An Eastern Association for the Surgery of Trauma multicenter trial examining prehospital procedures in penetrating trauma patients

Sharven Taghavi; Zoe Maher; Amy J Goldberg; Grace Chang; Michelle Mendiola; Christofer Anderson; Scott Ninokawa; Leah C Tatebe; Patrick Maluso; Shariq Raza; Jane J Keating; Sigrid Burruss; Matthew Reeves; Lauren E Coleman; David V Shatz; Anna Goldenberg-Sandau; Apoorva Bhupathi; M Chance Spalding; Aimee LaRiccia; Emily Bird; Matthew R Noorbakhsh; James Babowice; Marsha C Nelson; Lewis E Jacobson; Jamie Williams; Michael Vella; Kate Dellonte; Thomas Z Hayward 3rd; Emma Holler; Mark J Lieser; John D Berne; Dalier R Mederos; Reza Askari; Barbara U Okafor; Elliott R Haut; Eric W Etchill; Raymond Fang; Samantha L Roche; Laura Whittenburg; Andrew C Bernard; James M Haan; Kelly L Lightwine; Scott H Norwood; Jason Murry; Mark A Gamber; Matthew M Carrick; Nikolay Bugaev; Antony Tatar; Juan Duchesne; Danielle Tatum

doi:10.1097/TA.0000000000003151

An Eastern Association for the Surgery of Trauma multicenter trial examining prehospital procedures in penetrating trauma patients

J Trauma Acute Care Surg. 2021 Jul 1;91(1):130-140. doi: 10.1097/TA.0000000000003151.

Authors

Sharven Taghavi¹, Zoe Maher, Amy J Goldberg, Grace Chang, Michelle Mendiola, Christofer Anderson, Scott Ninokawa, Leah C Tatebe, Patrick Maluso, Shariq Raza, Jane J Keating, Sigrid Burruss, Matthew Reeves, Lauren E Coleman, David V Shatz, Anna Goldenberg-Sandau, Apoorva Bhupathi, M Chance Spalding, Aimee LaRiccia, Emily Bird, Matthew R Noorbakhsh, James Babowice, Marsha C Nelson, Lewis E Jacobson, Jamie Williams, Michael Vella, Kate Dellonte, Thomas Z Hayward 3rd, Emma Holler, Mark J Lieser, John D Berne, Dalier R Mederos, Reza Askari, Barbara U Okafor, Elliott R Haut, Eric W Etchill, Raymond Fang, Samantha L Roche, Laura Whittenburg, Andrew C Bernard, James M Haan, Kelly L Lightwine, Scott H Norwood, Jason Murry, Mark A Gamber, Matthew M Carrick, Nikolay Bugaev, Antony Tatar, Juan Duchesne, Danielle Tatum

Affiliation

¹ 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.

Abstract

Background: 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.

Methods: 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.

Results: 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.

Conclusion: 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.

Level of evidence: Prognostic, level III.

Publication types

Multicenter Study
Observational Study
Research Support, Non-U.S. Gov't

MeSH terms

Adult
Emergency Medical Services / methods
Emergency Medical Services / statistics & numerical data*
Female
Hospital Mortality
Humans
Injury Severity Score
Logistic Models
Male
Middle Aged
Prospective Studies
Trauma Centers / statistics & numerical data*
United States / epidemiology
Urban Health Services
Wounds, Gunshot / mortality*
Wounds, Gunshot / therapy
Wounds, Penetrating / mortality*
Wounds, Penetrating / therapy
Young Adult