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Examining prehospital intubation for penetrating trauma in a swine hemorrhagic shock model

Taghavi, Sharven MD, MPH; Jayarajan, Senthil N. MD; Khoche, Swapnil MD; Duran, Jason M.; Cruz-Schiavone, Gonzalo E. MD; Milner, Richard E.; Holt-Bright, Lewis; Gaughan, John P. PhD; Rappold, Joseph F. MD; Sjoholm, Lars O. MD; Dujon, Jay MD; Pathak, Abhijit MD; Santora, Thomas A. MD; Houser, Steven R. PhD; Goldberg, Amy J. MD

Journal of Trauma and Acute Care Surgery: May 2013 - Volume 74 - Issue 5 - p 1246–1251
doi: 10.1097/TA.0b013e31828dab10
Original Articles

BACKGROUND: Prehospital intubation does not result in a survival advantage in patients experiencing penetrating trauma, yet resistance to immediate transportation to facilitate access to definitive care remains. An animal model was developed to determine whether intubation provides a survival advantage during severe hemorrhagic shock. We hypothesized that intubation would not provide a survival advantage in potentially lethal hemorrhage.

METHODS: After starting a propofol drip, Yorkshire pigs were intubated (n = 6) or given bag-valve mask ventilation (n = 7) using 100% oxygen. The carotid artery was cannulated with a 14-gauge catheter, and a Swan-Ganz catheter was placed under fluoroscopy using a central venous introducer. After obtaining baseline hemodynamic and laboratory data, the animals were exsanguinated through the carotid line until death. The primary end point was time until death, while secondary end points included volume of blood shed, temperature, cardiac index, mean arterial pressure, lactic acid, base excess, and creatinine levels measured in 10-minute intervals.

RESULTS: There was no difference in time until death between the two groups (51.1 [2.5] minutes vs. 48.5 [2.4] minutes, p = 0.52). Intubated animals had greater volume of blood shed at 30 minutes (33.6 [4.4] mL/kg vs. 28.5 [4.3] mL/kg, p = 0.03), 40 minutes (41.7 [4.7] mL/kg vs. 34.9 [3.8] mL/kg, p = 0.04), and 50 minutes (49.2 [8.6] mL/kg vs. 40.2 [1.0] mL/kg, p = 0.001). In addition, the intubated animals were more hypothermic at 40 minutes (35.5°C [0.4°C] vs. 36.7°C [0.2°C], p = 0.01) and had higher lactate levels (2.4 [0.1] mmol/L vs. 1.8 [0.4] mmol/L, p = 0.04) at 10 minutes. Cardiac index (p = 0.66), mean arterial pressure (p = 0.69), base excess (p = 0.14), and creatinine levels (p = 0.37) were not different throughout the shock phase.

CONCLUSION: Intubation does not convey a survival advantage in this model of severe hemorrhagic shock. Furthermore, intubation in the setting of severe hemorrhagic shock may result in a more profuse hemorrhage, worse hypothermia, and higher lactate when compared with bag-valve mask ventilation.

From the Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania.

Submitted: August 22, 2012, Revised: October 20, 2012, Accepted: November 9, 2012.

Address for reprints: Amy Goldberg, MD, Temple University Hospital, 3401 N Broad Street, Parkinson Pavilion, Suite 400, Philadelphia, PA 19140; email: Sharven.Taghavi@tuhs.temple.edu.

© 2013 Lippincott Williams & Wilkins, Inc.