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Citation
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Brown JB, Rosengart MR, Forsythe RM, Reynolds BR, Gestring ML, Hallinan WM, Peitzman AB, Billiar TR, Sperry JL. J. Trauma Acute Care Surg. 2016; 81(1): 93-100. |
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Affiliation
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1 Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213 2 Division of Acute Care Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York 14642. |
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Abstract
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BACKGROUND: Trauma is time-sensitive and minimizing prehospital (PH) time is appealing. However, most studies have not linked increasing PH time with worse outcomes, as raw PH times are highly variable. It is unclear whether specific PH time patterns affect outcomes. Our objective was to evaluate the association of PH time interval distribution with mortality.
METHODS: Patients transported by EMS in the Pennsylvania trauma registry 2000-2013 with total prehospital time (TPT)≥20min were included. TPT was divided into three PH time intervals: response, scene, and transport time. The number of minutes in each PH time interval was divided by TPT to determine the relative proportion each interval contributed to TPT. A prolonged interval was defined as any one PH interval contributing≥50% of TPT. Patients were classified by prolonged PH interval or no prolonged PH interval (all intervals<50% of TPT). Patients were matched for TPT and conditional logistic regression determined the association of mortality with PH time pattern, controlling for confounders. PH interventions were explored as potential mediators, and prehospital triage criteria used identify patients with time-sensitive injuries.
RESULTS: There were 164,471 patients included. Patients with prolonged scene time had increased odds of mortality (OR 1.21; 95%CI 1.02-1.44, p=0.03). Prolonged response, transport, and no prolonged interval were not associated with mortality. When adjusting for mediators including extrication and PH intubation, prolonged scene time was no longer associated with mortality (OR 1.06; 0.90-1.25, p=0.50). Together these factors mediated 61% of the effect between prolonged scene time and mortality. Mortality remained associated with prolonged scene time in patients with hypotension, penetrating injury, and flail chest.
CONCLUSIONS: Prolonged scene time is associated with increased mortality. PH interventions partially mediate this association. Further study should evaluate whether these interventions drive increased mortality because they prolong scene time or by another mechanism, as reducing scene time may be a target for intervention. LEVEL OF EVIDENCE: IV, prognostic study.
Language: en |