A new study involving more than 21,000 patients who were transported to the hospital by ambulance after sustaining a severe head injury found that adherence to 3 simple interventions helped to increase chances of survival.
Focusing on adherence to these 3 simple interventions (by paramedics) demonstrated clear efficacy by doubling the survival rate of severe victims of traumatic brain injury (TBI) and tripling the survival rate in those who required a breathing tube to secure their airway (intubation).
The results of the Excellence in Prehospital Injury Care (EPIC) study were published last week in JAMA Surgery.
“The beauty of EPIC was that the “Three H-Bombs” (hypoxia, hypotension and hyperventilation) were managed by simple interventions–this wasn’t a million-dollar ‘un-obtainium’ drug being tested, explained Daniel Spaite, M.D., FACEP, Professor and Virginia Piper Distinguished Chair of Emergency Medicine, Co-Director of EMS Research, Associate Director-Arizona Emergency Medicine Research Center, University of Arizona.
For the study, over 11,000 paramedics from 130 locations in Arizona took a 2-hour training session on prehospital TBI treatment guidelines, which focus on adherence to the 3 interventions: prevention and treatment of hypoxia, prevention and avoidance of hyperventilation, and addressing and treatment of hypotension.
The study, evaluating over 21,000 patients with moderate, severe, or critical TBI, found that adherence to the prehospital TBI guidelines did not affect overall survival, but did significantly improve survival in patients with a severe TBI.
This is also the first major prehospital study to evaluate the impact of national prehospital TBI treatment guidelines, which were developed after years of research, replacing decades of management based on outdated protocols.
While there was no significant impact on overall survival in those with moderate TBI, the take-home is that simple interventions—addressing hypoxia, hypotension, and avoiding hyperventilation—in those most critically injured had a clear impact on their survival.
The findings from the study have important implications for the prehospital management of patients with severe TBI , which will lead to increased survival and improve neurological outcomes.
In the past, paramedics were taught to hyperventilate patients (who required intubation) to blow off carbon dioxide. While this maneuver may lower intracranial pressure, it also deprives the brain of critical blood flow and oxygen. After nearly 4-5 minutes of diminished blood flow, brain cells (neurons) begin to die.
EPIC reversed course by correcting old practices and reinforcing the importance of avoiding hyperventilation (by measuring end tidal carbon dioxide levels which are reflective of hyperventilation), allowing paramedics to monitor this important parameter which has a lasting impact on neurologic outcome.
In fact, the classic “golden hour” of trauma resuscitation, Spaite explains, is not an hour at all when looking at outcomes for TBI. More importantly, “given the time sensitive nature of neuronal survival, [4-5 min] if EMS doesn’t deliver a brain that has the potential to survive, then no amount of subsequent care will reverse this, no matter how good the neurosurgical and critical care is.”
“The EMS providers already know how to put oxygen on a patient, how to initiate IVs, and how to intubate and ventilate. EPIC simply taught them how to optimize/correct the use of these treatments for maximum benefit to the patients –it’s just those three simple interventions done right!,” emphasized Spaite.
“And this means that these life-saving best-practices can be done in essentially any EMS system because they don’t require expensive and sophisticated alterations in equipment or training,” added Spaite.
But training and re-training are essential to maximizing performance when attempting to adhere to any specific guideline or protocol, according to Peter Antevy, M.D., a pediatric emergency physician at Joe Dimaggio Children’s Hospital, and EMS medical director for Coral Springs Fire Department.
“These interventions, while seemingly basic, require training and re-training, for EMS professionals to remain consistent in their practice. This is similar to any other ‘protocol’ rollout which is the way of the world in EMS,” stressed Antevy.
When we rolled out the RACE (Rapid Arterial Occlusion Evaluation) scale for stroke [to evaluate for large vessel occlusion], we learned that unless we continuously trained on it, the usage degraded over time,” he added.
Similar to improving survival in TBI, improving survival in CPR using “high-performance CPR”, allows us to see the effects of guidelines or protocols on improving outcomes, according to Antevy.
“But having a guideline, and actually implementing the strategy are two different animals–similar to having CPR guidelines and using the High-Performance CPR process. Less than half of EMS agencies use the “HP-CPR” model which is the only way to operationalize the guidelines to enhance outcomes,” added Antevy.
EPIC further reinforces the concept that that prehospital interventions are part of the spectrum of overall patient care that begins at the scene and continues when a patient arrives in the emergency department (ED) and is subsequently admitted to the hospital.
“ This study demonstrates that caring for severe TBI patients is a team effort, ” Jason A. Ellis, M.D., Assistant Professor of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Department of Neurosurgery, Lenox Hill Hospital in New York City.
“ The best outcomes are achieved by initiating care as close to the time of injury as possible : the data confirms what we already know in the trenches that an EMS crew capable of optimizing patients prior to hospital arrival saves lives ,” added Ellis.
Simply put, what we do in the early stages after acute injury is an extension of principles of critical care that continue in the hospital. By focusing and adhering to principles that maximize oxygenation, reduce hypotension, and avoid hyperventilation, we can make a difference in who survives.
Implementing simple interventions by EMS providers—administering high flow oxygen, (intubating and ventilating when necessary), administering intravenous fluids, and avoiding hyperventilation (by focusing on end tidal carbon dioxide measurements)—can make a clear difference in outcome in those with severe neurological impairment after TBI.
The big take-away of the study is that adherence and implementation of these 3 simple resuscitative principles led to improved survival in the subgroup with severe injury. It’s these simple interventions that ultimately improved survival and neurological outcome in this at-risk group.
“In the last 40 years, essentially all of the treatments that have been studied in the emergency care of TBI have been negative: there’s a graveyard full of promising drugs and treatments that when finally tested led to no improvement (e.g., steroids, progesterone, cooling, etc).” explained Spaite.
“EPIC’s implementation of the Guidelines has broken a really long losing streak– it’s a major breakthrough after nearly half a century of attempting to find ways to improve TBI outcome,” he added.