Hypoxia and hypotension in patients intubated by physician staffed helicopter emergency medical services - a prospective observational multi-centre study

Geir Arne Sunde, Mårten Sandberg, Richard Lyon, Knut Fredriksen, Brian Burns, Karl Ove Hufthammer, Jo Røislien, Akos Soti, Helena Jäntti, David Lockey, Jon-Kenneth Heltne, Stephen J M Sollid, Geir Arne Sunde, Mårten Sandberg, Richard Lyon, Knut Fredriksen, Brian Burns, Karl Ove Hufthammer, Jo Røislien, Akos Soti, Helena Jäntti, David Lockey, Jon-Kenneth Heltne, Stephen J M Sollid

Abstract

Background: The effective treatment of airway compromise in trauma and non-trauma patients is important. Hypoxia and hypotension are predictors of negative patient outcomes and increased mortality, and may be important quality indicators of care provided by emergency medical services. Excluding cardiac arrests, critical trauma and non-trauma patients remain the two major groups to which helicopter emergency medical services (HEMS) are dispatched. Several studies describe the impact of pre-hospital hypoxia or hypotension on trauma patients, but few studies compare this in trauma and non-trauma patients. The primary aim was to describe the incidence of pre-hospital hypoxia and hypotension in the two groups receiving pre-hospital tracheal intubation (TI) by physician-staffed HEMS.

Methods: Data were collected prospectively over a 12-month period, using a uniform Utstein-style airway template. Twenty-one physician-staffed HEMS in Europe and Australia participated. We compared peripheral oxygen saturation and systolic blood pressure before and after definitive airway management. Data were analysed using Cochran-Mantel-Haenszel methods and mixed-effects models.

Results: Eight hundred forty three trauma patients and 422 non-trauma patients receiving pre-hospital TI were included. Non-trauma patients had significantly lower predicted mean pre-intervention SpO2 compared to trauma patients. Post-intervention and admission SpO2 for the two groups were comparable. However, 3% in both groups were still hypoxic at admission. For hypotension, the differences between the groups were less prominent. However, 9% of trauma and 10% of non-trauma patients were still hypotensive at admission. There was no difference in short-term survival between trauma (97%) and non-trauma patients (95%). Decreased level of consciousness was the most frequent indication for TI, and was associated with increased survival to hospital (cOR 2.8; 95% CI: 1.4-5.4).

Conclusions: Our results showed that non-trauma patients had a higher incidence of hypoxia before TI than trauma patients, but few were hypoxic at admission. The difference for hypotension was less prominent, but one in ten patients were still hypotensive at admission. Further investigations are needed to identify reversible causes that may be corrected to improve haemodynamics in the pre-hospital setting. We found high survival rates to hospital in both groups, suggesting that physician-staffed HEMS provide high-quality emergency airway management in trauma and non-trauma patients.

Trial registration: Clinicaltrials.gov Identifier: NCT01502111 . Registered 22 Desember 2011.

Keywords: Advanced trauma life support; Air ambulance; Airway management; Critical care; Helicopter emergency medical services; Intubation; Physician staffed HEMS.

Conflict of interest statement

Ethics approval and consent to participate

Norway: The Regional Committee for Medical and Health Research Ethics in Western Norway considered the study as a service evaluation study and exempted it from ethical review (Reference number: 2011/1123/REK VEST). Australia: The Royal Prince Alfred Hospital Human Research Ethics Committee approved the study. Hungary: Egészségügyi Tudományos Tanács, Tudományos és Kutatásetikai Bizottság – Scientific and Research Ethics Committee of the Medical Research Council approved the study (Reference number: 98/2012/EKU (3/PI/12.)). Switzerland: Ethikkommission beider Basel approved the study (Reference number: EK: 233/12). England: The Barts Health R&D department (for London’s Air Ambulance), and the UK National Institute for Health Research and local Ethics and Research Committee (for Kent Surrey Sussex HEMS), approved the study as a service evaluation project and exempted it from ethical review. Finland: The Ethics Committee of Kuopio University Hospital, Kuopio, approved the study (Reference number Kupio / Vantaa / Tampere132/2011, and Tampere ETL code R12020). Requirement for written informed consents was waived.

Consent for publication

See above. Consent for publication is not applicable.

Competing interests

The authors declare they have no conflict of interest.

Publisher’s Note

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

Figures

Fig. 1
Fig. 1
Study population flow chart. Flow chart of study population. One thousand two hundred sixty five non-cardiac arrest patients that received pre-hospital tracheal intubation were included
Fig. 2
Fig. 2
Patient vitals across airway intervention. Predicted means for patients SBP and SPO2 across airway intervention for trauma and non-trauma patients, based on linear mixed-effects models with time, trauma category and their interaction as fixed effects and random intercepts for patients and HEMS. Vertical lines show 95% pointwise confidence intervals. Non-trauma patients had a significantly lower mean SPO2, and higher mean SBP, before TI compared to trauma patients. Post-intervention and admission values for the two groups showed little difference. SBP: systolic blood pressure. SPO2: oxygen saturation. HEMS: helicopter emergency medical services

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