Pre-hospital severe traumatic brain injury – comparison of outcome in paramedic versus physician staffed emergency medical services

Abstract

BackgroundTraumatic brain injury (TBI) is one of the leading causes of death and permanent disability. Emergency Medical Services (EMS) personnel are often the first healthcare providers attending patients with TBI. The level of available care varies, which may have an impact on the patient’s outcome. The aim of this study was to evaluate mortality and neurological outcome of TBI patients in two regions with differently structured EMS systems.MethodsA 6-year period (2005 – 2010) observational data on pre-hospital TBI management in paramedic-staffed EMS and physician-staffed EMS systems were retrospectively analysed. Inclusion criteria for the study were severe isolated TBI presenting with unconsciousness defined as Glasgow coma scale (GCS) score ≤ 8 occurring either on-scene, during transportation or verified by an on-call neurosurgeon at admission to the hospital. For assessment of one-year neurological outcome, a modified Glasgow Outcome Score (GOS) was used.ResultsDuring the 6-year study period a total of 458 patients met the inclusion criteria. One-year mortality was higher in the paramedic-staffed EMS group: 57 % vs. 42 %. Also good neurological outcome was less common in patients treated in the paramedic-staffed EMS group.DiscussionWe found no significant difference between the study groups when considering the secondary brain injury associated vital signs on-scene. Also on arrival to ED, the proportion of hypotensive patients was similar in both groups. However, hypoxia was common in the patients treated by the paramedic-staffed EMS on arrival to the ED, while in the physician-staffed EMS almost none of the patients were hypoxic. Pre-hospital intubation by EMS physicians probably explains this finding.ConclusionThe results suggest to an outcome benefit from physician-staffed EMS treating TBI patients.Trial registrationClinicalTrials.gov ID NCT01454648

Effect of Physician-Staffed Emergency Medical Services (P-EMS) on the Outcome of Patients with Severe Traumatic Brain Injury: A Review of the Literature

“…For example, the presence of a helicopter can create substantial differences in prehospital times, especially in roughly shaped landscapes. Studies from different time periods (in this review from 1987 until 2015) are also subject to great differences in prehospital management with revised equipment and protocols (12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25).…”

“…The mean SpO 2 quantified by Klemen and Grmec was at least 7% higher after the implementation of P-EMS (p ¼ 0.04) (15). Garner et al, Pakkanen et al, and Pakkanen et al provided significant results as well, suggesting more adequate oxygen supply after additional assistance of a physician (13,14,21).…”

“…Three of the 14 studies suggested a significant decrease in overall mortality after the prehospital implementation of a physician (12)(13)(14). The study by Klemen and Grmec suggested a decrease of more than 50% in mortality as well, but only for patients with GCS 6-8 (p < 0.01) (15).…”

Evolução da vítima com trauma cranioencefálico na sala de emergência

“…Em geral, vítimas de TCE são encaminhadas a unidades de emergência onde exames radiológicos e profissionais especializados devem estar disponíveis para uma assistência imediata, eficaz e integrada que evite o aumento do risco de morte e danos adicionais (17) . O atendimento inicial dessas vítimas visa, sobretudo, evitar lesões secundárias, porém prioriza também a estabilidade hemodinâmica, a avaliação neurológica acurada e a apropriada seleção de pacientes que devem ser mantidos em atendimento (2,9,12,20,21,22) .…”

“…O maior tempo de permanência na SE esteve relacionado com uso de suporte hemodinâmico nesse serviço. (1,2,3,4,5,6,7,8,9,10,11,12,13) . Representa um grande problema de saúde em todo o mundo, por causar muitas mortes e incapacidades persistentes (14) .…”