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“Pre-hospital intubation is associated with increased mortality after traumatic brain injury”
j o u r n a l o f s u r g i c a l r e s e a r c h 1 7 9 ( 2 0 1 3 ) 1 8 3 e1 8 4
Available online at www.sciencedirect.com
journal homepage: www.JournalofSurgicalResearch.com
Letters to the Editor
“Pre-hospital intubation is associated with increased mortality after traumatic brain injury”
We are writing in response to the article “Pre-hospital intubation is associated with increased mortality after traumatic brain injury” [1]. After careful review of that article, we are concerned about the transparency of the presented data and the conclusions that were reached. Detailed analysis of the data presented in Table 1 reveals that the baseline clinical characteristics of the pre-hospital intubation (PHI) and posthospital intubation (no-PHI) groups are so glaringly different as to make it challenging to draw any conclusions about the effect that intubation had on their outcome. The PHI group was far more critically injured, with average systolic blood pressure’s of 45 mm Hg and a glasgow coma scale (GCS) of 3.3, compared with the non-PHI values of 137 mm Hg and 11.7, respectively. Moreover, 98% of the PHI group had a GCS of 8, whereas 76% of the non-PHI group had a GCS 8. These baseline clinical differences between groups should give any clinician reading the report grave doubts as to the validity of conclusions reached about the impact PHI had on mortality. No amount of logistic regression or propensity score calculation should be used to rationalize away the inhomogeneity of the two groups. Is it surprising that the PHI group experienced disproportionate mortality given the tremendous increase in the primary brain injury (as reflected by GCS and the penetrating mechanism of injury) or secondary brain injury (69% more PHI patients were hypotensive on admission) relative to the non-PHI group? Finally, given the serious heterogeneity of the clinical characteristics of the two groups, we do not believe it is appropriate for the article to suggest in its title that PHI was the main difference between groups. It would be a serious disservice to patient care if an emergency management service provider were to infer from the report that there is a causal relationship between PHI and mortality in patients with traumatic brain injury. We acknowledge the controversy and conflicting evidence in the literature surrounding PHI, and we recognize that the emergency management service providers in the study
reserved PHI for only the most severely injured (only 61 of 2,366 patients underwent PHI). To imply that withholding PHI from that group would have affected outcomes in a positive way is not supported by the presented data.
reference
[1] Bukur M, Kurtovic S, Berry C, et al. Pre-hospital intubation is associated with increased mortality after traumatic brain injury. J Surg Res 2011;170:e117.
Aaron M. Burnett, MD* Regions Hospital, Emergency Medical Services, 640 Jackson Street, Mail Stop 13801B, Saint Paul, Minnesota 55101 Keith Wesley, MD, FACEP HealthEast Medical Transportation, 799 Reaney Ave, Saint Paul, Minnesota 55106 Dave Page, MS, NREMT-P InverHills Community College Paramedic Program, 2500 80th St East, Inver Grove Heights, Minnesota 55076
Marshall Washick, NREMT-P HealthEast Medical Transportation, 799 Reaney Ave, Saint Paul, Minnesota 55106 *Corresponding author. Regions Hospital, Emergency Medical Services, 640 Jackson Street, Mail Stop 13801B, Saint Paul, Minnesota 55101. Tel.: þ1 6512547781; fax: þ1 6517783778. E-mail address: [email protected] 0022-4804/$ e see front matter ª 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2012.01.005
Available online at www.sciencedirect.com
journal homepage: www.JournalofSurgicalResearch.com
Letters to the Editor
“Pre-hospital intubation is associated with increased mortality after traumatic brain injury”
We are writing in response to the article “Pre-hospital intubation is associated with increased mortality after traumatic brain injury” [1]. After careful review of that article, we are concerned about the transparency of the presented data and the conclusions that were reached. Detailed analysis of the data presented in Table 1 reveals that the baseline clinical characteristics of the pre-hospital intubation (PHI) and posthospital intubation (no-PHI) groups are so glaringly different as to make it challenging to draw any conclusions about the effect that intubation had on their outcome. The PHI group was far more critically injured, with average systolic blood pressure’s of 45 mm Hg and a glasgow coma scale (GCS) of 3.3, compared with the non-PHI values of 137 mm Hg and 11.7, respectively. Moreover, 98% of the PHI group had a GCS of 8, whereas 76% of the non-PHI group had a GCS 8. These baseline clinical differences between groups should give any clinician reading the report grave doubts as to the validity of conclusions reached about the impact PHI had on mortality. No amount of logistic regression or propensity score calculation should be used to rationalize away the inhomogeneity of the two groups. Is it surprising that the PHI group experienced disproportionate mortality given the tremendous increase in the primary brain injury (as reflected by GCS and the penetrating mechanism of injury) or secondary brain injury (69% more PHI patients were hypotensive on admission) relative to the non-PHI group? Finally, given the serious heterogeneity of the clinical characteristics of the two groups, we do not believe it is appropriate for the article to suggest in its title that PHI was the main difference between groups. It would be a serious disservice to patient care if an emergency management service provider were to infer from the report that there is a causal relationship between PHI and mortality in patients with traumatic brain injury. We acknowledge the controversy and conflicting evidence in the literature surrounding PHI, and we recognize that the emergency management service providers in the study
reserved PHI for only the most severely injured (only 61 of 2,366 patients underwent PHI). To imply that withholding PHI from that group would have affected outcomes in a positive way is not supported by the presented data.
reference
[1] Bukur M, Kurtovic S, Berry C, et al. Pre-hospital intubation is associated with increased mortality after traumatic brain injury. J Surg Res 2011;170:e117.
Aaron M. Burnett, MD* Regions Hospital, Emergency Medical Services, 640 Jackson Street, Mail Stop 13801B, Saint Paul, Minnesota 55101 Keith Wesley, MD, FACEP HealthEast Medical Transportation, 799 Reaney Ave, Saint Paul, Minnesota 55106 Dave Page, MS, NREMT-P InverHills Community College Paramedic Program, 2500 80th St East, Inver Grove Heights, Minnesota 55076
Marshall Washick, NREMT-P HealthEast Medical Transportation, 799 Reaney Ave, Saint Paul, Minnesota 55106 *Corresponding author. Regions Hospital, Emergency Medical Services, 640 Jackson Street, Mail Stop 13801B, Saint Paul, Minnesota 55101. Tel.: þ1 6512547781; fax: þ1 6517783778. E-mail address: [email protected] 0022-4804/$ e see front matter ª 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2012.01.005