.

>> > Neural network analysis

>> > identified a subgroup of patients with more

>> > significant injuries as

>> > potentially benefiting from prehospital intubation.

>> >

>> > Conclusion: Prehospital intubation is associated

>> > with a decrease in survival

>> > among patients with moderate-to-severe TBI. More

>> > critically injured patients

>> > may benefit from prehospital intubation but may be

>> > difficult to identify

>> > prospectively.

>> >

>> >

>> >

>> > Article in pdf format attached.

>> >

>> >

>> >

>> > Jim<

>> >

>> >

>

[Guest guest]

Intubation increases mortality REALLY?

If you don¹t take your next breath nothing else matters.

This is a perfect example of junk science.

Inclusion and exclusion bias made this study worthless.

Of course, patients that were intubated were by far the most seriously

injured. They are going to have a much higher death rate. Despite claiming

logistic regression controlling for age, gender, mechanism, Glasgow Coma

Scale score, Head/Neck AIS score, Injury Severity Score, and hypotension.

Neural network analysis etc.--- nothing comes close to the triage that

occurred in the field by paramedics knowing which patients really needed

airway control and which ones did not.

The only way to prove the benefit or detriment of prehospital intubation is

to conduct a prospective randomized trial where on one day all patients get

intubated and on the next day none get intubated. Then, and only then, can

you eliminate this inclusion bias and draw conclusions about outcome.

Don¹t let the size of the sample or the people conducting the study confuse

you or deceive you. We must demand unbiased trials or else we will continue

to be victims of myths and EMS legends.

Larry MD

>

>

> From: [mailto: ] On

> Behalf Of Andy Wheeler

> Sent: Saturday, May 28, 2005 7:52 AM

> To:

> Subject: Re: Does Prehospital Intubation Worsen Severe TBI Pt

> Outcome?

>

>

>

> 2 thoughts on this- Perhaps the patients who appeared

> worse off are the ones who got intubated prehospital

> and they would have had a higher mortality either way.

> Secondly, why did the research exclude patients

> intubated by aeromedical crews? What were they doing

> different?

>

> Thanks,

>

> Andy W

> Paramedic

> --- wrote:

>> > Journal of Trauma May 2005 Volume 58 Issue 5

>> >

>> > Abstract:

>> > Background: Although early intubation to prevent the

>> > mortality that

>> > accompanies hypoxia is considered the standard of

>> > care for severe traumatic

>> > brain injury (TBI), the efficacy of this approach

>> > remains unproven.

>> >

>> > Methods: Patients with moderate to severe TBI

>> > (Head/Neck Abbreviated Injury

>> > Scale [AIS] score 3+) were identified from our

>> > county trauma registry.

>> > Logistic regression was used to explore the impact

>> > of prehospital intubation

>> > on outcome, controlling for age, gender, mechanism,

>> > Glasgow Coma Scale

>> > score, Head/Neck AIS score, Injury Severity Score,

>> > and hypotension. Neural

>> > network analysis was performed to identify patients

>> > predicted to benefit

>> > from prehospital intubation.

>> >

>> > Results: A total of 13,625 patients from five trauma

>> > centers were included;

>> > overall mortality was 22.9%, and 19.3% underwent

>> > prehospital intubation.

>> > Logistic regression revealed an increase in

>> > mortality with prehospital

>> > intubation (odds ratio, 0.36; 95% confidence

>> > interval, 0.32-0.42; p <

>> > 0.001). This was true for all patients, for those

>> > with severe TBI (Head/Neck

>> > AIS score 4+ and/or Glasgow Coma Scale score of

>> > 3-8), and with exclusion of

>> > patients transported by aeromedical crews. Patients

>> > intubated in the field

>> > versus the emergency department had worse outcomes.

>> > Neural network analysis

>> > identified a subgroup of patients with more

>> > significant injuries as

>> > potentially benefiting from prehospital intubation.

>> >

>> > Conclusion: Prehospital intubation is associated

>> > with a decrease in survival

>> > among patients with moderate-to-severe TBI. More

>> > critically injured patients

>> > may benefit from prehospital intubation but may be

>> > difficult to identify

>> > prospectively.

>> >

>> >

>> >

>> > Article in pdf format attached.

>> >

>> >

>> >

>> > Jim<

>> >

>> >

>

[Guest guest]

Lee,

In addition to your post...

In reality, it is the secondary insult to the brain that does more

damage and increases morbidity and mortality than does the initial

insult. Studies reveal that by maintaining a MAP = or > 90 will

facilitate the brain's pressure autoregulation function. In

addition, other studies DO recommend that head injured pts with a GCS

of 8 or lower should be intubated for oxygenation and ventilation

management.

It is also clearly documented that CO2 is one of the most potent

vasodilators known. If ICP builds, then normal regulatory efforts

will cause vasoconstriction to limit the amount of pressure and blood

volume delievered to the brain. In the TBI pt, it is imperitive that

field personnel aggresively manage BP, oxygenation, and

ventilations. Studies also show that maintaining ETCO2 levels in the

35-39mmHg range is beneficial in achieving normal blood flow. This

can usually be accomplished with a ventilation rate of 10-12/min.

Hypoventilation will result in elevated ETCO2 levels and will

stimulate profound vasodilation which can exacerbate ICP. If ETCO2

levels drop, simply slow the ventilation rate.

Capnography is critical in monitoring CO2 regulation in the pt with

TBI. Not to turn this into a Capnography subject, but this is yet

another reason (and there are many more) why Capnography should

become considered " standard of care " .

I am all for controlling the airway, mostly because we live by

the 'ole fashioned approach of " ABCs " . More specifically, in that

order. Just my opinion....

D. Stone

> >> > Journal of Trauma May 2005 Volume 58 Issue 5

> >> >

> >> > Abstract:

> >> > Background: Although early intubation to prevent the

> >> > mortality that

> >> > accompanies hypoxia is considered the standard of

> >> > care for severe traumatic

> >> > brain injury (TBI), the efficacy of this approach

> >> > remains unproven.

> >> >

> >> > Methods: Patients with moderate to severe TBI

> >> > (Head/Neck Abbreviated Injury

> >> > Scale [AIS] score 3+) were identified from our

> >> > county trauma registry.

> >> > Logistic regression was used to explore the impact

> >> > of prehospital intubation

> >> > on outcome, controlling for age, gender, mechanism,

> >> > Glasgow Coma Scale

> >> > score, Head/Neck AIS score, Injury Severity Score,

> >> > and hypotension. Neural

> >> > network analysis was performed to identify patients

> >> > predicted to benefit

> >> > from prehospital intubation.

> >> >

> >> > Results: A total of 13,625 patients from five trauma

> >> > centers were included;

> >> > overall mortality was 22.9%, and 19.3% underwent

> >> > prehospital intubation.

> >> > Logistic regression revealed an increase in

> >> > mortality with prehospital

> >> > intubation (odds ratio, 0.36; 95% confidence

> >> > interval, 0.32-0.42; p <

> >> > 0.001). This was true for all patients, for those

> >> > with severe TBI (Head/Neck

> >> > AIS score 4+ and/or Glasgow Coma Scale score of

> >> > 3-8), and with exclusion of

> >> > patients transported by aeromedical crews. Patients

> >> > intubated in the field

> >> > versus the emergency department had worse outcomes.

> >> > Neural network analysis

> >> > identified a subgroup of patients with more

> >> > significant injuries as

> >> > potentially benefiting from prehospital intubation.

> >> >

> >> > Conclusion: Prehospital intubation is associated

> >> > with a decrease in survival

> >> > among patients with moderate-to-severe TBI. More

> >> > critically injured patients

> >> > may benefit from prehospital intubation but may be

> >> > difficult to identify

> >> > prospectively.

> >> >

> >> >

> >> >

> >> > Article in pdf format attached.

> >> >

> >> >

> >> >

> >> > Jim<

> >> >

> >> >

> >

>

>

>

[Guest guest]

Lee,

In addition to your post...

In reality, it is the secondary insult to the brain that does more

damage and increases morbidity and mortality than does the initial

insult. Studies reveal that by maintaining a MAP = or > 90 will

facilitate the brain's pressure autoregulation function. In

addition, other studies DO recommend that head injured pts with a GCS

of 8 or lower should be intubated for oxygenation and ventilation

management.

It is also clearly documented that CO2 is one of the most potent

vasodilators known. If ICP builds, then normal regulatory efforts

will cause vasoconstriction to limit the amount of pressure and blood

volume delievered to the brain. In the TBI pt, it is imperitive that

field personnel aggresively manage BP, oxygenation, and

ventilations. Studies also show that maintaining ETCO2 levels in the

35-39mmHg range is beneficial in achieving normal blood flow. This

can usually be accomplished with a ventilation rate of 10-12/min.

Hypoventilation will result in elevated ETCO2 levels and will

stimulate profound vasodilation which can exacerbate ICP. If ETCO2

levels drop, simply slow the ventilation rate.

Capnography is critical in monitoring CO2 regulation in the pt with

TBI. Not to turn this into a Capnography subject, but this is yet

another reason (and there are many more) why Capnography should

become considered " standard of care " .

I am all for controlling the airway, mostly because we live by

the 'ole fashioned approach of " ABCs " . More specifically, in that

order. Just my opinion....

D. Stone

> >> > Journal of Trauma May 2005 Volume 58 Issue 5

> >> >

> >> > Abstract:

> >> > Background: Although early intubation to prevent the

> >> > mortality that

> >> > accompanies hypoxia is considered the standard of

> >> > care for severe traumatic

> >> > brain injury (TBI), the efficacy of this approach

> >> > remains unproven.

> >> >

> >> > Methods: Patients with moderate to severe TBI

> >> > (Head/Neck Abbreviated Injury

> >> > Scale [AIS] score 3+) were identified from our

> >> > county trauma registry.

> >> > Logistic regression was used to explore the impact

> >> > of prehospital intubation

> >> > on outcome, controlling for age, gender, mechanism,

> >> > Glasgow Coma Scale

> >> > score, Head/Neck AIS score, Injury Severity Score,

> >> > and hypotension. Neural

> >> > network analysis was performed to identify patients

> >> > predicted to benefit

> >> > from prehospital intubation.

> >> >

> >> > Results: A total of 13,625 patients from five trauma

> >> > centers were included;

> >> > overall mortality was 22.9%, and 19.3% underwent

> >> > prehospital intubation.

> >> > Logistic regression revealed an increase in

> >> > mortality with prehospital

> >> > intubation (odds ratio, 0.36; 95% confidence

> >> > interval, 0.32-0.42; p <

> >> > 0.001). This was true for all patients, for those

> >> > with severe TBI (Head/Neck

> >> > AIS score 4+ and/or Glasgow Coma Scale score of

> >> > 3-8), and with exclusion of

> >> > patients transported by aeromedical crews. Patients

> >> > intubated in the field

> >> > versus the emergency department had worse outcomes.

> >> > Neural network analysis

> >> > identified a subgroup of patients with more

> >> > significant injuries as

> >> > potentially benefiting from prehospital intubation.

> >> >

> >> > Conclusion: Prehospital intubation is associated

> >> > with a decrease in survival

> >> > among patients with moderate-to-severe TBI. More

> >> > critically injured patients

> >> > may benefit from prehospital intubation but may be

> >> > difficult to identify

> >> > prospectively.

> >> >

> >> >

> >> >

> >> > Article in pdf format attached.

> >> >

> >> >

> >> >

> >> > Jim<

> >> >

> >> >

> >

>

>

>

[Guest guest]

Lee,

In addition to your post...

In reality, it is the secondary insult to the brain that does more

damage and increases morbidity and mortality than does the initial

insult. Studies reveal that by maintaining a MAP = or > 90 will

facilitate the brain's pressure autoregulation function. In

addition, other studies DO recommend that head injured pts with a GCS

of 8 or lower should be intubated for oxygenation and ventilation

management.

It is also clearly documented that CO2 is one of the most potent

vasodilators known. If ICP builds, then normal regulatory efforts

will cause vasoconstriction to limit the amount of pressure and blood

volume delievered to the brain. In the TBI pt, it is imperitive that

field personnel aggresively manage BP, oxygenation, and

ventilations. Studies also show that maintaining ETCO2 levels in the

35-39mmHg range is beneficial in achieving normal blood flow. This

can usually be accomplished with a ventilation rate of 10-12/min.

Hypoventilation will result in elevated ETCO2 levels and will

stimulate profound vasodilation which can exacerbate ICP. If ETCO2

levels drop, simply slow the ventilation rate.

Capnography is critical in monitoring CO2 regulation in the pt with

TBI. Not to turn this into a Capnography subject, but this is yet

another reason (and there are many more) why Capnography should

become considered " standard of care " .

I am all for controlling the airway, mostly because we live by

the 'ole fashioned approach of " ABCs " . More specifically, in that

order. Just my opinion....

D. Stone

> >> > Journal of Trauma May 2005 Volume 58 Issue 5

> >> >

> >> > Abstract:

> >> > Background: Although early intubation to prevent the

> >> > mortality that

> >> > accompanies hypoxia is considered the standard of

> >> > care for severe traumatic

> >> > brain injury (TBI), the efficacy of this approach

> >> > remains unproven.

> >> >

> >> > Methods: Patients with moderate to severe TBI

> >> > (Head/Neck Abbreviated Injury

> >> > Scale [AIS] score 3+) were identified from our

> >> > county trauma registry.

> >> > Logistic regression was used to explore the impact

> >> > of prehospital intubation

> >> > on outcome, controlling for age, gender, mechanism,

> >> > Glasgow Coma Scale

> >> > score, Head/Neck AIS score, Injury Severity Score,

> >> > and hypotension. Neural

> >> > network analysis was performed to identify patients

> >> > predicted to benefit

> >> > from prehospital intubation.

> >> >

> >> > Results: A total of 13,625 patients from five trauma

> >> > centers were included;

> >> > overall mortality was 22.9%, and 19.3% underwent

> >> > prehospital intubation.

> >> > Logistic regression revealed an increase in

> >> > mortality with prehospital

> >> > intubation (odds ratio, 0.36; 95% confidence

> >> > interval, 0.32-0.42; p <

> >> > 0.001). This was true for all patients, for those

> >> > with severe TBI (Head/Neck

> >> > AIS score 4+ and/or Glasgow Coma Scale score of

> >> > 3-8), and with exclusion of

> >> > patients transported by aeromedical crews. Patients

> >> > intubated in the field

> >> > versus the emergency department had worse outcomes.

> >> > Neural network analysis

> >> > identified a subgroup of patients with more

> >> > significant injuries as

> >> > potentially benefiting from prehospital intubation.

> >> >

> >> > Conclusion: Prehospital intubation is associated

> >> > with a decrease in survival

> >> > among patients with moderate-to-severe TBI. More

> >> > critically injured patients

> >> > may benefit from prehospital intubation but may be

> >> > difficult to identify

> >> > prospectively.

> >> >

> >> >

> >> >

> >> > Article in pdf format attached.

> >> >

> >> >

> >> >

> >> > Jim<

> >> >

> >> >

> >

>

>

>