Guideline on Treatment of Patients with Severe and Multiple ... - AWMF

S3 <strong>Guideline</strong> on Treatment of Patients with Severe and Multiple Injuries
endotracheally in the prehospital phase, displayed abnormal cerebral computed tomography
(38%) and intracranial bleeding (28%) [36]. In a prehospital cohort study, it was shown that
endotracheal intubation has a positive effect on survival following severe traumatic brain injury
[56]. Another retrospective study showed a reduced case fatality rate for children with severe
traumatic brain injury who were intubated by emergency physicians in the prehospital phase as
compared to those receiving care on Basic Life Support (BLS) and delayed intubation in regional
trauma centers [91]. If consideration is limited to a pediatric patient population, the prehospital
endotracheal intubation in this study was carried out by emergency medical personnel with good
transferability to the German emergency physician system. Using the Trauma and Injury
Severity Score (TRISS) method, another study also confirms that prehospital endotracheal
intubation leads to improved outcomes in survival and neurologic function [38]. Another paper
further showed an improvement in measured systolic blood pressure, oxygen saturation and endtidal
carbon dioxide (etCO2 compared to the baseline values prior to prehospital intubation in
patients with severe traumatic brain injury [11].
Current review papers, however, refer to heterogeneous patient collectives, differing emergency
services systems and differently trained users and therefore do not always come to a positive
conclusion about intubation [9, 12, 25, 31, 60, 62, 69, 74, 98, 100]. The EAST guideline group
also tackled this problem. In the “<strong>Guideline</strong>s for Emergency Intubation immediately following
traumatic injury”, it was claimed that there are no randomized controlled trials on this research
question. On the other hand, however, the authors of the EAST <strong>Guideline</strong> also found no studies
that could present an alternative treatment strategy proven to be effective. In summary,
endotracheal intubation was assessed overall as such an established procedure in hypoxia/apnea
that, despite a lack of scientific evidence, a Grade A recommendation was formulated [73]. Other
indications for endotracheal intubation (e.g., chest injury) are controversial issues in the literature
[78]. There was evidence that hypoxia and respiratory insufficiency were a consequence of
severe chest injury (multiple rib fractures, pulmonary contusion, unstable chest wall).
Endotracheal intubation is recommended if the hypoxia cannot be remedied by oxygenation, by
the exclusion of tension pneumothorax, and by basic airway management procedures [32].
Prehospital endotracheal intubation in patients with severe chest injury is suitable for preventing
hypoxia and hypoventilation, which are associated with secondary neurologic damage and
extremely severe consequences for the rest of the body. However, with difficult, prolonged
intubation attempts and the associated hypoventilation and danger of hypoxia, endotracheal
intubation itself can cause procedure-related secondary harms or even death. A database analysis
of the Trauma Registry of the German Trauma Society showed no advantage in prehospital
endotracheal intubation in patients with chest injury without respiratory insufficiency [78].
However, severe chest injury with respiratory insufficiency does present an indication for
prehospital endotracheal intubation whereby the decision to intubate should be dependent on the
respiratory insufficiency and not on the (suspected) diagnosis of severe chest injury, which is
associated with a certain degree of uncertainty [7].
Endotracheal intubation is included as an “Advanced Life Support” procedure in the prehospital
action algorithms of various training programs (e.g., PHTLS ® [71]. Using a scoring system to
evaluate management problems plus the relevant autopsy reports, a series of fatal traffic
accidents were retrospectively analyzed to characterize the effectiveness of prehospital care and
potentially avoidable fatal incidents [76]. This flagged up an extended “prehospital and early in-
Prehospital – Airway management, ventilation and emergency anesthesia 19