Like all good studies, the results of the Intensive Care Unit Trauma Registry (REgistro de TRAuma en UCI [RETRAUCI])1 raise a series of questions referred to the reality of our healthcare practice. The pre-hospital management and/or preferential referral to trauma center strategies admittedly remain valid, though it is also true that they deserve in-depth revision, and continue to pose a challenge in relation to patient mortality.2 Much relevant information has been obtained, though it would be important to address certain aspects inherent to the initial phase of major trauma. As seems logical, an important proportion of patients are attended in situ and transferred by the out-hospital emergency services. Although there is a lesser delay in admission to the Intensive Care Unit (ICU) in these patients, it is not specified whether such transfer is preceded by the activation of some special code pre-alerting the hospital to the arrival of a patient with major trauma. Such activation is regarded as a key factor for ensuring rapid patient care, and has been practiced in Spain for years–with the collection of in other trauma registries as well as in many hospital centers and out-hospital emergency services3–including, by the way, some of the centers participating in the RETRAUCI.

Another aspect that also deserves attention is the origin of the patients. More than one-third of the cases come from hospital emergency rooms. Some additional information would be needed in relation to this patient population. Did the patients mainly arrive by their own means? Were they taken to hospital by non-medicalized out-hospital resources? Or were they transferred by the out-hospital emergency services? These patients have characteristics of their own, especially those attended in third-level hospitals, as is the case of most of the centers participating in the RETRAUCI, and at least some clinical data or basic initial severity scale information should be provided, explaining why they ended up being admitted to the ICU.3 The lack of such information gives the impression that the chain of care has shortcomings, since patients attended by the out-hospital emergency services are left in the emergency room and shortly afterwards appear in Intensive Care.

Lastly, it also would be very interesting to know the proportion of elderly patients that receive pre-hospital care. The decrease in traffic accidents has changed the profile of major trauma patients–increasing the mean age of the affected individuals and modifying the mechanisms underlying trauma, with a greater proportion of accidental falls among the elderly.4 We do not know whether these changes have an impact upon the way things are done by the out-hospital emergency services, or of whether such major trauma cases–traditionally underrated in comparison with traffic accidents–should receive some other type of care response.