Paramedic Rapid Sequence Intubation for Severe Traumatic Brain Injury: Perspectives from an Expert Panel

Although early intubation has become standard practice in the prehospital management of severe traumatic brain injury (TBI), many patients cannot be intubated without neuromuscular blockade. Several emergency medical services (EMS) systems have implemented paramedic rapid sequence intubation (RSI) protocols, with published reports documenting apparently conflicting outcomes effects. In response, the Brain Trauma Foundation assembled a panel of experts to interpret the existing literature regarding paramedic RSI for severe TBI andoffer guidance for EMS systems considering adding this skill to the paramedic scope of practice. The interpretation of this panel can be summarized as follows: (1) the existing literature regarding paramedic RSI is inconclusive, andapparent differences in outcome can be explained by use of different methodologies andvariability in comparison groups; (2) the use of Glasgow Coma Scale score alone to identify TBI patients requiring RSI is limited, with additional research needed to refine our screening criteria; (3) suboptimal RSI technique as well as subsequent hyperventilation may account for some of the mortality increase reported with the procedure; (4) initial andongoing training as well as experience with RSI appear to affect performance; and(5) the success of a paramedic RSI program is dependent on particular EMS andtrauma system characteristics.

[1]  D. Yealy,et al.  Defining the Learning Curve for Paramedic Student Endotracheal Intubation , 2005, Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors.

[2]  J. Miner,et al.  End-tidal carbon dioxide monitoring during procedural sedation. , 2002, Academic emergency medicine : official journal of the Society for Academic Emergency Medicine.

[3]  S. Leder.  Gag reflex and dysphagia , 1996, Head & neck.

[4]  J. Adams,et al.  Ischaemic brain damage in fatal non-missile head injuries , 1978, Journal of the Neurological Sciences.

[5]  I. Frew,et al.  The role of respiratory insufficiency in the mortality of severe head injuries. , 1958, Lancet.

[6]  D. Cone,et al.  A prospective study of the quality of pre-hospital emergency ventilation in patients with severe head injury. , 2003, British Journal of Anaesthesia.

[7]  M. Copass,et al.  An analysis of advanced prehospital airway management. , 2002, The Journal of emergency medicine.

[8]  D. Davis,et al.  Incidence of transient hypoxia and pulse rate reactivity during paramedic rapid sequence intubation. , 2003, Annals of emergency medicine.

[9]  D. Davis,et al.  The use of quantitative end-tidal capnometry to avoid inadvertent severe hyperventilation in patients with head injury after paramedic rapid sequence intubation. , 2004, The Journal of trauma.

[10]  M. Copass,et al.  The use of neuromuscular blocking agents to facilitate prehospital intubation does not impair outcome after traumatic brain injury. , 2005, The Journal of trauma.

[11]  D. Davis,et al.  Paramedic-performed rapid sequence intubation of patients with severe head injuries. , 2002, Annals of emergency medicine.

[12]  J. Hedges,et al.  Succinylcholine-assisted intubations in prehospital care. , 1988, Annals of emergency medicine.

[13]  J. Macmahon,et al.  Pharyngeal sensation and gag reflex in healthy subjects , 1995, The Lancet.

[14]  F. Carlton,et al.  The bispectral index monitor: a new tool for air medical personnel. , 2001, Air medical journal.

[15]  N. Mcswain,et al.  Prehospital endotracheal intubation for trauma does not improve survival over bag-valve-mask ventilation. , 2004, The Journal of trauma.

[16]  J. Atkinson,et al.  The neglected prehospital phase of head injury: apnea and catecholamine surge. , 2000, Mayo Clinic proceedings.

[17]  D. Steele,et al.  Capnography during sedation/analgesia in the pediatric emergency department. , 2000, Pediatric emergency care.

[18]  Thomas M Scalea,et al.  Endotracheal intubation in the field does not improve outcome in trauma patients who present without an acutely lethal traumatic brain injury. , 2003, The Journal of trauma.

[19]  D. Davis,et al.  The predictive value of field versus arrival Glasgow Coma Scale score and TRISS calculations in moderate-to-severe traumatic brain injury. , 2006, The Journal of trauma.

[20]  D. Demetriades,et al.  Prehospital intubation in patients with severe head injury. , 2000, The Journal of trauma.

[21]  K. J. Dalton,et al.  Artificial neural networks for decision support in clinical medicine. , 1995, Annals of medicine.

[22]  D. Davis,et al.  The association between field Glasgow Coma Scale score and outcome in patients undergoing paramedic rapid sequence intubation. , 2005, The Journal of emergency medicine.

[23]  D. Lockey,et al.  Survival of trauma patients who have prehospital tracheal intubation without anaesthesia or muscle relaxants: observational study , 2001, BMJ : British Medical Journal.

[24]  S. Teramoto,et al.  Detection of aspiration and swallowing disorder in older stroke patients: simple swallowing provocation test versus water swallowing test. , 2000, Archives of physical medicine and rehabilitation.

[25]  David B Hoyt,et al.  The effect of paramedic rapid sequence intubation on outcome in patients with severe traumatic brain injury. , 2003, The Journal of trauma.

[26]  J. Brokloff.  Endotracheal intubation in the field improves survival in patients with severe head injury , 1997 .

[27]  D. Davis,et al.  A follow-up analysis of factors associated with head-injury mortality after paramedic rapid sequence intubation. , 2005, The Journal of trauma.

[28]  D. Davis,et al.  The impact of hypoxia and hyperventilation on outcome after paramedic rapid sequence intubation of severely head-injured patients. , 2004, The Journal of trauma.

[29]  Henry E. Wang,et al.  Differential effects of out-of-hospital interventions on short- and long-term survival after cardiopulmonary arrest. , 2005, Resuscitation.

[30]  Steven M Green,et al.  Interrater reliability of Glasgow Coma Scale scores in the emergency department. , 2004, Annals of emergency medicine.

[31]  C. Buechler,et al.  Variation among trauma centers' calculation of Glasgow Coma Scale score: results of a national survey. , 1998, The Journal of trauma.

[32]  J. Ghajar,et al.  Predictors of compliance with the evidence-based guidelines for traumatic brain injury care: a survey of United States trauma centers. , 2002, The Journal of trauma.

[33]  D. Davis,et al.  Paramedic-administered neuromuscular blockade improves prehospital intubation success in severely head-injured patients. , 2003, The Journal of trauma.

[34]  David R. Miller,et al.  Emergency Medical Services Outcomes Project (EMSOP) II: developing the foundation and conceptual models for out-of-hospital outcomes research. , 2001, Annals of emergency medicine.

[35]  S. Fakhry,et al.  Prehospital rapid sequence intubation for head trauma: conditions for a successful program. , 2004, The Journal of trauma.

[36]  David Sibbritt,et al.  The Effective Use of a Summary Table and Decision Tree Methodology to Analyze Very Large Healthcare Datasets , 2004, Health care management science.

[37]  E. Lerner,et al.  Guidelines for Prehospital Management of Traumatic Brain Injury 2nd Edition , 2008, Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors.

[38]  M. Biros,et al.  Bispectral electroencephalographic analysis of head-injured patients in the emergency department. , 2004, Academic emergency medicine : official journal of the Society for Academic Emergency Medicine.

[39]  E. Mackenzie,et al.  Management of severe head injury: Institutional variations in care and effect on outcome* , 2002, Critical care medicine.

[40]  X. Combes,et al.  Prehospital standardization of medical airway management: incidence and risk factors of difficult airway. , 2006, Academic emergency medicine : official journal of the Society for Academic Emergency Medicine.

[41]  Colleen Buono,et al.  The impact of aeromedical response to patients with moderate to severe traumatic brain injury. , 2005, Annals of emergency medicine.

[42]  D. Davis,et al.  The ability of paramedics to predict aspiration in patients undergoing prehospital rapid sequence intubation. , 2006, The Journal of emergency medicine.

[43]  D. Marion,et al.  Problems with initial Glasgow Coma Scale assessment caused by prehospital treatment of patients with head injuries: results of a national survey. , 1994, The Journal of trauma.

[44]  J. Falk,et al.  Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. , 2001, Annals of emergency medicine.

[45]  M. Gratton,et al.  Effect of paramedic experience on orotracheal intubation success rates. , 2003, The Journal of emergency medicine.

[46]  C. Chudnofsky,et al.  The effect of paramedic rapid sequence intubation on outcome in trauma patients , 2004, Annals of Emergency Medicine.

[47]  D. Davis,et al.  Air medical transport of severely head-injured patients undergoing paramedic rapid sequence intubation. , 2004, Air medical journal.

[48]  David R. Miller,et al.  Emergency Medical Services Outcomes Project III (EMSOP III): the role of risk adjustment in out-of-hospital outcomes research. , 2002, Annals of emergency medicine.

[49]  R. Maier,et al.  A comparison of prehospital and hospital data in trauma patients. , 2004, The Journal of trauma.

[50]  R. Walls.  Rapid-sequence intubation in head trauma. , 1993, Annals of emergency medicine.

[51]  J. Bazarian,et al.  The relationship between pre-hospital and emergency department Glasgow coma scale scores , 2003, Brain injury.

[52]  A. Marmarou,et al.  Characterization of edema by diffusion-weighted imaging in experimental traumatic brain injury. , 1996, Journal of neurosurgery.

[53]  M A Foulkes,et al.  The role of secondary brain injury in determining outcome from severe head injury. , 1993, The Journal of trauma.

[54]  J. Adams,et al.  Ischaemic brain damage is still common in fatal non-missile head injury. , 1989, Journal of neurology, neurosurgery, and psychiatry.

[55]  S J Stratton,et al.  Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial. , 2000, JAMA.

[56]  D. Davis,et al.  Ventilation patterns in patients with severe traumatic brain injury following paramedic rapid sequence intubation , 2005, Neurocritical care.

[57]  D. Davis,et al.  Early ventilation and outcome in patients with moderate to severe traumatic brain injury* , 2006, Critical care medicine.

[58]  D. Davis,et al.  The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injury. , 2005, The Journal of trauma.

[59]  D. Dries,et al.  Introduction of pulse oximetry in the air medical setting. , 1991, The Journal of air medical transport.

[60]  R E Stephens,et al.  Assessing the laryngeal cough reflex and the risk of developing pneumonia after stroke. , 1999, Archives of physical medicine and rehabilitation.

[61]  J. Adams,et al.  Ischaemic brain damage in fatal head injuries. , 1971, Lancet.

[62]  Henry E. Wang,et al.  Out-of-hospital endotracheal intubation and outcome after traumatic brain injury. , 2004, Annals of emergency medicine.

[63]  E. Christensen,et al.  Prehospital tracheal intubation in severely injured patients: a Danish observational study , 2003, BMJ : British Medical Journal.

[64]  M. Wayne,et al.  Prehospital use of succinylcholine: a 20-year review. , 1999, Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors.

[65]  D. Hoyt,et al.  Endotracheal intubation in the field improves survival in patients with severe head injury. Trauma Research and Education Foundation of San Diego. , 1997, Archives of surgery.

[66]  D. Davis,et al.  Noninvasive capnometry for continuous monitoring of mental status: a tale of 2 patients. , 2006, American Journal of Emergency Medicine.

[67]  J. Pelensky.  Ischemic brain damage is still common in fatal nonmissile head injury , 1990 .

[68]  D. Hoyt,et al.  Rapid sequence intubation in the field versus hospital in trauma patients. , 2000, The Journal of emergency medicine.