Anaesthesia 2020, 75, 7–10
14854
Editorial
Early airway management of patients with severe head
injury: opportunities missed?
D. J. Lockey1,2 and M. Wilson3,4
1 Honorary Professor, School of Clinical Sciences, University of Bristol, Bristol, UK
2 Emergency Medical Retrieval and Transfer Service (EMRTS), Wales, UK
3 Honorary Professor of Brain Injury and Consultant Neurosurgeon, Imperial College London, London, UK
4 Gibson Chair of Pre-hospital Care, Faculty of Pre-hospital Care, Royal College of Surgeons Edinburgh, Edinburgh, UK
............................................................................................................................................................................................................................................................................................................
Correspondence to: D. J. Lockey
Email: david.lockey@nbt.nhs.uk
Accepted: 20 August 2019
Keywords: emergency anaesthesia; emergency medical services; head injury
This editorial accompanies an article by Gravesteijn et al., Anaesthesia 2020; 75: 45–53.
Twitter: @davidlbath; @markhwilson
Globally, there are approximately six million deaths per year
from trauma [1]. Traumatic brain injury (TBI) and spinal cord
injury are major contributors to this key public health
challenge and it has been estimated that in Europe there are
approximately 225 deaths a day from TBI [2]. Even in
regions with high levels of penetrating trauma, TBI is often
still the most common cause of death following trauma [3].
The epidemiology of TBI has been changing for some years
and we now see two patient groups dominating trauma
centre practice: older patients with low-impact trauma; and
young adults with more severe injuries, often related to road
traffic collisions [4, 5].
In this issue of Anaesthesia, Gravesteijn et al.,
(representing the CENTER-TBI investigators) publish a study
which reveals significant variation
management between European centres and countries [6].
This follows on from other studies from the same group
reporting significant variation in neurosurgical and intensive
care management in the same population [7, 8].
The study included 3843 patients from 45 centres. The
majority of patients’ tracheas were intubated in the pre-
hospital phase rather than after arrival in hospital, which is
likely to reflect the availability of physician delivered pre-
hospital care (and pre-hospital anaesthesia) in many
European countries. Not surprisingly, the patients whose
tracheas were intubated had lower GCS scores, were more
severely injured and had a higher rate of non-reactive
pupils. They also had higher injury severity scores for other
© 2019 Association of Anaesthetists
doi:10.1111/anae.
body regions, particularly chest and facial injuries. Pre-
hospital tracheal intubation appeared to add to on-scene
times although this may reflect the increased time required
to treat more severely injured patients at more difficult
scenes. Tracheal intubation was more likely where an
anaesthetist was present on scene, perhaps a marker for the
ability of the pre-hospital team to conduct drug-assisted
tracheal intubation. Tracheal intubation without drugs in
patients with a head injury is usually only possible in the
most obtunded patients, associated with very high mortality
and has not been demonstrated to be beneficial.
The authors comment on the fact that a policy of ‘scoop
and run’ rather than ‘stay and play’ reduced the tracheal
intubation rate. Although some systems have shorter scene
in early airway times than others, these terms are now outdated because
they neither reflect good practice or the reality in modern
care. Examination of times from incident to arrival in the
emergency department in Europe demonstrate that ‘scoop
and run’ times are rarely short enough to delay the
treatment of time-critical clinical problems (e.g. airway
obstruction, hypoventilation or major bleeding) until after
hospital arrival. Similarly, ‘stay and play’ suggests remaining
on scene to perform clinical interventions which are not
necessary. Effective pre-hospital care should deliver key
interventions where indicated (and available) and proceed
to the most appropriate hospital with minimum delay.
One of the points that this study raises is the question of
whether tracheal intubation is, or should be, indicated by a
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Anaesthesia 2020, 75, 7–10
GCS ≤ 8. A limitation of this and similar studies examining
the benefits or drawbacks of pre-hospital tracheal
intubation is the difficulty of differentiating unconscious
patients with and without airway or ventilatory compromise.
Benefit would be expected to be much greater in the group
with hypoxia and hypercapnia than those without
compromise. Some studies also fail to differentiate between
tracheal intubation with and without drugs. From a practical
perspective, we think that physicians in pre-hospital care
make their decision to perform pre-hospital anaesthesia on
a number of criteria including, but not limited to, the GCS
score. Airway and ventilatory compromise are probably
highly influential but other injuries, pain and trends in
physiology may also influence the decision. Many services
have a list of indications which also include anticipated
clinical course and ‘humanitarian’ reasons. Less discussed
are patients anaesthetised on scene with higher GCS
scores. In our experience, this is conducted frequently to
safely manage patients with head injury combined with
agitation.
Does access to pre-hospital anaesthesia
matter?
In hospital, patients with severe TBI are managed with
tracheal intubation and ventilation to allow therapeutic
intervention and prevent secondary injury; this is
uncontroversial. Pre-hospital tracheal intubation and
ventilation is more controversial. Randomised controlled
trials have been carried out to establish whether pre-
hospital tracheal intubation is beneficial in patients who
have suffered TBI but have often failed to demonstrate clear
benefits or run into major methodological problems [9, 10].
Analysis of retrospective studies is also difficult because
where pre-hospital anaesthesia is available there may be
selection bias in that compromised, or more severely
injured patients, are more likely to be anaesthetised (and
have worse outcomes) than less compromised patients who
may not be anaesthetised until after hospital arrival. The
mortality of patients is, therefore, usually lower in patients
whose tracheas are intubated in the emergency department
compared with on scene [11]. A recent large UK study
also reported higher mortality in the patient group
anaesthetised on-scene rather than in the emergency
department. However, it also reported a significantly higher
mortality in patients who received basic airway interventions
in the pre-hospital phase of care but whose tracheas were
not intubated (probably because anaesthesia and tracheal
intubation were not available on scene) compared with the
group where tracheal intubation and anaesthesia were
carried out on scene (51% vs. 34% mortality) [12].
8 © 2019 Association of Anaesthetists
Editorial
Some patients with a significantly reduced GCS score
still have airway reflexes and are moved to hospital with
oxygen supplementation and basic airway management.
Although many clinicians would find it uncomfortable to
transport an unconscious patient whose trachea was not
intubated to hospital, it is likely to be difficult to
demonstrate benefit for pre-hospital tracheal intubation in
this patient population. For those with airway or ventilatory
compromise it would be difficult to argue for any course of
action which does not rapidly correct the compromise. This
is the patient group who are most likely to benefit from
properly conducted pre-hospital anaesthesia and
intubation. Considerable unmet demand for pre-hospital
tracheal intubation has been reported both on scene where
airway compromise persists after basic airway management
by paramedics [13], and where urgent tracheal intubation is
required soon after arrival in the emergency department
[12, 14].
What should we be doing?
Pre-hospital anaesthesia is a frequently used key
intervention that is well-established in trauma practice but,
to improve outcomes, must be performed well. Although
the practice of pre-hospital anaesthesia and advanced
airway management is variable internationally, there is now
a high degree of consensus on the principles of good
management for patients with severe TBI. Recent
guidelines from France recommend advanced medical
management and pre-hospital tracheal intubation at scene
with direct transport to a neurosurgical centre [15]. In the
UK, guidelines set out the necessary requirements for the
safe conduct of pre-hospital anaesthesia including training,
equipment and governance [16]. The key principle of these
guidelines is straightforward – pre-hospital anaesthesia
should be conducted to the same standard as that in the
emergency department. Where pre-hospital anaesthesia
cannot be delivered to a high level, meticulous attention to
good basic airway management and rapid transfer to
hospital is recommended [16–18]. The UK National
Institute for Health and Care Excellence (NICE) published
guidelines for the management of major trauma in 2016. It
recommended that trauma networks should ensure that
anaesthesia and tracheal intubation is available where
required within 45 min of an emergency call either on
scene or, where expertise is not available, in an emergency
department [19]. The 45-min target is arbitrary and
probably a compromise between what is desirable and
what is practical. However, it does ensure that all trauma
networks consider how to provide safe, high-level pre-
hospital airway management for those that need it.
Editorial
There is a large body of evidence suggesting that less
skilled advanced airway management is problematic.
Evidence includes indirect quality indicators; for example,
higher failed tracheal intubation rates [20] but also
more direct indicators. One meta-analysis reported that
the odds of mortality doubled with less experienced
providers [21]. Where anaesthesia is conducted by
experienced providers meeting the criteria set out in
national guidelines, published results are very good
[22–24]. The systematic and straightforward approach to
pre-hospital anaesthesia taken by high-performing
pre-hospital services may even provide lessons for
improvement in the conduct of emergency anaesthesia in
receiving emergency departments [25].
Reducing variation may deliver better
outcomes
After an extended period where reports of significant
improvements in head injury outcomes were uncommon,
there are suggestions that, in line with overall trauma
survival, mortality is improving [26]. However, the CENTER-
TBI investigators have confirmed that there is still
considerable geographical variation in care in the patient
pathway from injury through to in-hospital management.
Irrespective of how much resource and expertise goes into
the in-hospital management of TBI, there is little prospect of
undoing the damage done by sub-optimal pre-hospital
management before emergency department arrival.
Improvements are possible with system development and
do not require significant innovation or research to deliver
on missed opportunities. Although this study focuses on
advanced airway management system improvement, the
improvement of basic airway management may also be an
attainable goal, especially in low- and middle-income
countries, where TBI is also a huge problem [1]. If trauma
systems can deliver consistent and safe pre-hospital
advanced airway management, it may be that TBI outcomes
can be improved by delivering patients to neurosurgical
units with minimum secondary brain injury.
Acknowledgements
No conflict of interest declared.
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© 2019 Association of Anaesthetists