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

S3 <strong>Guideline</strong> on Treatment of Patients with Severe and Multiple Injuries
Early intubation was seen as safe and effective by the authors [85]. These data also confirm that
endotracheal intubation of trauma patients is a safe procedure in the hands of trained personnel.
Another retrospective study from a paramedic-supported system with 175 endotracheally
intubated patients showed a success rate of 96.6% with a markedly higher cricothyroidotomy
rate of 2.3% [37]. In 1.1% of cases, the patient was ventilated by bag-valve-mask during transfer
to hospital. There were 5 instances found of right mainstem dislocation (2.9%) and 2 cases of
tube dislocation (1.1%). No case of failed intubation was documented.
In a retrospective study of a trauma registry, 3,571 prehospital endotracheal intubations in
trauma patients were compared with 746 in the emergency room phase [6]. The endotracheal
intubation first carried out during emergency admission was associated with a higher risk of a
fatal course compared both to non-intubated patients (odds ratio [OR] 3.1; 95% confidence
interval [-CI]; 2.1–4.5, p < 0.0001) and to patients who had already been endotracheally
intubated in the prehospital phase (OR 3.0; 95% CI: 1.9–4.9, p < 0.0001) [6]. In addition, it was
shown that patients who had been endotracheally intubated in the prehospital phase did not have
a higher risk of dying than non-intubated patients in the emergency room phase (OR: 1.1; 95%
CI: 0.7–1.9; p = 0.6). The authors concluded that the patients who were endotracheally intubated
during emergency admission should have already been intubated in the prehospital phase [6].
In a prehospital cohort study with comparable injury severity (ISS 23 versus 24) and similar
duration of care (27 versus 29 min, p = n.s.), 60 patients were treated by emergency services
personnel (emergency medical technician [EMT], intubation rate 3%) and 64 patients in
Advanced Life Support mode by emergency physicians (intubation rate 100%). Oxygen
saturation was significantly improved upon arrival in hospital (SaO2: 86 versus 96; p = 0.04) and
systolic blood pressure was significantly higher (105 versus 132 mmHg, p = 0.03). There was no
difference in all-cause case fatality rate (42% versus 40%, p = 0.76). However, a sub-group
analysis showed a significant survival advantage for those patients with a GCS between 6 and 8
who had been treated by an emergency physician (case fatality rate: 78 versus 24%, p < 0.01; OR
3.85, 95% CI: 1.84–6.38, p < 0.001). The authors concluded that the case fatality rate is reduced
by a prehospital emergency physician system offering rapid sequence induction, sufficient
oxygenation and circulation drug therapy particularly for patients with clouded consciousness
[56].
In the German-speaking emergency physician system, pediatric and adult emergency patients
can be endotracheally intubated with a very high success rate if this procedure is carried out by
experienced and trained personnel. In a prospective study over a period of 8 years, 4% of all
pediatric emergency patients (82 out of 2,040 children) were endotracheally intubated [35].
Pediatric emergency callouts made up 5.6% of all emergency calls (2,040 out of 36,677
emergency physician callouts). Anesthesiologists carried out 58 of the pediatric endotracheal
intubations with a success rate of 98.3%. Based on the incidence, the known number of
emergency physicians employed each year, and their absolute number of callouts, it was
calculated that each emergency physician in the emergency physician service has a gap of, on
average, 3 years between pediatric endotracheal intubations and 13 years between infant
endotracheal intubations. These results show that endotracheal intubation in childhood is rare
outside the hospital setting and special attention must therefore be paid to maintaining specialist
Prehospital – Airway management, ventilation and emergency anesthesia 21