Prehospital intubation for severe head injury

Letters

CJEM 2006;8(4):245

To the Editors: We greatly appreciated the detailed, yet succinct Journal Club summary by Topping and Ducharme1 of Wang and colleagues' paper2 on the deleterious association demonstrated by pre-hospital intubation in the seriously head-injured patient versus emergency department intubation of a similar cohort.

Topping and Ducharme1 carefully defined the population studied; the quality of the database used; the methodology for analysis (including use of a propensity score); the challenges of a possible randomized controlled trial to further delineate causation versus the clear association that has been recently demonstrated in several emergency medical services (EMS) intubation studies, including this one; and the lessons associated with unbridled enthusiasm for unproven yet seemingly common-sense interventions (i.e., pre-hospital intubation in significantly head-injured patients).

However, one key result from this large study2 seemed to elude the reviewers. In Wang and colleagues' study one group of pre-hospital providers (air medical transport crews) who used neuromuscular blocking agents had decreased mortality demonstrated in the population studied. Although Wang and colleagues qualify clear conclusions in this regard by pointing out that these 2 elements were used as covariates in the overall regression analysis, the impression is clearly given that this is an area that needs further study before the brush of nihilism for endotracheal intubation in the EMS environment is finalized. Indeed, several EMS air medical studies (observational in nature), where a small cohort of highly trained crew members are given intensive training and reasonable ongoing critical care exposure, have demonstrated exceptional airway management skills.3,4 Wang and colleagues' findings are consistent with another recent study that also showed an association with improved outcomes using this air medical model.5

We feel that Wang and colleagues' suggestive data on air medical rapid sequence intubation management in the seriously ill head-injured patient deserves further consideration and is of key interest to EMS physicians and providers.

John M. Tallon, MD

David Petrie, MD

Division of EMS

Department of Emergency Medicine

Dalhousie University, Halifax, NS

References

1. Topping C, Ducharme J. Prehospital intubation for patients with severe head injury: More is not necessarily better. Can J Emerg Med 2006;8(2):116-8.
2. Wang HE, Peitzman AB, Cassidy LD, et al. Out-of-hospital endotracheal intubation and outcome after traumatic brain injury. Ann Emerg Med 2004;44 (5): 439-50.
3. Sing RF, Rotondo MF, Zonies DH, et al. Rapid sequence induction for intubation by an aeromedical transport team: a critical analysis. Am J Emerg Med 1998; 16(6):598-602.
4. Ma OJ, Atchley RB, Hatley T, et al. Intubation success rates improve for an air medical program after implementing the use of neuromuscular blocking agents. Am J Emerg Med 1998;16(2): 125-7.
5. Davis DP, Peay J, Serrano JA, et al. The impact of aeromedical response to patients with moderate to severe traumatic brain injury. Ann Emerg Med 2005; 46(2):115-22.