Physician-staffed helicopter emergency medical service has a beneficial impact on the incidence of prehospital hypoxia and secured airways on patients with severe traumatic brain injury

Toni Pakkanen, Antti Kämäräinen, Heini Huhtala, Tom Silfvast, Jouni Nurmi, Ilkka Virkkunen, Arvi Yli-Hankala, Toni Pakkanen, Antti Kämäräinen, Heini Huhtala, Tom Silfvast, Jouni Nurmi, Ilkka Virkkunen, Arvi Yli-Hankala

Abstract

Background: After traumatic brain injury (TBI), hypotension, hypoxia and hypercapnia have been shown to result in secondary brain injury that can lead to increased mortality and disability. Effective prehospital assessment and treatment by emergency medical service (EMS) is considered essential for favourable outcome. The aim of this study was to evaluate the effect of a physician-staffed helicopter emergency medical service (HEMS) in the treatment of TBI patients.

Methods: This was a retrospective cohort study. Prehospital data from two periods were collected: before (EMS group) and after (HEMS group) the implementation of a physician-staffed HEMS. Unconscious prehospital patients due to severe TBI were included in the study. Unconsciousness was defined as a Glasgow coma scale (GCS) score ≤ 8 and was documented either on-scene, during transportation or by an on-call neurosurgeon on hospital admission. Modified Glasgow Outcome Score (GOS) was used for assessment of six-month neurological outcome and good neurological outcome was defined as GOS 4-5.

Results: Data from 181 patients in the EMS group and 85 patients in the HEMS group were available for neurological outcome analyses. The baseline characteristics and the first recorded vital signs of the two cohorts were similar. Good neurological outcome was more frequent in the HEMS group; 42% of the HEMS managed patients and 28% (p = 0.022) of the EMS managed patients had a good neurological recovery. The airway was more frequently secured in the HEMS group (p < 0.001). On arrival at the emergency department, the patients in the HEMS group were less often hypoxic (p = 0.024). In univariate analysis HEMS period, lower age and secured airway were associated with good neurological outcome.

Conclusion: The introduction of a physician-staffed HEMS unit resulted in decreased incidence of prehospital hypoxia and increased the number of secured airways. This may have contributed to the observed improved neurological outcome during the HEMS period.

Trial registration: ClinicalTrials.gov IDNCT02659046. Registered January 15th, 2016.

Keywords: Airway management (MeSH); Critical care (MeSH); Emergency medical services (MeSH); Endotracheal intubation (MeSH); Glasgow outcome scale (MeSH); Patient outcome assessment (MeSH); Prehospital emergency care (MeSH); Traumatic brain injury (MeSH).

Conflict of interest statement

Ethics approval and consent to participate

The study protocol was approved by the Regional Ethics Committee of the Pirkanmaa Hospital District (reference number R15158), permission to conduct the study was obtained from the Research Director of Tampere University Hospital and registered in Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Flow-chart
Fig. 2
Fig. 2
Six-month survival according to EMS system (Log Rank p = 0.066)

References

    1. Badjatia N, Carney N, Crocco TJ, Fallat ME, Hennes HM, Jagoda AS, et al. Guidelines for prehospital management of traumatic brain injury 2nd edition. Prehosp Emerg Care. 2008;12(Suppl 1):S1–52. doi: 10.1080/10903120701732052.
    1. Chesnut RM, Marshall LF, Klauber MR, Blunt BA, Baldwin N, Eisenberg HM, et al. The role of secondary brain injury in determining outcome from severe head injury. J Trauma. 1993;34(2):216–222. doi: 10.1097/00005373-199302000-00006.
    1. Stocchetti N, Furlan A, Volta F. Hypoxemia and arterial hypotension at the accident scene in head injury. J Trauma. 1996;40(5):764–767. doi: 10.1097/00005373-199605000-00014.
    1. Boer C, Franschman G, Loer SA. Prehospital management of severe traumatic brain injury: concepts and ongoing controversies. Curr Opin Anaesthesiol. 2012;25(5):556–562. doi: 10.1097/ACO.0b013e328357225c.
    1. Wang HE, Peitzman AB, Cassidy LD, Adelson PD, Yealy DM. Out-of-hospital endotracheal intubation and outcome after traumatic brain injury. Ann Emerg Med. 2004;44(5):439–450. doi: 10.1016/j.annemergmed.2004.04.008.
    1. Murray JA, Demetriades D, Berne TV, Stratton SJ, Cryer HG, Bongard F, et al. Prehospital intubation in patients with severe head injury. J Trauma. 2000;49(6):1065–1070. doi: 10.1097/00005373-200012000-00015.
    1. Davis DP. Prehospital intubation of brain-injured patients. Curr Opin Crit Care. 2008;14(2):142–148. doi: 10.1097/MCC.0b013e3282f63c40.
    1. Davis DP. Early ventilation in traumatic brain injury. Resuscitation. 2008;76(3):333–340. doi: 10.1016/j.resuscitation.2007.08.004.
    1. Botker MT, Bakke SA, Christensen EF. A systematic review of controlled studies: do physicians increase survival with prehospital treatment? Scand J Trauma Resusc Emerg Med. 2009;17:12. doi: 10.1186/1757-7241-17-12.
    1. Pakkanen T, Virkkunen I, Kamarainen A, Huhtala H, Silfvast T, Virta J, et al. Pre-hospital severe traumatic brain injury - comparison of outcome in paramedic versus physician staffed emergency medical services. Scand J Trauma Resusc Emerg Med. 2016;24:62. doi: 10.1186/s13049-016-0256-x.
    1. Ringburg AN, Thomas SH, Steyerberg EW, van Lieshout EM, Patka P, Schipper IB. Lives saved by helicopter emergency medical services: an overview of literature. Air Med J. 2009;28(6):298–302. doi: 10.1016/j.amj.2009.03.007.
    1. Frankema SP, Ringburg AN, Steyerberg EW, Edwards MJ, Schipper IB, van Vugt AB. Beneficial effect of helicopter emergency medical services on survival of severely injured patients. Br J Surg. 2004;91(11):1520–1526. doi: 10.1002/bjs.4756.
    1. Garner A, Rashford S, Lee A, Bartolacci R. Addition of physicians to paramedic helicopter services decreases blunt trauma mortality. Aust N Z J Surg. 1999;69(10):697–701. doi: 10.1046/j.1440-1622.1999.01688.x.
    1. Iirola TT, Laaksonen MI, Vahlberg TJ, Palve HK. Effect of physician-staffed helicopter emergency medical service on blunt trauma patient survival and prehospital care. Eur J Emerg Med. 2006;13(6):335–339. doi: 10.1097/01.mej.0000224429.51623.fb.
    1. Nicholl JP, Brazier JE, Snooks HA. Effects of London helicopter emergency medical service on survival after trauma. BMJ. 1995;311(6999):217–222. doi: 10.1136/bmj.311.6999.217.
    1. Traumatic Brain Injury (online). Current Care Guidelines.Working group set up by the Finnish Medical Society Duodecim. Helsinki: The Finnish Medical Society Duodecim. . Accessed 7 Jan 2017.
    1. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974;2(7872):81–84. doi: 10.1016/S0140-6736(74)91639-0.
    1. Jennett B, Bond M. Assessment of outcome after severe brain damage. Lancet. 1975;1(7905):480–484. doi: 10.1016/S0140-6736(75)92830-5.
    1. Jennett B, Snoek J, Bond MR, Brooks N. Disability after severe head injury: observations on the use of the Glasgow outcome scale. J Neurol Neurosurg Psychiatry. 1981;44(4):285–293. doi: 10.1136/jnnp.44.4.285.
    1. Bernard SA, Nguyen V, Cameron P, Masci K, Fitzgerald M, Cooper DJ, et al. Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury: a randomized controlled trial. Ann Surg. 2010;252(6):959–965. doi: 10.1097/SLA.0b013e3181efc15f.
    1. Davis DP, Dunford JV, Poste JC, Ochs M, Holbrook T, Fortlage D, et al. The impact of hypoxia and hyperventilation on outcome after paramedic rapid sequence intubation of severely head-injured patients. J Trauma. 2004;57(1):1–8. doi: 10.1097/01.TA.0000135503.71684.C8.
    1. Haltmeier T, Benjamin E, Siboni S, et al. Prehospital intubation for isolated severe blunt traumatic brain injury: worse outcomes and higher mortality. Eur J Trauma Emerg Surg. 2016. .
    1. Bossers SM, Schwarte LA, Loer SA, Twisk JW, Boer C, Schober P. Experience in Prehospital endotracheal intubation significantly influences mortality of patients with severe traumatic brain injury: a systematic review and meta-analysis. PLoS One. 2015;10(10):e0141034. doi: 10.1371/journal.pone.0141034.
    1. Susman M, DiRusso SM, Sullivan T, Risucci D, Nealon P, Cuff S, et al. Traumatic brain injury in the elderly: increased mortality and worse functional outcome at discharge despite lower injury severity. J Trauma. 2002;53(2):219–223. doi: 10.1097/00005373-200208000-00004.
    1. Mosenthal AC, Lavery RF, Addis M, Kaul S, Ross S, Marburger R, et al. Isolated traumatic brain injury: age is an independent predictor of mortality and early outcome. J Trauma. 2002;52(5):907–911.

Source: PubMed

Спонсоры и соавторы

Заболевания

Медикаментозные вмешательства

Подписаться