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PHARM Podcast 88 – Prehospital airway and TBI

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Today on the podcast,  I discuss prehospital airway management and severe head injury.

Take home messages:

  1. Hypoxia is not good for severe head injuries
  2. Even a short period of hypoxia or reduced oxygenation during a prehospital airway intervention maybe enough to worsen outcome
  3. Consider methods of maintaining oxygenation during any airway intervention for severe head injury e.g NODESAT, sedation only/spontaneous breathing methods of intubation…maybe the blind nasotracheal intubation will make a come back! ..maybe not too!

SHOW NOTES:

  1. Is Prehospital Endotracheal Intubation Associated with Improved Outcomes In Isolated Severe Head Injury? A Matched Cohort Analysis.
  2. Anaesthesiologist-provided prehospital airway management in patients with traumatic brain injury: an observational study.
  3. Outcomes following prehospital airway management in severe traumatic brain injury
  4. Prehospital Rapid Sequence Intubation Improves Functional Outcome for Patients With Severe Traumatic Brain Injury -A Randomized Controlled Trial
  5. Head Injury Retrieval Trial results – presentation slides by Dr Alan Garner

Podcast ( available here and on iTunes)

Right Click and Choose Save-as to Download the Podcast.

9 Comments Post a comment
  1. Matt King #

    Hey Minh thanks for taking the time to create this podcast. Lots of questions to still be answered. I’m gonna go out on a limb here and I may be wrong, but it seems like there could be a large difference in how each service in the US and around the world approaches airway management. My questions are how is airway Mx. approached from service to service? What is the initial training like? What does the continued training consist of and how often? Do they approach AW Mx. with a PT safety oriented approach? Are they fixing hypoxia and BPs appropriately prior to RSI? Are they using appropriate medications and doses? Have they adopted ApOx during RSI? Are they constatly training in AW resuscitation? Do they use checklists? Are they placing PTs on a ventilator with appropriate settings? I personally feel that if they are not accomplishing all of the above then yes there is a high chance that PTs will suffer unnecesarily. This is a no brainer. This happens all the time in ERs too. I have seen it many times through my own eyes.

    With that said, I feel the weight of this falls on the shoulders of all EMS involved, but mainly the medical directors of each service. They ultimately decide what kind of care their clinicians provide. So technically it is up to them to make sure that all of the above is accomplished. Yes it is a lot to do, but then again we are taking care of human beings, and so we have a lot to lose. In the end it is not our fault our PTs are sick or injured, but it is our fault if we screw up the care we give. My number is “Zero”… And that number represents my acceptable number of unnecesary adverse patient events we create. It is accomplishable! What are your thoughts?

    Matt

    January 4, 2014
  2. Matt King #

    Minh sorry, but erase my first post. Had to edit it. Thanks!

    January 4, 2014
  3. Mmmm…checklists. Well done that man.

    January 4, 2014
  4. Thanks Minh!

    Despite being a terrible, terrible laryngascopist my not-so-secret-love is RSI, which just happens to be perfect for traumatic brain injury.

    I’m going to say there is no controversy in prehospital airway management for traumatic brain injury as

    (1) If you are so unconscious you can be intubated without medicines then your mortality is going to be very high regardless of whether you are intubated and intubating likely increases your mortality.

    (2) RSI done well has shown to decrease morbidity and mortality in patients who have traumatic brain injury. It has also been shown safe in the hands of Paramedics provided they are very carefully selected, highly trained and get regular ongoing exposure with a high quality method (protocol)

    Basic airway care with a focus on high quality ventilation (i.e. not ventilating the buggery out of everybody with huge tidal volumes) is obviously best because you avoid all the risks associated with intubation including significant risk of desaturation during laryngascopy (however I acknowledge apnoeic oxygenation seems to overcome this problem …)

    A good well fitting LMA will probably achieve the same endpoints as an endotracheal tube provided ventilation is satisfactory and not overdone; particularly as it will tackle the hypoxia and hypercarbia.

    Take home point seems to reinforce what we already know; basic airway care done well is likely just as good if not better than RSI … of course that doesn’t mean there is not a place for RSI.

    January 8, 2014
  5. Hi Minh,
    Great podcast & discussion.

    With regards to the Karamanos paper from UCLA (I’m asking the following based on the abstract & your discussion as I can’t seem to get my hands on the full manuscript)…

    1) My first take on the numbers was that the sicker patients were the ones who needed intubation & could not safely be transported to hospital without a definitive airway. Hence the higher ISS, HLOS & ICU LOS ?
    – Does the pure NEED FOR INTUBATION predict worse outcomes ?

    2) Whilst statistically significant, do you think the PaO2 difference has any clinical significance or bares any influence on the actual patient outcome?
    – Assuming we are discussing ‘mmHg'; in a time when ‘too much O2 can be too much of a good thing’ does 187 vs 213 really demonstrate clinical harm ? Surely both are better than 400mmHg & 40mmHg ??

    3) Was there any review of pre-hospital observations, looking at either true hypoxia (or was it purely extrapolated from the lower-PaO2 ?) or hypotension ??

    I’d be interested in hearing your thoughts,
    Chris.

    January 10, 2014
    • thanks Chris for the comments and questions!
      the difference in PaO2 whilst statistically significant does seem not all that remarkable to explain the mortality difference. The theory is that the difference reflects a period of hypoxia during the perintubation phase prehospital in which the brain injury was worsened. no causal proof of that though in this study,
      there might be another explanation of course as you suggest. it is a matched retrospective analysis so despite attempts the matching maybe imprecise. another explanation maybe that the prehospital intubation caused short hypotensive period that is not captured in the data
      the fact is that the prehospital intubation seemed to produce a worse outcome overall ..why? could be all those reasons combined.

      they tried to control for this issue of more injured patients needing prehospital intubation by fancy statistics and a 3:1 ratio of groups.

      despite a larger group of unintubated controls with similar ISS, the prehospital ETI group still did worse.

      January 10, 2014
    • work from Davis shows that there is an association between lowish and highish PaO2 and outcomes in TBI
      his work suggested the sweet spot range starts at around 110mmHg and peaks around 200-350
      so certainly these results are plausible to show a difference.

      http://www.ncbi.nlm.nih.gov/pubmed/19811093

      January 10, 2014
  6. Jeff DeChellis #

    Minh –

    Very interesting Podcast. I am a little unclear as to why you feel as though lower PaO2s upon arrival to the hospital might be due to transient hypoxia experienced durign the RSI procedure itself. I would think if the same Fio2s were used post-intubation during transport, that by the time the ABG was drawn, evidence of the referenced transient hypoxia would be long gone, no? Thanks

    January 10, 2014
    • thanks Jeff
      it does seem weird as you would expect the prehospital ETI group to have higher PaO2 values but thats what they found.
      either the data is inaccurate or the patients in the prehosp ETI group had more lung injuries and so could not be oxygenated as well or something happened during the prehosp ETI that caused more hypoxia..maybe aspiration occurred but they say that rates of pneumonia during admission were no different.

      it is certainly plausible though that there is an ideal range of PaO2 for best TBI outcomes and maybe prehospital ETI is challenged to achieve that!

      January 10, 2014

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