Brain Injury
Fuller G, Woodford M, Lawrence T, et al. Do prolonged primary transport times for traumatic brain injury patients result in deteriorating physiology? A cohort study. Prehosp Emerg Care. Oct. 10, 2013. [Epub ahead
of print.]
Transporting directly to trauma centers is a bit of a hot topic lately. For urban providers, it’s a simple decision, but for rural providers, a trauma center may not be nearby, even by air transportation. Last month we discussed the national field triage decision scheme, which recommends all critical trauma patients go to the closest Level I or II trauma center.
Although the benefits of immediate surgical intervention are well documented for most trauma patients, there’s little research correlating transport time with the condition of traumatic brain injury (TBI) patients.
In this study from Salford, United Kingdom, researchers retrospectively reviewed all cases entered in a national reporting database of TBI patients transported to neuroscience specialty centers in the U.K. Patients’ blood pressure, pulse, respiratory rate, SpO2, and Glasgow Coma Scale (GCS) were recorded by EMS and compared to ED values. The primary measurement was to see if an improvement or deterioration in vital signs was seen in correlation to transport times.
A total of 23,846 patients with clinically significant traumatic brain injuries were entered in the database during the study period (2005—2011). Of these, 7,149 patients were transported directly to a neuroscience center and were included for study. The median age for all study patients was 48.8 years, and 72.3% (17,241) of patients were male. Many of the patients (3,224, or 45.1%) had no SpO2 reading documented by EMS but weren’t excluded. Patients who had a GCS <9, systolic BP <90, abnormal respiratory or heart rate, or SpO2 <93%, were defined as unstable.
There was a meaningful difference between EMS and in-hospital GCS scores (12 in EMS vs. 14 for in-hospital) but vital signs didn’t statistically differ. When placed in groups adjusted for transport time–<20 minutes, 20—40 minutes, 40—60 minutes, 60—80 minutes, 80—100 minutes, 100—120 minutes and >120 minutes–there was no statistical correlation of a deterioration in vital signs or GCS based on transport times. All of the groups had an odds ratio <2 for deterioration.
This is a large, retrospective study that only accounts for ED and hospital vital signs and care, not long-term outcome. The authors feel this study makes a strong case for stable or stabilized patients to go directly to a neuroscience center. Correlating that to our U.S. readers, this points toward patients being able to go trauma centers or hospitals specializing in neurology, even if it means a longer transport time. Because it would be incredibly difficult to correlate transport times to long-term survivability, we don’t expect to see research based off that in the near future.
Now, this might seem to make a case against air medical services, given that prolonged transport time was not associated with a deterioration in patient condition; however, multiple prior studies have shown the benefit of early surgical intervention at a trauma center for brain injury patients to relieve intracranial pressure and prevent herniation.
BOTTOM LINE
What we know: TBI patients benefit from being transported directly to specialty trauma and neuroscience centers.
What this study adds: Despite long transport times, TBI patients don’t tend to deteriorate en route to facilities.
WATCH BOX
Shaw L, Price C, McLure S, et al. Paramedic initiated lisinopril for acute stroke treatment (PIL-FAST): Results from the pilot randomised controlled trial. Emerg Med J. Sept. 27, 2013. [Epub ahead of print.]
It’s no secret we’re a fan of novel, cutting-edge treatment plans. This article presented results from a randomized, controlled, double-blind trial in the U.K. in which hypertensive patients with acute hypertension were administered a crushed tablet of either lisinopril or a placebo sublingually. Because this was a pilot, paramedics voluntarily attended training in the North of Tyne region of the U.K., with 76 of 200 paramedics attending training. In 14 months, patients qualified for this trial by having acute stroke symptoms less than three hours old as well as hypertension with a systolic blood pressure >150 mmhg. Patients were then read information about the study and had to provide consent. Following consent, patients were randomly given 5 mg of lisinopril or a placebo sublingually. Because this was a pilot, only 14 patients were enrolled in 14 months and data analysis wouldn’t be statistically significant. Because the authors wrote a phenomenal study including double blinding, randomization and patient consent, the footprint for an incredible study has been laid out. Look for the final research soon.
