Level of prehospital care and risk of mortality in patients with and without severe blunt head injury
Introduction
There is ongoing controversy regarding the benefits of advanced life support (ALS) versus basic life support (BLS) in the prehospital care of severely injured trauma patients. A systematic review of prehospital ALS versus BLS failed to show a benefit for onsite ALS and concluded that ‘scoop and run’ was the optimal strategy for trauma patients [12]. However, the sub-group of patients with severe head trauma has been suggested as a group that is particularly likely to benefit from on-scene stabilisation, as early correction of hypoxia and hypotension is critical for survival [6].
The objective of this study was to determine the association between mortality and the level of prehospital care in a population of severely injured blunt trauma patients with or without severe head injury. The study was approved by the Western Sydney Area Health Human Research Ethics Committee.
Section snippets
Patients and methods
We included patients who sustained severe blunt trauma with an injury severity score (ISS) >15 [5], with or without head injury, admitted to Westmead Hospital, western Sydney, Australia between July 1986 and December 2000. These patients were identified from the hospital trauma registry. Westmead Hospital is a tertiary referral hospital providing trauma services equivalent to an American College of Surgeons Level 1 trauma centre.
The Sydney prehospital trauma system is a tiered system involving
Statistical analysis
Analysis of variance (ANOVA) was used to compare the mean ISS between the various levels of prehospital care. Factors associated with mortality were examined by using logistic regression. The predictor variables included in the initial model were: level of prehospital care, time from injury to arrival in hospital, type of injury, mechanism of injury, age, sex, ISS, GCS and systolic blood pressure. The level of prehospital care was categorised into three groups: BLS (Levels 3 and 4 ambulance),
Population
Out of 2010 patients with severe blunt injury, most were males (76%). The median age was 30 years (interquartile range 21–49 years). The most common cause was road traffic accident (1355 (67%)), falls (271 (13%)) and assault (104 (5%)). There were 713 (36%) patients with no head injury, 1047 (52%) with isolated head injury and 250 (12%) with head injury with abdominal/chest injuries.
Patients received various levels of prehospital care: non-EMS transport (5%), Level 3 ambulance (23%), Level 4
Main findings
The multivariate analysis suggests that there was no evidence that patients with severe head injuries were more likely to benefit from advanced prehospital interventions, than patients with severe injuries but who did not have severe head injury. The level of prehospital care was associated with the risk of mortality after adjusting for age, physiological derangement, severity of injury, type of injury and prehospital time. There was an increased risk of mortality in those patients receiving
Acknowledgements
We thank the Trauma Registry of Westmead Hospital for their assistance in providing data for this study and the reviewer for his/her helpful comments. All authors contributed to the design of the study. AG supervised extraction of the data, and AL analysed the results. All authors contributed to the interpretation and drafting of the paper and will act as guarantors for the paper.
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