Survival of trauma patients who have prehospital tracheal intubation without anaesthesia or muscle relaxants: observational study.
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ABSTRACT:
SUBMITTER: Lockey D
PROVIDER: S-EPMC34726 | biostudies-literature | 2001 Jul
REPOSITORIES: biostudies-literature
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Survival of trauma patients who have prehospital tracheal intubation without anaesthesia or muscle relaxants: observational study.
Lockey D D Davies G G Coats T T
BMJ (Clinical research ed.) 20010701 7305
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Project description:ContextTracheal intubation is frequently facilitated with sevoflurane induction without the use of muscle relaxants in children.AimThe aim of this study was to compare the effects of two different doses of propofol preceded by a fixed dose of fentanyl during sevoflurane induction on quality of tracheal intubation in children.Settings and designThis was a prospective randomized study.Subjects and methodsNinety American Society of Anesthesiologists I-II children aged 2-6 years were randomly assigned to one of two equal groups to receive 2 μg/kg of fentanyl with 2 mg/kg of propofol (Group I) or 2 μg/kg of fentanyl with 3 mg/kg of propofol (Group II) during sevoflurane induction. The intubating conditions and hemodynamic responses were evaluated. The time from sevoflurane induction to loss of consciousness, to intravenous line insertion, and to intubation was measured. The occurrence of any adverse effect was recorded.Statistical analysis usedResults were analyzed using Student's t-test, paired t-test, and Chi-square test. P < 0.05 was considered statistically significant.ResultsThe incidence of excellent intubating conditions was achieved more significantly in Group II (41/45 patients, 91%) than that in Group I (31/45 patients, 69%) (P = 0.008) (95% confidence interval [CI] =0.39-0.8). Whereas, there were no significant differences between the two groups in terms of the overall acceptable intubating conditions in Group I (40/45 patients, 89%) and Group II (43/45 patients, 96%) (P = 0.81) (95% CI = 0.71-1.31). No patient developed any adverse effect.ConclusionThe administration of 3 mg/kg propofol preceded by 2 μg/kg fentanyl provided a higher proportion of excellent intubating conditions compared with 2 mg/kg propofol preceded by 2 μg/kg fentanyl during sevoflurane induction in children without muscle relaxants.
| S-EPMC5516495 | biostudies-literature
Project description:BackgroundTracheal rupture is a rare but life-threatening complication that most commonly occurrs after blunt trauma to the chest, but which may also complicate tracheal intubation. We report a case of post-intubation tracheal rupture after cataract surgery under general anesthesia treated conservatively.Case presentationFour hours after extubation, a 67 year-old woman developed subcutaneous emphysema of the facial, bilateral laterocervical and upper anterior chest. Tracheobronchial fiberendoscopy showed a posterior tracheal transmural rupture 4 cm long located 2.5 cm above the carina that opened in inspiration. The location of the lesion and features of the patient favoured conservative treatment with antibiotic cover. The patient made a full and uncomplicated recovery and was discharged fourteen days after the original injury.ConclusionTwo therapeutic strategies are currently employed for post-intubation tracheal rupture: a non-surgical strategy for small injuries and a surgical strategy for larger injuries. This case report presented the non-surgical therapeutic strategy of a large tracheal injury.
| S-EPMC2579287 | biostudies-literature
Project description:Prehospital care of severe trauma patients often involves endotracheal intubation (ETI), which has complications. The frequency and predictors of post-ETI hypotension and cardiac arrest are not well defined in this population. We sought to derive and validate a scoring system that predicts post-ETI hypotension in prehospital patients and to describe the impact of hypotension on outcome. We performed an observational cohort study including normotensive adult trauma patients requiring ETI, treated from 2001 to 2018 by critical care transport providers in a regional air medical transport system. We divided eligible patients into a derivation cohort (2001-2010) and validation cohort (2011-2018) for analysis. We identified predictors of new systolic hypotension (<90 mmHg) or cardiac arrest within 15 minutes of ETI then developed and validated a scoring system that stratified patients into low, moderate and high risk. We included 4,866 subjects, 3,127 in the derivation and 1,739 in the validation cohort. Post-ETI hypotension occurred in 11% and 21%, respectively; 5% of each cohort experienced post-ETI cardiac arrest. Major independent predictors of post-ETI hypotension were age, pre-ETI systolic blood pressure and pre-ETI oxygen saturation. We developed a well-calibrated scoring system based on these major and several minor risk factors. Applying our system, 890 (33%) derivation patients and 550 (37%) validation patients were higher risk for post-ETI adverse outcomes. Of these, 21% and 33% respectively experienced post-ETI hypotension and 6% and 4%, respectively suffered post-ETI cardiac arrest. Patients at high risk for post-ETI hypotension or arrest are common and identifiable in prehospital trauma care.
| S-EPMC7174085 | biostudies-literature
Project description:INTRODUCTION:The aim of this study was to measure the haemodynamic responses to a etomidate-propofol combination used for anaesthesia induction and to compare the haemodynamic responses with the separate use of each drug. METHODS:The patients were randomly divided into three groups as group P (n = 30, propofol 2.5 mg kg(-1)), group E (n = 30, etomidate 0.3 mg kg(-1)) and group PE (n = 30, propofol 1.25 mg kg(-1) + etomidate 0.15 mg kg(-1)). For each patient, the times of measurement of the heart rate (HR) and mean arterial pressure values were defined as baseline, after the induction, before the intubation, immediately after the intubation and 1, 2, 3, 4, 5 and 10 minutes after the intubation. RESULTS:In all 3 groups, a significant decrease in MAP values were seen at T2 and T3 compared to the baseline values, and this decrease was greater in group P compared to that in group E and PE (P < 0.001, P < 0.01). A significant increase was seen in all 3 groups in the mean arterial pressure (MAP) value at T4 after the intubation. When the groups were compared with each other, this increase was greater in group E than in the other two groups (with group P, P < 0.001; with group PE, P < 0.01). CONCLUSION:Etomidate-propofol combination may be a valuable alternative when extremes of hypotensive and hypertensive responses due to propofol and etomidate are best to be avoided.
| S-EPMC4685278 | biostudies-literature
Project description: Not available
| S-EPMC9805752 | biostudies-literature
Project description:BackgroundWe aimed to study the associations between pre- and in-hospital tracheal intubation and outcomes in traumatic brain injury (TBI), and whether the association varied according to injury severity.MethodsData from the international prospective pan-European cohort study, Collaborative European NeuroTrauma Effectiveness Research for TBI (CENTER-TBI), were used (n=4509). For prehospital intubation, we excluded self-presenters. For in-hospital intubation, patients whose tracheas were intubated on-scene were excluded. The association between intubation and outcome was analysed with ordinal regression with adjustment for the International Mission for Prognosis and Analysis of Clinical Trials in TBI variables and extracranial injury. We assessed whether the effect of intubation varied by injury severity by testing the added value of an interaction term with likelihood ratio tests.ResultsIn the prehospital analysis, 890/3736 (24%) patients had their tracheas intubated at scene. In the in-hospital analysis, 460/2930 (16%) patients had their tracheas intubated in the emergency department. There was no adjusted overall effect on functional outcome of prehospital intubation (odds ratio=1.01; 95% confidence interval, 0.79-1.28; P=0.96), and the adjusted overall effect of in-hospital intubation was not significant (odds ratio=0.86; 95% confidence interval, 0.65-1.13; P=0.28). However, prehospital intubation was associated with better functional outcome in patients with higher thorax and abdominal Abbreviated Injury Scale scores (P=0.009 and P=0.02, respectively), whereas in-hospital intubation was associated with better outcome in patients with lower Glasgow Coma Scale scores (P=0.01): in-hospital intubation was associated with better functional outcome in patients with Glasgow Coma Scale scores of 10 or lower.ConclusionThe benefits and harms of tracheal intubation should be carefully evaluated in patients with TBI to optimise benefit. This study suggests that extracranial injury should influence the decision in the prehospital setting, and level of consciousness in the in-hospital setting.Clinical trial registrationNCT02210221.
| S-EPMC7565908 | biostudies-literature
Project description:BackgroundWe examined the association between emergent postoperative tracheal intubation and the use of supraglottic airway devices (SGAs) vs tracheal tubes.MethodsWe included data from adult noncardiac surgical cases under general anaesthesia between 2008 and 2018. We only included cases (n=59 991) in which both airways were deemed to be feasible options. Multivariable logistic regression, instrumental variable analysis, propensity matching, and mediation analysis were used.ResultsUse of a tracheal tube was associated with a higher risk of emergent postoperative intubation (adjusted absolute risk difference [ARD]=0.80%; 95% confidence interval (CI), 0.64-0.97; P<0.001), and a higher risk of post-extubation hypoxaemia (ARD=3.9%; 95% CI, 3.4-4.4; P<0.001). The effect was modified by the use of non-depolarising neuromuscular blocking agents (NMBAs); mediation analyses revealed that 28.9% (95% CI, 14.4-43.4%; P<0.001) of the main effect was attributable to NMBA. Airway management modified the association of NMBA and risk of emergent postoperative intubation (Pinteraction=0.02). Patients managed with an SGA had higher odds of NMBA-associated reintubation compared to patients managed with a tracheal tube (adjusted odds ratio [aOR]=3.65, 95% CI, 1.99-6.67 vs aOR=1.68, 95% CI, 1.29-2.18 [P<0.001], respectively).ConclusionsIn patients undergoing procedures under general anaesthesia that could be managed with either SGA or tracheal tube, use of an SGA was associated with lower risk of emergent postoperative intubation. The effect can partly be explained by use of NMBAs. Use of NMBAs in patients with an SGA appears to increase the risk of emergent postoperative intubation.
| S-EPMC8014944 | biostudies-literature
Project description:Inadvertent tracheal tube misplacement and particularly endobronchial intubation are well-known complications of emergency endotracheal intubation (ETI) in pediatric trauma patients, which require repositioning of the tube to avoid impairment of gas exchange. The main aim of study was to identify the frequency of tube misplacement and associated factors of pediatric trauma patients who received ETI either by prehospital physician-staffed emergency medical service (EMS), or at emergency department (ED) admission to a single level-1 trauma center. Sixty-five patients (median age 14 years and median injury severity score 29) were included. Of these, 30 underwent helicopter EMS ETI, 29 ground EMS ETI, and 6 ED ETI. Seventeen cases (26%) of tracheal tube misplacement were recognized. After multivariable analysis, tracheal tube misplacement was independently negatively associated with body weight (OR 0.86; 95% CI, 0.76-0.99; p = 0.032) and helicopter EMS ETI (OR 0.20; 95% CI, 0.04-0.97; p = 0.036). Two of nineteen patients received tube thoracostomy due to endobronchial intubation. Mortality and length of stay were comparable in patients with misplaced tubes and correctly placed tubes. The results suggest that particularly small children require attention to avoid tracheal tube misplacement, which emphasizes the need for special training. Helicopter EMS physicians' expertise might be beneficial in prehospital pediatric trauma patients requiring advanced airway management.
| S-EPMC8870798 | biostudies-literature
Project description:BackgroundPre-hospital endotracheal intubation is frequently used for trauma patients in many emergency medical systems. Despite a wide range of publications in the field, it is debated whether the intervention is associated with a favourable outcome, when compared to more conservative airway measures.MethodsA systematic literature search was conducted to identify interventional and observational studies where the mortality rates of adult trauma patients undergoing pre-hospital endotracheal intubation were compared to those undergoing emergency department intubation.ResultsTwenty-one studies examining 35,838 patients were included. The median mortality rate in patients undergoing pre-hospital intubation was 48% (range 8-94%), compared to 29% (range 6-67%) in patients undergoing intubation in the emergency department. Odds ratios were in favour of emergency department intubation both in crude and adjusted mortality, with 2.56 (95% CI: 2.06, 3.18) and 2.59 (95% CI: 1.97, 3.39), respectively. The overall quality of evidence is very low. Twelve of the twenty-one studies found a significantly higher mortality rate after pre-hospital intubation, seven found no significant differences, one found a positive effect, and for one study an analysis of the mortality rate was beyond the scope of the article.ConclusionsThe rationale for wide and unspecific indications for pre-hospital intubation seems to lack support in the literature, despite several publications involving a relatively large number of patients. Pre-hospital intubation is a complex intervention where guidelines and research findings should be approached cautiously. The association between pre-hospital intubation and a higher mortality rate does not necessarily contradict the importance of the intervention, but it does call for a thorough investigation by clinicians and researchers into possible causes for this finding.
| S-EPMC5535283 | biostudies-literature
Project description:BackgroundSubcortical structures, including the basal ganglia, have been proposed to be crucial for arousal, consciousness, and behavioural responsiveness. How the basal ganglia contribute to the loss and recovery of consciousness during anaesthesia has, however, not yet been well characterised.MethodsTwelve patients with advanced Parkinson's disease, who were undergoing deep brain stimulation (DBS) electrode implantation in the subthalamic nucleus (STN), were included in this study. Local field potentials (LFPs) were recorded from the DBS electrodes and EEG was recorded from the scalp during induction of general anaesthesia (with propofol and sufentanil) and during tracheal intubation. Neural signatures of loss of consciousness and of the expected arousal during intubation were sought in the STN and EEG recordings.ResultsPropofol-sufentanil anaesthesia resulted in power increases in delta, theta, and alpha frequencies, and broadband power decreases in higher frequencies in both STN and frontal cortical areas. This was accompanied by increased STN-frontal cortical coherence only in the alpha frequency band (119 [68]%; P=0.0049). We observed temporal activity changes in STN after tracheal intubation, including power increases in high-beta (22-40 Hz) frequency (98 [123]%; P=0.0064) and changes in the power-law exponent in the power spectra at lower frequencies (2-80 Hz), which were not observed in the frontal cortex. During anaesthesia, the dynamic changes in the high-gamma power in STN LFPs correlated with the power-law exponent in the power spectra at lower frequencies (2-80 Hz).ConclusionsApart from similar activity changes in both STN and cortex associated with anaesthesia-induced unresponsiveness, we observed specific neuronal activity changes in the STN in response to the anaesthesia and tracheal intubation. We also show that the power-law exponent in the power spectra in the STN was modulated by tracheal intubation in anaesthesia. Our results support the hypothesis that subcortical nuclei may play an important role in the loss and return of responsiveness.
| S-EPMC7347416 | biostudies-literature