Paramedic-placed throat tube may up patient risk

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People who sustain a brain injury often require an endotracheal tube in their throats to help them breathe. However, new research shows that the risk of death and other poor outcomes increases when tube placement is performed by a paramedic before the patient reaches the hospital.

Previous studies investigating this topic have yielded conflicting results, according to the report in the Annals of Emergency Medicine. Some have shown benefits with pre-hospital intubation, whereas others have uncovered harmful effects.

"A few years ago a group in San Diego found that the introduction of an advanced (intubation) technique...among paramedics was linked to adverse outcomes,” lead author Dr. Henry E. Wang, from the University of Pittsburgh School of Medicine, told Reuters Heath. “We wanted to know if the same association would be seen in a larger study group” exposed to standard intubation techniques.

To investigate, Wang’s team analyzed data from all brain injury patients who required intubation and were treated at trauma centers in Pennsylvania between 2000 and 2002. Of the 4,098 patients identified, 1,797 were intubated outside the hospital and 2,301 were intubated in the ER.

Subjects intubated in the field were nearly four times more likely to die than their counterparts intubated in the ER, the authors note. Moreover, pre-hospital-intubated patients were 61 percent more likely to experience a poor neurological outcome and 92 percent more likely to have at least moderate functional impairment.

“The San Diego study involved a very select subset of specially trained paramedics,” Wang pointed out. In contrast, “our study included all paramedics, so I think the findings are probably more generalizable.”

As to how pre-hospital intubation may promote worse outcomes, Wang said the relatively chaotic atmosphere outside the hospital coupled with a lack of certain anesthetic agents could lead to more stressful intubations that worsen bleeding within the brain.

“Paramedic skill may also be part of the equation, but our study did not address this,” Wang noted. Other studies, however, have suggested that paramedic skill does play an important role, he added.

“Our study does not say that paramedics should stop intubating—a lot more data are needed” to reach that conclusion, Wang emphasized. “We see the findings as a signal that there are problems either with the procedure itself, its role in treating traumatic brain injury, or the way it’s being performed in the out-of-hospital setting.”

SOURCE: Annals of Emergency Medicine, November 2004.

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