EMS transport times and mortality in patients with penetrating trauma

Traumatic injury is one of the leading causes of death in the United States. (US)  The relationship between EMS transport times to a Level I trauma center and mortality if patients with penetrating trauma is a local debate in the city of Chicago to determine if there is a need for an additional trauma center.  The debate surrounds the idea that EMS transport times greater than twenty minutes or patients greater than 5 miles from a level I trauma center is associated with greater mortality; the most recent focus is on those suffering from penetrating trauma injuries.  

The development of trauma centers and trauma systems grew out of wartime experiences from the 1950s through the 1970s that increasingly emphasized early and aggressive care and treatment of injured combatants. Trauma centers and trauma systems, including prehospital triage criteria and transport plans, have been shown to significantly decrease mortality for injured patients.(1) 

In a literature review of four articles, Injury Severity Score (ISS) 16 or greater and a systolic blood pressure (SBP) less than 90 mmHg are associated with a poor prognosis. (1-4) There is greater mortality in patients with self-inflicted injuries (suicide), which at the time of arrival to the hospital, the details of the injury may not be clear.  Odds ratios (OR) of 0.4 to 5.90 have been recorded for mortality in patients with penetrating trauma and are greater in patients who are hypotensive and have a high ISS (1-4). One study showed there was an association with prehospital time, particularly scene times, and mortality in patients with high ISS presenting to a Level I trauma center.(2) 

Indeed patients with penetrating trauma may benefit from decreased pre-hospital times to the care of a Level I trauma center, however there remains the need for additional studies to determine if in fact it is the transport time (consider the time of day, traffic, weather, etc), the type of injury (self-inflicted injuries are of high (90%) mortality), or the prehospital care and scene times  (length of time that EMS crew is able to assess the patients, this is modified with security measures) that either supports or refutes the need to spend millions of taxpayers’ dollars for an additional trauma center in the city of Chicago. 

Crandall M, et al. Trauma Deserts: Distance From a Trauma Center, Transport Times, and Mortality From Gunshot Wounds in Chicago. American Journal of Public Health 2013;103(6):1103-09

McCoy CM, et al. Emergency Medical Services Out-of-Hospital Scene and Transport Times and Their Association With Mortality in Trauma Patients Presenting to an Urban Level I Trauma Center. Annals of Emergency Medicine 2013;61(2):167-74

Swaroop M, et al. Pre-hospital Transport Times and Survival for Hypotensive Patients with Penetrating Thoracic trauma. Journal of Emergencies, Trauma, and Shock 2013;6(1):16-20

Newgard CD, et al. Emergency Medical Services Intervals and Survival in Trauma: Assessment of the “Golden Hour” in a North American Prospective Cohort. Annals of Emergency Medicine 2010;55(3):235-244

from Dr. Andrea Boedecker