Date Published: July 18, 2017
Publisher: Public Library of Science
Author(s): David J. Lockey
Abstract: Noting that a variety of pre-hospital interventions can now be applied to treat traumatic injury, David J Lockey calls for research to determine which of these actually improve survival and reduce morbidity.
Partial Text: Twenty years ago, an editorial examining the evidence for, and worldwide expenditure on, pre-hospital emergency care noted that—despite considerable expenditure—the evidence base for the field was less than that of urticaria or constipation . Much has been published since, but many key questions about the provision of early trauma care still have to be addressed .
In Europe, where pre-hospital care is frequently physician-delivered, advanced pre-hospital critical care interventions are often performed at the scene of the injury, and new interventions are reported regularly. Advanced interventions are less commonly reported in the United States, where pre-hospital care is delivered by nonphysicians. Pre-hospital anaesthesia, mechanical ventilation, chest decompression, resuscitative thoracotomy, and advanced monitoring have been performed for many years. More recently reported interventions include pre-hospital transfusion , extracorporeal membrane oxygenation , CT scanning with stroke thrombolysis , resuscitative endovascular balloon occlusion of the aorta , and point-of-care testing (e.g., ultrasound imaging, blood gas analysis, plasma lactate, and tissue oxygen saturation). This wide range of interventions indicates that, with sufficient resources and training, most in-hospital interventions can be delivered before hospital arrival.
True innovation is rare in pre-hospital trauma care. Most promising interventions are developed in-hospital and, where practical, translated into the pre-hospital phase of care. Major breakthroughs in pre-hospital trauma care are likely to follow the same breakthroughs in in-hospital practice—effective blood substitutes and haemostatic and neuroprotective techniques are, for example, aspirations in both areas. There are exceptions to this, and some technological advances may only be applicable in the pre-hospital phase of care. Examples include vehicle automatic crash notification technology or the use of unmanned aerial vehicles for surveillance or for the rapid delivery of equipment or interventions to the scene of injury.
The barriers to effective pre-hospital trauma research are substantial. Trials involving acutely injured patients who cannot consent to treatment or trial recruitment are possible but arduous. Even well-designed randomised trials usually compromise to achieve recruitment, for example in using randomisation by provider, vehicle, or region rather than of patients . The lack of standardisation in case mix, providers, timelines, and endpoints can make generalisability of results difficult. Patients with very severe injuries tend to have many interventions during their hospital stay which may vary both in, and between, trauma centres. Mortality may therefore be an insensitive outcome measure of an isolated pre-hospital intervention. Pre-hospital trauma registry studies are increasingly performed with larger patient numbers , but patient heterogeneity, inconsistency in the care provided, and incomplete data make interpretation of this type of study difficult—particularly with mortality as the primary outcome. Even well-funded studies can encounter major limitations when service providers do not recruit and deliver interventions consistently .
Pre-hospital trauma care is a relatively undeveloped research area. Many advanced interventions are now possible, and future studies need to establish which improve survival and reduce morbidity. Advanced surgical interventions are likely to target a small number of severely injured patients in high-income countries but have shown promise. In-hospital trauma mortality is declining, and research to target accident prevention and reduce the mortality of patients who die before reaching hospital is key to reducing overall trauma mortality.