Guidelines for emergency tracheal intubation immediately after traumatic injury.

I. STATEMENT OF THE PROBLEM Hypoxia and obstruction of the airway are linked to preventable and potentially preventable acute trauma deaths. There is substantial documentation that hypoxia is common in severe brain injury and worsens neurologic outcome. The primary concern with acute postinjury respiratory system insufficiency is hypoxemic hypoxia and subsequent hypoxic encephalopathy or cardiac arrest. A secondary problem from acute postinjury respiratory system insufficiency is hypercarbia and attendant cerebral vasodilation or acidemia. An additional concern with acute postinjury respiratory system insufficiency is aspiration and the development of hypoxemia, pneumonia, or acute respiratory distress syndrome (ARDS) and acute lung injury. The primary categories of respiratory system insufficiency are airway obstruction, hypoventilation, lung injury, and impaired laryngeal reflexes. The physiologic sequelae of airway obstruction and hypoventilation are hypoxemia and hypercarbia. Adverse physiologic responses of lung injury and impaired laryngeal reflexes are nonhypercarbic hypoxemia and aspiration, respectively. Airway obstruction can occur with cervical spine injury, severe cognitive impairment (Glasgow Coma Scale [GCS] score 8), severe neck injury, severe maxillofacial injury, or smoke inhalation. Hypoventilation can be found with airway obstruction, cardiac arrest, severe cognitive impairment, or cervical spinal cord injury. Aspiration is likely to occur with cardiac arrest, severe cognitive impairment, or severe maxillofacial injury. A major clinical concern with thoracic injury is the development of nonhypercarbic hypoxemia. Lung injury and nonhypercarbic hypoxemia are also potential sequelae of aspiration. Trauma patients requiring emergency tracheal intubation are critically injured; however, the degree of injury is variable. The mean study Injury Severity Score (ISS) is 29; however, the range varies from 17 to 54. The average study GCS score for trauma patients undergoing emergency tracheal intubation is 6.5; however, the GCS score varies across its spectrum (3–15). The mean study mortality rate for emergency tracheal intubation in trauma patients is 41%, yet it ranges from 2% to 100%. There is substantial variation in the percentages of trauma patients undergoing emergency tracheal intubation among and between aeromedical, ground Emergency Medical Services (EMS), and trauma center settings. For aeromedical settings, the percentage of patients undergoing tracheal intubation is 18.5%; however, the variation among studies ranges from 6% to 51%. The ground EMS studies indicate that the rate of patients undergoing tracheal intubation is 4.0%, but varies from 2% to 37%. For trauma center settings, the percentage of patients undergoing tracheal intubation is 24.5%; however, the variation among studies ranges from 9% to 28%. Studies describing patients managed by ground EMS crews and a receiving trauma center staff indicate that the rate of tracheal intubation is 13.6%, but varies from 11% to 30%. It is clear that trauma patients with acute respiratory system insufficiency commonly have critical injuries, may need tracheal intubation, and develop adverse clinical outcomes. However, there is substantial variation in injury severity, mortality rates, and frequency of intubation. An eviSubmitted for publication May 13, 2003. Accepted for publication May 15, 2003. Copyright © 2003 by Lippincott Williams & Wilkins, Inc. From St. Elizabeth Health Center (C.M.D.), Youngstown, Ohio, SUNY-Stony Brook (R.D.B.), Stony Brook, New York, Maine Medical Center (D.E.C.), Portland, Maine, University of Tennessee (B.J.D.), Knoxville, Tennessee, Memorial Health Center (F.E.D.), Savannah, Georgia, Carolinas Medical Center (M.A.G.), Charlotte, North Carolina, Blanchfield Army Community Hospital (T.K.), Fort Campbell, Kentucky, Loyola University Medical Center (P.B.L., F.A.L.), Maywood, Illinois, Allegheny General Hospital (L.O.), Pittsburgh, Pennsylvania, Eastern Virginia Medical System (L.J.W.), Norfolk, Virginia, and Lancaster General Hospital (C.E.W.), Lancaster, Pennsylvania. Address for reprints: C. Michael Dunham, MD, St. Elizabeth Health Center, 1044 Belmont Avenue, Youngstown, OH 44501-1790; email: [email protected].