A Comparison of Invasive Airway Management and Rates of Pneumonia in Prehospital and Hospital Settings

Abstract Introduction. Infection is a major cause of morbidity and mortality in trauma. Infection in trauma is poorly understood. The impact of prehospital invasive airway management (IAM) on the incidence of pneumonia and health services utilization is unknown. We hypothesized that trauma patients exposed to prehospital IAM will suffer higher rates of pneumonia compared to no IAM or exposure to IAM performed in the hospital. We hypothesized that patients who develop pneumonia subsequent to prehospital IAM will have longer intensive care unit (ICU) and hospital length of stay (LOS) compared to patients who acquired pneumonia after IAM performed in the hospital. Methods. This is an observational cohort study of data previously collected for the Resuscitation Outcomes Consortium hypertonic resuscitation randomized trial. Patients were included if traumatic injury resulted in shock, traumatic brain injury, or both. Patients were excluded if they died 24 hours after injury, or pneumonia data were missing. Adjusted and unadjusted logistic regression was used to calculate the odds ratio of pneumonia if exposed in the prehospital setting compared to no exposure or exposure in the hospital. Results. Of 2,222 patients enrolled in the hypertonic resuscitation trial, 1,676 patients met enrollment criteria for this study. Four and a half percent of patients suffered pneumonia. IAM in the prehospital setting resulted in 6.8-fold increase (C.I. 2.0, 23.0, p = 0.003) in the adjusted odds of developing pneumonia compared to not being intubated, while in-hospital intubation resulted in 4.8-fold increase (C.I. 1.4, 16.6, p = 0.01), which was not statistically significantly different to the odds ratio of prehospital IAM. There were no statistically significant increases in health services utilization resulting from pneumonia incurred after IAM. Conclusion. Exposure to IAM in prehospital and hospital settings results in an increase in pneumonia, but there does not appear to be a link between the source of pneumonia and an increase in ICU or hospital LOS. Keywords: emergency medical services; endotracheal intubation; pneumonia; infection; health services utilization

[1]  J. Minei,et al.  Early nonbronchoscopic bronchoalveolar lavage: Predictor of ventilator-associated pneumonia? , 2013, The journal of trauma and acute care surgery.

[2]  D. Schoenfeld,et al.  Benchmarking Outcomes in the Critically Injured Trauma Patient and the Effect of Implementing Standard Operating Procedures , 2012, Annals of surgery.

[3]  R. Tompkins,et al.  The changing pattern and implications of multiple organ failure after blunt injury with hemorrhagic shock* , 2012, Critical care medicine.

[4]  Z. Basrai.  Prehospital Rapid Sequence Intubation Improves Functional Outcome for Patients with Severe Traumatic Brain Injury , 2011 .

[5]  I. Stiell,et al.  Out-of-hospital Hypertonic Resuscitation After Traumatic Hypovolemic Shock: A Randomized, Placebo Controlled Trial , 2011, Annals of surgery.

[6]  Mark Fitzgerald,et al.  Prehospital Rapid Sequence Intubation Improves Functional Outcome for Patients With Severe Traumatic Brain Injury: A Randomized Controlled Trial , 2010, Annals of surgery.

[7]  Vafa Ghaemmaghami,et al.  Changing Epidemiology of Trauma Deaths Leads to a Bimodal Distribution , 2010, Proceedings.

[8]  G. Mcgwin,et al.  Reassessment of the tri-modal mortality distribution in the presence of a regional trauma system. , 2009, The Journal of trauma.

[9]  L. Morrison,et al.  Hypertonic resuscitation: design and implementation of a prehospital intervention trial. , 2008, Journal of the American College of Surgeons.

[10]  G. Guyatt,et al.  A systematic review of studies comparing health outcomes in Canada and the United States , 2007, Open medicine : a peer-reviewed, independent, open-access journal.

[11]  D. Davis,et al.  A Descriptive Analysis of Emergency Medical Service Systems Participating in the Resuscitation Outcomes Consortium (ROC) Network , 2007, Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors.

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

[13]  Jonathan Cohen,et al.  The International Sepsis Forum Consensus Conference on Definitions of Infection in the Intensive Care Unit , 2005, Critical care medicine.

[14]  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.

[15]  J. Stockman.  Out-of-Hospital Hypertonic Resuscitation Following Severe Traumatic Brain Injury: A Randomized Controlled Trial , 2012 .