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Outcome in patients with traumatic brain injury (TBI) was better in patients with prehospital intubation (PHI), but most of the intubations were performed by air transport crews.
Why does this matter?
Prior observational, largely retrospective studies have shown PHI may worsen outcome. There have been questions as to whether placement of a supraglottic airway in the prehospital setting was helpful, though yesterday’s study was reassuring. Specifically, regarding PHI for TBI, observational data has shown a strong negative association with PHI and good neurological outcome and mortality. This study sheds more light on the subject.
PROTECT III your brain
PROTECT III was a multi-center RCT of progesterone in TBI patients that showed no improvement with treatment vs. placebo. The authors used this dataset for their study, with the hypothesis that PHI would be associated with worse outcomes. They were surprised to learn that, in fact, PHI was associated with improved mortality and neurologically favorable outcomes. More patients with PHI had a favorable neurological outcome than those who were not intubated, 57.3% vs. 46.0%, p = 0.003, respectively, and “odds of dying for those with prehospital intubation were 47% lower than for those that were not intubated.” But the groups were not well matched when stratified by PHI (rather than the initial study intent, progesterone vs placebo). 80% of those with PHI came by air; 91% without PHI came by ground. So what this study may be measuring is the beneficial effect of prehospital airway management in TBI by highly trained and skilled aeromedical personnel. The downside of this paper is that it is still, in effect, a retrospective observational study. They used rigorously and prospectively collected data, but the intent of the original study tested progesterone use in TBI and was not designed or powered to assess the effect on intubation on outcome. The take home for me is that if a highly trained aeromedical crew performs intubation for head injured patients, this is probably beneficial to the patient. Whether or not this holds true for ground crews remains to be seen.
Source
Prehospital Intubation is Associated with Favorable Outcomes and Lower Mortality in ProTECT III. Prehosp Emerg Care. 2017 Sep-Oct;21(5):539-544. doi: 10.1080/10903127.2017.1315201. Epub 2017 May 10.
Peer reviewed by Thomas Davis, MD
"The take home for me is that if a highly trained aeromedical crew performs intubation for head injured patients, this is probably beneficial to the patient. Whether or not this holds true for ground crews remains to be seen."
The key there is "highly trained." The Aussies have already shown a benefit in ground crews (the study specifically excluded flown patients from eligibility)…but intubation was limited to a fraction of them with advanced training (<20%), whereas the other 80% used LMAs and no RSI.
Benard SA et al. Annals of surgery, 2010; 252(6), 959-65. http://www.emottawa.ca/assets_secure/journal_club/articles/April%2011_3_Bernard%20RSI%20dec%202010.pdf
Yes, it’s not being in a helicopter that makes them successful, it’s the intense training most flight crews receive. Thanks for the reference. So we could take home that prehospital intubation in the hands of a highly trained provider improves outcome.