Prehospital care of trauma must be improved in UK

Editor—Lockey et al attempt to relate survival of patients with trauma given prehospital tracheal intubation without the aid of anaesthetic drugs.¹ Their comment that “it was surprising that the outcome was almost always fatal” when a tracheal tube could be passed without anaesthetic drugs deserves further discussion, as this highlights the suboptimal prehospital management of severe trauma in the United Kingdom. Prehospital endotracheal intubation has been associated with improved survival in patients with blunt injury and a score on the Glasgow coma scale of <8 at the scene in North America² and elsewhere.³

In multiple trauma the main reason for a decreased coma score is an associated head injury. The authors' data do not indicate how many of the patients who were intubated had head injuries, what proportion of them was intubated without drugs, and what their coma score was before intubation.

The extent of neurological damage is aggravated by the secondary insults of hypoxia, hypercapnia, hypotension, and increased intracranial pressure. Early tracheal intubation in severe head injury (defined as a score on the Glasgow coma scale of <8) is recommended not only to protect the airway in patients with obtunded airway reflexes but also to aid ventilation and prevent some of these secondary insults. Even if a patient's airway is secured by tracheal intubation, inadequate ventilation may lead to high arterial carbon dioxide pressure and concomitant brain swelling.

Intracranial pressure will increase during laryngoscopy and endotrachraeal intubation when anaesthetic drugs are not used. Laryngoscopy and intubation also produce a pronounced rise in blood pressure, and the rapidity of this rise may outstrip cerebral autoregulation, causing the intracranial pressure to rise.⁴ The use of induction agents, such as thiopentone, and muscle relaxants when a patient's airway reflexes are still present, can counteract these effects. Might these factors be contributing to the poor outcome shown in the report?

Outcome after head injury is closely correlated with the initial score on the Glasgow coma scale.⁵ Many patients might still do well, however, if secondary insults to the brain could be prevented. A patient with isolated head trauma who develops an extradural haematoma and subsequently loses consciousness but is managed early (that is, in the prehospital environment) and optimally will do better than a patient with the same injury but also the secondary insults.

The United Kingdom urgently needs to adopt an established prehospital scoring system⁵ and a management algorithm that will allow staff to identify and treat patients at risk; leaders in prehospital and immediate care must put such systems in place.