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Current guidelines call for treating traumatic brain injury patients with aggressive measures to prevent hypoxia (insufficient oxygen reaching the body's tissues), including the use of endotracheal intubation. Controversial advanced airway management techniques, including use of neuromuscular blockade-assisted endotracheal intubation, make it possible for paramedics to perform out-of-hospital intubation of these patients.
According to a recent study, individuals suffering from traumatic brain injury who are intubated by paramedics out of the hospital are four times as likely to die and nearly twice as likely to be functionally impaired as those who undergo the procedure in a hospital emergency department (ED). The study was supported by the Agency for Healthcare Research and Quality (HS13628) and led by Henry E. Wang, M.D., M.P.H., of the University of Pittsburgh School of Medicine.
Dr. Wang and his colleagues used a registry of patients treated at Pennsylvania trauma centers from 2000 to 2002 to examine the outcomes of 4,098 patients with a head/neck Abbreviated Injury Scale score of 3 or greater, who underwent out-of-hospital or ED endotracheal intubation. They examined the following outcomes: death, neurologic outcome (good versus poor, inferred from discharge to home versus a long-term care facility), and functional outcome.
In examining the impact of intubation site on outcomes, the researchers adjusted for other factors that might affect outcome. These included mode of transport to the hospital (ground versus helicopter), use of out-of-hospital neuromuscular blocking agents, and severity of injury. Overall 44 percent of patients were intubated out of the hospital, and 56 percent were intubated in the ED. Odds of death were 4 times higher for patients intubated out of the hospital. These patients also had higher odds of poor neurologic outcome and/or moderate or severe functional impairment.
Details are in "Out-of-hospital endotracheal intubation and outcome after traumatic brain injury," by Dr. Wang, Andrew B. Peitzman, M.D., Laura D. Cassidy, Ph.D., and others, in the November 2004 Annals of Emergency Medicine 44(5), pp. 439-450.
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