Two articles pertaining to the prehospital care of trauma patients were reviewed at this month’s Prehospital and Transport Medicine Journal Club: Bossers et al. (2023) conducted a retrospective trauma registry analysis seeking to determine the relationship between prehospital intubation and mortality in patients with severe TBI. The PATCH-Trauma Investigators and the ANZICS Clinical Trials Group conducted an international RCT seeking to determine if prehospital TXA improved functional outcomes for severe trauma patients. Both articles are summarized below.
Prehospital Intubation of Patients with Severe TBI
Background and Objectives
Patients with severe traumatic brain injury (TBI) are at risk for airway obstruction leading to hypoxia and consequent secondary brain injury. Protocols often emphasize that these patients should be intubated in the prehospital environment despite evidence that this may be hazardous. This study sought to determine the association between prehospital intubation and mortality in patients with severe TBI.
This was a retrospective analysis of a national (Dutch) trauma registry using multivariable logistic regression adjusted for potential confounders.
Population: Adult patients with severe TBI defined as having a Head Abbreviated Injury Scale (AIS) ≥4.
Intervention: Prehospital endotracheal intubation with or without the involvement of physician-staffed helicopter EMS (P-HEMS) crews.
Comparison: Not intubated during prehospital care.
Outcome(s): In-hospital mortality (i.e., dead at time of discharge).
Prehospital intubation was associated with higher mortality (OR 1.86, 95%CI 1.35-2.57, p <0.001). P-HEMS involvement attenuated but did not eliminate this adverse association.
“The data does not support the common practice of prehospital intubation. The effect of prehospital intubation on mortality might depend on EMS clinician experience, and it seems prudent to involve prehospital personnel well proficient in prehospital intubation whenever intubation is potentially required. The decision to perform prehospital intubation should not merely be based on the largely unsupported dogma that it is generally needed in severe TBI, but should rather individually weigh potential benefits and harms”.
This was a retrospective observational study with multiple residual confounders and missing data.
The decision of whether to intubate a patient with severe TBI in any setting (prehospital or in-hospital) is complex and multifactorial. The procedure is technically and physiologically challenging requiring an individualized approach. Routine prehospital endotracheal intubation of patients with severe TBI is associated with increased mortality and is not recommended.
Bossers SM, Verheul R, van Zwet EW, Bloemers FW, Giannakopoulos GF, Loer SA, Schwarte LA, Schober P. Prehospital Intubation of Patients with Severe Traumatic Brain Injury: A Dutch Nationwide Trauma Registry Analysis. Prehosp Emerg Care. 2023;27(5):662-668. doi: 10.1080/10903127.2022.2119494
Prehospital TXA for Patients with Severe Trauma
Background and Objectives
Early in-hospital use of tranexamic acid (TXA) in patients with trauma is associated with reduced mortality among patients with suspected bleeding and a good safety profile. This study sought to determine whether the prehospital administration of TXA in trauma patients at high risk for trauma-induced coagulopathy increased the likelihood of survival with a favourable functional outcome.
This was an international (Australia, NZ, Germany), multicentre, randomized, double-blind, placebo-controlled trial.
Population: Adult trauma patients at high risk for trauma-induced coagulopathy defined as having a Coagulopathy of Severe Trauma (COAST) score ≥3 at scene.
Intervention: Tranexamic acid (TXA) 1 g IV over 10 min at scene or en route to hospital, followed by 1 g IV over 8 hours after hospital arrival.
Comparison: 0.9% Normal Saline administered in similar fashion.
Outcome(s): Favourable functional outcome defined as Glasgow Outcome Scale-Extended (GOS-E) ≥5 at 6 months after injury. Secondary outcomes included mortality at 28 days and 6 months, and incidence of vascular occlusive events.
There was no difference in favourable functional outcome (GOS-E ≥5 at 6 months) between groups (RR 1.00, 95%CI 0.90-1.23). Among secondary outcomes, prehospital TXA reduced early mortality (RR 0.79 at 28 days after injury) and did not increase the risk for vascular occlusive events (RR 0.97–1.48).
“Among adults with major trauma and suspected trauma-induced coagulopathy who were being treated in advanced trauma systems, prehospital administration of tranexamic acid followed by an infusion over 8 hours did not result in a greater number of patients surviving with a favorable functional outcome at 6 months than placebo”.
The theoretical link between the intervention and primary outcome is questionable, there were protocol deviations in 35% of the patients, and the generalizability of the study is limited.
The benefit of prehospital TXA in major trauma remains inconclusive. Prehospital TXA may not improve functional outcome at 6 months, however, it appears safe and increases survival, which is the necessary first step along the rehabilitation journey.
PATCH-Trauma Investigators and the ANZICS Clinical Trials Group; Gruen RL, Mitra B, Bernard SA, McArthur CJ, Burns B, Gantner DC, Maegele M, Cameron PA, Dicker B, Forbes AB, Hurford S, Martin CA, Mazur SM, Medcalf RL, Murray LJ, Myles PS, Ng SJ, Pitt V, Rashford S, Reade MC, Swain AH, Trapani T, Young PJ. Prehospital Tranexamic Acid for Severe Trauma. N Engl J Med. 2023 Jul 13;389(2):127-136. doi: 10.1056/NEJMoa2215457
PTM Learning Point
Prehospital care is time-, resource-, and space-limited. Particularly in the setting of trauma, expediting transport to definitive care is the priority. In addition to system costs, adding a new intervention to a paramedic’s task load risks increasing scene time and the potential for omission of care if overwhelmed. The potential benefit of introducing an intervention to the prehospital clinician’s armamentarium must be weighed against the ‘direct’ risks associated with that intervention (e.g., vaso-occlusive events or mortality) as well as the costs and risks associated with adding another task to the prehospital clinician’s plate.