The establishment of Advanced Life Support (ALS) by emergency medical services (EMS) has led to an increasing number of procedures carried out in the field.1 2–4 1,2,5–7
The prehospital (PH) care of acutely injured patients in the United States continues to evolve. The use of blood products in the PH setting has been shown to be beneficial in trauma patients undergoing air transport, which is not applicable to urban penetrating trauma.8 9 10,11 12
The optimal care for penetrating trauma in the urban setting may actually involve minimal PH intervention.1,2,4,5
The deleterious effects of PHP in urban penetrating trauma are likely multifactorial.3,4 1 13–15
PATIENTS AND METHODS
This was an Eastern Association for the Surgery of Trauma (EAST)–sponsored, multicenter, prospective, observational trial of adults (18+ years) with penetrating trauma to the torso and/or proximal extremity who presented to 1 of the 25 participating urban trauma centers from May 2019 to May 2020. Torso was defined as the area between clavicles and above inguinal ligaments, pubic symphysis, and gluteal folds; proximal extremity was defined as proximal to elbow or knees. Patients were included if they presented with a gunshot or stab wound to the torso and/or proximal extremity. Patients with torso and/or proximal extremity penetrating injury combined with distal extremity penetrating injury or patients with penetrating torso and/or proximal extremity injury combined with a blunt injury were also included. This included patients with traumatic brain injury who also had penetrating injury to the torso and/or proximal extremity. Exclusion criteria included patients with isolated injury above the clavicle (including head or neck [including TBI]), distal extremity injury only (distal to elbows or knees), isolated blunt mechanism of injury, patients transferred from outside institutions, and known age 17 years or younger.
Data collected included patient demographics, type of PH transport (private vehicle, police vehicle, Basic Life Support [BLS crew], ALS crew), PH interventions, injuries and New Injury Severity Score (NISS), initial vital signs, initiation laboratory values, resuscitation requirements, mortality, location of and time to death (if applicable), hospital length of stay, intensive care unit length of stay, duration of mechanical ventilation, and complications as acute respiratory distress syndrome, venous thromboembolic events, acute kidney injury, and cerebrovascular accident. The specific PHP examined included the following: IV access, intraosseous access, fluid administration, bladder catheterization, endotracheal intubation, cervical spine immobilization, pleural decompression, tourniquet placement, pressure dressing application, cricothyrotomy, and pelvic stabilization. This study was conducted following approval from the appropriate institutional review board at each collaborating center.
Statistical Analysis
Patients were dichotomized into two groups based on whether they received PHP or not. Demographics, injury data, PH and emergency department (ED) variables, and in-hospital outcomes were compared between groups. Categorial values were described as frequencies, reported as n (%), and compared using χ2 analysis or Fisher’s exact test, where appropriate. Continuous variables were described as mean (SD) and compared using the Independent Samples t test. Percent survival of patients per number of PHP was examined and plotted. For each plot, χ2 analysis with Yates’ correction was used to determine if any number of PHP given was associated with probability of mortality. Univariate and multivariate logistic regression analyses were used to examine the relationship between patient variables and odds of mortality. The primary outcome of interest was in-hospital mortality. Incidence of in-hospital complications was the secondary outcome of interest. A p value of <0.05 was considered statistically significant. All statistical analyses were conducted using SPSS version 26 (IBM, Armonk, NY).
RESULTS
Patient Demographics
A total of 2,352 patients met inclusion criteria. Subjects with missing or unknown method of transport (n = 68) were excluded, yielding 2,284 patients for inclusion into the analysis (Fig. 1 ). Method of transport from most to least frequent was as follows: EMS ALS (n = 1,427, 62.5%), private vehicle (n = 392, 17.2%), police (n = 312, 13.7%), and EMS BLS (n = 153, 6.7%). Within the overall cohort, 60.7% (n = 1,386) received PHP and 39.3% (n = 898) did not. Demographic characteristics, injury data, and PH vitals are detailed in Table 1 . Those who received PHP had significantly higher mean age and NISS (both p < 0.001), were more likely than the no prehospital procedure (N-PHP) group to be injured in the chest (47.0% vs. 39.6%; p = 0.001) and abdomen (39.7% vs. 33.3%; p = 0.002), and were less likely than the N-PHP group to be injured by gunshot (63.3% vs. 70.5%; p < 0.001). The proportion of patients with NISS of >15 was significantly higher in the PHP cohort (38.6% vs. 27.5%; p < 0.001), but the mean NISS in this subgroup did not differ between the PHP and N-PHP cohorts (32 vs. 33; p = 0.84). Mean initial PH Glasgow Coma Scale (GCS) and systolic blood pressure were both significantly lower in the PHP cohort ([14.3 vs. 13.7; p = 0.02] and [128 mm Hg vs. 121 mm Hg; p = 0.03], respectively), while mean initial heart rate and respiratory rate did not differ between the groups.
Figure 1: Flow chart detailing study inclusion.
TABLE 1 -
Descriptive Details of Patient Demographics, Injury Characteristics, and PH Vitals and Procedures
Demographics
Total
No PHP
PHP
p
Age, y*
32.5 (12.4)
31.2 (11.6)
33.3 (12.9)
<0.001
Male
1,986 (87.5)
803 (89.5)
1,183 (86.1)
0.02
Race
White
446 (19.5)
116 (12.9)
330 (23.8)
<0.001
Black/AA
1,527 (66.9)
637 (71.0)
890 (64.3)
Asian
16 (0.7)
5 (0.6)
11 (0.8)
>1 Race
6 (0.3)
1 (0.1)
5 (0.4)
Unknown
275 (12.1)
136 (15.2)
139 (10.0)
Hispanic
248 (11.2)
97 (11.3)
151 (11.1)
0.12
Injury variables
Gunshot wound
1,510 (66.0)
633 (70.5)
877 (63.3)
<0.001
Knife stab wound
777 (34.0)
266 (29.6)
511 (36.9)
<0.001
Injury location
Chest
1,006 (44.1)
355 (39.6)
651 (47.0)
0.001
Abdomen
849 (37.2)
299 (33.3)
550 (39.7)
0.002
Pelvis
329 (14.4)
160 (17.8)
169 (12.2)
<0.001
Proximal extremity
1,128 (49.4)
489 (54.5)
639 (46.1)
<0.001
TBI
12 (0.5)
4 (0.4)
8 (0.6)
0.67
NISS*
14 (17)
12 (16)
16 (18)
<0.001
NISS >15
726 (34.1)
234 (27.5)
492 (38.6)
<0.001
NISS >15*
32 (19)
33 (18)
32 (19)
0.84
PH variables
Method of transport
ALS transport
1,427 (62.5)
149 (10.4)
1,278 (89.6)
<0.001
BLS transport
153 (6.7)
52 (34.0)
101 (66.0)
Police transport
312 (13.7)
306 (98.1)
6 (1.9)
Private vehicle
392 (17.2)
392
—
Glasgow Coma Scale
13.8 (3.4)
14.3 (2.6)
13.7 (3.5)
0.02
Systolic blood pressure
121.7 (39.1)
128.0 (32.9)
121.0 (39.6)
0.03
Heart rate
93.8 (30.1)
93.3 (33.0)
93.9 (29.8)
0.50
Respiratory rate
18.8 (7.9)
18.4 (8.4)
18.8 (7.8)
0.81
Shock index (HR/SBP)
0.8 (0.4)
0.7 (0.2)
0.8 (0.4)
<0.001
*indicates mean (SD).
All other variables are frequencies presented as n (%).
AA, African American; ALS, Advanced Life Support; BLS, Basic Life Support; HR, heart rate; SBP, systolic blood pressure; TBI, traumatic brain injury.
Prehospital Procedures
Frequency and location of use of individual PHP are detailed in Table 2 . The most commonly performed procedure was IV access (n = 1,211 of 1,386 patients, 87.4%) followed by fluid resuscitation (n = 666 of 1,386 patients, 48.1%) and application of pressure dressing (n = 409 of 1,386 patients, 29.5%). Endotracheal intubation was performed in 7.1% (n = 99) of PHP patients. The vast majority of those who received PH fluid resuscitation (n = 656 of 666 patients, 98.8%) received crystalloids. Only two patients received pelvic stabilization, and no patient received bladder catheterization or cricothyrotomy in this study. 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. All PHP examined except for fluid resuscitation were more frequently performed while on scene than during transport. Univariate logistic regression was performed to examine the odds of mortality associated with each PHP. Intubation, intraosseous access, fluid resuscitation, cervical spine immobilization, and pleural decompression were all significantly associated with increased odds of mortality. Conversely, application of pressure dressings was found to be significantly associated with decreased odds of mortality (odds ratio [OR], 0.58; 95% confidence interval (CI), 0.38–0.90; p = 0.01) as was IV access (OR, 0.54; 95% CI, 0.40–0.72; p < 0.001). Tourniquet application was not found to be associated with mortality (p = 0.30). Receipt of any PHP increased odds of mortality (OR, 1.38; 95% CI, 1.27–1.51; p < 0.001). Number of procedures performed on scene, number performed during transport, and total number received in the PH arena were all found to be significantly associated with increased odds of mortality.
TABLE 2 -
Frequency and Location of PHP Performed Followed by Univariate Logistic Regression Analysis Examining Association of Individual PHP With Odds of Mortality
PHP
n (%)
On Scene
Transport
OR
95% CI
p
Intubation
99 (7.1)
77 (5.6)
22 (1.6)
52.58
31.74–81.09
<0.001
IV access
1,211 (87.4)
673 (48.6)
587 (42.4)
0.54
0.40–0.72
<0.001
IO access
105 (7.6)
75 (5.4)
36 (2.6)
33.13
21.14–51.29
<0.001
Fluid resuscitation
666 (48.1)
216 (15.6)
437 (31.5)
1.52
1.14–2.04
0.01
Cricothyrotomy
0
0
0
C-spine immobilization
78 (5.6)
63 (4.5)
15 (1.1)
4.42
2.66–7.36
<0.001
Pleural decompression
113 (8.2)
64 (4.6)
56 (4.0)
8.21
5.47–12.34
<0.001
Pelvic stabilization
2
1
1
Pressure dressing
409 (29.5)
325 (23.4)
161 (11.6)
0.58
0.38–0.90
0.01
Tourniquet
108 (7.8)
86 (6.2)
29 (2.1)
0.66
0.30–1.44
0.30
Other
124 (8.9)
66 (4.7)
58 (4.2)
3.09
1.81–5.26
<0.001
No. scene PHP
1.66
1.48–1.87
<0.001
No. transport PHP
1.17
1.02–1.34
0.03
Total no. PHP
1.38
1.27–1.51
<0.001
All values for on-scene and transport PHP are frequencies presented as n (%). Percent was calculated using the number of patients who received PHP as the denominator.
C, cervical; IO, intraosseous.
ED Resuscitation
The clinical condition of patients upon arrival to the ED as well as ED procedures and resuscitation requirements were examined (Table 3 ). The initial ED vital signs and shock index were similar between both subgroups. Only mean initial GCS differed significantly and was lower in the PHP cohort (13.5 vs. 14.0; p = 0.01). Examination of the mean (SD) ED shock index in those who received PH fluids versus those who did not revealed no significant difference between the groups (0.79 [0.31] vs. 0.77 [0.28], respectively; p = 0.06]. Resuscitation requirements for the first 24 hours were also similar between the groups despite massive transfusion protocol activation occurring more frequently in the PHP cohort compared with the N-PHP group (13.7% vs. 7.0%; p < 0.001). Compared with no PHP, the PHP group was significantly less likely to undergo ED procedures (29.0% vs. 11.6%; p < 0.001) and more likely to undergo emergent surgery (40.9% vs. 28.8%; p < 0.001). Logistic regression analysis of all patients with NISS of >15 revealed that emergent surgery was associated with significantly reduced odds of mortality (OR, 0.17; 95% CI, 0.11–0.27; p < 0.001). Frequency of intubation, resuscitative balloon occlusion of the aorta (REBOA), ED thoracotomy, and tourniquet application did not differ between the groups.
TABLE 3 -
Description of ED Vitals, Resuscitation Requirements, Procedures, and In-hospital Outcome Measures
Parameter
Total (N = 2,284)
No PHPs (n = 898)
PHPs (n = 1,386)
p
Direct OR admit, n (%)
81 (3.5)
25 (2.8)
56 (4.1)
0.10
ED vitals
SBP
122.7 (40.7)
122.9 (42.0)
122.4 (39.7)
0.81
HR
90.6 (32.3)
91.4 (31.9)
89.9 (32.6)
0.36
Temp
36.6 (2.3)
36.7 (0.7)
36.5 (2.8)
0.15
RR
19.3 (8.4)
19.0 (7.9)
19.6 (8.7)
0.16
Shock index
0.77 (0.29)
0.78 (0.28)
0.77 (0.30)
0.67
GCS
13.7 (3.5)
14.0 (3.2)
13.5 (3.7)
0.01
Resuscitation, 1st 24 h
PRBC, U
2.1 (16.0)
1.6 (6.5)
2.4 (19.8)
0.23
FFP, U
1.2 (4.8)
1.1 (5.5)
1.2 (4.4)
0.83
Platelets
0.5 (2.9)
0.4 (2.4)
0.6 (3.1)
0.17
Crystalloid, mL
2,032.5 (2,760.8)
1,943.2 (2,923.0)
2,090.1 (2,650.4)
0.28
MTP activation, n (%)
252 (11.0)
63 (7.0)
189 (13.7)
<0.001
ED procedures, n (%)
None
505 (22.1)
105 (11.6)
400 (29.0)
<0.001
Intubation
238 (10.4)
89 (9.8)
149 (10.8)
0.44
IV access
1,439 (63.0)
749 (82.6)
690 (50.1)
<0.001
Foley
118 (5.2)
27 (3.0)
91 (6.6)
<0.001
Chest tube
396 (17.3)
137 (15.1)
259 (18.8)
0.02
REBOA
5 (0.2)
2 (0.2)
3 (0.2)
0.99
Thoracotomy
136 (6.0)
56 (6.2)
80 (5.8)
0.72
Tourniquet
24 (1.1)
5 (0.6)
19 (1.4)
0.06
Other
188 (8.2)
33 (3.6)
155 (11.3)
<0.001
Emergent surgery, n (%)
794 (36.1)
251 (28.8)
543 (40.9)
<0.001
Outcomes
LOS, d
5.0 (8.8)
4.0 (6.6)
5.6 (10.0)
<0.001
ICU-free days
3.5 (5.6)
3.0 (4.5)
3.7 (6.2)
<0.01
Ventilator-free days
4.1 (6.5)
3.6 (5.5)
4.5 (7.1)
<0.01
Highest BD, 24 h
−3.4 (7.1)
−3.3 (7.9)
−3.5 (6.6)
0.65
Highest lactate
5.1 (4.3)
5.7 (4.7)
4.7 (3.8)
<0.001
Mortality, n (%)
213 (9.4)
70 (7.8)
143 (10.3)
0.04
Time to death, n (%)
In ED
126 (61.2)
43 (61.4)
83 (61.0)
0.88
In OR
33 (16.0)
13 (18.6)
20 (14.7)
≤24 h
27 (13.1)
8 (11.4)
19 (14.0)
≤7 d
11 (5.3)
4 (5.7)
7 (5.1)
≤30 d
7 (3.4)
2 (2.9)
5 (3.7)
>30 d
2 (1.0)
0
2 (1.5)
Values are mean (SD) unless otherwise noted.
BD, base deficit; FFP, fresh frozen plasma; GCS, Glasgow Coma Scale; HR, heart rate; ICU, intensive care unit; LOS, length of stay; MTP, massive transfusion protocol; OR, operating room; PRBC, packed red blood cells; REBOA, resuscitative balloon occlusion of the aorta; RR, respiratory rate; Temp, temperature.
Hospital Outcomes
In-hospital outcomes are detailed in Table 3 . Patients who received PHP had longer mean lengths of stay (5.6 days vs. 4.0 days; p < 0.001) compared with the N-PHP group. The N-PHP cohort was more likely to not develop any complications during hospitalization compared with their PHP peers (95.3% vs. 92.2%, p < 0.01), while the PHP group was significantly more likely to develop acute respiratory distress syndrome (1.4% vs. 0.4%; p = 0.02), venous thromboembolism (1.9% vs. 0.6%; p < 0.01), and urinary tract infections (0.9% vs. 0.1%; p = 0.02). Other complications examined demonstrated no significant differences between the N-PHP and PHP groups, specifically acute kidney injury (1.1% vs. 1.9%; p = 0.15), pneumonia (0.8% vs. 1.4%; p = 0.09), cerebrovascular accident (0 vs. 0.2%; p = 0.16), and multiple organ dysfunction syndrome (0.3% vs. 0.5%; p = 0.55). Overall in-hospital mortality was higher in the PHP group compared with those who did not receive PHP (10.3% vs. 7.8%; p = 0.04), but there was no significant difference in time to death between the groups (p = 0.88).
Survival
Logistic regression examining variables associated with mortality are shown in Table 4 (A). The number of PHP carried out on scene (OR, 1.64; 95% CI, 1.38–1.96; p < 0.001) and during transport (OR, 1.33; 95% CI, 1.10–1.61; p < 0.01) were associated with mortality. Variables associated with mortality included increasing age, increasing injury severity, gunshot wounds, and injury to the chest. Logistic regression examining individual PHP in the PHP population is shown in Table 4 (B). Prehospital intubation was strongly associated with mortality (OR, 10.76; 95% CI, 4.02–28.78; p < 0.001). Other procedures found to be associated with mortality included fluid resuscitation (OR, 1.00; 95% CI, 1.00–1.01; p = 0.01), 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). Prehospital IV placement was associated with survival (OR, 0.27; 95% CI, 0.10–0.76; p = 0.01). Other variables found to be associated with mortality in this model included increasing age, increasing NISS, and gunshot wounds. Increasing PH systolic blood pressure was associated with survival.
TABLE 4 -
Multivariate Logistic Regression Examining Odds of Hospital Mortality (A) Among Number of PHP and (B) Among Individual PHP Within the PHP Population
Parameter
OR
95% CI
p
A.
Age, y
1.03
1.01–1.04
0.001
NISS
1.07
1.05–1.07
<0.001
GSW
2.94
1.65–5.23
<0.001
Chest injury
2.49
1.52–4.07
<0.001
No. scene PHPs
1.64
1.38–1.96
<0.001
No. transport PHPs
1.33
1.10–1.61
<0.01
B.
Age, y
1.04
1.02–1.07
<0.01
NISS
1.07
1.04–1.09
<0.001
GSW
4.01
1.38–11.66
0.01
Chest injury
0.65
0.27–1.53
0.32
Higher PH SBP
0.97
0.96–0.98
<0.001
PH intubation
10.76
4.02–28.78
<0.001
PH IO access
1.74
0.63–4.86
0.29
PH IV placement
0.27
0.10–0.76
0.01
PH fluids, mL
1.00
1.00–1.01
0.01
PH C-spine immobilization
5.80
1.85–18.26
<0.01
PH tourniquet
0.70
0.14–3.93
0.65
PH pressure dressing
0.80
0.34–1.87
0.60
PH pleural decompression
3.70
1.33–10.28
0.01
C, cervical; GSW, gunshot wound; IO, intraosseous; SBP, systolic blood pressure.
To further analyze PH crystalloid use, volumes of PH crystalloid given were categorized into groups by 250-mL increments, and logistic regression was performed. Prehospital crystalloid volumes of less than 250 mL, 251 to 500 mL, and 501 to 750 mL were not significantly associated with mortality when compared with no crystalloids. However, administration of crystalloid volumes larger than 750 mL was associated with mortality (OR, 3.10; 95% CI, 1.85–5.18; p < 0.001).
Logistic regression analysis of method of transport with private vehicle transport as the reference group revealed increased odds of mortality for both ALS (OR, 3.62; 95% CI, 1.99–6.59; p < 0.001) and police transport (OR, 5.50; 95% CI, 286–10.58; p < 0.001), while BLS transport was not found to be associated with odds of mortality (OR, 1.99; 95% CI, 0.82–4.83; p = 0.13). When age, injury severity, and mechanism of injury were accounted for, there were no longer any significant differences associated with method of transport and odds of mortality.
Percent survival was plotted against total number of PHP per patient, total number of on-scene PHP per patient, and total number of PHP performed during transport (Fig. 2 A–C). Within the PHP cohort, PH providers/first responders performed 2.2 ± 1.2 (mean ± SD) procedures. The cohort received 1.1 ± 1.0 procedures on the scene and 1.0 ± 1.0 during transport. Trendlines in the plots suggest an inverse relationship between decreasing survival and number of PHP increases, and this trend is particularly evident within the examination of PHP performed on scene (Fig. 2 B). In total number of PHP (Fig. 2 A) and total number of scene procedures (Fig. 2 B), survival was observed to be increased for those who received only one PHP before ED arrival. Further examination revealed that the procedure given to the majority of this group (83%) was IV access, which was found to be beneficial in logistic regression analysis. As seen in Figure 2 A, three or more total procedures worsened survival. As seen in Figure 2 B, two or more on-scene procedures worsened survival.
Figure 2: Line graph illustration of survival percentage versus number of PHP per patient. p Values were generated by Pearson’s χ2 analyses with a Yates’ correction. Those who received no PHP served as the reference group. (A ) Survival versus total number of PHPs per patient. (B ) Survival versus number of on-scene PHP per patient. (C ) Survival versus number of PHP performed during transport.
We further examined those patients who received IV access only and no PH fluids and sought to determine if this subgroup presented to EMS as physiologically better than those who received IV + fluids. The mean (SD) NISS in the IV only group was significantly lower than the IV plus fluids cohort (12.1 [15.3] vs. 17.1 [15.0]; p < 0.001). However, in a multivariable logistic regression, which controlled for age, NISS, presence of chest injury, and injury by gunshot, fluids were still found to be associated with increased odds of mortality. Furthermore, excluding those who only received IV access and no other procedure, PHP were still found to be significantly associated with higher odds of mortality (OR, 2.09; 95% CI, 1.05–4.15; p = 0.036).
DISCUSSION
In this multicenter study examining the effect of PHP in urban penetrating trauma patients, PHP were found to be largely associated with increased mortality, whether performed on the scene or en route to a hospital. The largest increase in odds of mortality was observed in patients who received endotracheal intubation. Prehospital use of tourniquets and pressure dressings were not associated with benefit on adjusted analysis. Use of most PHP, particularly intubation and crystalloid-based resuscitation, should be reconsidered, and rapid transport should be prioritized for urban penetrating trauma patients.
The development of a well-trained PH emergency response system in the United States has helped improve morbidity and mortality, whether by BLS (spine stabilization, bag-valve mask ventilation, etc.) or ALS (airway management, cardiac defibrillation, vascular access, intravenous fluid resuscitation, delivery of medications, etc.).3 16–18
We found that intubation is the PHP performed in the urban penetrating trauma patient that is by far the most strongly associated with mortality. Prior studies have corroborated the deleterious effects of PH intubation in penetrating trauma patients.1–3 13 19 20 21 5
Interestingly, we found that PH IV access was associated with survival, while IV fluid resuscitation was associated with mortality. While those who received IV fluid resuscitation were more severely injured in terms of higher mean NISS, increasing volumes of IV fluids remained significantly associated with greater odds of mortality when examined in the context of injury severity, age, presence of gunshot wound and chest injury. Furthermore, ED shock index was not different between those who received fluids and those who did not, suggesting that PH fluid resuscitation is at best not useful in this population. A selection bias may affect these results because patients who received IV access without IV fluid resuscitation were less severely injured than those that did receive IV fluids. To account for this possibility, we performed our analysis after excluding patients who received IV access without IV fluids and found that this did not change the results of our findings. Retrospective studies have shown that PH IV fluids are associated with death and that this association is especially increased in penetrating trauma patients.2 6 22 23 24
Other procedures found to be associated with mortality in this multicentered trial included cervical spine immobilization and pleural decompression. The negative effects of cervical collars have been demonstrated in numerous studies with increased risk of pressure ulcers, increased intracranial pressure, and increased difficulty in obtaining a definitive airway.25–27 28 29,30 31,32 33,34 35,36
Volume preserving procedures such as tourniquets and pressure dressings did not appear to be helpful in the PH setting for this specific patient population. Military tourniquet application has been shown to provide a survival benefit.37,38 10 39,40
To determine if true “scoop and run” results in better outcomes, we examined the influence of mode of transportation. Transport by BLS crew, police, or private vehicle did not result in a survival advantage when compared with ALS transport. This is consistent with prior studies that have shown that ALS transfer of penetrating trauma patients does not improve survival in certain patient populations.41 42 43 44,45
Interestingly, the study showed that the percentage of Black patients who got no PHP was higher than the percentage of White patients not receiving PHP. While the reason(s) behind this finding could not be determined based on the data available in this study, it is one that needs further investigation. Prior work has shown that underutilization of medical resources in Black patients in the United States is a significant societal problem.46,47
This study was not without limitation. The influence on PHP on transport time could not be examined in this multicenter trial. True transport times are impossible to determine in private vehicle and police transport, which made up the vast majority of our patient population. In addition, accurate time from injury to arrival of EMS often cannot be determined. Prior studies have indicated that procedures like intubation and wound care do increase transport time.20
In conclusion, PHP continue to be performed in urban penetrating trauma. The volume preserving procedures of tourniquets and pressure dressing were not associated with harm and may be beneficial. In addition, obtaining IV access in the PH setting also seems to be beneficial, and consideration should be given to performing this procedure in route to the hospital. These remaining PHP examined were found to impart no survival advantage and may be harmful in urban settings, even when performed during transport. These procedures should be foregone in favor of rapid transport, where definitive surgical control of bleeding and resuscitation with blood products can be performed. Guidelines by national trauma organizations to decrease PHP in urban penetrating trauma may help change practice and save lives.
AUTHORSHIP
S.T., D.T., Z.M., A.J.G., J.D., and E.R.H. contributed in the study conception and design. Z.M., G.C., M.M., C.A., S.N., D.T., L.C.T., P.M., S.R., J.J.K., S.B., M.R., L.E.C., D.V.S., A.G.-S., A.B., M.C.S., A.L., E.B., M.R.N., J.B., M.C.N., L.E.J., J.W., M.V., K.D., T.Z.H., E.H., M.J.L., J.D.B., D.R.M., R.A., B.U.O., E.R.H., E.W.E., R.F., S.L.R., L.W., A.C.B., J.M.H., K.L.L., S.H.N., J.M., M.A.G., M.M.C., N.B., A.T., and D.T. contributed in the acquisition of data. D.T., S.T., Z.M., A.J.G., and J.D. contributed in the analysis and interpretation of data. S.T., D.T., and J.D. contributed in the drafting of article. M.V., E.R.H., Z.M., L.E.C., T.Z.H., E.W.E., D.R.M., A.C.B., A.T., J.M.H., S.B., A.L., K.L.L., S.T., and D.T. contributed in the critical review/revision.
ACKNOWLEDGMENTS
The following deserve recognition and acknowledgement for their contributions to this collaborative effort: Eman Toraih, MD, PhD, Tulane University School of Medicine, New Orleans, Louisiana; Gerald Wang, DO, Mount Sinai Hospital, Chicago, Illinois; Ariel Nelson, BS, Mount Sinai Hospital, Chicago, Illinois; Kevin Kappenmann, BS, Mount Sinai Hospital, Chicago, Illinois; Jordan Caffe, MD, Cook County Health, Chicago, Illinois; Justin Mis, RN, Cook County Health, Chicago, Illinois; Howard Liu Li, University of Pennsylvania, Philadelphia, Pennsylvania; Xian Luo-Own, PhD, Loma Linda University Medical Center, Loma Linda, California; Hayden Moore, DO, Cape Fear Valley Hospital, Fayetteville, North Carolina; William Hallinan, MSBA, RN, University of Rochester Medical Center, Rochester, New York; Shenequa Deas, MPH, COMR, CCRC, Research Medical Center, Kansas City, Missouri; Mahsa Shariat, Brigham & Women’s Hospital, Boston, Massachusetts; Beck Lienau, Brigham & Women’s Hospital, Boston, Massachusetts; Amy Nixon, Brigham & Women’s Hospital, Boston, Massachusetts; LaDonna Allen, RN, UT Health Tyler, Tyler, Texas; Kathy Rodkey, CCRC, ACRP-PM, Medical City Plano, Plano, Texas; and Kokila Jeyamurugan, MD, Tufts Medical Center, Boston, Massachusetts.
DISCLOSURE
The authors have none to declare other than the following: E.R.H. reports research funding from The Patient-Centered Outcomes Research Institute, the Agency for Healthcare Research and Quality, the NIH/NHLBI, the DOD/Army Medical Research Acquisition Activity, and the Henry M. Jackson Foundation for the Advancement of Military Medicine. He also receives royalties from Lippincott Williams & Wilkins for a book, Avoiding Common ICU Errors , and was a paid speaker for the Vizient Hospital Improvement Innovation Network VTE Prevention Acceleration Network.
REFERENCES
1. Seamon MJ, Doane SM, Gaughan JP, Kulp H, D’Andrea AP, Pathak AS, Santora TA, Goldberg AJ, Wydro GC. Prehospital interventions for penetrating trauma victims: a prospective comparison between advanced life support and basic life support.
Injury . 2013;44(5):634–638.
2. Haut ER, Kalish BT, Cotton BA, EFron DT, Haider AH, Stevens KA, Kieninger AN, Cornwell EE 3rd, Chang DC. Prehospital intravenous fluid administration is associated with higher mortality in trauma patients: a National Trauma Data Bank analysis.
Ann Surg . 2011;253:371–377.
3. McSwain NE Jr. Scott B. Frame, MD Memorial Lecture. Judgment based on knowledge: a history of Prehospital trauma life support, 1970–2013.
J Trauma Acute Care Surg . 2013;75:1–7.
4. Wang HE, Schmicker RH, Daya MR, et al. Effect of a strategy of initial laryngeal tube insertion vs endotracheal intubation on 72-hour survival in adults with out-of-hospital cardiac arrest: a randomized clinical trial.
JAMA . 2018;320(8):769–778.
5. Taghavi S, Vora HP, Jayarajan SN, Gaughan JP, Pathak AS, Santora TA, Goldberg AJ. Prehospital intubation does not decrease complications in the penetrating trauma patient.
Am Surg . 2014;80(1):9–14.
6. Bickell WH, Wall MJ Jr., Pepe PE, Martin RR, Ginger VF, Allen MK, Mattox KL. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries.
N Engl J Med . 1994;331(17):1105–1109.
7. Haut ER, Kalish BT, Efron DT, Haider AH, Stevens KA, Kieninger AN, Cornwell EE 3rd, Chang DC. Spine immobilization in penetrating trauma: more harm than good?
J Trauma . 2010;68(1):115–120; discussion 120-1.
8. Sperry JL, Guyette FX, Brown JB, et al; PAMPer Study Group. Prehospital plasma during air medical transport in trauma patients at risk for hemorrhagic shock.
N Engl J Med . 2018;379(4):315–326.
9. Chapman MP, Moore EE, Chin TL, et al. Combat: initial experience with a randomized clinical trial of plasma-based resuscitation in the field for traumatic hemorrhagic shock.
Shock . 2015;44 Suppl 1(1):63–70.
10. Schroll R, Smith A, McSwain NE Jr., et al. A multi-institutional analysis of prehospital tourniquet use.
J Trauma Acute Care Surg . 2015;79(1):10–14; discussion 14.
11. McNickle AG, Fraser DR, Chestovich PJ, Kuhls DA, Fildes JJ. Effect of prehospital tourniquets on resuscitation in extremity arterial trauma.
Trauma Surg Acute Care Open . 2019;4(1):e000267.
12. Fox N, Rajani RR, Bokhari F, Chiu WC, Kerwin A, Seamon MJ, Skarupa D, Frykberg E; Eastern Association for the Surgery of Trauma. Evaluation and management of penetrating lower extremity arterial trauma: an Eastern Association for the Surgery of Trauma practice management guideline.
J Trauma Acute Care Surg . 2012;73(5 Suppl 4):S315–S320.
13. Taghavi S, Jayarajan SN, Ferrer LM, Vora H, McKee C, Milner RE, Gaughan JP, Dujon J, Sjoholm LO, Pathak A. “Permissive hypoventilation” in a swine model of hemorrhagic shock.
J Trauma Acute Care Surg . 2014;77(1):14–19.
14. Taghavi S, Jayarajan SN, Khoche S, et al. Examining prehospital intubation for penetrating trauma in a swine hemorrhagic shock model.
J Trauma Acute Care Surg . 2013;74(5):1246–1251.
15. Taghavi S, Duran JM, Jayarajan S, et al. Still making the case against prehospital intubation: a rat hemorrhagic shock model.
J Trauma Acute Care Surg . 2012;73(2):332–337; discussion 337.
16. Björklund E, Stenestrand U, Lindbäck J, Svensson L, Wallentin L, Lindahl B. Pre-hospital thrombolysis delivered by paramedics is associated with reduced time delay and mortality in ambulance-transported real-life patients with ST-elevation myocardial infarction.
Eur Heart J . 2006;27:1146–1152.
17. Stiell IG, Spaite DW, Field B, et al. Advanced life support for out-of-hospital respiratory distress.
N Engl J Med . 2007;356(21):2156–2164.
18. Stiell IG, Wells GA, DeMaio VJ, Spaite DW, Field BJ 3rd, Munkley DP, Lyver MB, Luinstra LG, Ward R. Modifiable factors associated with improved cardiac arrest survival in a multicenter basic life support/defibrillation system: OPALS Study Phase I results. Ontario Prehospital Advanced Life Support.
Ann Emerg Med . 1999;33(1):44–50.
19. Thim T, Krarup NH, Grove EL, Rohde CV, Lofgren B. Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach.
Int J Gen Med . 2012;5:117–121.
20. Ninokawa S, Friedman J, Tatum D, Smith A, Taghavi S, McGrew P, Duchesne J. Patient contact time and prehospital interventions in hypotensive trauma patients: should we reconsider the “ABC” algorithm when time is of the essence?
Am Surg . 2020;86(8):937–943.
21. Ferrada P, Callcut RA, Skarupa DJ, Duane TM, Garcia A, Inaba K, Khor D, Anto V, Sperry J, Turay D; AAST Multi-Institutional Trials Committee. Circulation first — the time has come to question the sequencing of care in the ABCs of trauma; an American Association for the Surgery of Trauma multicenter trial.
World J Emerg Surg . 2018;13:8.
22. Smith JP, Bodai BI, Hill AS, Frey CF. Prehospital stabilization of critically injured patients: a failed concept.
J Trauma . 1985;25(1):65–70.
23. Slovis CM, Herr EW, Londorf D, Little TD, Alexander BR, Guthmann RJ. Success rates for initiation of intravenous therapy en route by prehospital care providers.
Am J Emerg Med . 1990;8(4):305–307.
24. Cotton BA, Jerome R, Collier BR, et al. Guidelines for prehospital fluid resuscitation in the injured patient.
J Trauma . 2009;67(2):389–402.
25. Hunt K, Hallworth S, Smith M. The effects of rigid collar placement on intracranial and cerebral perfusion pressures.
Anaesthesia . 2001;56(6):511–513.
26. March JA, Ausband SC, Brown LH. Changes in physical examination caused by use of spinal immobilization.
Prehosp Emerg Care . 2002;6:421–424.
27. Jacobson TM, Tescher AN, Miers AG, Downer L. Improving practice: efforts to reduce occipital pressure ulcers.
J Nurs Care Qual . 2008;23(3):283–288.
28. Garcia A, Liu TH, Victorino GP. Cost-utility analysis of prehospital spine immobilization recommendations for penetrating trauma.
J Trauma Acute Care Surg . 2014;76(2):534–541.
29. Velopulos CG, Shihab HM, Lottenberg L, Feinman M, Raja A, Salomone J, Haut ER. Prehospital spine immobilization/spinal motion restriction in penetrating trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma (EAST).
J Trauma Acute Care Surg . 2018;84(5):736–744.
30. Stuke LE, Pons PT, Guy JS, Chapleau WP, Butler FK, McSwain NE. Prehospital spine immobilization for penetrating trauma—review and recommendations from the Prehospital Trauma Life Support Executive Committee.
J Trauma . 2011;71(3):763–769; discussion 769-70.
31. Dickson RL, Gleisberg G, Aiken M, Crocker K, Patrick C, Nichols T, Mason C, Fioretti J. Emergency medical services simple thoracostomy for traumatic cardiac arrest: postimplementation experience in a ground-based suburban/rural emergency medical services agency.
J Emerg Med . 2018;55(3):366–371.
32. Warner KJ, Copass MK, Bulger EM. Paramedic use of needle thoracostomy in the prehospital environment.
Prehosp Emerg Care . 2008;12(2):162–168.
33. Britten S, Palmer SH. Chest wall thickness may limit adequate drainage of tension pneumothorax by needle thoracocentesis.
Emerg Med J . 1996;13(6):426–427.
34. Britten S, Palmer SH, Snow TM. Needle thoracocentesis in tension pneumothorax: insufficient cannula length and potential failure.
Injury . 1996;27(5):321–322.
35. Cullinane DC, Morris JA Jr., Bass JG, Rutherford EJ. Needle thoracostomy may not be indicated in the trauma patient.
Injury . 2001;32(10):749–752.
36. Jones R, Hollingsworth J. Tension pneumothoraces not responding to needle thoracocentesis.
Emerg Med J . 2002;19(2):176–177.
37. Kragh JF Jr., Littrel ML, Jones JA, Walters TJ, Baer DG, Wade CE, Holcomb JB. Battle casualty survival with emergency tourniquet use to stop limb bleeding.
J Emerg Med . 2011;41(6):590–597.
38. Beekley AC, Sebesta JA, Blackbourne LH, Herbert GS, Kauvar DS, Baer DG, Walters TJ, Mullenix PS, Holcomb JB; 31st Combat Support Hospital Research Group. Prehospital tourniquet use in operation Iraqi freedom: effect on hemorrhage control and outcomes.
J Trauma . 2008;64(Suppl 2):S28–S37; discussion S37.
39. Davies GE, Lockey DJ. Thirteen survivors of prehospital thoracotomy for penetrating trauma: a prehospital physician-performed resuscitation procedure that can yield good results.
J Trauma . 2011;70(5):E75–E78.
40. Sadek S, Lockey DJ, Lendrum RA, Perkins Z, Price J, Davies GE. Resuscitative endovascular balloon occlusion of the aorta (REBOA) in the pre-hospital setting: an additional resuscitation option for uncontrolled catastrophic haemorrhage.
Resuscitation . 2016;107:135–138.
41. Rappold JF, Hollenbach KA, Santora TA, Beadle D, Dauer ED, Sjoholm LO, Pathak A, Goldberg AJ. The evil of good is better: making the case for basic life support transport for penetrating trauma victims in an urban environment.
J Trauma Acute Care Surg . 2015;79(3):343–348.
42. Band RA, Salhi RA, Holena DN, Powell E, Branas CC, Carr BG. Severity-adjusted mortality in trauma patients transported by police.
Ann Emerg Med . 2014;63(5):608–14.e3.
43. Wandling MW, Nathens AB, Shapiro MB, Haut ER. Police transport versus ground EMS: a trauma system-level evaluation of prehospital care policies and their effect on clinical outcomes.
J Trauma Acute Care Surg . 2016;81(5):931–935.
44. Wandling MW, Nathens AB, Shapiro MB, Haut ER. Association of prehospital mode of transport with mortality in penetrating trauma: a trauma system-level assessment of private vehicle transportation vs ground emergency medical services.
JAMA Surg . 2018;153(2):107–113.
45. Zafar SN, Haider AH, Stevens KA, et al. Increased mortality associated with EMS transport of gunshot wound victims when compared to private vehicle transport.
Injury . 2014;45(9):1320–1326.
46. Schoenfeld AJ, Sturgeon DJ, Dimick JB, Bono CM, Blucher JA, Barton LB, Weissman JS, Haider AH. Disparities in rates of surgical intervention among racial and ethnic minorities in Medicare accountable care organizations.
Ann Surg . 2019;269(3):459–464.
47. Tramontano AC, Chen Y, Watson TR, Eckel A, Hur C, Kong CY. Racial/ethnic disparities in colorectal cancer treatment utilization and phase-specific costs, 2000-2014.
PLoS One . 2020;15(4):e0231599.
DISCUSSION
Dr. Taghavi and colleagues have conducted a prospective multicenter trial that closely examines the association between prehospital procedures (PHP) and mortality in penetrating trauma patients in urban locations. The authors found that mortality was increased with each PHP performed regardless of location – either on scene or in route – and concluded that prehospital providers should prioritize rapid transport to a trauma center over PHP.
While the study is well done and the data analysis is robust, a significant concern is that the baseline characteristics of the two comparison groups – those who received PHP and those who did not – are significantly different with respect to factors related to severity of illness, including age, shock index, New Injury Severity Score, and need for emergency surgery. Thus, the conclusions drawn may be subject to bias. Another key variable that may confound the results is transport time. The authors address the reason why this was excluded from the analysis, as it could not easily be obtained, and there were a large number of patients transported by police or private vehicle. While a rapid transport time may be presumed due to the urban environment, variations in this parameter may explain why some patients had more PHP done or why some had poorer outcomes. In addition, although these data show that there is an association between PHP and mortality in these patients, causation cannot be assumed.
I commend the authors and believe that their study strengthens the argument against PHP in urban penetrating trauma patients. As prehospital protocols and provider abilities evolve over time, I look forward to definitive recommendations regarding PHP in this population as well as instruction on implementing change. Studies such as this one will be essential to the formulation of such guidance, and subsequent provider education remains crucial in improving patient outcomes.
—Alaina M. Lasinski, MD
MetroHealth Medical Center
Cleveland, OH
