Page 109 - 2022 Spring JSOM

Several studies have attempted to define physiologic param- Disclosure
eters that can help clinicians identify which patients may ex- The authors have nothing to disclose.
perience adverse outcomes associated with RSI. A particular
study by De Jong et al. found that main predictors of PA prior References
to intubation included arterial hypotension with an SBP <90, 1. Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield
hypoxemia prior to intubation, absence of preoxygenation, (2001–2011): implications for the future of combat casualty care. J
Trauma Acute Care Surg. 2012;73(6 Suppl 5):S431–437.
14
body mass index >25, and age >75. After multivariate analy- 2. Hudson AJ, Strandenes G, Bjerkvig CK, et al. Airway and ventila-
sis, intubation-related PA was also found to be an independent tion management strategies for hemorrhagic shock. To tube, or not
risk factor for 28-day mortality. Unfortunately, the aforemen- to tube, that is the question! J Trauma Acute Care Surg. 2018;84(6S
Suppl 1):S77–S82.
tioned study by De Jong et al. was performed on ICU patients 3. Green RS, Butler MB, Erdogan M. Increased mortality in trauma pa-
with several different indications for intubation and has lim- tients who develop postintubation hypotension. J Trauma Acute Care
ited generalizability to the traumatically wounded patient suf- Surg. 2017;83(4):569–574.
fering hemorrhagic shock. 4. Schauer SG, April MD, Tannenbaum LI, et al. A comparison of pre-
hospital versus emergency department intubations in Iraq and Af-
ghanistan. J Spec Oper Med. 2019;19(2):87–90.
Additional studies have evaluated whether physiologic pa- 5. A National Trauma Care System: Integrating Military and Civilian
rameters can be evaluated as a mathematic ratio, such as with Trauma Systems to Achieve Zero Preventable Deaths After Injury. Mil
Med. 2017;182(5):1563–1565.
shock index (HR/SBP), or modified shock index (HR/MAP), 6. Emerling AD, Bianchi W, Krzyzaniak M, et al. Rapid sequence induc-
to predict adverse events associated with RSI. Multiple in- tion strategies among critically injured U.S. military during the Af-
hospital and prehospital studies have demonstrated an associ- ghanistan and Iraq conflicts. Mil Med. 2021;186(Suppl 1):316–323.
ation between the need for large volume blood transfusion and 7. Butler FK, Holcomb JB, Schreiber MA, et al. Fluid resuscitation for
hemorrhagic shock in Tactical Combat Casualty Care: TCCC guide-
patients presenting with elevated shock index. 16–18 Shock index lines change 14-01--2 June 2014. J Spec Oper Med. 2014;14(3):13–38.
has also been associated with increased risk of post-intubation 8. ATLS Subcommittee; American College of Surgeons’ Committee on
adverse outcomes if >0.8–1. 11,16,19 However, there have been no Trauma; International ATLS working group. Advanced trauma life
®
support (ATLS ): the ninth edition. J Trauma Acute Care Surg. 2013;
specific studies addressing the use of shock index in the hypo- 74(5):1363–1366.
volemic trauma patient. The lethal outcomes in this case series 9. Pepe PE, Lurie KG, Wigginton JG, et al. Detrimental hemodynamic
highlights the need for further research in this area. effects of assisted ventilation in hemorrhagic states. Crit Care Med.
2004;32(9 Suppl):S414–420.
10. Cournand A, Motley HL. Physiological studies of the effects of inter-
Our case series underscores the lethality of performing RSI on mittent positive pressure breathing on cardiac output in man. Am J
a patient with hemorrhagic shock. Careful attention to vital Physiol. 1948;152(1):162–174.
signs, prioritizing hemorrhage control, and immediate blood 11. Heffner AC, Swords DS, Neale MN, et al. Incidence and factors as-
sociated with cardiac arrest complicating emergency airway manage-
product resuscitation should be at the forefront of emergency ment. Resuscitation. 2013;84(11):1500-1504.
care for this patient group. Forward deployed providers 12. Green RS, Edwards J, Sabri E, et al. Evaluation of the incidence, risk
should also remain vigilant of the physiologic changes that factors, and impact on patient outcomes of postintubation hemody-
namic instability. CJEM. 2012;14(2):74–82.
occur with administration of induction agents, paralytics, and 13. Kim WY, Kwak MK, Ko BS, et al. Factors associated with the oc-
positive pressure ventilation. It is equally important to con- currence of cardiac arrest after emergency tracheal intubation in the
2
sider alternatives to RSI, such as airway adjuncts, that can be emergency department. PLoS One. 2014;9(11):e112779.
used to maintain airway patency while achieving optimized 14. De Jong A, Rolle A, Molinari N, et al. Cardiac arrest and mortality
related to intubation procedure in critically ill adult patients: A multi-
2
blood resuscitation. Thomson et al. highlights in their recent center cohort study. Crit Care Med. 2018;46(4):532–539.
editorial the potential for iatrogenic harm with RSI and posi- 15. Mayglothling J, Duane TM, Gibbs M, et al. Emergency tracheal in-
tive pressure ventilation on patients with hemorrhagic shock. tubation immediately following traumatic injury: an Eastern Asso-
20
ciation for the Surgery of Trauma practice management guideline. J
This potential for harm forces the emergency provider to make Trauma Acute Care Surg. 2012;73(5 Suppl 4):S333–340.
a calculated assessment of the clinical scenario in an attempt 16. Wardi G, Villar J, Nguyen T, et al. Factors and outcomes associated
to avoid harm. The nuanced decisions behind performing RSI with inpatient cardiac arrest following emergent endotracheal intuba-
tion. Resuscitation. 2017;121:76–80.
on patients suffering from hemorrhagic shock is aptly summa- 17. Jehan F, Con J, McIntyre M, et al. Pre-hospital shock index correlates
rized by the revised first commandment of emergency medi- with transfusion, resource utilization and mortality; The role of pa-
cine: “Secure the ABCs, but carefully.” 21 tient first vitals. Am J Surg. 2019;218(6):1169–1174.
18. Rau CS, Wu SC, Kuo SC, et al. Prediction of massive transfusion in
trauma patients with shock index, modified shock index, and age
shock index. Int J Environ Res Public Health. 2016;13(7).
Conclusion 19. Althunayyan SM. Shock index as a predictor of post-intubation hy-
Combat-wounded patients experiencing hemorrhagic shock potension and cardiac arrest; A review of the current evidence. Bull
Emerg Trauma. 2019;7(1):21–27.
are at high risk for postintubation hypotension, PA, and death. 20. Thompson P, Hudson AJ, Convertino VA, et al. Risk of harm asso-
Future research should investigate the influence of preintuba- ciated with using rapid sequence induction intubation and positive
tion blood product resuscitation on patient-centered outcomes pressure ventilation in patients with hemorrhagic shock. J Spec Oper
Med. 2020;20(3):97–102.
and identifying vital signs or other calculations. These may be 21. Evans CS, Slovis C. Revisiting the Ten Commandments of emergency
able to predict which patients are at risk for poor outcomes. medicine: A resident’s perspective. Ann Emerg Med. 2021;77(3):
367–370.

Pulseless Arrest Postintubation in Hemorrhaged Warfighter | 107