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The OPALS Major Trauma Study: impact of advanced
life-support on survival and morbidity
Ian G. Stiell MD MSc, Lisa P. Nesbitt MHA, William Pickett PhD, Douglas Munkley MD,
Daniel W. Spaite MD, Jane Banek CHIM, Brian Field MBA EMCA, Lorraine Luinstra-Toohey BScN MHA,
Justin Maloney MD, Jon Dreyer MD, Marion Lyver MD, Tony Campeau MAEd PhD,
George A. Wells PhD, for the OPALS Study Group





OPALS (the Ontario Prehospital Advanced Life Support)

13 hôpitaux, Ontario (Canada)

Essai clinique contrôlé de type avant-après, 1998-2002

2867 patients > 16a

ALS vs BLS dans les traumatisés graves

Pas de ≠ concernant la survie (81,1% vs 81,8% p=0,65)

Si GCS<9 survie moindre ds ALS (50,9% vs 60% p=0,02)
  







 




Medical pre-hospital management reduces
mortality in severe blunt trauma: a prospective
epidemiological study
Jean-Michel Yeguiayan1*, Delphine Garrigue2, Christine Binquet3, Claude Jacquot4, Jacques Duranteau5,
Claude Martin6, Fatima Rayeh7, Bruno Riou8, Claire Bonithon-Kopp3, Marc Freysz1,
The FIRST (French Intensive Care Recorded In Severe Trauma) Study Group

 



FIRST (French Intensive care Recorded in Severe Trauma)

PHRC national impliquant 14 CHU

Etude observationnelle prospective 2004-2007

3089 patients >18a avec trauma fermé admis en réa/USC
dans les 72h et/ou PEC par un SMUR d
un des 14 CHU

Médicalisation SMUR vs non médicalisation VSAV

SMUR  risque de décès à J30
   

 





 

 






 

 










FIRST  ISR utilisée dans 84%

 EtCO2 utilisée dans 49,2%
 pas de sédation post-intubation dans 16%
  


 




Auteurs [Réf.] Année Nombre % ID % échec Type de population/ nature de
l'opérateur

Cantineau [2] 1997 224 4 0 Préhospitalier français/médecin

Adnet [15] 1998 691 11 0,9 Préhospitalier français/médecin
Orliaguet [1] 1997 157 2,6 2,6 Préhospitalier français/médecin
Adnet [16] 1997 394 19,8 0 Préhospitalier français,
patients en coma toxique/médecin
Ricard-Hibon [47] 1997 147 5,4 0 Préhospitalier français/médecin
Adnet [17] 1997 311 16,1 0,3 Préhospitalier français/médecin
Total préhospitalier français : 1 924 11,6 0,5
Stewart [22] 1984 779 6 10 Préhospitalier US/paramédical
Pointer [25] 1988 383 13,8 6,5 Préhospitalier US/paramédical
Krisanda [23] 1992 278 32 25 Préhospitalier US, patients non
ACR/paramédical
Sayre [38] 1998 103 NP 51 Préhospitalier US/EMT (techniciens)
Hedges [55] 1988 310 NP 4 Préhospitalier US/paramédical
Thompson [24] 1994 862 NP 5,3 Préhospitalier US/infirmier
ou paramédical
Total préhospitalier US : 2 715 13,1 7,8
Dufour [59] 1995 219 4 0 Département d'urgence US/médecin
Zonies [27] 1998 570 8,4 1,4 Département d'urgence US/médecin
Sackles [26] 1998 610 5,3 1,1 Département d'urgence US/médecin
Total département d'urgence US : 1 399 6,3 1,1

EMT = Emergency medical technician ; ID = intubation difficile ; NP = non précisé.

  


 





 

 



 
 




Difficile
 


 
 

 



 

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Table 5. Complications by Intubation Attempts

2 or fewer ⬎2 attempts Relative risk for
Complication attempts (90%) (10%)* ⬎2 attempts 95% CI for risk ratio
Hypoxemia 10.5% 70% 9X 4.20 – 15.92
Severe hypoxemia 1.9% 28% 14X 7.36 – 24.34
Esophageal intubation 4.8% 51.4% 6X 3.71 – 8.72
Regurgitation 1.9% 22% 7X 2.82 – 10.14
Aspiration 0.8% 13% 4X 1.89 – 7.18
Bradycardia 1.6% 18.5% 4X 1.71 – 6.74
Cardiac arrest 0.7% 11% 7X 2.39 – 9.87
* All categories P ⬍ 0.001 when comparing 2 or fewer attempts to ⬎2 attempts.
  


  














 

 
 
  

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Comparison of Plastic Single-use and Metal Reusable
Laryngoscope Blades for Orotracheal Intubation during
Rapid Sequence Induction of Anesthesia

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Out-of-Hospital Tracheal Intubation With Single-Use Versus
Reusable Metal Laryngoscope Blades: A Multicenter Randomized
Controlled Trial
 


 

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Table 3. Characteristics of patients in the trial. Table 4. Early intubation-related complications.*
Reusable Blades, Single-Use Blades, Absolute Difference, Number (%)
Characteristics nⴝ408 nⴝ409 % (95% CI) Reusable Blades, Single-Use Blades,
Complication nⴝ408 nⴝ409
Cormack and Lehane class, No. (%)
I 233 (57.1) 248 (60.6) 4 (–3 to 10) Esophageal intubation 15 (4) 14 (3)
II 93 (22.8) 108 (26.4) 4 (–2 to 10) Mainstem intubation 11 (3) 11 (3)
III 54 (13.2) 37 (9.0) 4 (–9 to 0) Vomiting 6 (2) 7 (2)
IV 28 (6.9) 16 (3.9) 3 (–6 to 0) Pulmonary aspiration 12 (3) 12 (3)
Dental trauma 1 (0) 1 (0)
IDS score, median (25th–75th percentiles) 1 (0–3) 1 (0–3) 0 (0 to 1)
Bronchospasm or 1 (0) 3 (1)
IDS score ⬎5, No. (%) (95% CI) 50 (12.3) 39 (9.5) 3 (–7 to 2) laryngospasm
Use of alternate intubation techniques, No. (%) 50 (12.3) 35 (8.6) 4 (–8 to 1) Ventricular tachycardia 1 (0) 0
Stylet, No. (%) 5 (1.2) 6 (1.5) Arterial desaturation 17 (4) 17 (4)
Gum elastic bougie,* No. (%) 44 (10.8) 29 (7.1) Hypotension 29 (7) 39 (10)
Intubating laryngeal mask airway, No. (%) 3 (0.7) 3 (0.7) Cardiac arrest 8 (2) 8 (2)
Cricothyrotomy, No. 0 0 Any complication 76 (19) 87 (21)
Impossible intubations, No. 1 0 *Complications were recorded from the start of the intubation process to 15
minutes postintubation. The total number of events exceeds the number of sub-
*In 5 patients, the intubating laryngeal mask airway was used after gum elastic bougie failure, 2 in the reusable-blade group and 3 in the single-use blade group. jects because some patients had more than 1 complication.


 


 


 

 

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Use of the Airtraq laryngoscope for emergency intubation in the
prehospital setting: A randomized control trial*
 






Table 2. Intubation success rates, time until endotreacheal intubation from opening of the airway until successful positioning of the tube (seconds), time
until first end-tidal CO2 reading (seconds), and number of attempts in patients undergoing prehospital endotracheal intubation with direct laryngoscopy
vs. Airtraq

p (Direct
Direct Laryngoscopy p (EMS vs. Airtraq p (EMS vs. Laryngoscopy
All (n ⫽ 106) Anesth.) (n ⫽ 106) Anesth.) vs. Airtraq)

Successful intubationsa n ⴝ 105a n ⴝ 50a <.0001a

All EMS (n ⫽ 58) Anesth. (n ⫽ 48) EMS (n ⫽ 63) Anesth. (n ⫽ 43)
Successful intubationsa n ⴝ 58a n ⴝ 47a .52 n ⴝ 28a n ⴝ 22a .72 <.0001a
Mean ⫾ SD time to intubation 23 ⫾ 24 24 ⫾ 78 .90 58 ⫾ 69 36 ⫾ 34 .07 .001
(seconds) 23 ⴞ 24a 24 ⴞ 78a .90a 34 ⴞ 37a 17 ⴞ 13a .06a .76a
Mean ⫾ SD time to end-tidal 85 ⫾ 59 77 ⫾ 90 .59 147 ⫾ 128 104 ⫾ 72 .06 .0005
CO2 reading (seconds) 85 ⴞ 59a 77 ⴞ 90a .59a 109 ⴞ 67a 84 ⴞ 68a .21a .20a
Mean ⫾ SD attempts 1.1 ⫾ 0.3 1.3 ⫾ 0.5 .21 1.8 ⫾ 0.9 1.7 ⫾ 0.9 .72 ⬍.0001
1.1 ⴞ 0.3a 1.3 ⴞ 0.5a .21a 1.2 ⴞ 0.5a 1.1 ⴞ 0.3a .62a .48a

Anesth., anesthetists; EMS, emergency medical service.

Data are presented as mean ⫾ SD.
a
Successful endotracheal intubation attempts only (also shown by boldface).
  



  

Use of the Airtraq laryngoscope for emergency intubation in the
prehospital setting: A randomized control trial*
 






Table 3. Reasons for failed intubation while em-
ploying the Airtraq

Reasons for failed endotracheal

intubation while employing the
Airtraq n ⫽ 56

Cuff damage noticed after 10

successful endotracheal tube
placement
Light source defect (continuous 2
flashing)
Impaired sight and visibility due to 9
vomitus, blood, or food bolus
Impaired mouth opening—Airtraq 5
difficult to insert
Poor visibility due to environmental 5
exposure (snow field, ambient
light)
Esophageal intubation despite 3
optimal view
Airtraq handling mistakes 3
Laryngospasm and hiccup 1
Airtraq and subsequent direct 3
laryngosocopy failed
Missing information 15

i f h i l bl ii f h i
 


 

The Assessment of Four Different Methods to Verify Tracheal
Tube Placement in the Critical Care Setting



 



Table 1. Sensitivity and Specificity of the Four Methods

Auscultation ETco2 EDM Trachlight™
Sensitivity 0.74 1.0 1.0 0.9
Specificity 0.95 1.0 0.91 0.81
EDM ⫽ esophageal detection method.
 


 

 





 












 






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Safety of sedation with ketamine in severe head injury patients:
Comparison with sufentanil 


 

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Figure 2. Systemic hemodynamics in patients

Figure 1. a, Control of intracranial pressure
(ICP); b, control of cerebral perfusion pressure
(CPP); and c, numbers of ICP elevation (ICP
elevation ⬎25 mm Hg and for ⬎5 mins) in the
ketamine (KET or K) and sufentanil (SUF or S)
groups. No significant difference was observed in
mean ICP, CPP values, and numbers of ICP ele-
vation. Over each graphic, n ⫽ number of pa-
tients in both groups.
Figure 3. Evolution of intracranial pressure
(ICP), cerebral perfusion pressure (CPP), heart
rate (HR), and mean velocity of middle cerebral
artery (VMCAM) during endotracheal suctioning in
the ketamine (K) and sufentanil (S) groups. Base-
line monitoring is represented by T0.
sedated with ketamine or sufentanil. Heart rate
(HR) increased on therapy day 3 (p ⫽ .03) and
day 4 (p ⫽ .01) in ketamine group. No significant
changes in mean arterial blood pressure (MABP)
were observed. *p ⬍ .05.
  


  
 
 


Etomidate versus ketamine for rapid sequence intubation in
acutely ill patients: a multicentre randomised controlled trial
 


  
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Etomidate (n=234) Ketamine (n=235) Difference (95% CI) p value
Outcomes
SOFAmax score (mean [SD]) 10·3 (3·7) 9·6 (3·9) 0·7 (0·0 to 1·4) 0·056
Δ-SOFA (median [IQR])* 1·5 (0 to 3) 1 (0 to 3) 0·5 (–1 to 1)† 0·20
28-day mortality (n [%, 95% CI]) 81 (35%, 29 to 41) 72 (31%, 25 to 37) 4 (–4 to 12) 0·36
Mechanical ventilation-free days at day 28 (median [IQR]) 12 (0 to 25) 15 (0 to 26) –2·4 (–9·9 to 5·7)† 0·36
Transfusions (n [%, 95% CI]) 42 (18%, 13 to 23) 38 (16%, 11 to 21) 2 (–5 to 9) 0·62
Fluid loading (mL/kg/h; mean [SD]) 2 (1) 2 (4) –0·1 (–0·7 to 0·5) 0·23
Catecholamine support (n [%, 95% CI]) 137 (59%, 53 to 65) 120 (51%, 45 to 57) 7·5 (–1·5 to 16·5) 0·10
Catecholamine-free days (until day 28; median [IQR]) 27 (14 to 28) 28 (20 to 28) –0·7 (–2·1 to 0·2)† 0·08
ICU-free days at day 28 (median [IQR]) 4 (0 to 22) 6 (0 to 23) –2 (–13 to 11)† 0·57
Glasgow outcome score (median [IQR]) 3 (1 to 5) 3 (1 to 5) 0 (–1 to 1)† 0·95
Intubation condition
IDS value (median [IQR]) 1 (0 to 3) 1 (0 to 3) 0 (0 to 0)† 0·70
Difficult intubation (n [%, 95% CI])‡ 24 (10%, 6 to 14) 20 (9%, 5 to 13) 2 (–4 to 7) 0·52
Change in arterial systolic blood pressure (mm Hg; median [IQR])§ 5 (–11 to 30) 10 (–10 to 33) –5 (–13 to 2)† 0·24
Change in arterial diastolic blood pressure (mm Hg; median [IQR])¶ 1 (–8 to 13) 5 (–7 to 18) –4 (–8 to 1)† 0·18
Change in SpO2 (%; median [IQR])|| 1% (0 to 6) 2% (0-7) –1 (–2 to 1)† 0·98
Cardiac arrest during intubation (n [%]) 7 (3%) 4 (2%) 1·3 (–1.5 to 4·0) 0·36
  


 
  
 


Etomidate Ketamine
(n=234) (n=235)
A Mean SOFAmax (SD; number of patients) Absolute difference of SOFAmax (95% CI)
(Continued from previous column)
Etomidate group Ketamine group
Laboratory values at admission
All patients 10·3 (3·7; n=234) 9·6 (3·9; n=235) 0·7 (0·0 to 1·4) PaO2/FiO2 (mm Hg) 299 (190) 282 (148)
(n=469) WBC (thousands/mm³) 14·2 (8·9) 12·9 (6·2)
Septic or trauma patients 11·0 (3·8; n=98) 10·3 (3·6; n=82) 0·7 (0·4 to 1·8) Haemoglobin (g/L) 122 (26) 121 (23)
(n=180) Platelets (thousands/mm³) 210 (84) 214 (89)
Septic patients 12·4 (3·8; n=41) 10·8 (4·5; n=35) 1·6 (–0·3 to 3·4) Glucose (mmol/L) 9 (4) 9 (5)
(n=76) Arterial lactates (mmol/L) 3 (3) 3 (3)
Trauma patients 10·0 (3·5; n=57) 9·9 (2·8; n=47) 0·1 (–1·2 to 1·3) SAPS II 51·2 (18·3) 50·5 (17·4)
(n=104) Final diagnosis
Non-trauma or Trauma 57 (24%) 47 (20%)
non-septic patients 9·7 (3·6; n=136) 9·2 (4·0; n=153) 0·5 (–0·3 to 1·4) Sepsis 41 (18%) 35 (15%)

(n=289) Other 136 (58%) 153 (65%)

–3 –2 –1 0 1 2 3 4 Reasons for emergency intubation

Etomidate better Ketamine better Comatose 162 (69%) 162 (69%)
Shock 31 (13%) 26 (11%)
B Number of deaths/total number of patients Odds ratio of death at day 28 (95% CI) Acute respiratory failure 37 (16%) 41 (17%)
Etomidate group Ketamine group Other 4 (2%) 6 (3%)
All patients 81/234 72/235 1·2 (0·8 to 1·8)
(n=469)
Septic or trauma patients 32/98 26/82 1·0 (0·6 to 2·0) Etomidate (n=116) Ketamine (n=116) p value
(n=180) Cortisol (nmol/L; median [IQR])
Septic patients 17/41 12/35 1·4 (0·5 to 3·5)
Baseline 441 (304–717) 690 (469–938) <0·0001
(n=76)
Trauma patients 15/57 14/47 0·8 (0·4 to 2·0) 30 min after ACTH test 497 (331–800) 911 (690–1131) <0·0001
(n=104) 60 min after ACTH test 524 (386–828) 1048 (776–1324) <0·0001
Non-trauma or Non-responder in ACTH test (n [%, 95% CI])* 93 (81%, 76–86) 49 (42%, 36–48) <0·0001
non-septic patients 49/136 46/153 1·3 (0·8 to 2·1) Adrenal insufficiency (n [%, 95% CI]) 100 (86%, 82–90) 56 (48%, 42–54) <0·0001
(n=289)
ACTH=adrenocorticotropin hormone. *Patient was a non-responder if maximum change was less than 250 nmol/L.
0 1 2 3 4
†Patient had adrenal insufficiency if baseline cortisol was less than 276 nmol/L or the maximum change (peak cortisol
minus baseline cortisol) was less than 250 nmol/L, or both.
Etomidate better Ketamine better
Table 3: Adrenal function assessment in study patients†
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Reversal of Profound Neuromuscular Block by
Sugammadex Administered Three Minutes after
Rocuronium
A Comparison with Spontaneous Recovery from Succinylcholine
Table 1. Time (min) from Start of Administration of
Neuromuscular Blocking Agent to Recovery of T1 to 10% and    
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T1 to 90%

Treatment Group
Table 2. Number of Patients with at Least One Adverse Event
Rocuronium ⫹ Succinylcholine Regardless of Relationship to Study Drug*
Sugammadex* (n ⫽ 55) Only (n ⫽ 55)
Rocuronium ⫹ Succinylcholine
Recovery to T1 10% Sugammadex, n ⫽ 56 (%) Only, n ⫽ 54 (%)
(primary endpoint)
Mean (SD) 4.4 (0.7) 7.1 (1.6)† Procedural pain 32 (57.1) 26 (48.1)
Median 4.2 7.1 Nausea 16 (28.6) 20 (37.0)
Min–max 3.5–7.7 3.8⫺10.5 Vomiting 9 (16.1) 8 (14.8)
Recovery to T1 90%
Procedural hypotension 7 (12.5) 13 (24.1)
Mean (SD) 6.2 (1.8) 10.9 (2.4)†
Median 5.7 10.7 Procedural hypertension 7 (12.5) 7 (13.0)
Min–max 4.2–13.6 5.0⫺16.2 Headache 8 (14.3) 2 (3.7)
Chills 6 (10.7) 7 (13.0)
* Protocol-specified sugammadex administration at 3 min after the start of
Pain in extremity 6 (10.7) 7 (13.0)
rocuronium administration (mean [SD] 3.1 [0.2]; range 2.7 to 4.2 min). † P ⬍ Incision site complication 5 (8.9) 7 (13.0)
0.001 between treatment groups. Arthralgia 3 (5.4) 6 (11.1)
 Journal of Surgical Research
 
" !!

Pre-Hospital Intubation is Associated with Increased Mortality After



Traumatic Brain Injury1
Marko Bukur, M.D., Silvia Kurtovic, M.D., Cherisse Berry, M.D., Mina Tanios, B.S.,
Daniel R. Margulies, M.D., Eric J. Ley, M.D., and Ali Salim, M.D.2




 
 

   
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Crude Outcomes by Pre-Hospital Intubation Adjusted Odds Ratio/Mean Differences for Pre-
Hospital Intubated Patients After Isolated Severe
Total Pre-hospital intubation Post-hospital intubation Odds ratio (95% CI) P value Traumatic Brain Injury

Adjusted odds Adjusted

Mortality 14.4% 90.2% 12.4% 64.7 (27.6–151.7) <0.001 ratio (95% CI)* P value*

Complication rate 10.9% 11.5% 10.8% 0.9 (0.4–2.1) 0.876 Mortality % 5.0 (1.7–13.7) 0.004
Propensity score mortality % 6.8 (2.3–19.6) 0.001
The P values for the categorical variables were derived from the c or Fishers exact test.
2
Complication rate % 1.5 (0.6–3.9) 0.397
V i bl th t i l d d h i fi j d i

Comparison of Demographics and Clinical Characteristics Between Study Groups

Pre-hospital Post-hospital
Total (n ¼ 2366) intubation (n ¼ 61) intubation (n ¼ 2305) P value

Age (y) mean 6 SD [median] 37.8 6 23.8 [35.0] 35.9 6 18.2 [30.0] 38.1 6 24.2 [35.0] 0.472
Age  55 y 24.3% (576/2366) 14.8% 24.6% 0.095
Male 71.0% (1,809/2366) 82.0% 76.3% 0.304
Blunt mechanism 81.1% (2068/2366) 39.3% (24/61) 88.7% (2,044/2305) <0.001
SBP (mmHg) 134.6 6 38.3 [137.0] 45.0 6 63.2 [0] 137.2 6 34.5 [138.0] <0.001
mean 6 SD [median]
Hypotension on admission 6.3% (147/2348) 73.8% (45/61) 4.5% (102/2287) <0.001
(SBP  90 mmHg)
GCS mean 6 SD [median] 11.6 6 4.3 [14.0] 3.3 6 1.1 [3] 11.7 6 4.2 [14.0] <0.001
GCS  8 23.3% (594/2366) 98.3% (58/59) 23.7% (536/2258) <0.001
Head AIS 4.0 6 0.8 [4.0] 4.8 6 0.5 [5.0] 4.0 6 0.8 [4.0] <0.001
ISS mean 6 SD [median] 18.3 6 7.2 [17.0] 26.7 6 8.4 [26.0] 18.4 6 7.0 [17.0] <0.001
ISS  16 66.7% (1700/2,549) 93.4% (57/61) 71.3% (1,643/2305) <0.001
Transport time 13.2 6 6.9 [12.0] (1,553/2366) 11.5 6 7.5 [9.0] (47/61) 13.3 6 6.8 [12.0] (1,506/2305) 0.073
(min) 6 SD [median]
ISS ¼ injury severity score; GCS ¼ Glasgow Coma Scale; AIS ¼ Abbreviated Injury Score; SBP ¼ systolic blood pressure.
 Medical prehospital rescue in head injury
J.-P.M. Rouxel a, K. Tazarourte b, S. Le Moigno a, C. Ract a, B. Vigué a,


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 Medical pre-hospital management reduces
mortality in severe blunt trauma: a prospective
epidemiological study
Jean-Michel Yeguiayan1*, Delphine Garrigue2, Christine Binquet3, Claude Jacquot4, Jacques Duranteau5,
Claude Martin6, Fatima Rayeh7, Bruno Riou8, Claire Bonithon-Kopp3, Marc Freysz1,
The FIRST (French Intensive Care Recorded In Severe Trauma) Study Group

 




FIRST (French Intensive care Recorded in Severe Trauma)

Médicalisation SMUR vs non médicalisation VSAV 2004-07

7% de patients non médicalisés
 62% admis en CHG
 26% avec lésions abdo (vs 29% médicalisés)

Chez patients avec lésions abdo
 gravité non médicalisés > médicalisés (63% vs 53%)
Prehospital ultrasound imaging improves management of
abdominal trauma
F. Walcher1 , M. Weinlich1,3 , G. Conrad2 , U. Schweigkofler4 , R. Breitkreutz5 , T. Kirschning5 and
I. Marzi1

Walcher F, Br J Surg 2006


 
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 The ne w engl a nd jour na l of medicine

special article

A National Evaluation of the Effect

of Trauma-Center Care on Mortality

 



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Direct Transport Within An Organized State Trauma System
Reduces Mortality in Patients With Severe Traumatic
Brain Injury
 



  



Survival of the fittest: the hidden cost of undertriage
of major trauma






 


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