1
1Adam
Fisher* DMD, Ivan Puente** MD, FACS, Marko Bukur** MD, FACS, Robyn Farrington*** RN,
Fahim Habib** MD, MPH, FACS
Broward Health Medical Center (BHMC)
OBJECTIVES: The overarching goal of pre-hospital management is number one to correct any life
threatening physiologic abnormality and number two expeditiously transport the patient to definite of care
center. Ensuring a patent airway and delivery of oxygen remains a paramount life-saving measure and is
an essential component in the assessment and management of the patient at the scene. Options for
advanced airway management, in order of increasing complexity, include the provision of bag mask
ventilation, supraglottic devices (post failed endotracheal intubation attempts), endotracheal intubation
(ETT), and the performance of an emergency cricothyroidotomy. The need to establish and secure the
airway at the scene prior to the initiation of transport can consume a significant portion of the on scene
time and delay care. We hypothesized that the increasing complexity of advanced airway management in
the prehospital setting would result in significant increases in on scene time and that increased on scene
time would result in greater mortality in the population of trauma patients
METHODS: To test this hypothesis we performed a retrospective review of prospectively collected trauma
registry data. Information specific to demographics, mechanism of injury, type of advanced airway, scene
time, as well as final outcome were collected. Level one trauma patients totaled 25,997 from January
2000 to December 2012. Patients who arrived with a systolic blood pressure (SBP) less than 90 mmHg
were considered to be hemodynamically unstable on arrival. A retrospective cohort of the 1146 level one
trauma patients requiring advanced airway intervention brought into Broward Health Medical Center by
Emergency Medical Services (EMS) was analyzed. On scene time was recorded in 1028 of the patients
in the cohort, this is the study set. Multivariable regression was performed to analyze the effect of each
type of advanced airway and scene time in the regards to the short term stability and long term outcome
of trauma patients in this study. A T-test was used to assess the p-value. A p-value of less than 0.05 was
considered a statistically significant difference. Chi-squared test and Fisher’s exact test were used when
appropriate.
RESULTS: A total of 443 patients were brought in with bag and mask ventilation accounting for 43% of
the patients requiring advanced airway intervention. A total of 526 patients were brought with oral ETT,
accounting for 51% of the cohort. It was immediately evident that patients who failed ETT attempts and
had supraglottic airways placed. The difference in on scene time was significantly between patients who
were bag and mask ventilated and those who were intubated on scene. On scene time increased from
14.12 minutes to 19.51 minutes when ETT was completed in the field in comparison to transport with bag
and mask ventilation, a 38% increase. The mortality rate was not statistically significantly different
between the two groups, 42%, regardless of mechanism of injury (Table II).
The incidence of hemodynamic instability (SBP <90mmHg) on arrival to the trauma center was
greater in patients who received ETT on the field, 49% as compared to patients who received bag mask
ventilation 39% (Table III).
1
*A. Fisher - Oral and Maxillofacial Surgery Resident, Department of Graduate Medical Education, Broward Health Medical Center,
1600 S. Andrews Ave, Fort Lauderdale, FL 33314. Afisher@BrowardHealth.org, 954-355-4400
1
**I. Puente, M Bukur, F. Habib- Trauma Surgeon Broward Health Medical Center
1
***R. Farrington - Trauma Program Manager, Broward Health Medical Center
2
CONCLUSION: This study demonstrates that an ETT does not improve survival rates among trauma
patients but does significantly increase on scene time and delay patient arrival to the trauma center.
Patients arriving with ETT tubes are also more apt to arrive in a more hemodynamically unstable
condition. The results from this study suggest the need to reevaluate the prehospital advanced airway
management. Consideration of supraglottic devices as an initial airway to minimize delay in on scene
time is certainly worth evaluation. Future considerations include a prospective study in conjunction with
local EMS of bag mask ventilation compared to immediate supraglottic airway insertion in attempt to
avoid the delay caused by ETT insertion.
TABLE I
Supraglottic
Airway Bag & (Post Failed
Type Mask ETT Attempt)
Patient
Total
Scene Time
(minutes)
Cricothyroidotomy
Nasal
ETT
Oral ETT
443
40
12
7
526
Mean 14.12
17.93
17.92
26.14
19.51
12.76
13.24
11.48
11.21
Std
Dev
8.73
3
TABLE II
Airway Type
Total Paients
Injury
Classification
Bag &
Mask
Supraglottic Cricoth
(Post Failed yroidot
ETT attempt)
omy
Nasal
ETT Oral ETT
443
40
12
7
526
Penetrating
79
9
4
0
106
Burn
3
0
0
0
10
Other
3
0
0
0
3
Died
189
27
7
1
222
Survived
254
13
5
6
304
p=0.08
Blunt
216
12
4
6
239
p=0.3
Penetrating
33
1
1
0
56
p-0.14
Overall
Survival
Percentage
42.66
32.50
41.67
Outcome
Survival
42.20
Table III
Advanced Airway Type
Supraglottic
Airway (Post
failed ETT
Nasal
attempt)
Cricothyroidotomy ETT
Bag &
Mask
Oral
ETT
Patients with SBP <90 on
Arrival
175
22
8
1
258
% Hemodynmically Unstable
39%
55%
67%
14%
49%