Scenario-ish: To intubate or not to intubate?

Remi said:
That's always the assumption, but blood gases on arrival were the same between the groups in this study. Other studies looking at this topic have found similar blood gases, as well.
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If you look at the methods, they didn't draw an ABG until after placing an art line and capturing the airway:

"In the hospital emergency department, patients who were not intubated underwent immediate RSI by a physician prior to chest x-ray and computed tomography head scan. In these patients, arterial blood gases were performed only after intubation and insertion of an arterial cannula."

Granted, there was no significant difference between arrival SpO2. There was a tendency towards lower body temperature and tachycardia in the prehospital group.

Inadvertent hyperventilation was postulated as a source of excess mortality during San Diego RSI trial, although the majority of the providers didn't have access to ETCO2 to direct their practice.

http://www.ncbi.nlm.nih.gov/pubmed/15284540
http://www.ncbi.nlm.nih.gov/pubmed/12634522
 
systemet said:
If you look at the methods, they didn't draw an ABG until after placing an art line and capturing the airway:

"In the hospital emergency department, patients who were not intubated underwent immediate RSI by a physician prior to chest x-ray and computed tomography head scan. In these patients, arterial blood gases were performed only after intubation and insertion of an arterial cannula."
Click to expand...

True, but presumably the non-intubated patients were were exchanging air well during transport, otherwise the paramedic in attendance would have intervened.

systemet said:
Inadvertent hyperventilation was postulated as a source of excess mortality during San Diego RSI trial, although the majority of the providers didn't have access to ETCO2 to direct their practice.

http://www.ncbi.nlm.nih.gov/pubmed/15284540
http://www.ncbi.nlm.nih.gov/pubmed/12634522
Click to expand...

I don't doubt that at all. I think a likely reason why some studies have shown better outcomes among intubated patients than others probably has a lot to do with better post-intubation care. Most of the lit that I've seen that looks at HEMS transport of these patients shows good outcomes. I think the those providers are more familiar with and thus more skilled at proper ventilation. Better sedation might play a roll too.
 
Remi said:
True, but presumably the non-intubated patients were were exchanging air well during transport, otherwise the paramedic in attendance would have intervened.
Click to expand...

"Of the 152 patients allocated to hospital intubation, 144(95%) arrived at the emergency department without intubation. In 5 patients, there was a decrease in conscious state and loss of airway reflexes during transport to hospital, and intubation was undertaken without supplemental drug therapy. In 2 patients, cardiac arrest occurred duringtransportand intubation wasundertaken during cardiopulmonary resuscitation without supplemental drug therapy. In 1 patient, a medical helicopter became available after randomization and the patient was successfully intubated for the flight using RSI

They also did an intention-to-treat analysis.

I don't doubt that at all. I think a likely reason why some studies have shown better outcomes among intubated patients than others probably has a lot to do with better post-intubation care. Most of the lit that I've seen that looks at HEMS transport of these patients shows good outcomes. I think the those providers are more familiar with and thus more skilled at proper ventilation. Better sedation might play a roll too.
Click to expand...

I agree completely.
 
Just want to say, fellas, that this has been one of the best EBM discussions I've seen on this forum.
 
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