Response to Burns et al

Abstract

Dear Editor, We thank Burns and colleagues for their interest in our study. The study set out to examine whether pre‐hospital emergency anaesthesia (PHEA) was associated with increased mortality in hypovolaemic trauma patients who are awake on scene. Most of the points raised are discussed in the limitations section and have arisen as a result of the retrospective methodology used. Feedback after publication has indicated that this issue is of concern to many pre‐hospital practitioners. Burns et al have commented on the fact that not all patients had numerical values documented for the initial systolic blood pressure. Although it is standard practice to record an early non‐invasive blood pressure on scene, where this is not recordable the use of central and peripheral pulses to estimate volume status is common practice. Where no numerical value was available, patients documented to have a good/strong radial pulse were excluded as this is likely to indicate a higher blood pressure. Patients with a weak or absent radial pulse were included as this was taken to reflect a lower systolic blood when compared with a normal pulse. Interestingly if patients with no numerical value for blood pressure are excluded, the mortality rate in the PHEA patients remains significantly higher; 23.3% mortality in the PHEA group compared with 5% intubated on hospital arrival (P = 0.01). In addition to the mortality reported in both groups the study went on to examine whether this difference was increased when clinical evidence of bleeding or injuries which are likely to cause bleeding were identified. This was the case. The pre‐hospital information was supplemented, where possible, with clinical information from in‐hospital records. The limitations comment on the fact that there was an element of subjectivity in this assessment. Burns et al refer to the use of a seven‐point scale to establish hypovolaemia, but a seven‐point scale was not created nor used and there is no reference to such a scale in the study. The paper also comments on the possible differences between the groups which may indicate more serious injuries or worse physiology in one patient group. Our study demonstrates an association between PHEA and in‐ hospital mortality in awake hypotensive trauma patients, which is strengthened where hypotension is likely secondary to hypovolaemia. Although this patient group is relatively small in most pre‐hospital systems we look forward to the publication of data from other systems in due course to clarify the scale of the problem and strategies to improve outcomes.