Intubation of Pediatric Trauma Patients in the Field: Predictor of Negative Outcome Despite Risk Stratification

DiRusso, Stephen; Sullivan, Thomas; Risucci, Donald A.; Nealon, Peter; Slim, Michel S.

doi:10.1097/01.ta.0000171462.28379.f3

Cited by 65 publications

(33 citation statements)

References 18 publications

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“…However, a correlation was drawn between severity of injury and increased likelihood of survival with direct transfer to a trauma centre. 12 With this study it is difficult to draw rational conclusions as to the benefits of direct transport of patients from the scene to either a neurosciences unit or general hospital, as there is doubt caused by retrospective definition of head injury and whether multiply injured patients were included. The other study showed that the mortality rate of immediate transfer to a neurosciences centre was more favourable (not significant).…”

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confidence: 99%

“…The cohort compared three branches defined by the site of intubation: field, trauma centre or non-trauma centre. 12 Taking data from the last two branches, risk stratification was performed; degree of head injury was measured using the New Injury Severity Score and Relative Head Injury Severity Scale. No significant differences were found between the two scales or the place of intubation.…”

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confidence: 99%

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The Head Injury Transportation Straight to Neurosurgery (HITS-NS) randomised trial: a feasibility study

Lecky

Russell

Fuller

et al. 2016

Health Technol Assess

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BackgroundReconfiguration of trauma services, with direct transport of traumatic brain injury (TBI) patients to neuroscience centres (NCs), bypassing non-specialist acute hospitals (NSAHs), could potentially improve outcomes. However, delays in stabilisation of airway, breathing and circulation (ABC) and the difficulties in reliably identifying TBI at scene may make this practice deleterious compared with selective secondary transfer from nearest NSAH to NC. National Institute for Health and Care Excellence guidance and systematic reviews suggested equipoise and poor-quality evidence – with regard to ‘early neurosurgery’ in this cohort – which we sought to address.MethodsPilot cluster randomised controlled trial of bypass to NC conducted in two ambulance services with the ambulance station (n = 74) as unit of cluster [Lancashire/Cumbria in the North West Ambulance Service (NWAS) and the North East Ambulance Service (NEAS)]. Adult patients with signs of isolated TBI [Glasgow Coma Scale (GCS) score of < 13 in NWAS, GCS score of < 14 in NEAS] and stable ABC, injured nearest to a NSAH were transported either to that hospital (control clusters) or bypassed to the nearest NC (intervention clusters). Primary outcomes: recruitment rate, protocol compliance, selection bias as a result of non-compliance, accuracy of paramedic TBI identification (overtriage of study inclusion criteria) and pathway acceptability to patients, families and staff. ‘Open-label’ secondary outcomes: 30-day mortality, 6-month Extended Glasgow Outcome Scale (GOSE) and European Quality of Life-5 Dimensions.ResultsOverall, 56 clusters recruited 293 (169 intervention, 124 control) patients in 12 months, demonstrating cluster randomised pre-hospital trials as viable for heath service evaluations. Overall compliance was 62%, but 90% was achieved in the control arm and when face-to-face paramedic training was possible. Non-compliance appeared to be driven by proximity of the nearest hospital and perceptions of injury severity and so occurred more frequently in the intervention arm, in which the perceived time to the NC was greater and severity of injury was lower. Fewer than 25% of recruited patients had TBI on computed tomography scan (n = 70), with 7% (n = 20) requiring neurosurgery (craniotomy, craniectomy or intracranial pressure monitoring) but a further 18 requiring admission to an intensive care unit. An intention-to-treat analysis revealed the two trial arms to be equivalent in terms of age, GCS and severity of injury. No significant 30-day mortality differences were found (8.8% vs. 9.1/%;p > 0.05) in the 273 (159/113) patients with data available. There were no apparent differences in staff and patient preferences for either pathway, with satisfaction high with both. Very low responses to invitations to consent for follow-up in the large number of mild head injury-enrolled patients meant that only 20% of patients had 6-month outcomes. The trial-based economic evaluation could not focus on early neurosurgery because of these low numbers but instead investigated the comparative cost-effectiveness of bypass compared with selective secondary transfer for eligible patients at the scene of injury.ConclusionsCurrent NHS England practice of bypassing patients with suspected TBI to neuroscience centres gives overtriage ratios of 13 : 1 for neurosurgery and 4 : 1 for TBI. This important finding makes studying the impact of bypass to facilitate early neurosurgery not plausible using this study design. Future research should explore an efficient comparative effectiveness design for evaluating ‘early neurosurgery through bypass’ and address the challenge of reliable TBI diagnosis at the scene of injury.Trial registrationCurrent Controlled Trials ISRCTN68087745.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 20, No. 1. See the NIHR Journals Library website for further project information.

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confidence: 99%

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confidence: 99%

The Head Injury Transportation Straight to Neurosurgery (HITS-NS) randomised trial: a feasibility study

Lecky

Russell

Fuller

et al. 2016

Health Technol Assess

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“…5). Three studies 7 30 36 reported on pneumonia after pre-hospital or in-hospital intubation; it was the primary study outcome in In-hospital mortality Suominen and colleagues 29 Sloane and colleagues 30 Winchell and colleagues 31 Gausche and colleagues 32 Murray and colleagues 33 Cooper and colleagues 34 Davis and colleagues 35 Bochicchio and colleagues 36 DiRusso and colleagues 37 Wang and colleagues 38 Davis and colleagues 39 Davis and colleagues 28 Klemen and Grmec 40 1 h mortality von Elm et al …”

Section: Harm Outcomesmentioning

confidence: 99%

“…Six studies 32 34 37 38 40 41 used scoring instruments for functional outcome. 'Good outcome' was defined as functional independence measure (FIM) level of 5 -7; 34 'normal' FIM score 37 (without definition of 'normal'); modified Pediatric Cerebral Performance Category Scale indicating either normal status, no change from baseline, or mild disability, 32 favourable final outcome (i.e. good recovery or moderate disability) 41 or functional impairment score of 0 -5 (i.e.…”

Section: Functional Outcomementioning

confidence: 99%

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Pre-hospital tracheal intubation in patients with traumatic brain injury: systematic review of current evidence

Elm

Schoettker

Henzi

et al. 2009

British Journal of Anaesthesia

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Pediatric medical priorities

Gross

Fuchs

2015

Emergency Medical Services

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Intubation of Pediatric Trauma Patients in the Field: Predictor of Negative Outcome Despite Risk Stratification

Abstract: Field intubation is an independent strong negative predictor of survival or good functional outcome despite adjustment for severity of injury. Although not causal, the magnitude of these differences should lead to future controlled studies of pediatric trauma field intubations.

Cited by 65 publications

References 18 publications

The Head Injury Transportation Straight to Neurosurgery (HITS-NS) randomised trial: a feasibility study

The Head Injury Transportation Straight to Neurosurgery (HITS-NS) randomised trial: a feasibility study

Pre-hospital tracheal intubation in patients with traumatic brain injury: systematic review of current evidence

Pediatric medical priorities

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