Prehospital advanced trauma life support for penetrating cardiac wounds

doi:10.1016/S0196-0644(05)81799-8

Annals of Emergency Medicine

Volume 19, Issue 2, February 1990, Pages 145-150

https://doi.org/10.1016/S0196-0644(05)81799-8 Get rights and content

Prehospital advanced trauma life support (ATLS) is controversial because the risks, benefits, and time required to accomplish it remain unknown. We studied 70 consecutive patients with penetrating cardiac injuries to determine the relationships among prehospital procedures, time consumed in the field, and ultimate patient outcome. Thirty-one patients sustained gunshot wounds, and 39 had stab wounds. The mean Revised Trauma Score was 2.8 ± 0.5. Paramedics spent an average of 10.7 ± 0.5 minutes at the scene. Seventy-one percent of the patients underwent endotracheal in tubation; 93% had at least one IV line inserted; and 57% had two IV lines inserted. Twenty-one (30%) survived. There was no correlation between on-scene time and either the total number of procedures performed (r = .17, P = .17) or IV lines established (r = .06, P = .06). On-scene times did not differ regardless of whether endotracheal intubation or pneumatic antishock garment applications occurred. We conclude that well-trained urban paramedics can perform multiple life-support procedures with very short on-scene times and a high rate of patient survival and that prehospital trauma systems require a minimum obligatory on-scene time to locate patients and prepare them for transport.

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Cited by (64)

The Impact of Prehospital Transport Mode on Mortality of Penetrating Trauma Patients
2020, Air Medical Journal
The optimal mode of transport of trauma patients from the scene to the hospital remains unknown. We aimed to study the impact of different prehospital modes of transport of penetrating trauma patients on hospital mortality.
Using the Trauma Quality Improvement Program 2010 to 2016 database, we identified all adults with a penetrating injury. Univariate then multivariable logistic regression analyses were performed to study the correlation between the mode of transport and in-hospital mortality, adjusting for several covariates.
A total of 92,427 subjects were included. The overall mean transport time for patients transported by a ground ambulance, helicopter, fixed wing ambulance, and police/private vehicle were 32.2, 61.2, 68.9, and 28.2 minutes, respectively. Multivariable analyses revealed that compared with ground ambulance, helicopter transport was associated with a 34% decrease in the odds of mortality (odds ratio = 0.66, P < .0001), whereas police transport and private vehicle transport were associated with a 52% decrease in the odds of mortality (odds ratio = 0.48, P < .0001).
Helicopter, police, and private vehicle transports are associated with a decreased odds of mortality compared with ground ambulance. Further research should examine the variation in levels of care within different modes of prehospital transport.
Every minute counts: The impact of pre-hospital response time and scene time on mortality of penetrating trauma patients
2020, American Journal of Surgery
Citation Excerpt :
However, such findings suggest that policy changes that improve EMS reach to injured patients, as well as a “scoop and run” strategy could significantly impact the ability to rescue penetrating injury trauma patients. Multiple previous studies showed results from a single institution, included undifferentiated trauma patients, were limited due to residual confounding or low number of patients, did not find a significant correlation between prehospital time and mortality after accounting for the severity of injuries, or were from a single geographical region.7–23 In a study of one regional trauma center, Lerner et al. found no significant correlation between total prehospital transport time and mortality.24
Prompt surgical control of hemorrhage is crucial in penetrating trauma patients. We aimed to study the impact of prehospital response time (PreRespT) and scene time (SceneT) on hospital mortality.
Using the Trauma Quality Improvement Program (TQIP) 2010–2016 database, we identified all adults with penetrating injury. We defined PreRespT as time from EMS dispatch to scene arrival, and SceneT as time spent on scene. Univariate then multivariable logistic regression analyses were performed to study the independent correlation between PreRespT and SceneT on hospital mortality, adjusting for several covariates.
Out of a total of 1,403,470 patients, 43,467 patients were included. Multivariable analyses suggested that: 1) every minute increase in PreRespT independently correlates with a 2% increase in mortality (OR 1.02, p < 0.0001), and 2) every minute increase in SceneT independently correlates with a 1% increase in mortality (OR 1.01, p = 0.001).
In the penetrating injury trauma patient, PreRespT and SceneT independently correlate with hospital mortality. This data suggests that a faster PreRespT and a “scoop and run” strategy may be more beneficial in this population.
Prehospital times and outcomes of patients who had hypotension at the scene after trauma: A nationwide multicentre retrospective study
2020, Injury
Citation Excerpt :
Furthermore, the relationship between prehospital times and patient outcomes following injury remains controversial. Some studies have revealed the relationship between earlier transport to the hospital and increased survival [2–9], whereas other studies reported no such association [9–18] or even decreased survival among patients who were transported early [17,19]. These conflicting results may be explained by limitations of the previous studies, including various time intervals, demographic differences of the patients, insufficient adjustment for confounding variables, and small sample sizes.
We aimed to investigate the association between prehospital times and outcomes of patients who had hypotension at the scene after trauma incidents.
We retrospectively analysed records from a nationwide database (2004–2017) of adults (aged ≥15 years) who were hypotensive (systolic blood pressure <90 mmHg) at the scene after trauma. The endpoint was in-hospital mortality. We used multivariable logistic regression analysis to adjust for confounding factors and to estimate the odds ratio (OR) of prehospital times for in-hospital mortality. Stratified analyses were performed based on patient age and type and severity of the trauma.
Among 5,499 patients included, 906 (16.5%) died in the hospital. The median Injury Severity Score (ISS) was 17 (interquartile range, 9–29). There was a significant trend towards patients having higher in-hospital mortality and ISS when their prehospital times were shorter (P < 0.001). However, the association between prehospital times and in-hospital mortality was not significant after adjusting for confounding factors, with an adjusted odds ratio of 1.00 (95% confidence interval: 0.98–1.01) per 10 min increments in prehospital time. The association remained insignificant when patients were stratified according to age and type and severity of the trauma.
Our analysis revealed that prehospital time was not significantly associated with in-hospital mortality among patients who had hypotension at the scene after trauma in the current emergency medical service system in Japan. Further studies are needed to validate our findings.
The influence of prehospital time on trauma patients outcome: A systematic review
2015, Injury
Time is considered an essential determinant in the initial care of trauma patients. Salient tenet of trauma care is the ‘golden hour’, the immediate time after injury when resuscitation and stabilization are perceived to be most beneficial. Several prehospital strategies exist regarding time and transport of trauma patients. Literature shows little empirical knowledge on the exact influence of prehospital times on trauma patient outcome. The objective of this study was to systematically review the correlation between prehospital time intervals and the outcome of trauma patients.
A systematic review was performed in MEDLINE, Embase and the Cochrane Library from inception to May 19th, 2014. Studies reporting on prehospital time intervals for emergency medical services (EMS), outcome parameters and potential confounders for trauma patients were included. Two reviewers collected data and assessed the outcomes and risk of bias using the STROBE-tool. The primary outcome was the influence on mortality.
Twenty level III-evidence articles were considered eligible for this systematic review. Results demonstrate a decrease in odds of mortality for the undifferentiated trauma patient when response-time or transfer-time are shorter. On the contrary increased on-scene time and total prehospital time are associated with increased odds of survival for this population. Nevertheless rapid transport does seem beneficial for patients suffering penetrating trauma, in particular hypotensive penetratingly injured patients and patients with a traumatic brain injury.
Swift transport is beneficial for patients suffering neurotrauma and the haemodynamically unstable penetratingly injured patient. For haemodynamically stable undifferentiated trauma patients, increased on-scene-time and total prehospital time does not increase odds of mortality. For undifferentiated trauma patients, focus should be on the type of care delivered prehospital and not on rapid transport.
Emergency medical services out-of-hospital scene and transport times and their association with mortality in trauma patients presenting to an urban level i trauma center
2013, Annals of Emergency Medicine
Citation Excerpt :
This study is the first to our knowledge to analyze data spanning more than a decade, including close to 20,000 patients, with specific aims to evaluate the association between out-of-hospital times and mortality in the urban setting. Our results are consistent with those of previous studies supporting the argument that minimizing out-of-hospital times is considered beneficial for survival.1-2,18,19 Two studies by Sampalis et al20,21 found that increased out-of-hospital times were associated with increased mortality among seriously injured trauma patients.
We determine the association between emergency medical services (EMS) out-of-hospital times and mortality in trauma patients presenting to an urban Level I trauma center.
We conducted a secondary analysis of a prospective cohort registry of trauma patients presenting to a Level I trauma center during a 14-year period (1996 to 2009). Inclusion criteria were patients sustaining traumatic injury who presented to an urban Level I trauma center. Exclusion criteria were extrication, missing or erroneous out-of-hospital times, and intervals exceeding 5 hours. The primary outcome was inhospital mortality. EMS out-of-hospital intervals (scene time and transport time) were evaluated with multivariate logistic regression.
There were 19,167 trauma patients available for analysis, with 865 (4.5%) deaths; 16,170 (84%) injuries were blunt, with 596 (3.7%) deaths, and 2,997 (16%) were penetrating, with 269 (9%) deaths. Mean age and sex for blunt and penetrating trauma were 34.5 years (68% men) and 28.1 years (90% men), respectively. Of those with Injury Severity Score less than or equal to 15, 0.4% died, and 26.1% of those with a score greater than 15 died. We analyzed the relationship of scene time and transport time with mortality among patients with Injury Severity Score greater than 15, controlling for age, sex, Injury Severity Score, and Revised Trauma Score. On multivariate regression of patients with penetrating trauma, we observed that a scene time greater than 20 minutes was associated with higher odds of mortality than scene time less than 10 minutes (odds ratio [OR] 2.90; 95% confidence interval [CI] 1.09 to 7.74). Scene time of 10 to 19 minutes was not significantly associated with mortality (OR 1.19; 95% CI 0.66 to 2.16). Longer transport times were likewise not associated with increased odds of mortality in penetrating trauma cases; OR for transport time greater than or equal to 20 minutes was 0.40 (95% CI 0.14 to 1.19), and OR for transport time 10 to 19 minutes was 0.64 (95% CI 0.35 to 1.15). For patients with blunt trauma, we did not observe any association between scene or transport times and increased odds of mortality.
In this analysis of patients presenting to an urban Level I trauma center during a 14-year period, we observed increased odds of mortality among patients with penetrating trauma if scene time was greater than 20 minutes. We did not observe associations between increased odds of mortality and out-of-hospital times in blunt trauma victims. These findings should be validated in an external data set.
Rural EMS en route IV insertion improves IV insertion success rates and EMS scene time
2011, American Journal of Surgery
Emergency medical service (EMS) personnel are trained to insert intravenous (IV) lines at trauma scenes if the time for insertion does not prolong scene time. However, EMS providers continue to insert IV lines on scene.
A rural EMS provider provided trauma patient EMS IV insertion data for a 1-year period. No IV lines were inserted en route during this period. During the following 1-year period, a prospective trauma patient study protocol was instituted in which all IV insertions were attempted while en route to the emergency room.
Three hundred six trauma patients had IV attempts on scene, and 341 trauma patients had IV insertion attempts en route. The average EMS on-scene time with IV insertions on scene was 19.8 minutes (IV insertion success, 79%) compared with 13.9 minutes (IV insertion success, 93%) on-scene time with IV insertions en route.
EMS IV insertion en route significantly decreases on-scene time and improves IV insertion success rates.

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Original contributionPrehospital advanced trauma life support for penetrating cardiac wounds

Am J Surg

Ann Emerg Med

Ann Emerg Med

The importance of prompt transport in salvage of patients with penetrating heart wounds

J Trauma

Is ALS necessary for prehospital trauma care?

J Trauma

Resuscitative thoracotomy: The effect of field time on outcome

J Trauma

Penetrating thoracic injuries: In-field stabilization vs prompt transport

J Trauma

Prehospital stabilization of critically injured patients: A failed concept

J Trauma

Original contribution
Prehospital advanced trauma life support for penetrating cardiac wounds