Impact on the delay on vasopressor administration on ROSC

Impact of Delayed and Infrequent Administration of Vasopressors on Return of Spontaneous Circulation during Out-of-Hospital Cardiac Arrest

Prehospital Emergency Care posted online on July 23, 2012.

Epinephrine and vasopressin are the only vasopressors associated with return of spontaneous circulation (ROSC). While current guidelines recommend rapid and frequent vasopressor administration during cardiac arrest, delays in their administration in the out-of- hospital setting remain a concern.

This aim of this study was to evaluate delays in vasopressor administration and their effect on field ROSC. This retrospective review included all adult patients who experienced cardiac arrest of medical origin and received field resuscitative efforts among 10 emergency medical services (EMS) systems. Data were abstracted from the EMS medical record and included response time intervals, calculated first-dose and interdosing intervals of vasopressors, and ROSC. Data were analyzed using Mann-Whitney tests, chi-square tests, and t-tests, survival analysis, and logistic regression, with p ≤ 0.05 indicating significance.

A total of 660 cardiac arrest patients were enrolled in the study. The mean EMS response time was 8.8 minutes; 52.7% of patients had witnessed cardiac arrests, 46.2% received bystander cardiopulmonary resuscitation (CPR), 23.0% had shockable initial rhythms, and 19.5% experienced field ROSC. In total, 1,913 doses of epinephrine and 111 doses of vasopressin were administered, with mean and 90th-percentile scene arrival–to–first drug intervals of 9.5 and 17 minutes, respectively. The mean and 90th-percentile interdosing intervals were 6.1 and 10 minutes, respectively. Patients experiencing ROSC had shorter scene arrival–to–first drug intervals than those without ROSC (8.1 vs. 9.8 min, but there was no difference in the mean interdosing interval (6.8 vs. 6.0 min). In the logistic regression analysis of ROSC, the adjusted odds ratio for call receipt–to–first drug interval ≤10 minutes was 1.91.

Patients receiving advanced airway control prior to vasopressor administration were less likely to have a call receipt–to–first drug interval within 10 minutes (4.0% vs. 17.3%) and were less likely to attain ROSC (15.7% vs. 25.4%.

The authors concluded that the interval between scene arrival and first administration of vasopressors is significantly shorter among patients who experience ROSC compared with those who do not. Airway control procedures delay vasopressor administration and reduce the likelihood of ROSC. Although the interdosing intervals of most patients were not consistent with current recommendations, there was no difference in the mean interdosing times between those who achieved ROSC and those who did not.

http://informahealthcare.com/doi/abs/10.3109/10903127.2012.702193

Comparison of pre-hospital and in-hospital blood pressure measurements

Agreement between Emergency Medical Services and Expert Blood Pressure Measurements

The Journal of Emergency Medicine Volume 43, Issue 1 , Pages 64-68

Emergency Medical Services (EMS)-measured blood pressures (BPs) are utilized for administering medications in the field and for triage decisions. Retrospective work has demonstrated poor agreement between EMS and Emergency Department (ED) BP but has lacked a valid, reliable reference standard so the authors decided to compare EMS BP measurements with those of trained research assistants (RA) and observe measurement technique for sources of error.

A prospective study was performed with a large urban EMS. BP measurements were made by RA within 5 min of patients presenting to the ED. EMS personnel were asked about technique. EMS personnel were then observed while RA simultaneously measured BP. Analysis was performed using methods outlined by Bland and Altman.

There were 100 patients enrolled for each phase. In the first phase, the mean difference in systolic BP was −3.8 ± 18.6 mm Hg  and the mean difference in diastolic BP was 0.42 ± 13.8 mm Hg. In the second phase, the mean difference in systolic BP was −4.6 ± 10.1 mm Hg and the mean difference in diastolic BP was −3.6 ± 10.6 mm Hg. EMS personnel failed to properly place the cuff or deflate it 2–3 mm Hg/s in over 90% of the readings. They failed to properly inflate the cuff in 74% of the patients, and failed to properly place the stethoscope in 40%. EMS personnel demonstrated a significant preference for the terminal digit of “0”.

EMS and expert BP measurements showed smaller discrepancies than those previously noted, especially with simultaneous measurements. However, the authors believe that EMS demonstrated poor adherence to American Heart Association recommendations for measuring BP and that EMS also showed terminal digit preference.

http://www.jem-journal.com/article/S0736-4679(11)00648-2/abstract?elsca1=etoc&elsca2=email&elsca3=0736-4679_201207_43_1&elsca4=emergency_medicine

Comparision of morphine and fentanyl

The Effectiveness and Adverse Events of Morphine versus Fentanyl on a Physician-staffed Helicopter

The Journal of Emergency Medicine Volume 43, Issue 1 , Pages 69-75

Morphine and fentanyl are both frequently used in prehospital trauma patients, but due to limited formulary size, the authors sought to study whether both drugs should be included. The purpose of the study was to evaluate the effectiveness and safety of fentanyl as compared to morphine for patients requiring analgesic medications for a traumatic injury during transport via a physician-staffed air medical service.

Trauma patients were grouped by even and odd days (even – morphine 4 mg, odd – fentanyl 50 μg). Patients were excluded based on age (< 18 or > 64 years), hypotension, inability to communicate a pain score (intubated), or known allergy to the study drugs. During the flight, medical crew assessed numeric pain score, vital signs, and incidence of pruritis or nausea.

There were 103 patients enrolled in the morphine arm and 97 patients in the fentanyl arm. The mean pain score at the beginning of enrollment was 8.0 ± 2.0 in the morphine arm and 8.0 ± 1.8 in the fentanyl arm. The mean final pain score was 5.8 ± 2.7 in the morphine arm and 5.5 ± 2.4 in the fentanyl arm (n.s. by either t-test or non-parametric testing). There was no significant difference in analgesia between fentanyl and morphine. There were no significant differences in the incidence of pruritis or vomiting between the two groups. Average transport time was 37 ± 8 min in the morphine group, and 43 ± 11 min in the fentanyl group. Average number of morphine doses was 3 ± 1.2. For fentanyl, average number of doses was 3 ± 1.3.

In the study, there was not a significant difference in analgesic effectiveness between morphine and fentanyl. There was no significant difference in the incidence of adverse effects between the two drugs. The authors conclude that study suggests that either drug can be used safely with equivalent effectiveness.

http://www.jem-journal.com/article/S0736-4679(11)00528-2/abstract?elsca1=etoc&elsca2=email&elsca3=0736-4679_201207_43_1&elsca4=emergency_medicine

Are we resuscitating for long enough?

Duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study

The Lancet, Early Online Publication

Are we performing resuscitation for long enough? In this study the authors wanted to know for in-hospital cardiac arrests, how long resuscitation attempts should be continued before termination of efforts. While this is an in-hospital study, the answer could be relevant for pre-hospital guidelines. The authors investigated whether duration of resuscitation attempts varied between hospitals and whether patients at hospitals that attempt resuscitation for longer have higher survival rates than do those at hospitals with shorter durations of resuscitation efforts.

Between 2000 and 2008, 64,339 patients with cardiac arrests were identified at 435 US hospitals within the Get with the Guidelines – Resuscitation registry. For each hospital, the median duration of resuscitation before termination of efforts in non-survivors was. Multilevel regression models were used to assess the association between the length of resuscitation attempts and risk-adjusted survival. Primary endpoints were immediate survival with return of spontaneous circulation (ROSC) during cardiac arrest and survival to hospital discharge.

31,198 of 64,339 (48·5%) patients achieved return of spontaneous circulation and 9,912 (15·4%) survived to discharge. For patients achieving return of spontaneous circulation, the median duration of resuscitation was 12 min compared with 20 min for non-survivors. Compared with patients at hospitals in the quartile with the shortest median resuscitation attempts in non-survivors (16 min), those at hospitals in the quartile with the longest attempts (25 min) had a higher likelihood of return of spontaneous circulation and survival to discharge.

It was found that duration of resuscitation attempts varies between hospitals. The authors believe that although they cannot define an optimum duration for resuscitation attempts on the basis of these observational data, their findings suggest that efforts to systematically increase the duration of resuscitation could improve survival in this high-risk population.

According to the Australian Resuscitation Council, there is substantial variability in the approaches to termination of resuscitation attempts during cardiac arrest management and factors taken into account include whether the arrest was witnessed, whether bystander CPR was provided, the duration of cardiac arrest, and associated co-morbidities. Just looking to the US for examples of their termination of resuscitation recommendations, while advanced level providers have a minimum time of 20 minutes specified, basic level providers can terminate after 6 minutes (3 full rounds) of CPR and AED analysis.

A large proportion of pre-hospital guidelines specify that resuscitation cannot be terminated until after 20 minutes of ALS care, which once you include the initial CPR, defibrillation, venous access and airway management skills would probably amount to a resuscitation time of 25 minutes or longer which would follow the study’s findings of a greater likelihood of survival and ROSC. However, where there are no guidelines specifying time limits, or those that follow the ‘no ROSC within 3 full cycles of CPR and AED analysis’ rule, should be we saying that these ambulance crews should be staying on scene for longer (maybe even 20 – 25 minutes), especially when considering the poor effectiveness of CPR during extrication and in a moving ambulance.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60862-9/abstract

While on the subject of poor effectiveness of CPR, a recent study has found that fatigue can affect chest compression delivery within the second minute of CPR, providing more evidence of the importance of, wherever possible, changing the chest compression provider after every rhythm analysis..

Rescuer fatigue under the 2010 ERC guidelines and its effect on cardiopulmonary resuscitation (CPR) performance

Emerg Med J 2012 Published online

This study sought to determine the impact of the 2010 resuscitation guidelines on rescuer fatigue and cardiopulmonary resuscitation (CPR) performance.

62 Health science students performed 5 min of conventional CPR in accordance with the 2010 ERC guidelines. A SkillReporter manikin was used to objectively assess temporal change in determinants of CPR quality. Participants subjectively reported their end-fatigue levels, using a visual analogue scale, and the point at which they believed fatigue was affecting CPR delivery.

49 (79%) participants reported that fatigue affected their CPR performance, at an average of 167 s. End fatigue averaged 49.5/100. The proportion of chest compressions delivered correctly decreased from 52% in min 1 to 39% in min 5, approaching significance. A significant decline in chest compressions reaching the recommended depth occurred between the first (53%) and fifth (38%) min. Almost half this decline (6%) was between the first and second minutes of CPR. Neither chest compression rate, nor rescue breath volume, were affected by rescuer fatigue.

Fatigue affects chest compression delivery within the second minute of CPR under the 2010 ERC guidelines, according to the authors, and is poorly judged by rescuers. Rescuers should, therefore, be encouraged to interchange after 2 min of CPR delivery. Team leaders should be advised to not rely on rescuers to self-report fatigue, and should, instead, monitor for its effects.

http://emj.bmj.com/content/early/2012/07/31/emermed-2012-201610.abstract

Prehospital diagnosis of STEMI by basic level providers

Prehospital diagnosis and triage of ST-elevation myocardial infarction by paramedics without advanced care training.

American Heart Journal 2012, Volume 164, Issue 2

Prehospital triage of ST-elevation myocardial infarction (STEMI) for primary percutaneous coronary intervention (PCI) reduces treatment times. Prehospital triage and transport of STEMI patients have traditionally been undertaken in emergency medical service systems with advanced care paramedics (ACPs). However, ACPs are not available in many regions. A pilot study was conducted to determine the feasibility of prehospital STEMI triage in a region with only primary care paramedics.

Hemodynamically stable patients with chest pain and suspected STEMI were brought directly to a catheterisation laboratory for primary PCI. All paramedics received an additional 4 hours of training on 12-lead ECG interpretation for identification of STEMI. There was no transmission of the ECG. End points included accuracy of prehospital STEMI identification, complications during transfer, and treatment times.

One hundred thirty-four consecutive patients with suspected STEMI were triaged for primary PCI. Only 1 patient developed complications during transport (rapid atrial flutter) that required ACP skills. One hundred thirty-three patients underwent urgent angiography, and 105 patients underwent PCI. Based on physician interpretation of the prehospital electrocardiogram, there was agreement with triage decision for 121 (90%) of the 134 cases. The final diagnosis based on the angiogram and cardiac markers was true STEMI for 106 patients and false positive for 28 patients. The median first medical contact to balloon time was 91 (81-115) minutes.

Hemodynamically stable patients with suspected STEMI can be safely and effectively transported directly for primary PCI by paramedics without advanced care training. Prehospital STEMI triage for primary PCI can be extended to regions that have few or no paramedics with advanced care training.

http://www.ahjonline.com/article/S0002-8703(12)00365-1/abstract

Prehospital validation of the ROSIER stroke assessment tool

Validation of the use of the ROSIER scale in prehospital assessment of stroke

Annals of Indian Academy of Neurology: 2012 vol:15 iss:3 pg:191

It was the intention of the authors to determine the utility of the Recognition of Stroke in the Emergency Room (ROSIER) scale as a stroke recognition tool among Chinese patients in the prehospital setting. Emergency physicians compared the Cincinnati Prehospital Stroke Scale (CPSS) with the ROSIER as a stroke recognition tool on suspected patients in the prehospital setting. The final discharge diagnosis of stroke or transient ischemic attack made by neurologists, after assessment and review of clinical symptomatology and brain imaging findings, was used as the reference standard for diagnosis in the study. Then, the ROSIER and the CPSS like sensitivity (Se), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV), related coefficient (r) and Kappa value were calculated.

The ROSIER was recently developed and has been claimed to be better than the CPSS, FAST and LAPSS in the emergency department (ED) setting, however, its performance in the prehospital setting is still unknown. The ROSIER assesses elements of history and physical examination (loss of consciousness, seizure activity, asymmetric facial, arm and leg weakness, speech disturbance and visual field defect) to produce a score between two and five. Patients with a total score of >0 are taken as being consistent with stroke, whereas scores of 0 signify a low probability of stroke.

In this study, 540 of 582 suspected stroke patients met the study criteria. The CPSS showed a diagnostic Se of 88.77%, Sp of 68.79%, PPV of 87.40%, NPV of 71.52% and r of 0.503. Relatively, the ROSIER showed a diagnostic Se of 89.97%, Sp of 83.23%, PPV of 92.66%, NPV of 77.91% and r of 0.584. According to the final discharge diagnosis, both the ROSIER and the CPSS were associated with the final discharge diagnosis.The Kappa statistic value of the ROSIER and the CPSS were 0.718 and 0.582, respectively. However, there was no statistical significance of the positive rate between the ROSIER and the CPSS in this study.

The authors concluded that ROSIER is a sensitive and specific stroke recognition tool for health providers’ use among Chinese patients in the prehospital setting. However, it cannot be used to confidently rule out or identify stroke as a diagnosis. Comprehensive clinical assessment and further examination on potential stroke patients are still important and cannot be replaced. When it is difficult to objectively complete the ROSIER for patients, the CPSS could replace it in the prehospital setting.

http://www.annalsofian.org/article.asp?issn=0972-2327;year=2012;volume=15;issue=3;spage=191;epage=195;aulast=Mingfeng;type=0

Endotracheal intubation versus supraglottic airway insertion in out-of-hospital cardiac arrest

Resuscitation, Volume 83, Issue 9, September 2012, Pages 1047–1048

To simplify airway management and minimise interruptions to cardiopulmonary resuscitation (CPR) chest compression, there has been an increase in the use of supraglottic airway (SGA) devices instead of endotracheal intubation (ETI) as the primary airway adjunct in out-of-hospital cardiac arrest (OHCA). For this research the authors compared the outcomes of patients receiving ETI with those receiving SGA following OHCA.

A secondary analysis of data from the multicenter Resuscitation Outcomes Consortium (ROC) PRIMED trial was undertaken with adult non-traumatic OHCA receiving successful SGA insertion (King Laryngeal Tube, Combitube, and Laryngeal Mask Airway) or successful ETI studied. The primary outcome was survival to hospital discharge with satisfactory functional status (Modified Rankin Scale ≤3). Secondary outcomes included return of spontaneous circulation (ROSC), 24-h survival, major airway or pulmonary complications (pulmonary oedema, internal thoracic or abdominal injuries, acute lung injury, sepsis, and pneumonia). Using multivariable logistic regression, the authors studied the association between out-of-hospital airway management method (ETI vs. SGA) and OHCA outcomes, adjusting for confounders.

Of 10,455 adult OHCA, 8487 (81.2%) received ETI and 1968 (18.8%) received SGA. Survival to hospital discharge with satisfactory functional status was4.7% for ETI, compared with 3.9% for SGA. Compared with successful SGA, successful ETI was associated with increased survival to hospital discharge, ROSC and 24-h survival. ETI was not associated with secondary airway or pulmonary.

In this secondary analysis of data from the trial, ETI was associated with improved outcomes when compared with SGA insertion after OHCA.

Following the various published research studies which states that pre-hospital tracheal intubation can be associated with no benefit or is harmful this article could be welcomed by some as good news, providing the more evidence for they importance of paramedic intubation, but it may not be as simple as that.

The clinical trial was never intended to be used for the evaluation of airway management techniques and did not record such variables as time of airway insertion (for example before or after ROSC), number of airway attempts, whether the airway was displaced during resuscitation or transportation and interruptions to chest compressions. Likewise, the decision to intubate over the use of a SGA was left to the decision of the attending paramedic (no randomised trial) and, as the SGA is still thought to by some as a failed intubation device, could be the reason that a SGA was used, without intubation being attempted, in only 12.2% of cases. While taking this into consideration, this is a trial involving a large number of patients – over 10,000 – and the authors might have found some evidence in favour for the, often argued subject of whether paramedics should intubate.

It is clear that more research, not only randomised comparisons on airway devices with minimal variables (yes, I know how hard this is in the cardiac arrest situation but large number studies may reduce the effect of such variables) is required, but also a comparison on the different types of SGA device. As SGAs used to be considered as a failed intubation tool, the disadvantages were sometimes accepted, however with the increased use, or especially when considered as a primary adjunct, the risks associated with a SGA should be considered. In animal models it has been shown that there has been 15–50% decrease in carotid blood flow observed with the use of SGA (King LT, LMA and Combitube) compared with ETI, thought to be caused by the cuff and/or balloons applying pressure on the carotid artery. If this is found to be true in humans, this could affect neurological outcome and survival.  Other reported complications associated with Combitube use including aspiration pneumonitis, airway and esophageal injuries, and cranial nerve injury, similar adverse events may be possible with King LT or LMA use in OHCA.

One study which should provide interesting reading is the randomised trial of the I-gel versus LMA Supreme versus standard care in OHCA currently being undertaken within the UK (http://www.controlled-trials.com/ISRCTN18528625/18528625), especially as the I-gel does not have an inflatable cuff or balloon which not only decreases the time of insertion but could also reduce the pressure on the carotid artery when compared with other SGA devices.

Airway management is only a part of the resuscitation attempt, studies face a huge number of variables which could affect survival and ROSC, for example, the time taken until CPR started and first shock, the training and experience levels of paramedics, any difficult extrication causing prolonged interruptions to chest compressions, hyperventilation (both during CPR and post ROSC) and the use of therapeutic hypothermia. Until we have more evidence which clearly identifies the most appropriate airway management technique, I believe we should continue doing what we already know that improves ROSC and survival, for example:

  • Early recognition of cardiac arrest and ambulance activation;
  • Early CPR by bystanders and community responders;
  • Minimise time to first shock through the use of public access defibrillators, community responders and rapid ambulance response;
  • Good quality CPR with minimal interruptions and frequent changes to CPR providers to prevent tiring, this may also include the use of mechanical CPR devices but more research on these would be nice;
  • Utilisation of appropriate airway management devices without causing interruptions to compressions, this may be either an ETI or SGA, but the important thing is that chest compressions are not interrupted and hypoxia minimised during airway management attempts. Where resources are limited, it may be appropriate for a SGA device to be inserted very early while chest compressions are being undertaken and then when/ if ROSC is obtained, changed to a ET tube for the transportation phase and ROSC management strategy; and
  • Use of adrenaline, yes, the jury is still out on this but studies have shown that it can increase the likelihood of ROSC. Once we have ROSC, strategies such as therapeutic hypothermia, maintenance of blood pressure and arrhythmias, adequate ventilation and oxygenation (including the use of end-tidal capnography) and transport to PCI capable centres, where appropriate, should become our focus.

http://www.sciencedirect.com/science/article/pii/S0300957212002705

Paramedics successfully perform humeral EZ-IO intraosseous access in adult out-of-hospital cardiac arrest patients

American Journal of Emergency Medicine, Volume 30, Issue 7, Pages 1095-1099, September 2012

With the increase in the use of the intraosseous route for gaining venous access, especially in cardiac arrest and adult patients, the authors wanted to determine the first-attempt success rate at humeral placement of the EZ-IO by paramedics among prehospital adult cardiac arrest patients. The humerus has been considered as more difficult to access than other sites, possibly due to challenges in identifying the landmarks.

A retrospective cohort analysis of data prospectively collected over a 9-month period in San Antonio, Texas. The cohort consisted of adult cardiac arrest patients in whom the EZ-IO placement was attempted in the humerus by paramedics. The choice of vascular access was at the discretion of the paramedic and options included tibial or humeral EZ-IO and intravenous. Primary outcome is the percentage of successful placements (stable, flow, without extravasation) on first attempt. Secondary outcomes are overall successful placement, complications, and reason for failure. Data were collected during a post–cardiac arrest interview.

Humeral intraosseous (IO) access was attempted in 61% of 405 cardiac. First-attempt successful placement was 91%. Successful placement was 94%, considering the second attempts. In the unsuccessful attempts, 2% reported obesity as the cause (thought to be due to difficulty in locating the landmarks), 1% reported stable placement without flow, and 2% reported undocumented causes for failure. There were also 2% reports of successful placement with subsequent dislodgement during resuscitation or transport to hospital. Other studies have shown that humerus IO placement is at high risk of displacement, especially if usual length IO needles are used (longer 45 mm needles were used in this study for humeral access) but the report does not specify whether the Ez-IO securing device was used to reduce this risk.

The results of this study suggest a high degree of paramedic proficiency in establishment of IO access in the proximal humerus of the out-of-hospital cardiac arrest. Few complications suggest that proximal humeral IO access is a reliable method for vascular access in this patient population.

http://www.ajemjournal.com/article/S0735-6757(11)00327-5/abstract?elsca1=etoc&elsca2=email&elsca3=0735-6757_201209_30_7&elsca4=emergency_medicine

Burning Man 2011: Mass Gathering Medical Care in an Austere Environment

Burning Man 2011: Mass Gathering Medical Care in an Austere Environment

Prehospital Emergency Care, Vol. 16, No. 4 , Pages 469-476
For those involved in the organisation of medical coverage for large events may find the review detailing the planning and subsequent medical care for Burning Man 2011 interesting.  Burning Man is a large weeklong outdoor arts festival held annually in the rugged and austere Black Rock Desert in northern Nevada. The 2011 event presented several unusual challenges in terms of emergency medical services (EMS) and medical care provision.

Attendance at Burning Man 2011 was 53,735. Of these attendees, 2,307 were treated in the field hospital. While most patients had minor injuries, 33 were subsequently transported to a hospital (28 by ambulance and five by helicopter). The most common conditions treated were soft-tissue injuries, dehydration, eye problems, and urinary tract infections. There was one death (subarachnoid haemorrhage) and one patient in cardiac arrest (thoracic aortic dissection) who was successfully resuscitated and transferred. Burning Man 2011 presented numerous challenges in provision of EMS and medical care because of attendance size, the austere environment, and significant distance (150 miles) to definitive medical care. EMS operations included six dedicated ambulances, three quick-response vehicles, two first-aid stations, and a physician-staffed field hospital. The hospital had limited diagnostic capabilities (e.g., x-ray, ultrasound, basic laboratory analysis) and a limited formulary. It was found that the use of physicians was necessary because much of the care provided was beyond the scope of paramedics.

http://informahealthcare.com/doi/abs/10.3109/10903127.2012.695432

The Impact of Distance on Triage to Trauma Centre Care in an Urban Trauma System

The Impact of Distance on Triage to Trauma Centre Care in an Urban Trauma System

Prehospital Emergency Care, Vol. 16, No. 4, Pages 456-462

Urban trauma systems are characterised by high population density, availability of trauma centres, and acceptable road transport times (within 30 minutes). In such systems, patients meeting field trauma triage (FTT) criteria should be transported directly to a trauma centre, bypassing closer non–trauma centres. The authors evaluated emergency medical services (EMS) triage practices to identify opportunities for improving care delivery. Specifically, the effect of the additional distance to a trauma centre, compared with a closer non–trauma centre, was evaluated on the noncompliance with trauma destination criteria by EMS personnel in an urban environment.

Inclusion criteria identified 898 patients; 53% were transported directly to a trauma centre. Falls, female gender, and age greater than 65 years were associated with transport to non–trauma centres. Differential distances greater than 1 mile were associated with a decreased likelihood of triage to a trauma centre.

According to the authors, the differential distance between the closest non–trauma centre and the closest trauma centre is associated with lower compliance with triage protocols, even in an urban setting where trauma centres can be accessed within approximately 30 minutes. The authors suggest that the gap between ideal and actual application of field trauma triage guidelines can be reduced through a process of education and feedback.

http://informahealthcare.com/doi/abs/10.3109/10903127.2012.695431