Clinical paperThe importance of pre-trauma centre treatment of life-threatening events on the mortality of patients transferred with severe trauma☆
Introduction
The benefit of a well organised trauma system with specialized trauma centres is fully acknowledged,1, 2, 3, 4 but doubts still remain concerning what could be considered as the optimal pre-hospital trauma care. Several authors have studied the effect of pre-hospital advanced life support (ALS) in comparison with pre-hospital basic life support (BLS) approaches on trauma mortality and other outcomes.5, 6, 7, 8, 9 However, there are no large or controlled studies on that subject and the controversy is far from being resolved. Even studies that address the effect of specialized trauma teams and helicopters on trauma patients’ outcome showed conflicting results.10, 11, 12
Moreover, studies that compare pre-hospital ALS and BLS approaches often have different definitions for ALS and BLS, study only partial ALS attitudes or techniques – instead of the whole concept – and above all do not study and compare ALS and BLS in a population of trauma patients with life-threatening events needing treatment.13
Traumatic life-threatening events were defined in the medical literature as events that endanger life and that should be corrected during the primary survey of treatment of trauma patients. By definition life-threatening events should be treated urgently. The methodology to identify and treat life-threatening events is also known as ABCD methodology and is taught in different trauma courses around the world namely European Trauma Course14 and ATLS.15
Our aim was to estimate the effect on mortality of treating the life-threatening events prior to arrival at the trauma centre (either in the pre-hospital scene or in the first hospital) in comparison with treatment of life-threatening events only at the trauma centre. We considered two hypotheses: (1) The early treatment of life-threatening events in trauma patients decreases the risk of death. (2) Time from accident to definitive treatment at trauma centre is an independent factor contributing to mortality.
Section snippets
Setting
We analysed data from a trauma registry that includes all patients admitted to a neurosurgical centre in the North of Portugal (Hospital de Santo António—HGSA). HGSA is a 700 bedded University acute central hospital with neurosurgical cover and intensive care facilities. No other hospital within this trauma system has emergency neurosurgical coverage. HGSA serves Northeast Portugal (a mixed urban/rural area) with a catchment area of approximately 2,500,000 inhabitants. The Emergency Medical
Population characteristics
Between 1st January 2001 and 31st December 2006, 1050 trauma patients were admitted to the emergency room of HGSA and enrolled in the prospective registry. We included in this study 761 trauma patients transferred from another hospital. Twenty-five patients who had no life-threatening events identified were excluded from subsequent analyses. We also excluded 8 patients with missing data related to the presence or the treatment of life-threatening events.
Patients included had a mean age of 44
Discussion
Our main finding was that the treatment of life-threatening events in the pre-hospital scene (compared to the treatment of life-threatening events only at first hospital or the trauma centre) decreased the mortality of severe trauma patients transferred to a trauma centre. A reduction of almost 50% in crude mortality was found for those patients having their life-threatening events treated in the pre-hospital phase. This observed benefit was maintained after adjustment for confounders in
Conflict of interest statement
All authors’ deny any conflicts of interest.
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A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2009.12.014.