Major trauma: What is important for the best outcome and survival?

TP Valentino 
 Emergency Department, Polyclinic Ospedali Riuniti University Hospital, Foggia, Apulia, Italy

Correspondence Address:
T P Valentino
Emergency Department, Polyclinic Ospedali Riuniti Hospital, Foggia, Apulia
Italy

Full Text

Major trauma is a condition that needs immediate and efficient multidisciplinary management. Even if the afflicted patient is treated by the best trauma team and in the best trauma center, the mortality is often high because of multiple life-threatening injuries that have already occurred. In the present research study,[1] the authors have addressed the question whether the duration of prehospital time influences the survival of major trauma patients referred to their trauma center situated in a tertiary care hospital in the megacity of Mumbai. Their research question has been formulated keeping in mind that no state-of-the-art prehospital care services are available in their city or adjoining areas from where major trauma patients get referred to their center.

A noteworthy feature of this study [1] is that it was conducted over a long period of 12 months and a large number of trauma patients (1181) were enrolled for analysis. Of these, only 352 (29.8%) had been admitted to their center directly from the accident site, and this group had a significantly lower mortality in spite of having more patients with severe injury. Surprisingly, mortality was significantly higher (odds ratio = 1.869, 95% confidence interval = 1.233–2.561, P = 0.005) in the group of 829 (70.2%) patients who had been transferred to their center after stabilization at another primary facility hospital which was not having any state-of-the-art facilities for managing trauma patients and that too despite this group having fewer patients with severe injury. In the present study,[1] the authors have defined the time duration between trauma and arrival to their center as: (i) “Prehospital time” (for the directly arriving patients) and (ii) “time to tertiary care” (for those transferred from primary facility hospitals). The authors after analysis have found that mortality was not associated with “prehospital time” nor with “time to tertiary care” but with age, mechanism and mode of injury, shock, Glasgow Coma Scale <9, Injury Severity Score ≥16, and need for intubation and ventilatory support on arrival.[1] Furthermore, the group of transferred patients had a significantly higher mortality despite having fewer patients with severe injury which indicated that these transferred patients had not received the required care at primary facility hospitals. To substantiate their conjecture, they have pointed out that 294 (35%) transferred patients needed airway intervention and 108 (13%) needed chest tube insertion on arrival to their trauma unit. Keeping in mind that state-of-the-art prehospital care services are not available in their city and adjoining areas; these lifesaving treatments should have at least been initiated at the primary facility hospitals.

The present study [1] highlights an important learning point that the survival of major trauma patients is to their receiving timely and appropriate state-of-the-art medical care and not necessarily related to injury-arrival time lag. The present study [1] should inspire the health authorities to ensure that state-of-the-art prehospital care services are now made available to major trauma patients at the site of the accident. Furthermore, authorities should ensure that primary facility hospitals get upgraded on a priority basis so that they have functioning resources for resuscitation and doctors and paramedical staff that are well trained to treat major trauma patients.

The concern of time in the treatment of major trauma patients is obvious, but, in recent times, it is being increasingly recognized that the famous “golden hour” is not really a medical dogma, especially for patients who are hemodynamically stable.[2] Hsiao et al. (Taiwan)[3] conducted a prospective observational study (January–December, 2010) in a much smaller sample size (231 major trauma patients, of which 75 were transfer patients) and found no difference in survival between the trauma patients directly transported to their hospital and those transferred for further management, after stabilization at another hospital. In Taiwan, the prehospital care services provide only basic and noninvasive care, namely, oxygen support, immobilization, and basic life support as needed, and only a small percentage of patients receive advanced airway management, fluid resuscitation, or medications.[3] Davies and Chesters [4] have reviewed the state-of-the-art prehospital care services available to major trauma patients in the UK (including air ambulances) and have highlighted that the skills of the trauma team or the paramedic personnel, at the site of the accident, are the most important factor that determines the outcome of major trauma patients. They have also stressed that the trauma team should have access to local or national guidelines to take an informed decision whether or not to directly transfer the patient to the major trauma center (bypassing a nearer primary facility hospital).[4] The general principles that the trauma team follow are (i) to provide no worse care en route than what has been provided at the departure destination and (ii) to transport patients to a destination capable of delivering whichever intervention the patient is deemed to require.[4]

In my country, Italy, the National Emergency Prehospital System, called “118,” provides the first response to the urgent-emergency medical calls, by sending either a trained paramedic or a trained paramedic plus an emergency physician in an intensive care ambulance to the place of the accident and treating the patient according with laid down protocols based on the international standards. As in the UK, depending on the condition and assessment, the trauma patient is transported to a low-intensity care hospital, a trauma center, or to a high-intensity care or Polyclinic University Hospital, according with the assigned code (from life threatening to nonurgent cases: red, yellow, green, and white codes). These prehospital care services were started in Northern Italy around the year 1980 and are in place all over the country since 2000. In particular, in the University Hospital Polyclinic in Foggia, Southern Italy, where I work, the major trauma patients will be treated, starting spring 2017, by a new Team, called “GrInTA,” comprising a well-trained senior emergency physician and two experienced nurses, in a dedicated “shock room” which will cater exclusively to patients having a prehospital Injury Severity Score of more than 15. This team will, in addition, be responsible for the entire duration of treatment of the patient during the hospital stay.

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