Review of: Hartl R, Gerber L, Iacono L, et al: Direct transport within an organized state trauma system reduces mortality in patients with severe traumatic brain injury." Journal of Trauma-Injury Infection & Critical Care. 2006. 60:1250–1256.
The New York State trauma registry tracked 1,449 patients with traumatic brain injury (TBI). The authors looked at the primary outcome of two-week mortality. They segregated the patients into those that were taken from the scene directly to a level one or two trauma center (direct transport), and those that were transported to a non-trauma center and then transferred later to a trauma center (indirect transport) within 24 hours of the injury. The median time of arrival at a trauma center for the direct transports was significantly shorter than that for indirect transports by about four hours. The two-week mortality for TBI patients indirectly transported was 50% higher than those transported directly to a trauma center.
There was no difference in mortality, whether the patient was transported by BLS versus ALS crews or ground versus air. There were an equal percentage of patients that received prehospital intubation in both groups and there was no significant mortality difference in the two groups relative to hypotension, and the Glasgow Coma Scale.
The impetus for this study was based on the recommendations put forth in the Guidelines for the Prehospital Management of Traumatic Brain Injury published by the Brain Trauma Foundation. While there is no question that in this study the two-week mortality was higher for those patients transported indirectly to a trauma center, the reason for this difference eludes me. There was no clinical difference reported between the two groups. Perhaps there were differences, but the authors did not examine the proper parameters. It is difficult to accept that the two- to four-hour delay alone was responsible for the higher mortality.
One difference identified was the need for neurosurgical intervention. Of the indirectly transported, 70% received emergent neurosurgical intervention at the trauma center versus 35% of the direct transports. Unfortunately, the power of the study could not definitively link this difference to mortality.
The accompanying editorial to the article brings up many of the questions raised by this study. Was there a difference in the cared provided by the non-trauma centers that may have impacted mortality? Why were the patients transported to non-trauma centers in the first place? Was it distance, time, unavailability of air medical or some clinical parameter that was not examined by this study?
While the conclusion is clear that mortality is lower for TBI patients transported directly to a trauma center, more studies are needed to explain why. This may lead to changes in the care rendered at the non-trauma centers or identification of more pertinent clinical parameters that should be evaluated in the field to better determine which patients would benefit most from trauma center care.