Prolonged Prehospital Time Research Articles

Prehospital time and mortality in pediatric trauma

PurposeThe “Golden Hour” of transportation to a hospital has long been accepted as a central principal of trauma care. However, this has not been studied in pediatric populations. We assessed for non-linearity of the relationship between prehospital time and mortality in pediatric trauma patients, redefining the threshold at which reducing this time led to more favorable outcomes.MethodsWe performed an analysis of the 2017–2018 American College of Surgeons Trauma Quality Improvement Program, including trauma patients age < 18 years. We examined the association between prehospital time and odds of in-hospital mortality using linear, polynomial, and restricted cubic spline (RCS) models, ultimately selecting the non-linear RCS model as the best fit.Results60,670 patients were included in the study, of whom 1525 died and 3074 experienced complications. Prolonged prehospital time was associated with lower mortality and fewer complications. Both models demonstrated that mortality risk was lowest at 45–60 min, after which time was no longer associated with reduced probability of mortality.ConclusionsThe demonstration of a non-linear relationship between pre-hospital time and patient mortality is a novel finding. We highlight the need to improve prehospital treatment and access to pediatric trauma centers while aiming for hospital transportation within 45 min.

Abstract WMP37: Neighborhood Socioeconomic Status, Race and Prehospital Emergency Care and Time to Presentation for Stroke

Introduction: It is unclear how neighborhood socioeconomic status (nSES) affects the pre-hospital recognition and care of acute stroke at the national level. Methods: Patients with ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage in the Get With the Guidelines-Stroke registry, presenting from July 2015 to December 2019, with symptom onset &lt;24 hours were included. Social deprivation index (SDI) at the county level approximated nSES. Logistic and quantile regressions evaluated the impact of SDI on EMS use, EMS prenotification, and time of symptom onset to emergency department (ED) arrival. Sequential models were adjusted for patient age, gender, race, vascular risk factors, arrival mode, stroke severity (NIHSS), and insurance status. Results: 634,823 patients met inclusion criteria. Patients were 51.2% Male, 67.1% White, with median NIHSS of 4 (IQR: 2-10), and median SDI of 51 (IQR: 27-75). Median symptom onset to arrival time was 176 mins (IQR: 63-565). SDI was not associated with differences in EMS use, but was associated with lower odds of EMS prenotification (upper SDI tercile vs lowest, OR 0.87, 95% CI 0.86-0.89). SDI was also significantly associated with stroke symptom onset to ED arrival time (upper SDI tercile vs lowest +2.72 mins, 95% CI 0.68-4.77); however, this association became nonsignificant when insurance was added to the model. By contrast, Black race was significantly associated with prolonged symptom onset to ED arrival time (+28.7 mins, 95% CI 26.0-31.5), and decreased odds of EMS prenotification OR 0.76 (95% CI 0.74-0.77). Conclusions: Higher SDI was associated with reduced odds of EMS prenotification, despite similar odds of EMS use across SDI levels. Race had a greater effect, with prolonged prehospital times and decreased odds of EMS pre-notification. Efforts to reduce place-based disparities in stroke care must address significant race-based inequities which exist in pre-hospital recognition and care of stroke.

Prehospital Simple Thoracostomy Does Not Improve Patient Outcomes Compared to Needle Thoracostomy in Severely Injured Trauma Patients.

ATLS suggests simple thoracostomy (ST) after failure of needle thoracostomy (NT) in thoracic trauma. Some EMS agencies have adopted ST into their practice. We sought to describe our experience implementing ST in the prehospital setting, hypothesizing that prehospital ST would reduce failure rates and improve outcomes compared to NT. This was a retrospective review of adult trauma patients who received prehospital ST or NT from 2017 to 2020. There were 48 patients with 64 procedures included. 83.7% were male and 65.8% injured by penetrating mechanism and of median (IQR) age of 31 (25-46)years. 28 (43.8%) procedures were NT and 36 (56.3%) were ST. Rates of improved patient response (P = .15), noted return of blood/air (P = .19), and return of spontaneous circulation (P = .62) did not differ. On-scene times were higher for ST (16.8 vs 11.5minutes; P < .02). Overall mortality did not differ between ST and NT (68.2% vs 46.4%, respectively; P = .125). For patients that survived beyond the ED, procedure-related complication rates were 2 of 21 patients (9.5%) in ST and 1 of 12 (8.3%) in NT. In penetrating trauma, simple thoracostomy had longer on-scene time and total prehospital time. ST did not improve success rates of ROSC and was associated with prolonged prehospital times, especially in penetrating trauma patients. Given the benefit of "scoop and run" in urban penetrating trauma, consideration should be given to direct transport in lieu of ST. Use of ST in blunt trauma should be evaluated prospectively.

Impact of emergency physician-staffed ambulances on preoperative time course and survival among injured patients requiring emergency surgery or transarterial embolization: A retrospective cohort study at a community emergency department in Japan.

Injured patients requiring definitive intervention, such as surgery or transarterial embolization (TAE), are an extremely time-sensitive population. The effect of an emergency physician (EP) patient care delivery system in this important trauma subset remains unclear. We aimed to clarify whether the preoperative time course and mortality among injured patients differ between ambulances staffed by EPs and those staffed by emergency life-saving technicians (ELST). This was a retrospective cohort study at a community emergency department (ED) in Japan. We included all injured patients requiring emergency surgery or TAE who were transported directly from the ED to the operating room from January 2002 to December 2019. The primary exposure was dispatch of an EP-staffed ambulance to the prehospital scene. The primary outcome measures were preoperative time course including prehospital length of stay (LOS), ED LOS, and total time to definitive intervention. The other outcome of interest was in-hospital mortality. One-to-one propensity score matching was performed to compare these outcomes between the groups. Of the 1,020 eligible patients, 353 (34.6%) were transported to the ED by an EP-staffed ambulance. In the propensity score-matched analysis with 295 pairs, the EP group showed a significant increase in median prehospital LOS (71.0 min vs. 41.0 min, P < 0.001) and total time to definitive intervention (189.0 min vs. 177.0 min, P = 0.002) in comparison with the ELST group. Conversely, ED LOS was significantly shorter in the EP group than in the ELST group (120.0 min vs. 131.0 min, P = 0.043). There was no significant difference in mortality between the two groups (8.8% vs.9.8%, P = 0.671). At a community hospital in Japan, EP-staffed ambulances were found to be associated with prolonged prehospital time, delay in definitive treatment, and did not improve survival among injured patients needing definitive hemostatic procedures compared with ELST-staffed ambulances.

Prehospital Delay and its Impact on 30 days Outcomes in patients with Myocardial Infarction in Alshaab teaching hospital, Khartoum November2020-April 2021

BackgroundIschemic heart diseases are the most common cause of death worldwide, Prehospital delay associated with increased mortality and poorer outcome. This study aimed to determine whether particular patient's characteristics are associated with delays in seeking care, it also determined the impact of the delay on in-hospital outcomes, 30 days’ outcomes, and the cardiac functional status for patients after 30 days of their disease. MethodsThis prospective 30 days’ cohort study was conducted in Al shaab tertiary hospital in Khartoum. All patients diagnosed with myocardial infarction from 13th of January to 13th of February 2021 were included. Sociodemographic, clinical features, and health seeking behavior were collected using structured questionnaire, Patients were followed up by telephone to collect in-hospital and 30 days’ outcomes data. The Duke Activity Status Index (DASI) was used to assess the cardiac functional status after 30 days; Wilcoxon rank-sum test, Chi-square test of independence and Fisher's exact test were used to find if there is difference between groups categorized according to pre-hospital delay to tertiary hospital (< 6 hours or ≥ 6 hours), and to find the difference in the prognosis of patients according to pre-hospital delay time to hospital. Results98 patients were enrolled. The mean age for the participants was (58.6 ± 10.3) years. The mean total pre-hospital delay time was (11.0 ± 6.3) hours and the mean time patients took to decide that their condition requires medical attention was (5.6 ± 5.9) hours. The mean time for first medical interactions patients had was (6.9 ± 6.0) hours. Patients misperception of symptoms significantly contributed to prolonged pre-hospital times (p=0.002). Prolonged referral time led to prolonged prehospital time as the mean time for making the referrals was (2.7 ± 3.1) hours (p=0.005). STEMI patients tended to have earlier first medical interactions than patients diagnosed with Non-STEMI. Hypertensive patients had prolonged first medical interactions (p=0.016). In addition, prolonged time to first medical interaction led to a significant decrease in the cardiac functional status index after 30 days of admission as measured by the Duke Activity Status Index (DASI). ConclusionSome modifiable factors contribute to longer pre-hospital delay of myocardial infarction patients, resulting in decreased cardiac functional status after one month, patient's awareness about cardiovascular disease and improved referral pathway of the existing health care system may reduce the delay.

Prolonged Prehospital Time Is a Risk Factor for Pneumonia in Trauma (the PRE-TRIP Study): A Retrospective Analysis of the United States National Trauma Data Bank

Although multiple risk factors for development of pneumonia in patients with trauma sustained in a motor vehicle accident have been studied, the effect of prehospital time on pneumonia incidence post-trauma is unknown. Is prolonged prehospital time an independent risk factor for pneumonia? We retrospectively analyzed prospectively collected clinical data from 806,012 motor vehicle accident trauma incidents from the roughly 750 trauma hospitals contributing data to the National Trauma Data Bank between 2010 and2016. Prehospital time was independently associated with development of pneumonia post-motor vehicle trauma (P< .001). This association was primarily driven by patients with low Glasgow Coma Scale scores. Post-trauma pneumonia was uncommon (1.5%incidence) but was associated with a significant increase in mortality (P< .001, 4.3%mortality without pneumonia vs12.1%mortality with pneumonia). Other pneumonia risk factors included age, sex, race, primary payor, trauma center teaching status, bed size, geographic region, intoxication, comorbid lung disease, steroid use, lower Glasgow Coma Scale score, higher Injury Severity Scale score, blood product transfusion, chest trauma, and respiratory burns. Increased prehospital time is an independent risk factor for development of pneumonia and increased mortality in patients with trauma caused by a motor vehicle accident. Although prehospital time is often not modifiable, its recognition as a pneumonia risk factor is important, because prolonged prehospital time may need to be considered in subsequent decision-making.

Helicopter Hoist Operations in Difficult Nonalpine Terrain

ObjectiveHelicopter hoist operations (HHOs) are an option for rescue in difficult- or impossible-to-access environments. At present, only a few helicopters in German helicopter emergency medical services have a hoist capability; most of them are located in the Bavarian Alps. We sought to study the demand for hoist operations in difficult terrain outside of alpine regions. MethodsThe setting for this study was a city borough between the Rhine valley and the Black Forest (Germany). We retrospectively studied all rescue operations in difficult terrain from January 1, 2007, to July 31, 2018. The characteristics of the terrain and operational, demographic, and medical aspects were analyzed. The predictors for a prolonged response time and the total prehospital time were identified by multivariate regression analysis. In addition, a simulation study creating time intervals for the alternative rescue procedure (ground vs. hoist) was performed. Operational data for the simulation were taken from an expert survey as well as field data collection in the course of HHO training. ResultsA total of 251 missions were included. Patients were predominantly male (66.7%) adults (57.5%) with traumatic lesions (75.0%); 14.1% had severe or multiple injuries, 4.7% had life-threatening medical conditions, and 4.3% were deceased. Two hundred eight patients (93%) were rescued by ground procedures. The prehospital time of HHO missions was significantly longer (104 vs. 72 minutes, P < .001). However, the simulation of all missions showed a significantly shorter prehospital time with 80 versus 91 minutes (P < .001) for rescue by HHOs. The predictors for prolonged prehospital times were a vague description of the accident site, difficult terrain, distance from the road, slope gradient, and life-threatening nontraumatic conditions of the patient. ConclusionWe found a significant benefit of hoist operations regarding the total prehospital time and admission to an appropriate trauma center. Consistent dispatch procedures for HHO missions can improve patient outcomes. Adding HHO capabilities to some selected helicopter emergency medical service helicopters should be considered.

Effect of Covid-19 pandemic process on STEMI patients timeline.

ObjectiveDelayed revascularisation in patients with ST‐segment elevation myocardial infarction (STEMI) is associated with poor prognosis. The aim of this study is to investigate how the timeline in STEMI treatment was affected during the Covid‐19 outbreak.MethodConsecutive 165 STEMI patients were enrolled in the study during the Covid‐19 pandemic period (Pandemic period) and the prepandemic period (Control period). The time period until patients' leaving their current position after the onset of pain (home delay), the time from the onset of pain to the first medical contact (FMC delay), door‐to‐balloon time, procedure time and hospitalisation time were recorded.ResultsA total of 165 patients, 82 in the Pandemic period and 83 in the Control period, were included in the study. When compared with the control period, home delay [30 (5‐6912) minutes vs 165 (10‐360) minutes, P < .001] and FMC delay [61 (20‐6932) minutes vs 190 (15‐3660) minutes, P < .001] were significantly prolonged during the pandemic period. In addition, non‐IRA PCI rate (8.8% vs 19.3% P = .043) and hospitalisation time [71 (15‐170) vs 74.2 (37‐329) hours, P = .045] were decreased.ConclusionDuring the Covid‐19 pandemic period, prolonged prehospital time parameters were observed in STEMI patients. Therefore, additional measures may be required to prevent unfavourable delays in STEMI patients during the outbreak.

Pathologic Fibrinolysis is More Common in a Rural Trauma Setting.

Fibrinolysis (lysis) has been extensively studied in trauma patients. Many studies on the distribution of lysis phenotype have been conducted in setting with short prehospital time. This study aimed to evaluate the distribution of lysis phenotypes in a population with prolonged prehospital times in a rural environment. A retrospective study was performed at an American College of Surgeons-verified level 1 trauma center, serving a large rural population. Full trauma team activations from January 1, 2017 to August 31, 2018 were evaluated, and all patients with an ISS>15 analyzed. Thromboelastography was routinely performed on all participants on arrival. Lysis phenotypes were classified based on LY30 results: shutdown (≤.8%), physiologic (.9-2.9%), and hyper (>2.9%). 259 patients were evaluated, 134 (52%) presented direct from the scene. For scene patients, lysis distribution was 24% physiologic, 49% shutdown, and 27% hyper. Transferred patients demonstrated a reduction in physiologic lysis to 14% (P = .03), shutdown present in 66%, and hyper in 20%. Empiric prehospital tranexamic acid was given to 18 patients, physiologic lysis was present in 6%, shutdown 72%, and hyper 22%; this increase was not statistically significant (P = .5). Fibrinolysis phenotypes are not consistent across all trauma populations. This study showed rural trauma patients had a significantly increased rate of pathologic lysis. This was consistent for scene and transfer patients who received care at another facility prior to arrival for definitive care. Future studies to evaluate the factors influencing these differences are warranted.

Does increased prehospital time lead to a “trial of life” effect for patients with blunt trauma?

BackgroundVariance in prehospital time among severely injured blunt trauma patients is dependent upon numerous factors. Effects on subsequent mortality and trauma team activation (TTA) rates are also unclear. The primary aim of this study was to evaluate the relationship between prehospital time and mortality at level I trauma referral centers amongst critically blunt injured patients. Materials and methodsThis multiinstitutional study from three geographically distinct level I trauma centers analyzed all severely blunt injured patients (Injury Severity Score [ISS] ≥12). The relationship between prehospital time and survival was evaluated. Secondary outcomes included the association between prehospital time and TTA. Standard statistical methodology was used (P < 0.05 = significance). ResultsBetween January 1, 2011, and January 1, 2016, 5375 severely blunt injured patients (mean ISS = 25; mean length of stay = 16.3 d) were analyzed (center 1 = 3376; center 2 = 2401; and center 3 = 1104). As prehospital time interval increased, overall mortality decreased (0-30 min = 24.1%; 31-60 min = 14.7%; 61-90 min = 10.3%; 91-120 min = 10.4%; 121-150 min = 10.2%; P < 0.05). This pattern was especially strong for patients with an arrival measurement of hypotension, despite corrections for ISS (P < 0.05). TTA and patient outcomes were extremely variable across intervals and centers (P < 0.05). ConclusionsA trial of life effect is present for severely blunt injured patients who arrive with vital signs. Despite arrival measurements of hypotension, patients with prolonged prehospital times have a substantially lower risk of subsequent mortality. This concept should contribute to decision-making with regard to TTA.

Physician staffed helicopter emergency medical systems can provide advanced trauma life support in mountainous and remote areas

IntroductionIn remote and mountainous areas, helicopter emergency medical systems (HEMS) are used to expedite evacuation and provide pre-hospital advanced trauma life support (ATLS) in major trauma victims. Aim of the study was to investigate feasibility of ATLS in HEMS mountain rescue missions and its influence on patient condition at hospital admission. Patients58 major trauma victims (Injury Severity Score ≥16), evacuated by physician staffed HEMS from remote and mountainous areas in the State of Tyrol, Austria between 1.1.2011 and 31.12.2013. ResultsPre-hospital time exceeded 90min in 24 (44%) cases. 31 (53%) patients suffered critical impairment of at least one vital function (systolic blood pressure <90mmHg, GCS <10, or respiratory rate <10 or >30). 4 (6.9%) of 58 patients died prior to hospital admission. Volume resuscitation was restrictive: 18 (72%) of 25 hypotensive patients received ≤500ml fluids and blood pressure was increased >90mmHg at hospital admission in only 9 (36%) of these 25 patients. 8 (50%) of 16 brain trauma patients with a blood pressure <90mmHg remained hypotensive at hospital admission. Endotracheal intubation was accomplished without major complications in 15 (79%) of 19 patients with a Glasgow Coma Scale score <10. Rope operations were necessary in 40 (69%) of 58 cases and ATLS was started before hoist evacuation in 30 (75%) of them. ConclusionsThe frequent combination of prolonged pre-hospital times, with critical impairment of vital functions, supports the need for early ATLS in HEMS mountain rescue missions. Pre-hospital endotracheal intubation is possible with a high success and low complication rate also in a mountain rescue scenario. Pre-hospital volume resuscitation is restrictive and hypotension is reversed at hospital admission in only one third of patients. Prolonged pre-hospital hypotension remains an unresolved problem in half of all brain trauma patients and indicates the difficulties to increase blood pressure to a desired level in a mountain rescue scenario. Despite technical considerations, on-site ATLS is feasible for an experienced emergency physician in the majority of rope rescue operations.

Trauma care in Scotland: effect of rurality on ambulance travel times and level of destination healthcare facility.

The aim of this study was to determine the effect of rurality on the level of destination healthcare facility and ambulance response times for trauma patients in Scotland. We used a retrospective analysis of pre-hospital data routinely collected by the Scottish Ambulance Service from 2009-2010. Incident locations were categorised by rurality, using the Scottish urban/rural classification. The level of destination healthcare facility was coded as either a teaching hospital, large general hospital, general hospital, or other type of facility. A total of 64,377 incidents met the inclusion criteria. The majority of incidents occurred in urban areas, which mostly resulted in admission to teaching hospitals. Incidents from other areas resulted in admission to a lower-level facility. The majority of incidents originating in very remote small towns and very remote rural areas were treated in a general hospital. Median call-out times and travel times increased with the degree of rurality, although with some exceptions. Trauma is relatively rare in rural areas, but patients injured in remote locations are doubly disadvantaged by prolonged pre-hospital times and admission to a hospital that may not be adequately equipped to deal with their injuries. These problems may be overcome by the regionalisation of trauma care, and enhanced retrieval capability.

Paramedic rapid sequence induction (RSI) in a South African emergency medical service: A retrospective observational study

Early access to critical care interventions may improve outcomes for severely ill and injured patients. South Africa (SA) faces the unique challenges of prolonged pre-hospital times and limited access to physicians. In 2008, the Health Professions Council of SA introduced paramedic rapid sequence induction (RSI), the gold standard critical care intervention for emergency airway management; however, the risk to benefit ratio in this context is unclear. We conducted a pilot study to identify if paramedic RSI in the SA pre-hospital care setting is effective and safe. We undertook a retrospective observational study of paramedic RSI performed by an emergency medical service, between 12 December 2009 and 12 December 2011. Eighty-six RSIs were performed during the study period. No failed intubations were reported. Heart rate was significantly reduced from a median baseline value of 112 to 90 bpm, and oxygen saturations improved from 92% to 99% at handover following RSI. Nineteen patients (22%), however, had an adverse event (AE). Female patients (odds ratio (OR) 18.3; 95% confidence interval (CI) 3.46 - 99.38; p=0.001) and patients subsequently transported by helicopter (OR 7.24; 95% CI 1.44 - 36.32; p=0.016) remained independently associated with AEs after adjusting for confounders. RSI performed by specially trained paramedics is effective in terms of self-reported success. However, the 1 in 5 AE rate highlights safety concerns. The importance of a robust clinical governance programme to identify problems, refine practice and improve the quality of care is underscored.

Paramedic Rapid Sequence Intubation (RSI) in a South African Emergency Medical Service (EMS) is effective, but is it safe?

Background Early access to critical care interventions may improve outcomes for severely ill and injured patients. A Cochrane review [1] in 2009 reported that evidence supporting prehospital emergency intubation is lacking, but this does not equate to lack of benefit and prehospital RSI remains controversial. South Africa faces unique challenges due to prolonged prehospital times and limited access to physicians. In response to these challenges, the Health Professions Council of South Africa introduced paramedic RSI in 2008. This has been shown to be superior to intubation without paralysis, but a recent meta-analysis concluded that in the absence of prehospital physicians, alternatives to RSI should be strongly considered due to patient safety concerns[2]. This study aimed to identify if RSI performed by paramedics, in the South African prehospital care context is effective and safe.

Severe traumatic brain injury: consequences of early adverse events

Several factors associated with an unfavourable outcome after severe traumatic brain injury (TBI) have been described: prolonged pre-hospital time, secondary referral to a level 1 trauma centre, the occurrence of secondary insults such as hypoxia, hypotension or low end-tidal carbon dioxide (ETCO(2)). To determine whether adverse events were linked to outcome, patients with severe TBI were studied before arrival at a level 1 trauma centre. Prospective, observational study design. Patients with severe TBI (n = 48), admitted to Umeå University Hospital between January 2002 to December 2005 were included. All medical records from the site of the accident to arrival at the level 1 trauma centre were collected and evaluated. A pre-hospital time of >60 min, secondary referral to a level 1 trauma centre, documented hypoxia (oxygen saturation <95%), hypotension (systolic blood pressure <90 mmHg), hyperventilation (ETCO(2) <4.5 kPa) or tachycardia (heart rate >100 beats/min) at any time before arrival at a level 1 trauma centre were not significantly related to an unfavourable outcome (Glasgow Outcome Scale 1-3). Early adverse events before arrival at a level 1 trauma centre were without significance for outcome after severe TBI in the trauma system studied.

Clinical manifestations and effects of primary percutaneous coronary intervention for patients with delayed pre-hospital time in acute myocardial infarction

Prolonged pre-hospital time for acute myocardial infarction (AMI) is associated with decreased indication for primary percutaneous coronary intervention (PCI). However, the efficacy of primary PCI in AMI patients with prolonged pre-hospital time has not been fully investigated in Japan. A total of 3010 consecutive AMI patients admitted to AMI-Kyoto Multi-Center Risk Study Group hospitals were retrospectively analyzed, and the clinical characteristics and in-hospital prognosis of these patients were reviewed. Patients with pre-hospital delay [elapsed time (ET)>12 h] had a lower frequency of Killip≥3 (9.3%) and less frequently received primary PCI (77.7%) compared with patients with ET≤12 h. In the ET>12 h group, older patients or patients with MI history tended to be complicated by heart failure. Primary PCI was performed for patients with ET>12 h, irrespective of the severity of heart failure [Killip 1 (78.7%) vs Killip≥2 (74.0%); p=0.3827]. On multivariate logistic regression analysis, age [odds ratio (OR) 1.053], MI history (OR 2.860), Killip≥2 (OR 10.235), and multi-vessels or left main coronary artery as culprit (OR 11.712) were significant independent positive predictors of in-hospital mortality for patients with ET>12 h. Practice of primary PCI was not a significant negative predictor for patients with ET>12 h (OR 0.812), but it was for patients with ET≤12 h (OR 0.425). These findings indicate that patients with ET>12 h have a less severe condition and less frequently receive primary PCI compared with patients with ET≤12 h. Although primary PCI is often performed for these patients irrespective of the severity of heart failure, no preferable effect of primary PCI on the in-hospital mortality is demonstrated. In contrary, practice of primary PCI is a significant negative predictor of in-hospital mortality for patients with ET≤12 h.

Délais de prise en charge de l'IDM en phase aiguë : résultats d'une enquête dans la région de Sousse (Tunisie)

The goal of our work was to assess the delays of admission for Acute Myocardial Infarction (AMI) in Sousse (Tunisia) and to identify predictors of these delays. Our prospective survey was led from January 1999 to December 2001; 232 patients with AMI were included. The onset of symptoms usually occurred in the patient's home (80.6%). The chest pain was atypical in 19.4% of cases; 91% of patients directly consulted the emergency departments, whereas the ambulatory emergency services were used in only in 2.2% of cases. Delays of hospitalization in coronary care units were on average too long (14h 21min ± 19h 16min). This prolongation was essentially caused by a too long period between onset of symptoms and first patient call. In bivariate analysis, dyslipidemia, diabetes, absence of smoking and an atypical symptoms were associated with prolonged hospitalization delays. However in multivariate analysis, only diabetes and atypical symptoms were independent factors associated with a hospitalization delay of more than 12h. In 23% of the patients, a prolonged pre-hospital time period prevented the use of thrombolysis. Conclusion: Pre-hospital delays should be shortened by a multidisciplinary action that especially focuses on a better sanitary education of patients to risk.

Road traffic accidents with vehicular entrapment: incidence of major injuries and need for advanced life support.

Road traffic accidents (RTAs) with entrapment are perceived as a challenge to emergency systems because of the severity of the ensuing traumas and the inherent complexity of the rescue procedures. To clarify these two aspects this prospective cohort study enrolling 244 entrapped trauma patients was conducted by a Regional Medical Helicopter Service. Forty-six victims (18.9%) were found dead, 101 (51%) of the 198 patients who reached the hospital alive had an injury severity score (ISS) > or = 16. The use of seat belts was associated with lower trauma severity. Out of the 101 severely traumatized patients (ISS > or = 16), 46 (42.6%) were intubated at road side, 12 required decompression of a tension pneumothorax on the scene and in 15 cases a pneumothorax was drained during the early intrahospital phase. Thirty-six (34.7%) patients had the first systolic blood pressure (SBP) < or = 90 mmHg and were then aggressively infused: in 75% of these cases, the SBP on arrival at the emergency department increased. The first SBP was significantly correlated with mortality. There was no correlation of extrication time, total rescue time and mortality. Fourteen patients (13.9%) died during hospitalization. These data demonstrate that a high percentage of entrapped patients require advanced life support (ALS), including on scene intubation and chest decompression. Aggressive field resuscitation and immediate transport to a level 1 trauma centre is associated with a mortality lower than that predicted by TRISS in spite of the prolonged prehospital time.