From the Division of Trauma and Critical Care, Department of Surgery (S.T., C.A., S.N., J.D.), Tulane University School of Medicine, New Orleans, Louisiana; Department of Surgery, Division of Trauma and Acute Care Surgery (Z.M., A.J.G.), Temple University Hospital, Philadelphia, Pennsylvania; Department of Surgery (G.C., M.M.), Mount Sinai Hospital; Department of Trauma and Burn (L.C.T., P.M.), Cook County Health, Chicago, Illinois; Division of Traumatology, Surgical Critical Care & Emergency Surgery, Department of Surgery (S.R., J.J.K.), University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Department of Surgery (S.B., M.R.), Loma Linda University Medical Center, Loma Linda; Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Department of Surgery (L.E.C., D.V.S.), University of California Davis Medical Center, Sacramento, California; Department of Surgery (A.G.-S., A.B.), Cooper University Hospital, Camden, New Jersey; Department of Surgery, Division of Trauma and Acute Care Surgery (M.C.S., A.L.), Grant Medical Center, Columbus, Ohio; Trauma Specialist Program (E.B., D.T.), Our Lady of the Lake Regional Medical Center, Baton Rouge, Louisiana; Department of Surgery (M.R.N., J.B.), Allegheny General Hospital, Pittsburgh, Pennsylvania; Department of Surgery (M.C.N.), Cape Fear Valley Hospital, Fayetteville, North Carolina; Trauma Administration (L.E.J., J.W.), Ascension St. Vincent Hospital, Indianapolis, Indiana; Division of Acute Care Surgery and Trauma, Department of Surgery (M.V., K.D.), University of Rochester Medical Center, Rochester, New York; Division of Acute Care Surgery, Department of Surgery (T.Z.H., E.H.), Sydney & Lois Eskenazi Hospital (Smith Level I Shock Trauma), Indianapolis, Indiana; Department of Surgery (M.J.L.), Research Medical Center, Kansas City, Missouri; Division of Trauma/Critical Care (J.D.B., D.R.M.), Broward Health Medical Center, Ft Lauderdale, Florida; Division of Trauma, Burn, Surgical Critical Care and Emergency General Surgery, Department of Surgery (R.A., B.U.O.), Brigham & Women's Hospital, Boston, Massachusetts; Division of Acute Care Surgery, Department of Surgery (E.R.H., E.W.E.), The Johns Hopkins University School of Medicine; Division of Acute Care Surgery, Department of Surgery (R.F., S.L.R.), Johns Hopkins Bayview Medical Center, Baltimore, Maryland; Division of Acute Care Surgery, Department of Surgery (L.W., A.C.B.), University of Kentucky, Lexington, Kentucky; Trauma Services (J.M.H., K.L.L.), Ascension Via Christi Hospital St Francis, Wichita, Kansas; Trauma Service (S.C.N., J.M.), University of Texas Health at Tyler, Tyler, Texas; Envision Surgical Services (M.A.G., M.M.C.), Medical City Plano, Plano, Texas; and Division of Trauma and Acute Care Surgery, Department of Surgery (N.B., A.T.), Tufts Medical Center, Boston, Massachusetts.
J Trauma Acute Care Surg. 2021 Jul 1;91(1):130-140. doi: 10.1097/TA.0000000000003151.
Prehospital procedures (PHP) by emergency medical services (EMS) are performed regularly in penetrating trauma patients despite previous studies demonstrating no benefit. We sought to examine the influence of PHPs on outcomes in penetrating trauma patients in urban locations where transport to trauma center is not prolonged. We hypothesized that patients without PHPs would have better outcomes than those undergoing PHP.
This was an Eastern Association for the Surgery of Trauma-sponsored, multicenter, prospective, observational trial of adults (18+ years) with penetrating trauma to the torso and/or proximal extremity presenting at 25 urban trauma centers. The impact of PHPs and transport mechanism on in-hospital mortality were examined.
Of 2,284 patients included, 1,386 (60.7%) underwent PHP. The patients were primarily Black (n = 1,527, 66.9%) males (n = 1,986, 87.5%) injured by gunshot wound (n = 1,510, 66.0%) with 34.1% (n = 726) having New Injury Severity Score of ≥16. A total of 1,427 patients (62.5%) were transported by Advanced Life Support EMS, 17.2% (n = 392) by private vehicle, 13.7% (n = 312) by police, and 6.7% (n = 153) by Basic Life Support EMS. Of the PHP patients, 69.1% received PHP on scene, 59.9% received PHP in route, and 29.0% received PHP both on scene and in route. Initial scene vitals differed between groups, but initial emergency department vitals did not. Receipt of ≥1 PHP increased mortality odds (odds ratio [OR], 1.36; 95% confidence interval [CI], 1.01-1.83; p = 0.04). Logistic regression showed increased mortality with each PHP, whether on scene or during transport. Subset analysis of specific PHP revealed that intubation (OR, 10.76; 95% CI, 4.02-28.78; p < 0.001), C-spine immobilization (OR, 5.80; 95% CI, 1.85-18.26; p < 0.01), and pleural decompression (OR, 3.70; 95% CI, 1.33-10.28; p = 0.01) had the highest odds of mortality after adjusting for multiple variables.
Prehospital procedures in penetrating trauma patients impart no survival advantage and may be harmful in urban settings, even when performed during transport. Therefore, PHP should be forgone in lieu of immediate transport to improve patient outcomes.
Prognostic, level III.
尽管先前的研究表明没有益处，但在穿透性创伤患者中，急救医疗服务（EMS）仍经常进行院前处理（PHP）。我们试图研究在没有延长创伤中心转运的情况下，城市地区的穿透性创伤患者中 PHP 对结局的影响。我们假设没有接受 PHP 的患者比接受 PHP 的患者有更好的结局。
这是一项由东部创伤外科学会赞助的多中心前瞻性观察性试验，研究对象为 25 个城市创伤中心就诊的躯干和/或近端肢体穿透性创伤的成年患者（18 岁以上）。检查了 PHP 和转运机制对院内死亡率的影响。
在纳入的 2284 名患者中，有 1386 名（60.7%）接受了 PHP。患者主要为黑人（n=1527，66.9%）男性（n=1986，87.5%），受伤原因是枪伤（n=1510，66.0%），新损伤严重程度评分≥16 的有 34.1%（n=726）。共有 1427 名患者（62.5%）由高级生命支持的 EMS 转运，17.2%（n=392）由私人车辆转运，13.7%（n=312）由警察转运，6.7%（n=153）由基本生命支持的 EMS 转运。在 PHP 患者中，69.1%在现场接受 PHP，59.9%在转运途中接受 PHP，29.0%在现场和转运途中均接受 PHP。虽然各组的初始现场生命体征不同，但初始急诊科生命体征并无差异。接受≥1 次 PHP 会增加死亡风险（比值比 [OR]，1.36；95%置信区间 [CI]，1.01-1.83；p=0.04）。逻辑回归显示，每次 PHP 都会增加死亡率，无论是在现场还是在转运过程中。特定 PHP 的亚组分析表明，插管（OR，10.76；95%CI，4.02-28.78；p<0.001）、颈椎固定（OR，5.80；95%CI，1.85-18.26；p<0.01）和胸腔减压（OR，3.70；95%CI，1.33-10.28；p=0.01）在调整多个变量后，死亡风险最高。
穿透性创伤患者的院前处理并不能带来生存优势，在城市环境中甚至可能有害，因此，为了改善患者结局，应避免进行 PHP，而直接转运。
预后，III 级。
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