Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

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Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury – Summary


ResearchBlogging.org
Also posted over at Paramedicine 101, which is now at EMS Blogs, and at Research Blogging.

Go check out the excellent material at those sites.

In response to my post If We Were Really Serious About Intubation Quality was a comment from drastic suggesting that I take a look at a couple of studies that demonstrate that Australian paramedics do not need to improve their intubation skills and that intubation improves outcomes.

One of the studies does show a lot of positives for intubation. The big problem is the lack of statistical significance. A larger study needs to be done to confirm the results, an LMA (Laryngeal Mask Airway) or other group should be added. Otherwise, this appears to be a great study.

Does EMS RSI (Rapid Sequence Induction/Intubation) lead to better outcomes than delaying intubation until arrival at the trauma center for patients with TBI (Traumatic Brain Injury)?


Click on the image to make it bigger.

The difference in outcomes would no longer be statistically significant whether one more patient had a positive outcome in the treatment group (P = 0.059) or one less in the control group (P = 0.061).[1]

That limitation is very important, since 13 patients were lost to follow-up (10 in the hospital intubation group and 3 in the EMS RSI group), because their families lost contact with them. This apparent independence suggests, but certainly does not prove, that these patients would not have fallen into the more severely impaired categories. Even if all of the EMS RSI patients did have severe disabilities, while all of the hospital intubation patients had good neurological outcomes, the hospital intubation group would only come up to 43% (66/152) with a good neurological outcome, which is still less than the possible 50% (80/160) for the EMS RSI group. Therefore, the results would not change to the point of demonstrating worse outcomes with EMS RSI, but the results would no longer be statistically significant.

More likely is that they all have good neurological outcomes and the results would change to 52% (83/163) vs. 43% (66/152). Both outcomes improve, but the results are still not statistically significant.

All EMS RSI patients had waveform capnography, which may explain why the results are so different from the results of the study by Davis on EMS RSI for TBI. This study raised a bunch of questions about those results, which showed worse outcomes for EMS RSI. One hypothesis was that the much higher incidence of hypocapnea contributed to the bad outcomes even though the EMS intubation success rates more than doubled for TBI patients.

Conclusion: Paramedic RSI protocols to facilitate intubation of head-injured patients were associated with an increase in mortality and decrease in good outcomes versus matched historical controls.[2]

airway management success rates for severely head-injured patients in our prehospital system increased from 39% in the pre-trial period to 86% during the trial.20,21[2]

In this study, the intubation success rate for TBI patients was 97%, which is dramatically higher than 86%. 1/7 lack of success vs. 1/33.

Does this study demonstrate good outcomes with paramedic intubation for TBI?

Yes.

Does this study demonstrate excellent intubation success with RSI for TBI?

Yes.

There is a lot more to discuss about this study, but I will go into more depth later.

Footnotes:

[1] Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury: a randomized controlled trial.
Bernard SA, Nguyen V, Cameron P, Masci K, Fitzgerald M, Cooper DJ, Walker T, Std BP, Myles P, Murray L, David, Taylor, Smith K, Patrick I, Edington J, Bacon A, Rosenfeld JV, Judson R.
Ann Surg. 2010 Dec;252(6):959-65.
PMID: 21107105 [PubMed – indexed for MEDLINE]

[2] The effect of paramedic rapid sequence intubation on outcome in patients with severe traumatic brain injury.
Davis DP, Hoyt DB, Ochs M, Fortlage D, Holbrook T, Marshall LK, Rosen P.
J Trauma. 2003 Mar;54(3):444-53.
PMID: 12634522 [PubMed – indexed for MEDLINE]

Bernard SA, Nguyen V, Cameron P, Masci K, Fitzgerald M, Cooper DJ, Walker T, Std BP, Myles P, Murray L, David, Taylor, Smith K, Patrick I, Edington J, Bacon A, Rosenfeld JV, & Judson R (2010). Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury: a randomized controlled trial. Annals of surgery, 252 (6), 959-65 PMID: 21107105

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Comments

  1. If only we could all be on the same page. Everyone has their own recipe.

    • ErRanter,

      If only we could all be on the same page. Everyone has their own recipe.

      I don’t have any problem with different recipes, as long as those recipes work well.

      Uniformity is only a good thing, when things are uniformly excellent.

      Too often, we choose uniformity over excellence.

      I would like to know what method they used to produce such good results in so little time.

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