Reducing time-to-treatment decreases mortality of trauma patients with acute subdural hematoma

Homer C N Tien, Vincent Jung, Ruxandra Pinto, Todd Mainprize, Damon C Scales, Sandro B Rizoli
Annals of Surgery 2011, 253 (6): 1178-83

OBJECTIVES: To determine if reducing prehospital time and time-to-craniotomy is associated with decreased mortality in trauma patients with acute subdural hematomas.

BACKGROUND: Time-to-treatment is an important performance filter for trauma systems, yet very little evidence exists to support its use. Despite the biological rationale supporting the notion of the "Golden Hour" for trauma patients, no evidence exists to support it. Likewise, it remains controversial whether or not time-to-craniotomy is associated with survival in patients with subdural hematomas. Previous studies may have been affected by selection bias.

METHODS: Retrospective cohort study of all trauma patients who arrived directly from the scene of injury. Study patients were all patients with acute subdural hematomas and without severe torso injuries, who required craniotomy at a Canadian level 1 trauma center from January 1 1996 to December 31 2007. The independent variables of interest were prehospital time and time-to-craniotomy. The primary outcome measure was in-hospital mortality.

RESULTS: Of 12,105 trauma patients assessed, 149 patients met inclusion criteria. Overall, 40% (n = 60) patients died. On univariate analysis, there was a strong trend suggesting that patients arriving within the "Golden Hour after trauma" had decreased mortality (37% vs. 53%, P = 0.09). However, there was no difference in mortality for patients undergoing craniotomy within 4 hours and after 4 hours (42% vs. 36%, P = 0.4). On multivariate logistic regression, increased prehospital time was found to be associated with increased mortality (odds ratio 1.03 per minute, 95% CI 1.004-1.05, P = 0.024). Surprisingly, there was a trend showing that increased trauma room to craniotomy times were associated with lower mortality (odds ratio 0.995 per minute, 95% CI 0.99-1.0, P = 0.056). However, patients who quickly had their craniotomy seemed to have more severe neurological injury.

CONCLUSION: Rapid transport of patients with traumatic subdural hematomas hospital is associated with decreased mortality.

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