Is Prehospital Intubation of Severely Injured Children in Accordance with Guidelines?

Overview

Journal BMC Emerg Med

Publisher Biomed Central

Specialty Emergency Medicine

Date 2022 Dec 6

PMID 36474145

Authors

Teresa Maek

Ulrike Fochtmann

Anna von Loewenich

Pascal Jungbluth

Werner Zimmermann

Rolf Lefering

Sven Lendemans

Bjoern Hussmann

Affiliations

Soon will be listed here.

Abstract

Background: The current German S3 guideline for polytrauma lists five criteria for prehospital intubation: apnea, severe traumatic brain injury (GCS ≤8), severe chest trauma with respiratory failure, hypoxia, and persistent hemodynamic instability. These guideline criteria, used in adults in daily practice, have not been previously studied in a collection of severely injured children. The aim of this study was to assess the extent to which the criteria are implemented in clinical practice using a multivariate risk analysis of severely injured children.

Methods: Data of 289,698 patients from the TraumaRegister DGU® were analyzed. Children meeting the following criteria were included: Maximum Abbreviated Injury Scale 3+, primary admission, German-speaking countries, years 2008-2017, and declaration of intubation. Since children show age-dependent deviating physiology, four age groups were defined (years old: 0-2; 3-6; 7-11; 12-15). An adult collective served as a control group (age: 20-50). After a descriptive analysis in the first step, factors leading to prehospital intubation in severely injured children were analyzed with a multivariate regression analysis.

Results: A total of 4489 children met the inclusion criteria. In this cohort, young children up to 2 years old had the significantly highest injury severity (Injury Severity Score: 21; p ≤ 0.001). Falls from both high (> 3 m) and low heights (< 3 m) were more common in children than in adults. The same finding applied to the occurrence of severe traumatic brain injury. When at least one intubation criterion was formally present, the group up to 6 years old was least likely to actually be intubated (61.4%; p ≤ 0.001). Multivariate regression analysis showed that Glasgow Coma Scale score ≤ 8 in particular had the greatest influence on intubation (odds ratio: 26.9; p ≤ 0.001).

Conclusions: The data presented here show for the first time that the existing criteria in the guideline for prehospital intubation are applied in clinical practice (approximately 70% of cases), compared to adults, in the vast majority of injured children. Although severely injured children still represent a minority of all injured patients, future guidelines should focus more on them and address them in a specialized manner.

Citing Articles

Pediatric intensive care unit admissions network-rationale, framework and method of operation of a nationwide collaborative pediatric intensive care research network in Germany.

Bruns N, Dohna-Schwake C, Olivieri M, Urschitz M, Blomenkamp S, Frosch C Front Pediatr. 2024; 11:1254935.

PMID: 38269291 PMC: 10806156. DOI: 10.3389/fped.2023.1254935.

References

Ilie G, Trenholm M, Boak A, Mann R, Adlaf E, Asbridge M . Adolescent traumatic brain injuries: Onset, mechanism and links with current academic performance and physical injuries. PLoS One. 2020; 15(3):e0229489. PMC: 7067417. DOI: 10.1371/journal.pone.0229489. View

Hussain E . Traumatic Brain Injury in the Pediatric Intensive Care Unit. Pediatr Ann. 2018; 47(7):e274-e279. DOI: 10.3928/19382359-20180619-01. View

Levy M, Fink M, Marshall J, Abraham E, Angus D, Cook D . 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. 2003; 31(4):1250-6. DOI: 10.1097/01.CCM.0000050454.01978.3B. View

Haarbauer-Krupa J, Haileyesus T, Gilchrist J, Mack K, Law C, Joseph A . Fall-related traumatic brain injury in children ages 0-4 years. J Safety Res. 2019; 70:127-133. PMC: 6927527. DOI: 10.1016/j.jsr.2019.06.003. View

Hussmann B, Lefering R, Waydhas C, Ruchholtz S, Wafaisade A, Kauther M . Prehospital intubation of the moderately injured patient: a cause of morbidity? A matched-pairs analysis of 1,200 patients from the DGU Trauma Registry. Crit Care. 2011; 15(5):R207. PMC: 3334751. DOI: 10.1186/cc10442. View

Gassler M, Ruppert M, Lefering R, Bouillon B, Wafaisade A . [Treatment of severely injured patients by emergency physicians from different medical specialties : A retrospective multicenter investigation of data from the ADAC Air Recue Service and the German TraumaRegister DGU®]. Unfallchirurgie (Heidelb). 2021; 125(12):967-974. PMC: 9705456. DOI: 10.1007/s00113-021-01094-4. View

DiRusso S, Sullivan T, Risucci D, Nealon P, Slim M . Intubation of pediatric trauma patients in the field: predictor of negative outcome despite risk stratification. J Trauma. 2005; 59(1):84-90. DOI: 10.1097/01.ta.0000171462.28379.f3. View

Paneitz D, Ahmad S . Pediatric Trauma Update. Mo Med. 2018; 115(5):438-442. PMC: 6205270. View

Laurer H, Wutzler S, Wyen H, Westhoff J, Lehnert M, Lefering R . [Quality of prehospital and early clinical care of pediatric trauma patients of school age compared to an adult cohort. A matched-pair analysis of 624 patients from the DGU trauma registry]. Unfallchirurg. 2009; 112(9):771-7. DOI: 10.1007/s00113-009-1589-y. View

10.

Lefering R . Development and validation of the revised injury severity classification score for severely injured patients. Eur J Trauma Emerg Surg. 2016; 35(5):437-47. DOI: 10.1007/s00068-009-9122-0. View

11.

Eich C, Roessler M, Nemeth M, Russo S, Heuer J, Timmermann A . Characteristics and outcome of prehospital paediatric tracheal intubation attended by anaesthesia-trained emergency physicians. Resuscitation. 2009; 80(12):1371-7. DOI: 10.1016/j.resuscitation.2009.09.004. View

12.

Emami P, Czorlich P, Fritzsche F, Westphal M, Rueger J, Lefering R . Observed versus expected mortality in pediatric patients intubated in the field with Glasgow Coma Scale scores < 9. Eur J Trauma Emerg Surg. 2019; 45(5):769-776. DOI: 10.1007/s00068-018-01065-2. View

13.

Schauer S, Naylor J, Hill G, Arana A, Roper J, April M . Association of prehospital intubation with decreased survival among pediatric trauma patients in Iraq and Afghanistan. Am J Emerg Med. 2017; 36(4):657-659. DOI: 10.1016/j.ajem.2017.11.066. View

14.

Bernard S, Nguyen V, Cameron P, Masci K, Fitzgerald M, Cooper D . Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury: a randomized controlled trial. Ann Surg. 2010; 252(6):959-65. DOI: 10.1097/SLA.0b013e3181efc15f. View

15.

Schlechtriemen T, Masson R, Burghofer K, Lackner C, Altemeyer K . [Pediatric cases in preclinical emergency medicine: critical aspects in the range of missions covered by ground ambulance and air rescue services]. Anaesthesist. 2005; 55(3):255-62. DOI: 10.1007/s00101-005-0922-2. View

16.

Hawkins R, Raymond S, Hamann H, Taylor J, Mustafa M, Islam S . Outcomes After Prehospital Endotracheal Intubation in Suburban/Rural Pediatric Trauma. J Surg Res. 2020; 249:138-144. DOI: 10.1016/j.jss.2019.11.034. View

17.

Lockey D, Healey B, Crewdson K, Chalk G, Weaver A, Davies G . Advanced airway management is necessary in prehospital trauma patients. Br J Anaesth. 2014; 114(4):657-62. DOI: 10.1093/bja/aeu412. View

18.

Kerrey B, Rinderknecht A, Geis G, Nigrovic L, Mittiga M . Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review. Ann Emerg Med. 2012; 60(3):251-9. PMC: 3400706. DOI: 10.1016/j.annemergmed.2012.02.013. View

19.

Tarpgaard M, Hansen T, Rognas L . Anaesthetist-provided pre-hospital advanced airway management in children: a descriptive study. Scand J Trauma Resusc Emerg Med. 2015; 23:61. PMC: 4549899. DOI: 10.1186/s13049-015-0140-0. View

20.

Ashburn N, Hendley N, Angi R, Starnes A, Nelson R, McGinnis H . Prehospital Trauma Scene and Transport Times for Pediatric and Adult Patients. West J Emerg Med. 2020; 21(2):455-462. PMC: 7081873. DOI: 10.5811/westjem.2019.11.44597. View