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Increased Mortality With Prehospital Intubation

September 15, 2017

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Numerous observational studies have suggested that prehospital intubation (PHI) (in this case of trauma patients) was associated with greater mortality than when it was done in the ED, and this systematic review indicated the same thing.

Why does this matter?
Many of you are EMS professionals or medical directors.  This evidence is concerning.  Until we have a clearer picture, intubation in the prehospital setting should probably be viewed as a last resort.  The relative infrequency of the procedure for most EMS personnel makes it very difficult to maintain this complex skill set.

In general, don’t tube ’em in the field.
This was a systematic review of 21 studies looking at prehospital vs emergency department intubation of trauma patients.  They found the pooled mortality rate for patients intubated prehospital was 48% as opposed to 29% in the ED.  This could simply be confounded, and prehospital intubation was a marker for more severely ill patients who would have had higher mortality regardless.  Overall, quality of the studies was low, largely retrospective observational.  The only RCT showed no difference in mortality, a trend toward improved mortality, and improved neurological outcome with PHI; it was not powered to detect a mortality difference. But most of the evidence we have, though low quality, suggests that avoidance of intubation for trauma patients in the field should be preferred.  It is not a simple procedure, and error leads to death or serious morbidity.

A systematic review and meta-analysis comparing mortality in pre-hospital tracheal intubation to emergency department intubation in trauma patients.  Crit Care. 2017 Jul 31;21(1):192. doi: 10.1186/s13054-017-1787-x.

What are your thoughts?