The association between total prehospital time and mortality in physician-staffed trauma systems remains uncertain.OBJECTIVE To describe the association of total prehospital time and in-hospital mortality in prehospital, physician-staffed trauma systems in France, with the hypothesis that total prehospital time is associated with increased mortality. DESIGN, SETTING, AND PARTICIPANTSThis cohort study was conducted from January 2009 to December 2016. Data for this study were derived from 2 distinct regional trauma registries in France (1 urban and 1 rural) that both have a physician-staffed emergency medical service. Consecutive adult trauma patients admitted to either of the regional trauma referral centers during the study period were included. Data analysis took place from March 2018 to September 2018. MAIN OUTCOMES AND MEASURESThe association between death and prehospital time was assessed with a multivariable model adjusted with confounders. Total prehospital time was the primary exposure variable, recorded as the time from the arrival of the physician-led prehospital care team on scene to the arrival at the hospital. The main outcome of interest was all-cause in-hospital mortality.RESULTS A total of 10 216 patients were included (mean [SD] age, 41 [18] years; 7937 men [78.3%]) affected by predominantly nonpenetrating injuries (9265 [91.5%]), with a mean (SD) Injury Severity Score of 17 ( 14) points. Of the patients, 6737 (66.5%) had at least 1 body region with an Abbreviated Injury Scale score of 3 or more. A total of 1259 patients (12.4%) presented in shock (with systolic pressure <90 mm Hg) and 2724 (26.9%) with severe head injury (Abbreviated Injury Scale score Ն3 points). On unadjusted analysis, increasing prehospital times (in 30-minute categories) were associated with a markedly and constant increase in the risk of in-hospital death. The odds of death increased by 9% for each 10-minute increase in prehospital time (odds ratio, 1.09 [95% CI, 1.07-1.11]) and after adjustment by 4% (odds ratio, 1.04 [95% CI, 1.01-1.07]). CONCLUSIONS AND RELEVANCEIn this study, an increase in total prehospital time was associated with increasing in-hospital all-cause mortality in trauma patients at a physician-staffed emergency medical system, after adjustment for case complexity. Prehospital time is a management objective in analogy to physiological targets. These findings plead for a further streamlining of prehospital trauma care and the need to define the optimal intervention-to-time ratio.

BackgroundOrgan failure, including acute kidney injury (AKI), is the third leading cause of death after bleeding and brain injury in trauma patients. We sought to assess the prevalence, the risk factors and the impact of AKI on outcome after trauma.MethodsWe performed a retrospective analysis of prospectively collected data from a multicenter trauma registry. AKI was defined according to the risk, injury, failure, loss of kidney function and end-stage kidney disease (RIFLE) classification from serum creatinine only. Prehospital and early hospital risk factors for AKI were identified using logistic regression analysis. The predictive models were internally validated using bootstrapping resampling technique.ResultsWe included 3111 patients in the analysis. The incidence of AKI was 13% including 7% stage R, 3.7% stage I and 2.3% stage F. AKI incidence rose to 42.5% in patients presenting with hemorrhagic shock; 96% of AKI occurred within the 5 first days after trauma. In multivariate analysis, prehospital variables including minimum prehospital mean arterial pressure, maximum prehospital heart rate, secondary transfer to the trauma center and data early collected after hospital admission including injury severity score, renal trauma, blood lactate and hemorrhagic shock were independent risk factors in the models predicting AKI. The model had good discrimination with area under the receiver operating characteristic curve of 0.85 (0.82–0.88) to predict AKI stage I or F and 0.80 (0.77–0.83) to predict AKI of all stages. Rhabdomyolysis severity, assessed by the creatine kinase peak, was an additional independent risk factor for AKI when it was forced into the model (OR 1.041 (1.015–1.069) per step of 1000 U/mL, p < 0.001). AKI was independently associated with a twofold increase in ICU mortality.ConclusionsAKI has an early onset and is independently associated with mortality in trauma patients. Its prevalence varies by a factor 3 according to the severity of injuries and hemorrhage. Prehospital and early hospital risk factors can provide good performance for early prediction of AKI after trauma. Hence, studies aiming to prevent AKI should target patients at high risk of AKI and investigate therapies early in the course of trauma care.Electronic supplementary materialThe online version of this article (10.1186/s13054-018-2265-9) contains supplementary material, which is available to authorized users.

In the Paris area, the French physician-based prehospital triage system for patients with suspicion of major trauma showed a high rate of overtriage and a low rate of undertriage. Criteria of global assessment of speed and mechanism alone were poor predictors of major trauma.