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RESEARCH PRODUCT

182 Does emergency physician prehospital management improve outcome of severe blunt trauma?

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Severe blunt traumas are a leading cause of premature death and handicap. The benefit for the patient of pre-hospital management by emergency physicians remains under debate because of possible delayed hospital admission. This study aimed at comparing the impact of basic life support (BLS) performed by fire brigades with advanced life support (ALS) performed by SMUR (Service Mobile d9Urgences et de Reanimation) physicians, on 30-day mortality. The FIRST study (French Intensive Care Recorded Severe Trauma) is a French observational multicentric study designed in order to describe the modalities of severe blunt trauma management. The study population was composed of trauma patients over 18 years requiring an admission in intensive care units from university hospital within 72 h after injury with or without university hospital SMUR intervention. For this analysis, Injury Severity Score (ISS) and clinical status were a priori categorized as follows: ISS ( 34), GCS score ( 13), systolic arterial blood pressure ( 110 mmHg), SpO2 ( 29 min −1 ). Univariate comparisons were performed using χ 2 tests or Fisher9s exact tests, if needed. Multivariable analysis was performed by using logistic regression models. Independent variables were: pre-hospital management (physician involved or not), age, sex, injury severity score, systolic blood pressure, SpO2, respiratory rate, GCS score (model 1); and second, hospital admission delay (model 2). Interaction terms between physician pre-hospital management and other independent variables were systematically tested. As none were significant, they were dropped from the final model. Among 2703 patients, 190 received pre-hospital BLS from fire brigades and 2513 received ALS from SMUR physicians. SMUR patients presented a poorer initial clinical status and higher ISS and were admitted to hospital after a longer delay than BLS patients (see table 1). The crude 30-day mortality rate was comparable for BLS and ALS patients (15% and 17% respectively; p=0.61). After adjustment (see table 2), pre-hospital ALS by an emergency physician significantly reduced the risk of 30-day mortality (OR: 0.55, 95% CI: 0.32 to 0.94, p=0.03). Further adjustment for hospital admission delay only marginally affected these results. This observational study suggests that medical pre-hospital care may have a favourable impact on 30-day mortality, possibly due to careful medical assessment of the patient and high use of intensive pre-hospital life-sustaining treatments by SMUR. Further studies are needed to better understand the reasons of such benefit. La traumatologie grave est l9une des principales causes de deces precoce et de handicap. L9impact de la medicalisation pre hospitaliere par un medecin urgentiste est l9objet de debat, notamment en raison de l9allongement du delai d9admission hospitaliere. L9objectif de ce travail est de comparer l9impact de la medicalisation pre hospitaliere par les equipes SMUR (Service Mobile d9Urgences et de Reanimation) sur la survie a 30 jours par rapport aux patients pris en charge uniquement par une equipe non medicale. L’etude FIRST (French Intensive Care Recorded Severe Trauma) est une etude prospective francaise observationnelle realisee dans le but de decrire les modalites de prise en charge des patients presentant un traumatisme grave ferme. Les criteres d9inclusion choisis pour cette etude sont: âge superieur ou egal a 18 ans, admission dans les 72 heures post-traumatiques dans un service de reanimation de l9un des 14 CHU participants avec ou sans prise en charge pre hospitaliere par une equipe SMUR. Pour cette analyse, L9Injury Severity Score (ISS) et l’etat clinique initial ont ete categorises comme suit: ISS ( 34), GCS score ( 13), Pression arterielle systolique (PAS) ( 110 mm Hg), SpO2 ( 29 min-1). L9analyse univariee a ete realisee en utilisant un test du Chi 2 ou si besoin un test exact de Fischer. L9analyse multi variee a ete realisee par regression logistique. Les variables independantes sont pour le premier modele, l9existence ou non d9une medicalisation pre-hospitaliere, l’âge, le sexe, l9ISS, la PAS, le frequence respiratoire, le GCS, et dans le second modele a ete introduit en plus le delai d9admission a l9hopital. Les interactions avec le type de prise en charge pre hospitaliere ont systematiquement ete testees, du fait de l9absence d9interaction les variables ont finalement ete retenues dans le modele final. Sur les 2629 patients inclus, 190 n9ont pas ete medicalises et 2439 ont ete pris en charge par une equipe medicale. Les patients medicalises sont significativement plus graves sur le plan clinique, presentent un ISS plus eleve et sont admis plus tardivement sur l9hopital. La mortalite a 30 jours ne parait pas differente (15% vs 17%, p=0,61). Apres ajustement, il apparait que la medicalisation pre hospitaliere reduit significativement le risque de deces a 30 jours (OR: 0,55, 95% CI: 0,32-0,94, p=0,03). L9ajustement sur le delia d9admission a l9hopital affecte peu le resultat. Cette etude prospective observationnelle, suggere que la medicalisation prehospitaliere pourrait avoir un impact favorable sur la mortalite a 30 jours. Ce benefice pourrait s9expliquer par une meilleure evaluation initiale et par le recours aux soins de reanimation prehosiptaliere utilises par les equipes SMUR. Des travaux restent a realiser pour tenter de mieux comprendre les raisons de ce benefice.