title: Does prehospital time affect survival of major trauma patients where there is no prehospital care?
abstract: Survival after major trauma is considered to be time dependent. Efficient prehospital care with rapid transport is the norm in developed countries, which is not available in many lower middle and low-income countries. The aim of this study was to assess the effect of prehospital time and primary treatment given on survival of major trauma patients in a setting without prehospital care.
  
  
  
  This prospective observational study was carried out in a university hospital in Mumbai, from January to December 2014. The hospital has a trauma service but no organized prehospital care or defined interhospital transfer protocols. All patients with life- and/or limb-threatening injuries were included in the study. Injury time and arrival time were noted and the interval was defined as "prehospital time" for the directly arriving patients and as "time to tertiary care" for those transferred. Primary outcome measure was in-hospital death (or discharge).
  
  
  
  Of 1181 patients, 352 were admitted directly from the trauma scene and 829 were transferred from other hospitals. In-hospital mortality was associated with age, mechanism and mode of injury, shock, Glasgow Coma Score <9, Injury Severity Score ≥16, need for intubation, and ventilatory support on arrival; but neither with prehospital time nor with time to tertiary care. Transferred patients had a significantly higher mortality (odds ratio = 1.869, 95% confidence interval = 1.233-2.561, P = 0.005) despite fewer patients with severe injury. Two hundred and ninety-four (35%) of these needed airway intervention while 108 (13%) needed chest tube insertion on arrival to the trauma unit suggesting inadequate care at primary facility.
  
  
  
  Mortality is not associated with prehospital time but with transfers from primary care; probably due to deficient care. To improve survival after major trauma, enhancement of resources for resuscitation and capacity building of on-duty doctors in primary centers should be a priority in countries with limited resources.
authors.affiliation: Department of Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India.
authors.forename: S B
authors.initials: SB
authors.lastname: Dharap
authors.affiliation: Department of Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India.
authors.forename: S
authors.initials: S
authors.lastname: Kamath
authors.affiliation: Department of Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India.
authors.forename: V
authors.initials: V
authors.lastname: Kumar
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D004632:Emergency Medical Services / Q000379:methods; D005260:Female; D015600:Glasgow Coma Scale; D017052:Hospital Mortality; D006801:Humans; D007194:India / Q000453:epidemiology; D007223:Infant; D015601:Injury Severity Score; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D013997:Time Factors; D014193:Trauma Centers / Q000458:organization & administration*; D014947:Wounds and Injuries / Q000145:classification / Q000453:epidemiology* / Q000401:mortality; D055815:Young Adult