Review of: Carr BG, Brachet T, David G, et al: "The time cost of prehospital intubation and intravenous access in trauma patients." Prehospital Emergency Care. 12(3):327-332, 2008.
The Office of Emergency Planning and Response at the Mississippi Department of Health extracted data from their state prehospital run database of trauma victims from 2001-2005. During this time, 192,055 prehospital runs were made for trauma patients. Of these, 121,495 (63%) included prehospital procedures. Average on-scene duration for those runs was 15 minutes and 24 seconds. The authors then examined various specific procedures alone and in combination to determine their impact on scene time.
They examined intubation and IV alone and in combination with procedures in categories. Category A/B was airway or breathing-related intervention (airway management, suctioning, oxygen, etc.) Category C was circulation-related intervention (vascular access, CPR, defibrillation, etc.). D was disability-related intervention (extrication, splinting, immobilization, etc.), and; C/D was circulatory- or disability-related intervention,
On average, each procedure was associated with an addition of one minute to the on-scene duration (95% confidence interval: 58 62 seconds). One scene involving the establishment of IV access prior to transport was 5:04 longer, while one involving tracheal intubation was 3:39 longer.
"Intubation was associated with an increased scene time between 2:36 and 3:39 (minutes:seconds), and IV access was associated with an increase in on-scene duration of 3:17 and 5:04," the authors concluded. "There are policy and planning implications for the time trade-off of prehospital procedures, especially discretionary ones."
If you've wondered why states collect data, this study alone should answer your question. Of course, we can debate the issues of data validity and clinical significance. But before that interesting discussion can occur we must have a starting point of reference.
Here, the state of Mississippi has provided us a glimpse at the impact various procedures have on scene time. Clearly, intubation is a life-saving procedure, and no one will dispute that spending an additional two to four minutes on scene to perform it is acceptable.
But what of the other procedures? The table included in the study showed IV access and intubation in combination with any other procedure increased the scene time the longest. Procedures not involving IV access or intubation added only an average of one minute each.
However, there is a fly in the ointment that even the authors recognize. This study assumes all procedures were performed on-scene. Although one may assume IV access was performed to facilitate fluid replacement or dry administration, that may not be the case. We have no knowledge from this study about which procedures were performed when. We may presume that the majority of intubations occurred on-scene. However, the authors found the following breakdown of the 121,495 patients:
- 1,059 had only an IV established and no other procedure;
- 1,072 had IV with A/B;
- 6,925 with C/D;
- 32,261 with A/B and C/D, and
- 24,904 patients had A/B without intubation.
Therefore, the actual increase in scene time for a given procedure may be underestimated by this study.
So, back to the original question: Should this change your practice? I don't know. It's impossible to extrapolate state data to one service. These authors have merely chipped at the tip of the iceberg. If we knew which procedures actually prolonged the scene time, the patients' injury severity scores (which can be used to predict survival), and (optimally) patient outcomes, then perhaps we could better adapt our prehospital protocols. Until then, we must use our best judgment and weigh the data accordingly.