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Following the ABCs for prehospital trauma care is outdated and the evidence points towards harm. We need to resequence away from the ABCs and resuscitate before intubation or potentially avoid intubation altogether
https://link.springer.com/article/10.1007/s43678-020-00050-2
@CJEM @Hillier6Morgan
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https://link.springer.com/article/10.1007/s43678-020-00050-2
@CJEM @Hillier6Morgan
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Very few trauma patients present with true airway emergencies that require immediate intubation. In Canada, the incidence of traumatic airway injuries was found to be 0.4% for blunt trauma and 4.5% for penetrating trauma
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The evidence: a systematic review of 21 studies with 35,838 trauma patients found higher mortality rates in injured patients that were intubated in the prehospital environment compared to in the ED (OR 2.56, 95%CI 2.06–3.18), including when adjusted for severity of illness
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Intubation worsens trauma physiology. Always. PPV increases intrathoracic pressure, decreases venous return and reduces cardiac output, resulting in further hypoperfusion and shock. In the setting of hemorrhagic or obstructive shock this can be enough to precipitate death
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In the setting of cardiac tamponade, even in hospital, we will defer intubating these patients until they are in the operating room with surgeons ready to open the chest due to the high-risk nature of intubating these patients.
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Many trauma centres follow guidelines to perform resuscitative thoracotomies only if less than 10-15 min of CPR, so the decision to intubate on-scene may be enough of a delay for patients to no longer be considered for this intervention
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Our suggestion: Less is more. Keep trauma patients breathing spontaneously. OPA/NPA/SGA w/ careful + slow BVM ventilation - similar to the suggested approach with medical cardiac arrests. Rapid transport to trauma centres. Call for air backup if appropriate
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I can remember patients that the decision by paramedics to NOT intubate is what saved their life. I also remember the patients that were intubated who had a worse outcome because of it. The ABCs are outdated, we’ve learned that in-hospital. Time to do the same prehospital
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