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Rescue Airway Techniques

Mauritz Walter, Prim., Prof., UBA Walter.Mauritz at auva.at
Mon Apr 10 07:59:48 BST 2006


Dear Ben,

Sorry if I misunderstood what you wanted to say (English is not my first
language; I sometimes have problems to understand the finer points).

As far as TBI is concerned, all authors studied the same type of
patients. Even >18.000 cases (that is the total number of patients in
all the studies) don't prove anything because the bias remains the same
in all these cases.
I have not yet read the full papers of the other studies you cited.

I think it is obvious that a prospective study should be done. The
problem is that most European emergency physicians might be less than
willing NOT to intubate patients with severe TBI, but I will try to find
out how they think about such a study.

Best wishes


Walter Mauritz MD PhD
Professor of Anesthesia and Critical Care Medicine
Trauma Hospital "Lorenz Boehler"
A - 1200 Vienna, AUSTRIA, EU
phone: ++43 1 33110 789
fax: ++43 1 33110 277
e-mail: walter.mauritz at auva.at


-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Ben Reynolds
Sent: Friday, April 07, 2006 1:59 PM
To: Trauma &amp, Critical Care mailing list
Subject: RE: Re: Rescue Airway Techniques

Walter:

Actually the points you are raising largely mirror
what I'm trying to convey.  In general:

1.  No solid conclusions or broad recommendations can
be drawn from these studies.

2.  Poorer outcomes in these patients are
multifactorial as you've highlighted.  The one thing
which seems to be consistent (at least consistent
enough to be mentioned as significant by the authors)
among them all is prehospital intubation.  Why?  The
fact that we're seeing REPLICATION among different
studies at different institutions looking at different
cohorts makes the findings more compelling and less
likely to be spurrious.

3.  Your analysis reinforced my contention that
PROSPECTIVE data is needed in this area.  Salvaging
quality of life after severe brain trauma is difficult
enough; this may point to a SPECIFIC area where we can
make a difference in outcomes.

Ben Reynolds, PA-C
Pittsburgh, PA 

--- "Mauritz Walter, Prim., Prof., UBA"
<Walter.Mauritz at auva.at> wrote:

> Dear Ben,
> 
> Some of the references you gave do not say what you
> may think they say.
> I am only familiar with the papers on traumatic
> brain injury, and will
> have to look up the other references.
> 
> As far as the TBI papers (Davis, Wang) are
> concerned, these compared
> patients who had been intubated in the field with
> those who had not. The
> patients who were intubated fell into two different
> groups: in most
> patients intubation was done without anesthesia, in
> few patients
> (aeromedical teams) it was done with anesthesia (or
> at least the use of
> relaxants). All three papers found that intubated
> patients had a
> significantly higher mortality. They used logistic
> regression to correct
> for cofounding factors (age, ISS, GCS, etc.). All
> three papers describe
> a subgroup of patients where no difference in
> mortality (or even a
> beneficial effect of intubation) was found: it was
> the group of patients
> where anesthesia or relaxants were used.
> 
> It is obvious that patients who tolerate
> endotracheal intubation without
> anesthesia or relaxants are different from patients
> who do not need
> intubation, or who will not tolerate it without
> anesthesia or relaxants,
> even if logistic regression will correct for all
> other significant
> factors. The intubated patients in these studies
> were more seriously
> injured, and that explains the difference in
> mortality. And if you
> compare the mortality rates for the intubated
> patients (49% and 55%!) it
> is clear that this were patients who were most
> severely injured; the
> "standard" mortality for patients with severe TBI
> (GCS <9) is somewhere
> between 30 and 35%; at least, that are the rates
> published by other
> groups.
> 
> It is also telling that there was no deleterious
> effect of intubation in
> the patients who were treated by aeromedical teams;
> they can freely
> decide whether to intubate or not, because they can
> use drugs whenever
> they are required.
> 
> To conclude, at present there is no evidence that
> endotracheal
> intubation in the field worsens outcome. The studies
> published so far
> are all retrospective, and are biased because the
> intubated patients
> were more seriously injured than those that were not
> intubated. It would
> need a prospective study done in a system where
> drugs may be used to
> facilitate intubation to answer that question
> convincingly.
> 
> One question, however, remains: is intubation really
> the "gold
> standard"? There are so many other effective means
> to secure the airway
> that are easier to learn and to teach.
> 
> with best regards
> 
> Walter Mauritz MD PhD
> Professor of Anesthesia and Critical Care Medicine
> Trauma Hospital "Lorenz Boehler"
> A - 1200 Vienna, AUSTRIA, EU
> phone: ++43 1 33110 789
> fax: ++43 1 33110 277
> e-mail: walter.mauritz at auva.at
> 
> 
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of
> Ben Reynolds
> Sent: Thursday, April 06, 2006 5:44 PM
> To: Trauma &amp, Critical Care mailing list; Melissa
> Markey
> Subject: Re: Re: Rescue Airway Techniques
> 
> There is an evolving body of literature which argues
> exactly the OPPOSITE, that in fact prehospital
> intubation as an independent event in severe head
> injury*, hypovolemic shock** AND in pediatric
> patients*** is associated with HIGHER morbidity and
> mortality.
> 
> 
> Ben Reynolds, PA-C
> Pittsburgh, PA
> 
> *Bochicchio GV, Ilahi O, Joshi M, Bochicchio K,
> Scalea
> TM. Endotracheal intubation in the field does not
> improve outcome in trauma patients who present
> without
> an acutely lethal traumatic brain injury. J Trauma.
> 2003 Feb;54(2):307-11.
> 
> *Davis DP, Peay J, Sise MJ, Vilke GM, Kennedy F,
> Eastman AB, Velky T, Hoyt DB. The impact of
> prehospital endotracheal intubation on outcome in
> moderate to severe traumatic brain injury. J Trauma.
> 2005 May;58(5):933-9.
> 
> *Sen A, Nichani R. Best evidence topic report.
> Prehospital endotracheal intubation in adult major
> trauma patients with head injury. Emerg Med J. 2005
> Dec;22(12):887-9.
> 
> *Wang HE, Peitzman AB, Cassidy LD, Adelson PD, Yealy
> DM. Out-of-hospital endotracheal intubation and
> outcome after traumatic brain injury. Ann Emerg Med.
> 2004 Nov;44(5):439-50.
> 
> *Davis DP, Stern J, Sise MJ, Hoyt DB. A follow-up
> analysis of factors associated with head-injury
> mortality after paramedic rapid sequence intubation.
> J
> Trauma. 2005 Aug;59(2):486-90.
> 
> **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
> Nov;59(5):1140-5; discussion 1145-7.
> 
> ***DiRusso SM, Sullivan T, Risucci D, Nealon P, Slim
> M. Intubation of pediatric trauma patients in the
> field: predictor of negative outcome despite risk
> stratification. J Trauma. 2005 Jul;59(1):84-90;
> discussion 90-1.
> 
> 
> --- stefmazur at ausdoctors.net wrote:
> 
> > Melissa,
> > 
> > What is the evidence that shows having an ET tube
> > placed pre-hospital saves these patients
> > "significant mortality and morbidity"?
> > 
> > My reading (admittedly limited) seems to suggest
> the
> > opposite, so would be interested in what evidence
> > has lead you to your conclusion.
> > 
> > Cheers,
> > Stefan Mazur
> > Emergency Physician
> > 
> > >With all due respect, I have a different
> suggestion
> > - how about
> > >anesthetists and anesthesiologists willingly
> > sharing their knowledge and
> > >giving paramedics more chances to practice
> > intubation in a controlled
> > >setting (i.e., consider us as important to train
> as
> > you do residents,
> > >and stop giving the residents all the tubes). 
> Last
> > time I was in the OR
> > >for ET practice, I got 0 chances out of an 8 hour
> > day.  Why?  Because
> > >anesthesia always found a reason to say no -  No,
> > this patient has caps
> > >on her teeth.  No, this patient is in for
> elective
> > surgery.  No, we want
> > >the resident to get some experience.  Not a very
> > effective investment of
> > >my time.  And not a very appropriate way to
> behave,
> > to my thinking.
> > >
> > >Experienced paramedics can intubate quite
> > successfully - and quickly.
> > >The determining factor is not whether you have an
> 
=== message truncated ===

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