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Observational Study
. 2023 Nov 24;31(1):85.
doi: 10.1186/s13049-023-01151-4.

Prehospital and emergency department airway management of severe penetrating trauma in Sweden during the past decade

Mattias Renberg  1 , Martin Dahlberg  2 , Mikael Gellerfors  3   4   5   6 , Elham Rostami #  7   8 , Mattias Günther #  9   7   10
Affiliations
Observational Study

Prehospital and emergency department airway management of severe penetrating trauma in Sweden during the past decade

Mattias Renberg et al. Scand J Trauma Resusc Emerg Med. .

Abstract

Background: Prehospital tracheal intubation (TI) is associated with increased mortality in patients with penetrating trauma, and the utility of prehospital advanced airway management is debated. The increased incidence of deadly violence in Sweden warrants a comprehensive evaluation of current airway management for patients with penetrating trauma in the Swedish prehospital environment and on arrival in the emergency department (ED).

Methods: This was an observational, multicenter study of all patients with penetrating trauma and injury severity scores (ISSs) ≥ 15 included in the Swedish national trauma register (SweTrau) between 2011 and 2019. We investigated the frequency and characteristics of prehospital and ED TI, including 30-day mortality and patient characteristics associated with TI.

Result: Of 816 included patients, 118 (14.5%) were intubated prehospitally, and 248 (30.4%) were intubated in the ED. Patients who were intubated prehospitally had a higher ISS, 33 (interquartile range [IQR] 25, 75), than those intubated in the ED, 25 (IQR 18, 34). Prehospital TI was associated with a higher associated mortality, OR 4.26 (CI 2.57, 7.27, p < 0.001) than TI in the ED, even when adjusted for ISS (OR 2.88 [CI 1.64, 5.14, p < 0.001]). Hemodynamic collapse (≤ 40 mmHg) and low GCS score (≤ 8) were the characteristics most associated with prehospital TI. Traumatic cardiac arrests (TCAs) occurred in 154 (18.9%) patients, of whom 77 (50%) were intubated prehospitally and 56 (36.4%) were intubated in the ED. A subgroup analysis excluding TCA showed that patients with prehospital TI did not have a higher mortality rate than those with ED TI, OR 2.07 (CI 0.93, 4.51, p = 0.068), with OR 1.39 (0.56, 3.26, p = 0.5) when adjusted for ISS.

Conclusion: Prehospital TI was associated with a higher mortality rate than those with ED TI, which was specifically related to TCA; intubation did not affect mortality in patients without cardiac arrest. Mortality was high when airway management was needed, regardless of cardiac arrest, thereby emphasizing the challenges posed when anesthesia is needed. Several interventions, including whole blood transfusions, the implementation of second-tier EMS units and measures to shorten scene times, have been initiated in Sweden to counteract these challenges.

Keywords: Airway management; Intubation; Penetrating trauma; Prehospital; Trauma.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Flowchart of patient inclusion. Abbreviations: ED = emergency department, ISS = injury severity score, PHAAM = prehospital advanced airway management, SGA = supraglottic airway device, SweTrau = Swedish national trauma registry, TI = tracheal intubation
Fig. 2
Fig. 2
Mortality associated with prehospital TI and ISS. Abbreviation: ISS = injury severity score
Fig. 3
Fig. 3
Regression model for mortality associated with prehospital TI. Probabilities calculated using the median age (31 years). Abbreviation: GCS = Glasgow coma scale
Fig. 4
Fig. 4
Patient characteristics associated with prehospital TI. Abbreviation: GCS = Glasgow coma scale
Fig. 5
Fig. 5
Mortality associated with prehospital TI and ISS with traumatic cardiac arrests excluded. Abbreviation: ISS = injury severity score
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