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Paper text:
the british medical journal recently published a report by christensen and hoyer   on prehospital tracheal intubation in severely injured patients .
this retrospective observational study identified 220 severely injured patients ( injury severity score > 15 ) , who were treated by the anaesthesiologist staffed mobile emergency care unit in aarhus ( denmark ) over a period of 3 years ( 19982000 ) .
a total of 172 patients were taken to the hospital , and 41% ( 74/172 ) of these were intubated before arrival .
the majority ( 84% [ 62/74 ] ) of intubations were facilitated by anaesthesia ( hypnotics , analgesics and muscle relaxants ) , and 58% ( 36/62 ) of patients intubated in this manner survived for at least 6 months .
this contrasted with only 8% ( 1/12 ) survivors among those patients who were intubated without administration of anaesthetics .
the authors concluded the following from their data : endotracheal intubation in traumatized patients who do not require the use of anaesthetics should not be considered hopeless ; and ambulance personnel may be unable to master administration of anaesthesia and intubation in the prehospital setting ( a corresponding paper was published previously elsewhere by the same group ) .
the work reported by christensen and hoyer   lacks substantial supplemental information , making it difficult to appreciate how the authors drew their conclusions from the actual data presented in the article .
the group of patients who received anaesthetics for intubation appears very heterogeneous , exhibiting large variations in glasgow coma scale and injury severity scores .
therefore , differences in injury characteristics between the groups might have contributed , at least in part , to the differences in survival rates ( see the report by eckstein and coworkers   for comments on the limitations of the injury severity score for characterizing a group of severely injured patients ) . additionally , it is difficult to appreciate why christensen and hoyer concluded that ambulance personnel may not be able to master anaesthesia and intubation in trauma patients , because their data were collected in a physician - based emergency care system .
they relate their data to a previous study from the uk conducted by lockey and coworkers , which analyzed the survival of severely traumatized patients after out - of - hospital endotracheal intubation without the use of anaesthetics .
this group , however , analyzed data from patients who were intubated by paramedics or by physicians at the scene .
all but one of their patients eventually died before hospital discharge ( n = 486 ) but , in contrast to the suggestion by christensen and hoyer , lockey and coworkers attribute this adverse outcome to the severity of the sustained injuries rather than to the quality of care provided ( e.g. by the participating paramedics ) . giving credit to the limited empirical evidence , lockey and coworkers even question the current practice in the uk that allows paramedics to perform non - drug - assisted intubations only .
however , the work by christensen and hoyer raises an interesting set of questions on the overall role of endotracheal intubation in out - of - hospital advanced trauma life support .
is intubation actually beneficial , and what are the risks and benefits associated with this intervention ?
should a physician perform the intubation ? finally , should severely injured patients , given their bad prognosis , be intubated at all ?
there is broad consent that providing adequate oxygenation at all times is of paramount importance to the critically injured patient because hypoxaemia or , worse , asphyxia may result in secondary damage ( e.g. to the cardiovascular system or the brain ) .
accordingly , control of the airway is given the highest priority in the current algorithms for trauma management .
moreover , trauma victims are at risk for pulmonary aspiration of , for example , stomach contents or blood . as a consequence , early control of the airway by endotracheal intubation appears to be the best therapeutic approach , and
indeed has been shown to improve outcome in critically injured patients [ 5 - 7 ] .
invasive airway management at the scene is successfully performed in systems that supply physician staffed ambulances , and is considered a vital part of their advanced trauma life support [ 7 - 12 ] .
some experts , however , argue that out - of - hospital intubation may be deleterious to traumatized patients who are not in respiratory distress , because of the risks involved ( e.g. airway trauma , oesophageal intubation , hazard to the cervical spine ) . moreover , they believe that intubation unnecessarily prolongs the time spent on - scene and that it does not improve long - term outcome [ 3,13 - 17 ] . however , there is little scientific evidence to support either opinion .
most of the studies favouring prehospital endotracheal intubation of severely traumatized patients were conducted in out - of - hospital systems that rely on highly skilled personnel such as anaesthesiologists , emergency physicians , or specially trained nurses , mostly in continental europe or australia .
in contrast , studies that do not support this approach rely on data from paramedic or emergency technician staffed services , mostly in the usa or the uk .
there is no doubt that endotracheal intubation in the prehospital setting is more difficult and involves a higher risk for failure compared with in - hospital intubation .
intubation may be particularly difficult in the severely but not fatally injured patient , who will fight laryngoscopy and gag or cough on passage of the endotracheal tube .
these situations not only require additional skills and experience but also the use of anaesthetics and/or muscle relaxants . because both drugs may only be applied by physicians
, it appears obvious that outcome may be influenced by the skills and training of the emergency personnel .
specially trained physicians or appropriately skilled nonphysician care providers may actually be required at the trauma scene for patients to benefit from prehospital intubation .
recent studies indeed support the idea that , for example , rapid sequence induction before endotracheal intubation can safely be administered by paramedics in the field [ 19 - 22 ] .
invasive airway management requires sufficient training of personnel and immediate availability of appropriate salvage airway devices   and monitoring . however ,
if adequate skills are not available , then critically traumatized patients may rather benefit from adequate ventilation using less invasive means ( e.g. bag  valve  mask ventilation if transport times are short ) .
unfortunately , no study has yet related outcome to the availability of qualified personnel in the different prehospital emergency care systems
. this might actually be very difficult because multiple issues must be considered , including manual skills , case load and continuing training opportunities for the providers , applicable guidelines for airway management , drug treatment options available and subsequent ventilation patterns , as well as access to prehospital emergency medical services and many other social and economic issues that could all affect outcomes after severe trauma .
christensen and hoyer   do not contribute to this discussion because their study was performed in a purely physician staffed medical system .
a survival rate of only 0.2% in severely injured patients who could be intubated without anaesthetics   is indeed very discouraging and appears to suggest that endotracheal intubation should be abandoned in this setting .
christensen and hoyer reported a slightly better survival ( 8% [ 1/12 ] of patients ) and concluded that invasive airway management is not a hopeless intervention .
however , given the small size of the nondrug intubation group ( n = 12 ) , it is difficult to conclude that the outcome is actually better than that reported by lockey and coworkers .
regardless of this , the above - mentioned question relates to an extremely complex ethical problem , which must be addressed on broader grounds . from our perspective
, the decision to provide or withhold a potentially life - saving treatment must be based on a thorough consideration of individual circumstances in every single case , although empirical data may help to reach this decision . even if survival seems unlikely ,
all appropriate means should be applied in the out - of - hospital setting to allow further diagnosis and treatment in a qualified trauma centre .
at present we can only conclude that appropriate oxygenation is essential in any critically traumatized patient .
the applied means of airway management should be based on the skills of the respective provider .
it seems unlikely that prehospital endotracheal intubation by itself may influence outcome after severe trauma , because it mainly reflects the overall standard of prehospital medical care
. a more important question might be whether intensive care ( e.g. optimal airway management and appropriate ventilation ) should already be started in the field and maintained during transport , which may indeed require the presence of a physician or another adequately skilled person at the scene .
if such a system is considered desirable , then the benefits of early intensive care must be balanced against the increased costs of this service .
adequate oxygenation at all times is of paramount importance to the critically injured patient to avoid secondary damage . 
 the role of endotracheal intubation in out - of - hospital advanced trauma life support , however , remains controversial . 
 initiated by a recent observational study , this commentary discusses risks and benefits associated with prehospital intubation , the required personnel and training , and ethical implications . 
 recent evidence suggests that comprehensive ventilatory care already initiated in the field and maintained during transport may require the presence of a physician or another adequately skilled person at the scene . 
 benefits of such as service need to be balanced against increased costs .