Prehospital Rapid Sequence Intubation Improves Functional Outcome for Patients with Severe Traumatic Brain Injury

This multicenter study from Victoria, Australia was a prospective, randomized, controlled trial comparing long-term neurologic outcomes in patients with severe traumatic brain injury (TBI) who receive paramedic Rapid Sequence Intubation (RSI) vs. hospital intubation. The primary outcome measure was the median extended Glasgow Outcome Scale (GOSe) score at 6 months. Secondary end points were favorable vs. unfavorable outcome at 6 months, length of intensive care and hospital stay, and survival to hospital discharge. Patients were included in the study if there was evidence of head trauma, Glasgow Coma Score<9, age>15 years, and intact airway reflexes. Patients were excluded if they were within 10 min of a designated trauma hospital, had no intravenous access, had an allergy to any of the RSI drugs, or were transported by helicopter. Patients assigned to paramedic intubation received fentanyl (100 μg), midazolam (0.1 mg/kg), and succinylcholine (1.5 mg/kg) administered in rapid succession. An intensive care paramedic who had undergone an additional 16-h training program in the theory and practice of RSI would then intubate the patient. Tracheal intubation was confirmed by capnography. If intubation was not achieved on the first attempt, a second attempt was allowed with the use of a plastic airway bougie. If intubation still could not be achieved, bag/mask ventilation was performed until patient arrival to the hospital. Patients assigned to in-hospital intubation underwent immediate RSI on arrival by a physician. Once patients were admitted, intensive care management was at the discretion of the treating physicians, but generally followed the recommendation of the Brain Trauma Foundation. Six months after the injury, patient or next of kin were interviewed to determine the GOSe. The interviewer was blinded to the treatment allocation. Between April 2004 and January 2008, 1045 patients were evaluated for possible enrollment in the study. Three hundred twenty-eight patients met the enrollment criteria. Of these, 16 patients were not enrolled due to paramedic error. Of the 312 enrolled, 160 patients were randomly assigned to paramedic RSI and 152 were randomly assigned to hospital intubation. A total of 10 patients in both groups were lost to follow-up. At 6 months, the median GOSe was 5 in the paramedic intubation group compared to 3 in the hospital intubation group (p=0.28). The proportion of favorable neurologic outcome (GOSe 5–8) was found in 51% of patients with paramedic intubation vs. 39% in patients intubated in the hospital (risk ratio, 1.28; 95% confidence interval 1.00–1.64; p=0.046). Median Intensive Care Unit stay was 107 h in the paramedic RSI group vs. 103 h in the hospital intubation group (p=0.74). The authors concluded that pre-hospital RSI reduces the adverse neurological outcome in severe TBI patients.