Interventions associated with survival after prehospital intubation in the deployed combat setting

Michael D April; Rachel E Bridwell; William T Davis; Joshua J Oliver; Brit Long; Andrew D Fisher; Adit A Ginde; Steven G Schauer

doi:10.1016/j.ajem.2024.01.047

Interventions associated with survival after prehospital intubation in the deployed combat setting

Am J Emerg Med. 2024 May:79:79-84. doi: 10.1016/j.ajem.2024.01.047. Epub 2024 Feb 7.

Authors

Michael D April¹, Rachel E Bridwell², William T Davis³, Joshua J Oliver², Brit Long³, Andrew D Fisher⁴, Adit A Ginde⁵, Steven G Schauer⁶

Affiliations

¹ Uniformed Services University of the Health Sciences, Bethesda, MD, USA; 14th Field Hospital, Fort Stewart, GA, USA. Electronic address: michael.d.april@post.harvard.edu.
² Uniformed Services University of the Health Sciences, Bethesda, MD, USA; Department of Emergency Medicine, Madigan Army Medical Center, Joint Base Lewis-McChord, WA, USA.
³ Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
⁴ Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM, USA.
⁵ Departments of Emergency Medicine and Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA; Center for Combat and Battlefield (COMBAT) Research, University of Colorado School of Medicine, Aurora, CO, USA.
⁶ Uniformed Services University of the Health Sciences, Bethesda, MD, USA; Departments of Emergency Medicine and Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA; Center for Combat and Battlefield (COMBAT) Research, University of Colorado School of Medicine, Aurora, CO, USA.

PMID: 38401229
DOI: 10.1016/j.ajem.2024.01.047

Abstract

Introduction: Airway compromise is the second leading cause of potentially preventable death on the battlefield. Prehospital airway management is often unavoidable in a kinetic combat environment and expected to increase in future wars where timely evacuation will be unreliable and air superiority not guaranteed. We compared characteristics of survivors to non-survivors among combat casualties undergoing prehospital airway intubation.

Materials and methods: We requested all Department of Defense Trauma Registry (DODTR) encounters during 2007-2023 with documentation of any airway intervention or assessment within the first 72-h after injury. We conducted a retrospective cohort study of all casualties with intubation documented in the prehospital setting. We used descriptive and inferential statistical analysis to compare survivors through 7 days post injury versus non-survivors. We constructed 3 multivariable logistic regression models to test for associations between interventions and 7-day survival after adjusting for injury severity score, mechanism of injury, and receipt of sedatives, paralytics, and blood products.

Results: There were 1377 of 48,301 patients with documentation of prehospital intubation in a combat setting. Of these, 1028 (75%) survived through 7 days post injury. Higher proportions of survivors received ketamine, paralytic agents, parenteral opioids, and parenteral benzodiazepines; there was no difference in the proportions of survivors versus non-survivors receiving etomidate. The multivariable models consistently demonstrated positive associations between 7-day survival and receipt of non-depolarizing paralytics and opioid analgesics.

Conclusions: We found an association between non-depolarizing paralytic and opioid receipt with 7-day survival among patients undergoing prehospital intubation. The literature would benefit from future multi-center randomized controlled trials to establish optimal pharmacologic strategies for trauma patients undergoing prehospital intubation.

Keywords: Airway; Combat; Endotracheal; Intubation; Military; Outcome.

Published by Elsevier Inc.

MeSH terms

Airway Management
Emergency Medical Services*
Humans
Intubation, Intratracheal
Registries
Retrospective Studies
Wounds and Injuries* / therapy