Prehospital care of severely injured trauma patients : studies on management, assessment, and outcome
Abstract: Trauma is a public health issue. According to statistics from the Swedish National Board of Health and Welfare, circumstances related to injury are the most common cause of death in the age group 15– 44 years for both genders. Prehospital care is the first link in the chain of life support. Trauma systems and regionalized trauma care have been shown to improve outcome in severely injured trauma patients, but less is known about whether gender influences the prehospital trauma care. Management in the prehospital phase of traumatic brain injury (TBI) is focused on limiting the effects of secondary insults, such as hypoxia and hypotension, and advanced prehospital airway management might potentially improve the outcome. The overall aim of this thesis was to evaluate the prehospital assessment, management and outcome in severely injured trauma patients within a regional trauma system. Paper I. A retrospective observational study based on local trauma registries and hospital and ambulance records in Stockholm County. 693 primarily admitted trauma patients were included for the years 2006 and 2008. For the years 2006, 2008, and 2013, there were 114 secondarily transported trauma patients. The number of primary patient transports to the trauma center increased during these years by 20.2%, (p <0.001). Primarily transported patients had a significantly higher Injury Severity Score (ISS) in 2008 than in 2006, and the number of patients transported secondarily to the trauma center in 2006 was higher compared to 2008 and 2013 (p<0.001). Paper II. A retrospective observational study based on local trauma registries and hospital and ambulance records in Stockholm County. A total of 383 trauma patients (279 males and 104 females) >15 years of age with an ISS of >15 transported to emergency care hospitals in the Stockholm area were included. Male patients had a 2.75 higher odds ratio (95% CI, 1.2–6.2) for receiving the highest prehospital priority compared to females on controlling for injury mechanism and vital signs on scene. Paper III. A retrospective observational study based on 2750 prehospital medical records of suspected TBI patients. 25.2 % of the patients were assessed according to all four core-elements in the guidelines and 78.6% of the patients underwent at least one intervention by the PECNs. Male patients were to a higher extent assessed according to guidelines and were given higher transport priority while females were more often assessed for vital parameters and received significantly more analgesics. Paper IV. A retrospective observational study based on 459 TBI patients ≥15 years admitted to the neurosurgical unit in Stockholm between the years 2008 and 2014. High energy trauma, prehospital hypotension, pupil unresponsiveness, mode of transportation and distance to the hospital were independently related to an increased rate of pre-hospital intubation (model explained p<0.001, pseudo-R2 0.482). Pre-hospital intubation did not correlate to outcome of the unconscious patients (p=0.296), or add independent information to the model of significant parameters in multivariate analysis vs. GOS (p=0.154). Transports >10 km had an intubation frequency of about 50%. With the introduction of a prehospital trauma transport directive, an increase in patients transported to the regional trauma center and a decrease in secondary transfers were detected, but a considerable number of severely injured patients were still transported to local hospitals. The results also indicated that prehospital prioritization among the severely injured and the assessment and management of parameters related to head trauma differed between genders. Pre-hospital intubation could not be related to outcome. Large multicenter prospective studies with structured protocols are of importance in order to determine potentially beneficial effects of prehospital advanced airway management.
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