Prospectively collected data on 727 major trauma patients from a Portugese trauma centre registry enabled the comparison of mortality between three groups of patients with a priori defined life threatening ‘ABCD’ problems: those whose ABCD issues were treated in the field by a pre-hospital emergency physician, those that were treated at another hospital prior to trauma centre transfer, and those whose ABCD issues were first treated on arrival at the trauma centre. The study population included mixed urban and rural trauma.
Patients from the pre-hospital and first hospital groups had 20% and 27% mortality respectively, compared to 38% among those whose life-threatening events were corrected only at the trauma centre.
Patients whose life- threatening events were treated in the pre-hospital environment had lower mortality but at the same time were younger and less severely injured, so a multivariate logistic regression was performed to adjust the odds of death to patient characteristics and trauma severity as well as time from accident to trauma centre. Logistic regression showed that increases in mortality were associated with female gender and older age, penetrating type of trauma, higher anatomic severity (ISS), higher physiological severity (RTS) and having the life-threatening events corrected only at the trauma centre. Logistic regression showed that patients whose life-threatening events were corrected only at the trauma centre had an odds of death 3.3 times greater than those from the pre-hospital group, adjusted for patient and trauma characteristics and time to trauma centre.
Correcting life-threatening events pre- trauma centre (pre-hospital and first hospital) increased the total time from the accident to trauma centre, but long pre-hospital times were not associated with worse outcome.
The importance of pre-trauma centre treatment of life-threatening events on the
mortality of patients transferred with severe trauma
Resuscitation. 2010 Apr;81(4):440-5
A retrospective study from Italy compared outcomes of head injured patients cared for by a ground ambulance service (GROUND) with those managed by a HEMS team that included an experienced pre-hospital anaesthetist. Interestingly 73% of the ground group were also attended by a physician, but one ‘with only basic life-support capabilities and no formal training in airways management’. Despite these limited skills a results table shows that 36% of the GROUND group were intubated on scene (compared with 92% of the HEMS group), although without the use of neuromuscular blockers.
The HEMS group consisted of 89 patients and the GROUND group of 105 patients. There were no statistical differences in age, ISS, aISShead, or GCS, although arterial hypotension at arrival at the ER was present in 18% of HEMS patients and in 36% of GROUND patients (P < 0.001).
The overall mortality rate was lower in the HEMS than in the GROUND group (21 vs. 25% , P < 0.05). The survival with or without only minor neurological disabilities was higher in the HEMS than in the GROUND group (54 vs. 44% respectively, P < 0.05); among the survivors, the rate of severe neurological disabilities was lower in the HEMS than in the GROUND group (25 vs. 31%, P < 0.05). The out-of-hospital phase duration was longer in the HEMS group but this group had a faster time to definitive care (neurosurgery or neurocritical care).
Influence of prehospital treatment on the outcome of patients with severe blunt traumatic brain injury: a single-centre study
Eur J Emerg Med. 2009 Dec;16(6):312-7
Over twelve years in Queensland the RFDS undertook over 72000 fixed wing retrievals, including over 4000 critically ill patients. Trauma was the commonest diagnostic category. There were only 90 primary retrievals, from locations without healthcare facilities – less than one per month on average. This fascinating service covers vast distances, low population density, and a high number of indigenous people.
Aeromedical retrieval for critical clinical conditions: 12 years of experience with the Royal Flying Doctor Service, Queensland, Australia
J Emerg Med. 2009 May;36(4):363-8
Prehospital airway management on rescue helicopters in the United Kingdom
26 of 27 identified UK rescue helicopter bases responded to a questionnaire sent by German anaesthesiologists on the airway equipment they carried. The take home message is that there were some important gaps: not all carried equipment for establishing a surgical airway and not all had a means of capnometry. Pull your socks up guys the Germans are watching.
Anaesthesia. 2009 Jun;64(6):625-31
This systematic review by Scandinavian authors examined controlled studies comparing physician with non-physician treatment in pre-hospital care. Fourteen of the 26 studies identified demonstrated significantly improved survival in the intervention (physician-treated) group. Most survival benefit has been demonstrated in trauma and cardiac arrest, reflecting the fact that these two areas are the most studied. The authors rightly remind us of the paucity of pre-hospital controlled studies of sufficient quality and strength.
A systematic review of controlled studies: do physicians increase survival with prehospital treatment?
Scand J Trauma Resusc Emerg Med. 2009 Mar 5;17(1):12
Full text available at http://www.sjtrem.com/content/pdf/1757-7241-17-12.pdf
Two English HEMS services covering the same geographical area, one physican / paramedic crewed and one double paramedic crewed, were compared. There were no differences in scene times. As well as predictably providing more rapid sequence induction, nerve blocks, and ketamine use, the physician-paramedic team discharged more people at scene and were more likely to cease resuscitation attempts in GCS 3 patients.
Influence of air ambulance doctors on on-scene times, clinical interventions, decision-making and independent paramedic practice.
Emerg Med J. 2009 Feb;26(2):128-34