Mortality after trauma intubation without drugs in Scottish emergency departments

doi:10.1016/j.resuscitation.2005.10.025

Resuscitation

Volume 69, Issue 3, June 2006, Pages 395-397

https://doi.org/10.1016/j.resuscitation.2005.10.025 Get rights and content

Summary

Background

Trauma patients who are intubated without anaesthetic drugs in the pre-hospital phase of care have universally poor outcomes. This study aimed to determine the mortality of trauma patients intubated without drugs in emergency departments in Scotland.

Methods

This retrospective cohort study used the prospective Scottish Trauma Audit Group (STAG) database to identify how many patients were intubated and how many required drugs for intubation between 1 January 1999 and 31 December 2002. The mortality of those intubated with drugs and without drugs was determined from the database.

Results

24,756 patients were included in the STAG database. There were 1469 intubations: 1287 with drugs and 182 without drugs. 92.5% of all intubations were for blunt trauma. There was no difference in the proportion of males or median age between groups. Median GCS was 8 (E1M5V2) in the drugs group and 3 (E1M1V1) in the no drugs group (p < 0.001). Median ISS was higher in those intubated without drugs (33 versus 25, p < 0.001). Median RTS and probability of survival were lower in those intubated without drugs (both p < 0.001). Mortality was higher in those intubated without drugs (91.2% versus 29.4%, p < 0.001). Sixteen patients, intubated without drugs, survived. These patients had a higher median respiratory rate (9 versus 0, p = 0.013) and higher median systolic blood pressure (80 mmHg versus 0 mmHg, p = 0.041) than non-survivors.

Conclusion

Trauma patients in Scottish emergency departments who are intubated without drugs have high mortality rates. Outcomes are not universally fatal and aggressive resuscitation efforts may be of benefit to a small number of such patients.

Introduction

Effective airway management is the cornerstone of major trauma management.¹ Tracheal intubation is regarded as the gold standard for airway management in the emergency department (ED) for trauma patients who have a Glasgow Coma Scale (GCS) score ≤ 8.² Previous work from the United Kingdom³ and Denmark⁴ has shown the futility of tracheal intubation without drugs in the prehospital setting for patients with trauma.

Experience and anecdotal evidence suggests that trauma patients who can be intubated without anaesthetic drugs in the ED have a poor outcome. The aim of this study was to investigate the mortality of trauma patients who were intubated without drugs in the ED setting in Scotland.

Section snippets

Material and methods

The Scottish Trauma Audit Group (STAG) database collected data prospectively on the majority of trauma patients reaching hospital alive in Scotland between 1992 and 2002. Data has been collected on tracheal intubation in the ED since 1998.⁵ This data included whether or not the patient was intubated; speciality of the intubator; use of anaesthetic drugs; GCS score on ED admission; physiological variables (respiratory rate, systolic blood pressure); mortality (patients were followed up to

Results

During the 4-year study period, 24,756 patients were enrolled into the STAG database. 1469 patients were intubated, 1287 (87.6%) with drugs and 182 (12.4%) without drugs. 1359 intubations (92.5%) were for blunt trauma. The two groups were comparable in terms of age and sex (Table 1).

Of 151 patients who were GCS 3 on arrival and were intubated without drugs, 13 survived (8.6%). The survivors had higher median systolic blood pressure (112 mmHg versus 0 mmHg, p = 0.013), higher median respiratory rate

Discussion

8.8% of patients intubated without drugs in the ED following trauma survived in our study. Previous studies in prehospital settings (including physician and paramedic intubation) have suggested that fewer patients survive (95% CI 0.2–8%). It is possible that there is a population of severely injured patients who reach the ED at the limit of physiological compensation who may benefit from aggressive resuscitation.

Although trauma patients who are intubated without drugs have a demonstrably high

Conclusions

Trauma patients who are intubated without drugs have a very high mortality, but it suggests that intensive resuscitation efforts in the ED may yield occasional survivors in this critically injured population.

Conflict of interest

All three authors have no conflicts of interest to declare with respect to this paper.

Acknowledgements

We thank the Director of STAG, Diana Beard, and all the staff of STAG for collecting and recording the data that formed the STAG database. We also thank the Consultants and Specialist Registrars in Emergency Medicine throughout the hospitals contributing to STAG for their help in checking data at their centres. Details of contributors: Colin Graham had the original idea, designed the study, collected data, drafted and edited the manuscript. Gary Wares assisted in study design, data collection

References (5)

R.M. Walls
Management of the difficult airway in the trauma patient
Emerg Med Clin North Am
(1998)
Advanced Trauma Life Support Student Manual
(1997)

There are more references available in the full text version of this article.

Cited by (5)

Intubation of emergency traumatic head injury patient outside the operation theatre: Cross-sectional study
2020, International Journal of Surgery Open
Citation Excerpt :
Intubation after sedatives administration in this study was 72% but it needs to be improved. A retrospective cohort study in Scottish to determine mortality in the emergency department patients who were intubated without drug administration have higher mortality rates (91.2%) than patients intubated after drug administration (29.4%) [24]. Generally, in UOGCSH there was no application of a traumatic patient intubation standard so after this study, the intubation should be with the application of this standard.
Immediate and effective airway management is a priority to save the victim's life. Maintaining a patent airway and ensuring adequate oxygenation is vital to protect the patient from secondary injury due to hypoxia.
This study was aimed to assess the practice of emergency traumatic brain injury patient intubation outside the operation theatre.
This study was conducted from 1^st September 2018 to February 28, 2019. All trauma patients that were admitted to the emergency department were included. The data was collected by a standardized questionnaire prepared from the recommendations of an Eastern Association for the surgery of trauma practice, by direct observation while performing the procedure and reviewing the patient's chart for any drug given and any documented procedure.
A total of 75 trauma patients intubation was observed during the study period. All of the patients were successfully intubated but the standards of maintaining hemodynamic stability, administration of vomiting prophylaxis, and application of capnograph had nil performance. Rapid sequence intubation and maintenance of cervical spine mobility were underperformed.
Even though emergency intubations were successfully performed most of the standards of intubation did not meet the criteria, and it needs improvement. Regarding the findings of this audit emergency, traumatic patient intubation needs to be improved in line with the standards for a better patient outcome to avoid secondary injury.
The European Trauma Course (ETC) and the team approach: Past, present and future
2009, Resuscitation
Citation Excerpt :
The main attributes of such a team are well recognised: competent team members, good leadership9,10 and excellent cooperation between all the medical specialists involved.11–13 To achieve these, team co-ordination is as important as the adequate performance of separate skills14–17 or the implementation of evidence-based guidelines.18 To address these educational needs an international Working Group was established on behalf of the European Resuscitation Council (ERC), consisting of members of the European Society of Trauma and Emergency Surgery (ESTES), the European Society of Emergency Medicine (EuSEM), and the European Society of Anaesthesiology (ESA).
The European Trauma Course (ETC) was officially launched during the international conference of the European Resuscitation Council (ERC) in 2008. The ETC was developed on behalf of ESTES (European Society of Trauma and Emergency Surgery), EuSEM (European Society of Emergency Medicine), the ESA (European Society of Anaesthesiology) and the ERC. The objective of the ETC is to provide an internationally recognised and certified life support course, and to teach healthcare professionals the key principles of the initial care of severely injured patients. Its core elements, that differentiates it from other trauma courses, are a strong focus on team training and a novel modular design that is adaptable to the differing regional European requirements.
This article describes the lessons learnt during the European Trauma Course development and provides an outline of the planned future development.
In this issue
2006, Resuscitation
The impact of minimum unit pricing on traumatic brain injury in Scotland: a retrospective cohort study of routine national data
2023, British Journal of Neurosurgery
European trauma course
2009, Notfall und Rettungsmedizin

^☆: A Spanish translated version of the summary of this article appears as Appendix in the online version at 10.1016/j.resuscitation.2005.10.025.

View full text

Clinical paperMortality after trauma intubation without drugs in Scottish emergency departments☆

Summary

Background

Methods

Results

Conclusion

Introduction

Section snippets

Material and methods

Results

Discussion

Conclusions

Conflict of interest

Acknowledgements

Emerg Med Clin North Am

Advanced Trauma Life Support Student Manual

Clinical paper
Mortality after trauma intubation without drugs in Scottish emergency departments☆