Intubated Trauma Patients Do Not Require Full Trauma Team Activation when Effectively Triaged - 24/03/16

Doi : 10.1016/j.jamcollsurg.2015.12.039

Brian G. Harbrecht, MD, FACS ^a,^⁎ , Glen A. Franklin, MD, FACS ^a, Jason W. Smith, MD, FACS ^a, Matthew V. Benns, MD, FACS ^a, Keith R. Miller, MD, FACS ^a, Nicholas A. Nash, MD ^a, Matthew C. Bozeman, MD ^a, Royce Coleman, MD ^b, Dan O'Brien, MD ^b, J. David Richardson, MD, FACS ^a
^a Department of Surgery, University of Louisville School of Medicine, Louisville, KY
^b Department of Emergency Medicine, University of Louisville School of Medicine, Louisville, KY

^∗Correspondence address: Brian G Harbrecht, MD, FACS, Hiram C Polk Jr, MD Department of Surgery, University of Louisville School of Medicine, 550 S Jackson St, Louisville, KY 40292.Hiram C Polk Jr, MD Department of SurgeryUniversity of Louisville School of Medicine550 S Jackson StLouisvilleKY40292

Abstract

Background

Full trauma team activation in evaluating injured patients is based on triage criteria and associated with significant costs and resources that should be focused on patients who truly need them. Overtriage leads to inefficient care, particularly when resources are finite, and it diverts care from other vital areas. Although shock and gunshot wounds to the abdomen are accepted indicators for full trauma activation, intubation as the sole criterion is controversial. We evaluated our experience to assess if intubation alone merited the highest level of trauma activation.

Study Design

All trauma patients from 2012 to 2013 were assessed for level of activation, injury characteristics, presence of intubation, and outcomes.

Results

Of 5,881 patients, 646 (11%) were level 1 (full) and 2,823 (48%) were level 2 (partial) activations. Level 1 patients were younger (40 ± 17 vs 45 ± 20 years), had more penetrating injuries (42% vs 9%), and had higher mortality (26% vs 8%)(p < 0.001). Intubated level 2 patients (n = 513), compared with intubated level 1 patients (n = 320), had higher systolic blood pressure (133 ± 44 vs 90 ± 58 mmHg), lower Injury Severity Score (21 ± 13 vs 25 ± 16), more falls (25% vs 3%), fewer penetrating injuries (11% vs 23%), and lower mortality (31% vs 48%)(p < 0.01). Fewer intubated level patients went directly to the operating room from the emergency department (ED)(16% vs 33%), and most who did had a craniotomy (63% vs 13%). Only 3% of intubated level 2 patients underwent laparotomy compared with 20% of intubated level 1 patients (p < 0.001). The ED lengths of stay before obtaining a head CT (47 ± 26 vs 48 ± 31 minutes) and craniotomy (109 ± 61 vs 102 ± 46 minutes) were similar. Deaths in intubated level 2 patients were primarily from fatal brain injuries.