Page 89 - JSOM Summer 2019

A Comparison of Prehospital Versus
Emergency Department Intubations in Iraq and Afghanistan

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Steven G. Schauer, DO, MS *; Michael D. April, MD, DPhil ; Lloyd I. Tannenbaum, MD ;
Joseph K. Maddry, MD ; Cord W. Cunningham, MD, MPH ; Megan B. Blackburn, PhD ;
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Allyson A. Arana, PhD ; Stacy A. Shackelford, MD 8
ABSTRACT
Background: Airway obstruction is the second most common recommend endotracheal intubation until the tactical evacu-
cause of potentially preventable death on the battlefield. We ation phase; however, intubations remain the leading airway
compared survival in the combat setting among patients un- intervention in the prehospital setting. 3,4
dergoing prehospital versus emergency department (ED) intu-
bation. Methods: Patients were identified from the Department Civilian-based studies show high rates of endotracheal intu-
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of Defense Trauma Registry (DODTR) from January 2007 to bation complications. Prehospital endotracheal intubation
August 2016. We defined the prehospital cohort as subjects un- (ETI) is significantly more challenging than ETI performed in
dergoing intubation prior to arrival to a forward surgical team the well-controlled setting of a hospital for many reasons. In-
(FST) or combat support hospital (CSH), and the ED cohort tubation on the battlefield is complicated by the dangerous
as subjects undergoing intubation at an FST or CSH. We com- environment, poor lighting, and confined spaces. Conversely,
pared study variables between these cohorts; survival was our a recent subanalysis from a larger head injury study noted no
primary outcome. Results: There were 4341 intubations docu- worse outcomes, and possibly improved outcomes, in trau-
mented in the DODTR during the study period: 1117 (25.7%) matic brain injury patients intubated in the prehospital set-
patients were intubated prehospital and 3224 (74.3%) were ting. A recent systematic review and meta-analysis comparing
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intubated in the ED. Patients intubated prehospital had a prehospital intubations performed by physicians versus non-
lower median age (24 versus 25 years, p < .001), composed a physicians found that physicians had higher overall success
higher proportion of host nation forces (36.1% versus 29.1%, rates and higher first-pass success rates. The rates of com-
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p < .001), had a lower proportion of injuries from explosives plications appear to be lower when performed by emergency
(57.6% versus 61.0%, p = .030), and had higher median injury physicians, even in the prehospital setting. 11–15
severity scores (20 versus 18, p = .045). A lower proportion of
the prehospital cohort survived to hospital discharge (76.4% However, these studies all took place in developed countries
versus 84.3%, p < .001). The prehospital cohort had lower among civilian trauma patients. It is unclear whether these
odds of survival to hospital discharge in both univariable (odds results are applicable to the combat setting. Moreover, the
ratio [OR] 0.60, 95% confidence interval [CI] 0.51–0.71) and prehospital combat setting, which includes Role 1 and Role
multivariable analyses controlling for confounders (OR 0.70, 2 facilities, are frequently staffed by physicians and physician
95% CI 0.58–0.85). In a subgroup analysis of patients with a assistants that lack significant airway training. This contrasts
head injury, the lower odds of survival persisted in the multi- with the FSTs and CSHs, which have emergency medicine phy-
variable analysis (OR 0.49, 95% CI 0.49–0.82). Conclusions: sicians, anesthesiologists, and anesthetists on staff. The impact
Patients intubated in the prehospital setting had a lower sur- of medical personnel and facility airway capabilities on patient
vival than those intubated in the ED. This finding persisted af- outcomes remains unclear.
ter controlling for measurable confounders.
Study Goal
Keywords: airway; intubation; prehospital; military; emergency We sought to compare the outcomes of combat casualties in-
tubated in the prehospital setting (Role 1 and Role 2 without
FST augmentation) versus the ED (FST or CSH).
Introduction
Methods
Background
Airway obstruction is the second leading cause of potentially Data Acquisition
preventable death on the battlefield. 1,2 The current itera- We identified subjects as part of a larger descriptive study of ED
tion of the Tactical Combat Casualty Care guidelines do not interventions for trauma patients in Iraq and Afghanistan using
*Correspondence to Steven G. Schauer, 3698 Chambers Pass, JBSA Fort Sam Houston, TX 78234; or steven.g.schauer.mil@mail.mil
1 MAJ Schauer is affiliated with the US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX; 59th Medical Wing, JBSA Lackland Air
Force Base, TX; and San Antonio Military Medical Center, JBSA Fort Sam Houston, TX. MAJ April is affiliated with the San Antonio Military
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Medical Center, JBSA Fort Sam Houston, TX. CPT Tannenbaum is affiliated with San Antonio Military Medical Center, JBSA Fort Sam Hous-
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ton, TX. Lt Col Maddry is affiliated with 59th Medical Wing, JBSA Lackland Air Force Base, TX; and San Antonio Military Medical Center,
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JBSA Fort Sam Houston, TX. LTC Cunningham and Dr Blackburn are affiliated with the US Army Institute of Surgical Research, JBSA Fort
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Sam Houston, TX. Dr Arana is affiliated with 59th Medical Wing, JBSA Lackland Air Force Base, TX. Col Shackelford is affiliated with the
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US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX; San Antonio Military Medical Center, JBSA Fort Sam Houston, TX; and
the Joint Trauma System, JBSA Fort Sam Houston, TX.
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