The importance of pre-trauma centre treatment of life-threatening events on the mortality of patients transferred with severe trauma

Gomes, Ernestina; Araújo, Rui Esteves; Carneiro, Antônio Fernando; Dias, Cláudia Camila; Costa‐Pereira, Altamiro; Lecky, Fiona

doi:10.1016/j.resuscitation.2009.12.014

Cited by 43 publications

(29 citation statements)

References 33 publications

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“…16 Such studies do not mention matching for severity or the possibility of selection bias. It is possible that the initial resuscitation care at our secondary hospitals is better than that of previous studies, and this would be consistent with the report of Gomes et al 14 Also, there are no large, well controlled studies in the civilian population that addresses whether quicker definitive care is universally better in trauma care. 16 The numerous smaller studies are not sufficiently similar to use meta-analysis to resolve the question.…”

Section: Discussionsupporting

confidence: 79%

A comparison of major trauma patients transported to trauma centres vs. non-trauma centres in metropolitan Perth

Fatovich¹,

Phillips²,

Jacobs³

2011

Resuscitation

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Section: Discussionsupporting

confidence: 79%

A comparison of major trauma patients transported to trauma centres vs. non-trauma centres in metropolitan Perth

Fatovich¹,

Phillips²,

Jacobs³

2011

Resuscitation

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“…16 Finally, modelling of unpublished Portuguese observational data suggests that early intubation was associated with greater mortality benefits than early neurosurgery for patients with TBI in coma; however, recording of timings in this analysis was suboptimal, as was the performance of the model for predicting survival. 17 A further important consideration is that TARN data suggest that only 80% of patients with apparent TBI [significant reductions in consciousness level (GCS score of < 13) at the scene] are subsequently shown to have brain injury as the explanation. Other causes include haemorrhage and alcohol.…”

mentioning

confidence: 99%

The Head Injury Transportation Straight to Neurosurgery (HITS-NS) randomised trial: a feasibility study

Lecky

Russell

Fuller

et al. 2016

Health Technol Assess

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BackgroundReconfiguration of trauma services, with direct transport of traumatic brain injury (TBI) patients to neuroscience centres (NCs), bypassing non-specialist acute hospitals (NSAHs), could potentially improve outcomes. However, delays in stabilisation of airway, breathing and circulation (ABC) and the difficulties in reliably identifying TBI at scene may make this practice deleterious compared with selective secondary transfer from nearest NSAH to NC. National Institute for Health and Care Excellence guidance and systematic reviews suggested equipoise and poor-quality evidence – with regard to ‘early neurosurgery’ in this cohort – which we sought to address.MethodsPilot cluster randomised controlled trial of bypass to NC conducted in two ambulance services with the ambulance station (n = 74) as unit of cluster [Lancashire/Cumbria in the North West Ambulance Service (NWAS) and the North East Ambulance Service (NEAS)]. Adult patients with signs of isolated TBI [Glasgow Coma Scale (GCS) score of < 13 in NWAS, GCS score of < 14 in NEAS] and stable ABC, injured nearest to a NSAH were transported either to that hospital (control clusters) or bypassed to the nearest NC (intervention clusters). Primary outcomes: recruitment rate, protocol compliance, selection bias as a result of non-compliance, accuracy of paramedic TBI identification (overtriage of study inclusion criteria) and pathway acceptability to patients, families and staff. ‘Open-label’ secondary outcomes: 30-day mortality, 6-month Extended Glasgow Outcome Scale (GOSE) and European Quality of Life-5 Dimensions.ResultsOverall, 56 clusters recruited 293 (169 intervention, 124 control) patients in 12 months, demonstrating cluster randomised pre-hospital trials as viable for heath service evaluations. Overall compliance was 62%, but 90% was achieved in the control arm and when face-to-face paramedic training was possible. Non-compliance appeared to be driven by proximity of the nearest hospital and perceptions of injury severity and so occurred more frequently in the intervention arm, in which the perceived time to the NC was greater and severity of injury was lower. Fewer than 25% of recruited patients had TBI on computed tomography scan (n = 70), with 7% (n = 20) requiring neurosurgery (craniotomy, craniectomy or intracranial pressure monitoring) but a further 18 requiring admission to an intensive care unit. An intention-to-treat analysis revealed the two trial arms to be equivalent in terms of age, GCS and severity of injury. No significant 30-day mortality differences were found (8.8% vs. 9.1/%;p > 0.05) in the 273 (159/113) patients with data available. There were no apparent differences in staff and patient preferences for either pathway, with satisfaction high with both. Very low responses to invitations to consent for follow-up in the large number of mild head injury-enrolled patients meant that only 20% of patients had 6-month outcomes. The trial-based economic evaluation could not focus on early neurosurgery because of these low numbers but instead investigated the comparative cost-effectiveness of bypass compared with selective secondary transfer for eligible patients at the scene of injury.ConclusionsCurrent NHS England practice of bypassing patients with suspected TBI to neuroscience centres gives overtriage ratios of 13 : 1 for neurosurgery and 4 : 1 for TBI. This important finding makes studying the impact of bypass to facilitate early neurosurgery not plausible using this study design. Future research should explore an efficient comparative effectiveness design for evaluating ‘early neurosurgery through bypass’ and address the challenge of reliable TBI diagnosis at the scene of injury.Trial registrationCurrent Controlled Trials ISRCTN68087745.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 20, No. 1. See the NIHR Journals Library website for further project information.

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“…If we assert that hypoxia and hypoventilation is more likely to occur in a non-intubated patient, then to abstain from ETI to reduce scene to door time has the potential to harm the patient. The findings of a recent study also indicate that delayed treatment of critically injured patients until arrival in the trauma centre worsens outcome [40]. The potential effect of delayed treatment, in our case ETI, was regarded as important in the consequence analysis of our top event and was one of the reasons why we assigned a high probability of possible sequela and delayed hospital stay following the top event.…”

Section: Discussionmentioning

confidence: 70%

Risk assessment of pre-hospital trauma airway management by anaesthesiologists using the predictive Bayesian approach

Sollid

Lossius

Nakstad

et al. 2010

Scand J Trauma Resusc Emerg Med

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IntroductionEndotracheal intubation (ETI) has been considered an essential part of pre-hospital advanced life support. Pre-hospital ETI, however, is a complex intervention also for airway specialist like anaesthesiologists working as pre-hospital emergency physicians. We therefore wanted to investigate the quality of pre-hospital airway management by anaesthesiologists in severely traumatised patients and identify possible areas for improvement.MethodWe performed a risk assessment according to the predictive Bayesian approach, in a typical anaesthesiologist-manned Norwegian helicopter emergency medical service (HEMS). The main focus of the risk assessment was the event where a patient arrives in the emergency department without ETI despite a pre-hospital indication for it.ResultsIn the risk assessment, we assigned a high probability (29%) for the event assessed, that a patient arrives without ETI despite a pre-hospital indication. However, several uncertainty factors in the risk assessment were identified related to data quality, indications for use of ETI, patient outcome and need for special training of ETI providers.ConclusionOur risk assessment indicated a high probability for trauma patients with an indication for pre-hospital ETI not receiving it in the studied HEMS. The uncertainty factors identified in the assessment should be further investigated to better understand the problem assessed and consequences for the patients. Better quality of pre-hospital airway management data could contribute to a reduction of these uncertainties.

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The importance of pre-trauma centre treatment of life-threatening events on the mortality of patients transferred with severe trauma

Cited by 43 publications

References 33 publications

A comparison of major trauma patients transported to trauma centres vs. non-trauma centres in metropolitan Perth

A comparison of major trauma patients transported to trauma centres vs. non-trauma centres in metropolitan Perth

The Head Injury Transportation Straight to Neurosurgery (HITS-NS) randomised trial: a feasibility study

Risk assessment of pre-hospital trauma airway management by anaesthesiologists using the predictive Bayesian approach

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