Feature
EMERGENCY
40
vital
Pre-hospital intubation
A study by David Lockey, Rowan Hardy and Gareth Davies, suggests that intubation, particularly without the assistance of drugs, does little to improve the outcome with trauma patients. Compiled by: Bronwyn Barnard in association with David Lockey and Timothy Hardcastle However, as intubation remains in practice, the fundamental aspect to remember is that the same standards and expertise need to be applied in the hospital and outside of it. Lockey comments that even although there has been a general lack of well conducted studies, many people still believe that drugassisted tracheal intubation is a core skill in effective pre-hospital trauma care. The reason for this? “We believe that hypoxemia, particularly in the context of a head injury, is associated with poor outcomes and we often see severely injured patients that are hypoxaemic but that still have airway reflexes, thus making intubation without drugs difficult or impossible.” Lockey adds that intubation without drugs does not appear to be useful for the following reason: “We are concerned that this vulnerable period may be prolonged because we are aware of the fact that the majority of the first hours following an accident are spent in the pre-hospital phase.” While this may appear to be prolonged, scene times include emergency call times, dispatch times, transport from the scene, and the unloading times. In addition, these times only apply to non-trapped patients. Where a patient has been trapped, the times extend for an even longer duration. Lockey rationally comments that, “We cannot imagine that any ethics committee would give approval for a study where patients with head injuries were left hypoxaemic for this period of time in the emergency department unintubated, compared with those who were provided with skilled intubation on arrival.” Lockey adds that he sees no reason as to why a patient should not be intubated in FIRE AFRICA l January / February 2012
On-scene tracheomy
the pre-hospital phase provided that, when an RSI is performed, there is a standard of care similar to that achieved in the emergency room. In addition, he deems it safe only if all potential risks and benefits have been weighed up and considered. The South African context In South Africa, intubation may only be performed by an advanced life support (ALS) paramedic present at the scene. Timothy Hardcastle and Thomas Goff conducted research into Trauma Unit Emergency Doctor Airways Management. The study was as follows: Objectives To audit indications for and practice (in terms of training/qualification) of definitive airway management compared with current UK practices. Design Consecutive observational study. Setting Tygerberg Academic Hospital Trauma Service, Western Cape. Subjects All trauma patients either arriving intubated, or requiring intubation, at the Trauma unit during the period 1-31 August. Outcome measures A data collection proforma was completed either at the time of intubation or from medical records.