Isolated prehospital hypotension after traumatic injuries: a predictor of mortality?

In patients with traumatic injuries, prehospital hypotension that resolves by Emergency Department (ED) arrival is of uncertain significance. We examined the impact of prehospital hypotension (PH) in normotensive ED patients with traumatic injuries on predicting mortality and chest/abdominal operative intervention. A retrospective cohort study was conducted of consecutive patients undergoing helicopter transport to two trauma centers between 1993 and 1997. Outcomes were mortality and chest or abdominal operative intervention. Of 545 scene transports, 55 (10.1%) patients were hypotensive on ED arrival, leaving 490 normotensive ED patients. Of 490 patients, 35 (7%) had PH and 455 (93%) had no PH. Multiple logistic regression showed the PH group to have a relative risk for death of 4.4 (95% CI: 1.2-16.6, p < 0.03) and for chest or abdominal operative intervention of 2.9 (1.1-7.6, p < 0.03). In this study of normotensive trauma center patients, prehospital hypotension was associated with increased risk of mortality and significant chest or abdominal injury.     

Evaluation of the prehospital management of road traffic fatalities in Victoria, Australia

INTRODUCTION: This study was undertaken to identify prehospital system and management deficiencies and preventable deaths between 01 January 1997 and 31 December 1998 in 243 consecutive Victorian road crash victims with fatal outcomes. METHODS: The complete prehospital and hospital records, the deposition to the coroner, and autopsy findings were evaluated by computer analysis and peer group review with multidisciplinary discussion. RESULTS: One-hundred eighty-seven (77%) patients had prehospital errors or inadequacies, of which 135 (67%) contributed to death. Three-hundred ninety-four (67%) related to management and 130 (22%) to system deficiencies. Technique errors, diagnosis delays, and errors relatively were infrequent. One of 24 deaths at the crash scene or en route to hospital was considered to be preventable and two potentially preventable. CONCLUSION: The high prevalence of prehospital deficiencies has been addressed by a Ministerial Task Force on Trauma and Emergency Services and followed by the introduction of a new trauma care system in Victoria.     

An analysis of prehospital mortality in an earthquake. Disaster Reanimatology Study Group

INTRODUCTION: Anecdotal observations about prehospital emergency medical care in major natural and human-made disasters, such as earthquakes, have suggested that some injured victims survive the initial impact, but eventually die because of a delay in the application of life-saving medical therapy. METHODS: A multidisciplinary, retrospective structured interview methodology to investigate injury risk factors, and causes and circumstances of prehospital death after major disasters was developed. In this study, a team of United States researchers and Costa Rican health officials conducted a survey of lay survivors and health care professionals who participated in the emergency medical response to the earthquake in Costa Rica on 22 April 1991. RESULTS: Fifty-four deaths occurred prior to hospitalization (crude death rate = 0.4/1,000 population). Seventeen percent of these deaths (9/54) were of casualties who survived the initial impact but died at the scene or during transport. Twenty-two percent (2/9) were judged preventable if earlier emergency medical care had been available. Most injuries and deaths occurred in victims who were inside wooden buildings (p < .01) as opposed to other building types or were pinned by rubble from building collapse. Autopsies performed on a sample of victims showed crush injury to be the predominant cause of death. CONCLUSIONS: A substantial proportion of earthquake mortality in Costa Rica was protracted. Crush injury was the principal mechanism of injury and cause of death. The rapid institution of enhanced prehospital emergency medical services may be associated with a significant life-saving potential in these events.     

Could bystander first‐aid prevent trauma deaths at the scene of injury?

Objective: To identify potentially preventable prehospital deaths following traumatic cardiac arrest. Methods: Deaths following prehospital traumatic cardiac arrest during 2003 were reviewed in the state of Victoria, Australia. Possible survival with optimal bystander first‐aid and shorter ambulance response times were identified. Injury Severity Scores (ISS) were calculated. Victims with an ISS <50 and signs of life were reviewed for potentially preventable factors contributing to death including signs of airway obstruction, excessive bleeding and/or delayed ambulance response times. Results: We reviewed 112 cases that had full ambulance care records, hospital records and autopsy details in Victoria 2003. Most deaths involved road trauma and 55 victims had an ISS <50. Twelve patients received first‐aid from bystanders. Ambulance response times >10 min might have contributed to five deaths with an ISS <25. Conclusion: Five (4.5%) potentially preventable prehospital trauma deaths were identified. Three deaths potentially involved airway obstruction and two involved excessive bleeding. There is a case for increased awareness of the need for bystander first‐aid at scene following major trauma.     

Emergency department thoracotomy for penetrating injuries: predictive value of patient classification

In 18 months, 44 patients underwent thoracotomy in an emergency department (ED) for penetrating thoracic injuries. Of 14 patients resuscitated, seven (50%) survived, and all were neurologically intact. Patients were classified according to the quality of signs of life in transit or upon arrival at the ED. Identical survival rates of 29% were noted for patients in Group I (profound shock) and in Group II (agonal), with survival at 14% for individuals in Group III ("dead" on arrival). There were no survivors among patients in Group IV ("dead" on the scene), and ED thoracotomy, in the authors' opinion, is fruitless in this group. In Groups I, II, and III, total salvage from cardiac injuries was six of 24 patients (25%), and for those with non-cardiac injuries, it was one of 11 (9%). The rate of survival from cardiac stab wounds in Groups I, II, and III, was five of 16 (31%) and one of eight (13%) for gunshot wounds. Five of the seven survivors (71%) arrived at the ED by rapid transport without the benefit of any pre-hospital life support. Patient classification appears to be a valuable tool in evaluating the benefit of ED thoracotomy. The neurological status of all survivors and pertinent transportation data should be included in all future studies of ED thoracotomy. "Scoop and run" in the urban setting with rapid transport capability may be superior to pre-hospital stabilization of victims of penetrating thoracic trauma.     

Examining emergency medical services' prehospital transport times for trauma patients during COVID-19

IntroductionLonger prehospital times were associated with increased odds for survival in trauma patients. The purpose of this study was to determine how the COVID-19 pandemic affected emergency medical services (EMS) prehospital times for trauma patients.MethodsThis retrospective cohort study compared trauma patients transported via EMS to six US level I trauma centers admitted 1/1/19–12/31/19 (2019) and 3/16/20–6/30/20 (COVID-19). Outcomes included: total EMS pre-hospital time (dispatch to hospital arrival), injury to dispatch time, response time (dispatch to scene arrival), on-scene time (scene arrival to scene departure), and transportation time (scene departure to hospital arrival). Fisher's exact, chi-squared, or Kruskal-Wallis tests were used, alpha = 0.05. All times are presented as median (IQR) minutes.ResultsThere were 9400 trauma patients transported by EMS: 79% in 2019 and 21% during the COVID-19 pandemic. Patients were similar in demographics and transportation mode. Emergency room deaths were also similar between 2019 and COVID-19 [0.6% vs. 0.9%, p = 0.13].There were no differences between 2019 and during COVID-19 for total EMS prehospital time [44 (33, 63) vs. 43 (33, 62), p = 0.12], time from injury to dispatch [16 (6, 55) vs. 16 (7, 77), p = 0.41], response time [7 (5, 12) for both groups, p = 0.27], or on-scene time [16 (12−22) vs. 17 (12,22), p = 0.31]. Compared to 2019, transportation time was significantly shorter during COVID-19 [18 (13, 28) vs. 17 (12, 26), p = 0.01].ConclusionThe median transportation time for trauma patients was marginally significantly shorter during COVID-19; otherwise, EMS prehospital times were not significantly affected by the COVID-19 pandemic.     

Survival and neurologic outcome after traumatic out-of-hospital cardiopulmonary arrest in a pediatric and adult population: a systematic review

ABSTRACT: INTRODUCTION: This systematic review is focused on the in-hospital mortality and neurological outcome of survivors after prehospital resuscitation following trauma. Data were analyzed for adults/pediatric patients and for blunt/penetrating trauma. METHODS: A systematic review was performed using the data available in Ovid Medline. 476 articles from 1/1964 - 5/2011 were identified by two independent investigators and 47 studies fulfilled the requirements (admission to hospital after prehospital resuscitation following trauma). Neurological outcome was evaluated using the Glasgow outcome scale. RESULTS: 34 studies/5391 patients with a potentially mixed population (no information was found in most studies if and how many children were included) and 13 paediatric studies/1243 children (age ≤ 18 years) were investigated. The overall mortality was 92.8% (mixed population: 238 survivors, lethality 96.7%; paediatric group: 237 survivors, lethality 86.4% = p < 0.001).Penetrating trauma was found in 19 studies/1891 patients in the mixed population (69 survivors, lethality: 96.4%) and in 3 pediatric studies/91 children (2 survivors lethality 97.8%).44.3% of the survivors in the mixed population and 38.3% in the group of children had a good neurological recovery. A moderate disability could be evaluated in 13.1% in the mixed population and in 12.8% in children. A severe disability was found in 29.5% of the survivors in the mixed patients and in 38.3% in the group of children. A persistent vegetative state was the neurological status in 9.8% in the mixed population and in 10.6% in children.For each year prior to 2010, the estimated log-odds for survival decreased by 0.022 (95%-CI: [0.038;0.006]). When jointly analyzing the studies on adults and children, the proportion of survivors for children is estimated to be 17.8% (95%-CI: [15.1%;20.8%]). The difference of the paediatric compared to the adult proportion is significant (p < 0.001). CONCLUSIONS: Children have a higher chance of survival after resuscitation of an out-of-hospital traumatic cardiac arrest compared to adults but tend to have a poorer neurological outcome at discharge.     

Effect of physician-staffed helicopter emergency medical service on blunt trauma patient survival and prehospital care.

OBJECTIVE: The aim of the study was to assess the immediate and long-term effect of a helicopter emergency physician giving advanced life support on-scene compared with conventional load and go principle in urban and rural settings in treating blunt trauma patients. METHODS: In a retrospective study, 81 blunt trauma patients treated prehospitally by a physician-staffed helicopter emergency medical service were compared with 77 patients treated before the era of the helicopter emergency medical service. The data were collected in the prehospital and hospital files and a questionnaire was sent to the survivors 3 years after the trauma. RESULTS: The physicians treated the patients more aggressively (gave drugs, intubated and cannulated) and had the patients transported directly to a university hospital. The given treatment did not delay arrival at the hospital. No statistically significant difference was found, but a trend (P = 0.065) to lower survival in the helicopter emergency medical service group. Almost half of the deaths in the helicopter emergency medical service group and none in the control group, however, occurred in the emergency department. No difference was found 3 years later between the groups in the health-related quality of life or decrease in the income owing to the accident. CONCLUSION: The physicians treated the patients more aggressively, but it did not delay the arrival at the hospital. A beneficial effect of this aggressive treatment or direct transport to a university hospital could not be seen in the immediate physiological parameters or later health-related quality of life. The physician-staffed helicopter emergency medical service was not beneficial to blunt trauma patients in this setting.     

Do we know what people die of in the emergency department?

Objective: To establish the discrepancy rate between the predicted cause of death and the actual cause of death as determined by postmortem examination result, for all deaths in the emergency department reported to the Scottish Procurator Fiscal and subsequently undergoing postmortem examination. Methods: A prospective study of all patients who were dead on arrival or died in the emergency department of a busy Glasgow hospital over a 12 month period. The most senior emergency physician present at the time of death predicted the cause of death. This was then compared to the actual postmortem examination determined cause of death and was considered either to be correct or incorrect. Results: During the study period, 146 patients were pronounced dead in the department. Of these, 81 patients (age range 39–99 years, median 71; male:female 2.5:1) had death certificates issued, 63 patients (age range 26 days to 99 years, median 48; male:female 2.4:1) had a postmortem performed by the forensic pathologist, and two patients underwent a "view and grant". Of the 63 deaths reported to the Procurator Fiscal, the emergency physician attributed 51 (80.1%) to non-trauma, 9 (14.2%) to trauma, and in 3 (4.7%) cases were uncertain. Of the 63 (39.7%) deaths, 25 were inaccurately predicted (99% confidence interval 24.3% to 56.6%; p<0.0)1. Cardiovascular related and drugs poisoning deaths occurred most commonly. They were also the most accurately predicted cause of deaths. Intracranial events, pulmonary thromboembolism, and airway obstruction were also frequently predicted, but were often wrong. Conclusions: This study highlights the difficulties in accurately identifying cause of death for patients who die suddenly. This could have implications for the accuracy of health service statistics.     

Prehospital needle aspiration and tube thoracostomy in trauma victims: A six-year experience with aeromedical crews

The use of prehospital tube thoracostomy (TT) for the treatment of suspected tension pneumothorax (TPtx) in trauma patients is controversial. A study is presented that reviews a 6-year experience with the use of needle catheter aspiration (NA) and chest tubes performed in the field by air medical personnel. Prehospital flight charts and hospital records from 207 trauma patients who underwent one or both of these procedures in the field were retrospectively reviewed. The clinical indications used to determine treatment are presented for both procedures. Improvement in clinical status of patients observed by flight personnel were similar for both treatment groups (54% for NA, 61% for TT). Thirty-two (38%) of the TT patients had failed NA attempts prior to chest tube placement. Average time on scene (T.O.S.) was significantly greater for the TT group (25.7 min versus 20.3 min for NA group). Fewer patients were pronounced dead on arrival (D.O.A.) with TT treatment compared to NA alone (7% versus 19%, respectively). Injury severity scores, number of hospital complications, length of stay (L.O.S.), and total hospital costs were not different between the two groups. There were no cases of lung damage or empyema formation associated with prehospital TT treatment. Overall mortality was similar for both groups. From these data, we conclude that NA is a relatively rapid intervention in the treatment of suspected TPtx in the prehospital setting; however, TT is an effective adjunct for definitive care without increasing morbidity or mortality. A better understanding of the physiology of intrapleural air masses is needed to determine the most effective decompression requirements prior to aeromedical transport.     

Motorcycle‐related major trauma: On‐road versus off‐road incidence and profile of cases

Objective: To describe and compare the incidence and profile of on‐ and off‐road motorcycle‐related major trauma (including death) cases across a statewide population. Methods: A review of prospectively collected data on adult, motorcycle‐related major trauma cases from 2001 to 2008 was conducted. Major trauma survivors were identified from the population‐based Victorian State Trauma Registry, and deaths were extracted from the National Coroners Information System. Poisson regression was used to test for increasing incidence using two measures of exposure: population of Victoria aged ≥16 years, and registered motorcycles. Results: There were 1157 major trauma survivors and 344 deaths with motorcycle‐related injuries over the study period. There was no change in the incidence of motorcycle‐related major trauma (both survivors plus deaths) (Incident Rate ratio [IRR]= 1.14, 95% confidence interval [CI] 0.94–1.37) over the study period. Similarly, there was no change over time in the incidence of on‐road motorcycle‐related injury (survivors plus deaths) per 100 000 population (IRR = 1.03, 95% CI 0.84–1.27). However, the incidence of off‐road motorcycle‐related injury (survivors plus deaths) increased over the study period (IRR = 1.69, 95% CI 1.10–2.60). Among survivors and deaths, 882 (76%) and 301 (87.5%) cases, respectively, occurred on road. Conclusions: Off‐road motorcycle‐related major trauma has increased and this has not been targeted in injury prevention campaigns in Australia. The incidence of on‐road motorcycle‐related death in adults has decreased. Preventive strategies to address on‐road injuries have been enforced and these are expected to lead to further reduction of on‐road motorcycle crashes in the future.     

Prehospital Injury Severity of Children Evacuated by Helicopters from Combat Zones: A Retrospective Report

Background

In Israel, the Airborne Rescue and Evacuation Unit (AREU) provides prehospital trauma care in times of peace and during times of armed conflict. In peacetime, the AREU transports children who were involved in motor vehicle collisions (MVC) and those who fall off cliffs (FOC). During armed conflict, the AREU evacuates children who sustain firearm injuries (FI) from the fighting zones.

Objective

To report on prehospital injury severity of children who were evacuated by the AREU from combat zones.

Methods

A retrospective comparative analysis was conducted on indicators of prehospital injury severity for patients who had MVC, FOC, and FI. It included the National Advisory Committee for Aeronautics (NACA) score, the Glasgow Coma Scale (GCS) score on scene, and the number of procedures performed by emergency medical personnel and by the AREU air-crew.

Results

From January 2003 to December 2009, 36 MVC, 25 FOC, and 17 FI children were transported from the scene by the AREU. Five patients were dead at the scene: 1 (2.8%) MVC, 1 (4%) FOC, and 3 (17.6%) FI. Two (11.7%) FI patients were dead on arrival at the hospital. MVC, FOC, and FI patients had mean (±SD) NACA scores of 4.4 ± 1.2, 3.6 ± 1.2, and 5 ± 0.7, respectively. Mean (±SD) GCS scores were 8.9 ± 5.6, 13.6 ± 4, and 6.9 ± 5.3, respectively. Life support interventions were required by 29 (80.6%) MVC, 3 (12%) FOC, and 15 (88.2%) FI patients.

Conclusions

In the prehospital setting, children evacuated from combat zones were more severely injured than children who were transported from the scene during peacetime.     

Longer Prehospital Time was not Associated with Mortality in Major Trauma: A Retrospective Cohort Study

Objective: The objective of this study was to determine the association between prehospital time and outcomes in adult major trauma patients, transported by ambulance paramedics. Methods: A retrospective cohort study of major trauma patients (Injury Severity Score >15) attended by St John Ambulance paramedics in Perth, Western Australia, who were transported to hospital between January 1, 2013 and December 31, 2016. Inverse probability of treatment weighting (IPTW) using the propensity score was performed to limit selection bias and confounding. The primary outcome was 30-day mortality and the secondary outcome was the length of hospital stay (LOS) for 30-day survivors. Multivariate logistic and log-linear regression analyses with IPTW were used to determine if prehospital time of more than the one hour (from receipt of the emergency call to arrival at hospital) or any individual prehospital time interval (response, on-scene, transport, or total time) was associated with 30-day mortality or LOS. Results: A total of 1,625 major trauma patients were included and 1,553 included in the IPTW sample. No significant association between prehospital time of one hour and 30-day mortality was found (adjusted odds ratio 1.10, 95% confidence interval (CI) 0.71–1.69). No association between any individual prehospital time interval and 30-day mortality was identified. In the 30-day survivors, one-minute increase of on-scene time was associated with 1.16 times (95% CI 1.03–1.31) longer LOS. Conclusion: Longer prehospital times were not associated with an increased likelihood of 30-day mortality in major trauma patients transported to hospital by ambulance paramedics. We found no evidence to support the hypothesis that prehospital time longer than one hour resulted in an increased risk of 30-day mortality. However, longer on-scene time was associated with longer hospital LOS (for 30-day survivors). Our recommendation is that prehospital care is delivered in a timely fashion and delivery of the patient to hospital is reasonably prompt.     

Road traffic accidents with vehicular entrapment: incidence of major injuries and need for advanced life support.

Road traffic accidents (RTAs) with entrapment are perceived as a challenge to emergency systems because of the severity of the ensuing traumas and the inherent complexity of the rescue procedures. To clarify these two aspects this prospective cohort study enrolling 244 entrapped trauma patients was conducted by a Regional Medical Helicopter Service. Forty-six victims (18.9%) were found dead, 101 (51%) of the 198 patients who reached the hospital alive had an injury severity score (ISS) > or = 16. The use of seat belts was associated with lower trauma severity. Out of the 101 severely traumatized patients (ISS > or = 16), 46 (42.6%) were intubated at road side, 12 required decompression of a tension pneumothorax on the scene and in 15 cases a pneumothorax was drained during the early intrahospital phase. Thirty-six (34.7%) patients had the first systolic blood pressure (SBP) < or = 90 mmHg and were then aggressively infused: in 75% of these cases, the SBP on arrival at the emergency department increased. The first SBP was significantly correlated with mortality. There was no correlation of extrication time, total rescue time and mortality. Fourteen patients (13.9%) died during hospitalization. These data demonstrate that a high percentage of entrapped patients require advanced life support (ALS), including on scene intubation and chest decompression. Aggressive field resuscitation and immediate transport to a level 1 trauma centre is associated with a mortality lower than that predicted by TRISS in spite of the prolonged prehospital time.     

The feasibility of a regional cardiac arrest receiving system

BACKGROUND: Patients suffering out-of-hospital cardiac arrest (OOHCA) are generally transported to the closest ED, presumably to expedite a hospital level of care and improve the chances of return for spontaneous circulation (ROSC) or provide post-resuscitative care for patients with prehospital ROSC. As hospital-based therapies for survivors of OOHCA are identified, such as hypothermia and emergency primary coronary interventions (PCI), certain hospitals may be designated as cardiac arrest receiving facilities. The safety of bypassing non-designated facilities with such a regional system is not known. OBJECTIVES: To explore the potential ED contribution in OOHCA victims without prehospital ROSC and document the relationship between transport time and outcome in patients with prehospital ROSC. METHODS: This was a prospective, observational study conducted in a large, urban EMS system over an 18-month period. Data were collected using the Utstein template for OOHCA. The incidence of prehospital ROSC was calculated for patients who were declared dead on scene, transported but died in the ED, died in the hospital, and survived to hospital discharge. The relationship between transport time and survival was also explored for patients with prehospital ROSC. RESULTS: A total of 1141 cardiac arrest patients were enrolled over the 18-month period. A strong association between prehospital ROSC and final disposition was observed (chi-square test for trend p<0.001). Only two patients who survived to hospital discharge did not have prehospital ROSC. Mean transport times were not significantly different for patients with prehospital ROSC who were declared dead in the ED (8.3min), died following hospital admission (7.8min), and survived to hospital discharge (8.5min). Outcomes in patients with prehospital ROSC who had shorter (7min or less) versus longer transport times were similar, and receiver-operator curve analysis indicated no predictive ability of transport time with regard to survival to hospital admission (area under the curve=0.52). CONCLUSIONS: In this primarily urban EMS system, the vast majority of survivors from OOHCA are resuscitated in the field. A relationship between transport time and survival to hospital admission or discharge was not observed. This supports the feasibility of developing a regional cardiac arrest system with designated receiving facilities.     

Out-of-hospital cardiac arrest in an oriental metropolitan city

To investigate the epidemiology of out-of-hospital cardiac arrest in Taipei City, Taiwan, a prospective chart review and follow-up study was conducted by collecting the prehospital cardiac arrest record from 10 designated responsible emergency departments (EDs) from August 1, 1992 through May 31, 1993. Cases with the restoration of spontaneous circulation (ROSC) were followed up until discharged from hospital. The information gathered included age, sex, bystander cardiopulmonary resuscitation, response time (time elapsed from receiving the call to arrival on the scene), advanced cardiac life support (ACLS) time (time elapsed from receiving the call to arrival at the ED), initial cardiac rhythm in the ED, ROSC, survival to discharge from the hospital, underlying disease, past history, personal history, and neurological outcome at discharge. Of 638 out-of-hospital cardiac arrests, 554 (86.7%) were nontraumatic. Response time, ACLS time, ROSC rates, and survival rates were 7.4 minutes, 21.6 minutes, 15.8%, and 1.4%, respectively. In comparing the trauma and nontrauma group, there were significant differences in age, sex, response time, and ACLS time. Between cases of patients who had ROSC and those who died, the data were statistically significant, P = .0143, showing that ACLS time was shorter in the ROSC group (19.5 v 21.9 minutes). In analysis of underlying disease, definite and probable cardiac-origin sudden deaths were found in only 120 patients, which may extend the annual sudden cardiac death rates to be 0.0053%. In conclusion, the low resuscitation and survival rates in this country were because of delayed initiation of both basic life support and ACLS. Out-of-hospital arrests of noncardiac origin had an extremely low survival rate     

Resuscitation of drowning victims in south-east Scotland.

INTRODUCTION: Immersion in cold water is compatible with long-term survival, even when the period of immersion is relatively long. Guidelines for resuscitation after immersion stress the importance of prolonged resuscitation using advanced life support techniques. METHODS: Deaths due to drowning in south-east Scotland between 1991 and 1997 were reviewed, using a variety of data sources. RESULTS: 95 deaths (69 males, 26 females) from drowning occurred in the following sites: sea, 35; bath, 15; flowing freshwater, 26; still freshwater, 19; 22 (23%) of the drowning incidents were witnessed, 73 (77%) were unwitnessed. 28 individuals were recovered within 1 h of being seen alive, 13 having had witnessed accidents, 15 having had unwitnessed accidents. Six individuals were not resuscitated at the scene by the emergency services, despite being last seen alive within the previous hour. A further five individuals were initially resuscitated, but declared dead at the scene within 1 h of being known to be alive. CONCLUSIONS: Members of the emergency services, are failing to both initiate prehospital resuscitation and to continue this to hospital for victims of near drowning. There appears to be potential to reduce the drowning death rate by improving resuscitation. The emergency services and the public should be educated about the need to resuscitate those found in water.     

Efficacy of the presence of an emergency physician in prehospital major trauma care: A nationwide cohort study in Japan

PurposeThe beneficial effect of the presence of an emergency physician in prehospital major trauma care is controversial. The aim in this study is to assess whether an emergency physician on scene can improve survival outcome of critical trauma patients.MethodsThis retrospective cohort study was conducted by using nationwide trauma registry data between 2004 and 2013 in Japan. Severe trauma patients (injury severity score (ISS) ≥ 16) who were transported directly to the hospital from the injury site were included in our analysis. Patients who were predicted to be untreatable (abbreviated injury score (AIS) = 6 and/or cardiopulmonary arrest at least one time before hospital arrival) were excluded. Participants were divided into either a physician or paramedics group based on the prehospital practitioner. The primary outcome was survival rate at discharge. Multivariable logistic regression analysis was performed to compare the outcome with adjustment for age, gender, ISS, cause of injury, and pre-hospital vital signs.ResultsA total of 30,283 patients were eligible for the selection criteria (physician: 1222, paramedics: 29,061). Overall, 172 patients (14.1%) died in the physician group compared to 3508 patients (12.1%) in the paramedics group. Patients in the physician group had higher ISSs than those in the paramedics group. In multivariable logistic regression, the physician group had an odds ratio (OR) of 1.16 (95% confidence interval (CI) = 0.97 to 1.40, p = 0.11) for in-hospital survival.ConclusionsOur results failed to show a difference in survival at discharge between non-physician-staffed ambulances and physician-staffed ambulances.