6928例创伤的院前急救特点

目的探讨院前创伤急救的组织实施及救治技术当前的特点。方法回顾性分析总结2000年12月至2003年12月我院“120”出诊急救的创伤病人6928例救治资料。结果21～50岁占79.30%;伤因:交通伤39.00%、治安事件伤30.00%、工伤及坠落伤10.74%;伤情按院前创伤指数(TI)分:重伤病人20.99%,中度伤38.11%;院前急救成功率96.43%,现场心肺复苏成功率12.97%。结论控制救治反应时间,落实“三线出诊”机制,实施有效的现场急救技术,完善急救及转运设备,建立专业化、专职化的急救队伍是提高创伤救治成功率的关键。     

The association between vital signs and major hemorrhagic injury is significantly improved after controlling for sources of measurement variability

Purpose

Measurement error and transient variability affect vital signs. These issues are inconsistently considered in published reports and clinical practice. We investigated the association between major hemorrhagic injury and vital signs, successively applying analytic techniques that excluded unreliable measurements, reduced transient variation, and then controlled for ambiguity in individual vital signs through multivariate analysis.

Methods

Vital sign data from 671 adult prehospital trauma patients were analyzed retrospectively. Computer algorithms were used to identify and exclude unreliable data and to apply time averaging. An ensemble classifier was developed and tested by cross-validation. Primary outcome was hemorrhagic injury plus red cell transfusion. Areas under receiver operating characteristic curves (ROC AUCs) were compared by the test of DeLong et al.

Results

Of initial vital signs, systolic blood pressure (BP) had the highest ROC AUC of 0.71 (95% confidence interval, 0.64-0.78). The ROC AUCs improved after excluding unreliable data, significantly for heart rate and respiratory rate but not significantly for BP. Time averaging to reduce temporal variability further increased AUCs, significantly for BP and not significantly for heart rate and respiratory rate. The ensemble classifier yielded a final ROC AUC of 0.84 (95% confidence interval, 0.80-0.89) in cross-validation.

Conclusions

Techniques to reduce variability in vital sign data can lead to significantly improved diagnostic performance. Failure to consider such variability could significantly reduce clinical effectiveness or confound research investigations.     

Prehospital Trauma Life Support (PHTLS) training of ambulance caregivers and impact on survival of trauma victims

Background

The Prehospital Trauma Life Support (PHTLS) course has been widely implemented and approximately half a million prehospital caregivers in over 50 countries have taken this course. Still, the effect on injury outcome remains to be established. The objective of this study was to investigate the association between PHTLS training of ambulance crew members and the mortality in trauma patients.

Methods

A population-based observational study of 2830 injured patients, who either died or were hospitalized for more than 24 h, was performed during gradual implementation of PHTLS in Uppsala County in Sweden between 1998 and 2004. Prehospital patient records were linked to hospital-discharge records, cause-of-death records, and information on PHTLS training and the educational level of ambulance crews. The main outcome measure was death, on scene or in hospital.

Results

Adjusting for multiple potential confounders, PHTLS training appeared to be associated with a reduction in mortality, but the precision of this estimate was poor (odds ratio, 0.71; 95% confidence interval, 0.42–1.19). The mortality risk was 4.7% (36/763) without PHTLS training and 4.5% (94/2067) with PHTLS training. The predicted absolute risk reduction is estimated to correspond to 0.5 lives saved annually per 100,000 population with PHTLS fully implemented.

Conclusions

PHTLS training of ambulance crew members may be associated with reduced mortality in trauma patients, but the precision in this estimate was low due to the overall low mortality. While there may be a relative risk reduction, the predicted absolute risk reduction in this population was low.     

Definitive airway management after pre-hospital supraglottic airway insertion: Outcomes and a management algorithm for trauma patients

Background

Prehospital airway management increasingly involves supraglottic airway insertion and a paucity of data evaluates outcomes in trauma populations. We aim to describe definitive airway management in traumatically injured patients who necessitated prehospital supraglottic airway insertion.

社区创伤的院前救护与护理管理调查

目的 探讨社区创伤的发病规律及院前救护措施,以提高院前救护水平.方法 对我院962例由"120"指挥中心调度出车救治的社区创伤患者进行回顾性分析,采用自设问卷进行调查.结果 社区创伤的特点是以交通事故所致的多发伤为主;院前救护措施主要是包扎、止血、固定、吸氧、静脉输液、心肺复苏、气管插管术,环甲膜穿刺术等,其中包扎止血固定术占92.7%.结论 早期对创伤患者快速的应急处置与正确的医疗救援十分重要,是提高抢救成功率的关键,而正确的护理管理、准确的医护配合具有至关重要的作用.     

社区创伤的院前救护与护理管理调查

目的探讨社区创伤的发病规律及院前救护措施,以提高院前救护水平。方法对我院962例由“120”指挥中心调度出车救治的社区创伤患者进行回顾性分析,采用自设问卷进行调查。结果社区创伤的特点是以交通事故所致的多发伤为主;院前救护措施主要是包扎、止血、固定、吸氧、静脉输液、心肺复苏、气管插管术,环甲膜穿刺术等,其中包扎止血固定术占92．7％。结论早期对创伤患者快速的应急处置与正确的医疗救援十分重要,是提高抢救成功率的关键,而正确的护理管理、准确的医护配合具有至关重要的作用。     

Prehospital clinical presentation in patients with acute coronary syndrome complicated by cardiogenic shock: A single center study

BackgroundThe development of cardiogenic shock remains the most important factor affecting the prognosis of patients with acute coronary syndrome. Despite significant advances in treatment, achieved in the last two decades, the mortality rate is still very high. The development of knowledge about the pathophysiology of cardiogenic shock, necessitates a thorough and comprehensive assessment of its progress at all stages of medical care.ObjectivesThe aim of the study was to assess the prehospital clinical presentation in patients with acute coronary syndrome complicated by cardiogenic shock.MethodsThe population of our study consisted of 40 patients with acute coronary syndrome complicated by cardiogenic shock who were transported to the Intensive Cardiac Therapy Clinic by ambulances directly from place of the event in order to implement primary coronary intervention. The control group was selected among age, gender and infarct location-matched patients with acute coronary syndrome uncomplicated by shock. The clinical presentation in investigated patients was assessed on the basis of the data contained in the medical records of Emergency Medical Services teams.ResultsIn univariate logistic regression analysis eight prehospital clinical symptoms proved to be statistically significant predictors of the development of cardiogenic shock: fainting and/or impaired consciousness, pale skin, cold skin, clammy skin, dyspnea, pulmonary congestion, peripheral cyanosis and hyperglycemia >11,1 mmol/l. In the multivariate model significant predictors of cardiogenic shock development were: pale skin and hyperglycemia >11.1 mmol/l. A risk prediction model was constructed. It proved to differentiate patients from study and control group highly significantly (p < 0.001).ConclusionsPatients with acute coronary syndrome who develop cardiogenic shock, present a different clinical symptoms at the moment of the first medical contact. The proposed 4S Scale can be used for quick assessment of risk in patients with acute coronary syndrome before the development of a fully-blown cardiogenic shock with severe, long-lasting hypotonia.     

The Resuscitation Outcomes Consortium Epistry-Trauma: design, development, and implementation of a North American epidemiologic prehospital trauma registry

Injury is a major public health problem generating substantial morbidity, mortality, and economic burden on society. The majority of seriously injured persons are initially evaluated and cared for by prehospital providers, however the effect of emergency medical services (EMS) systems, EMS clinical care, and EMS interventions on trauma patient outcomes is largely unknown. Outcome-based information to guide future EMS care has been hampered by the lack of comprehensive, standardized, multi-center prehospital data resources that include meaningful patient outcomes. In this paper, we describe the background, design, development, implementation, content, and potential uses of the first North American comprehensive epidemiologic prehospital data registry for injured persons. This data registry samples patients from 264 EMS agencies transporting to 287 acute care hospitals in both the United States and Canada.     

Prehospital airway management: a prospective evaluation of anaesthesia trained emergency physicians

STUDY OBJECTIVE: To determine the characteristics of prehospital tracheal intubation and the incidence of difficult-to-manage airways in out-of-hospital patients managed by emergency medicine physicians with anaesthesia training. METHODS: In a prospective study, conducted over a 4-year period, we evaluated all airway interventions performed by anaesthesia-trained emergency physicians. RESULTS: One thousand, one hundred and six out of 16,559 patients (6.8%) required tracheal intubation. Orotracheal intubation was attempted in 982, laryngoscopic aided nasotracheal intubation in 64 and blind nasotracheal intubation in 90 of the cases. Two techniques were used in 30 patients. Failure rates were 2.4, 8.1 and 25.6%, respectively. A Combitube or LMA was used in 2.0%. In one case of failed Combitube insertion successful needle cricothyrotomy was performed. In patients undergoing direct laryngoscopy, Cormack-Lehane laryngeal grade views I-IV were seen in 52.0, 28.8, 12.6 and 6.6% of cases, respectively. A difficult to manage airway (DMA) was reported in 14.8%, multiple intubation attempts in 4.3% and failed intubation in 2.0% of all cases. Grouping patients based on clinical presentation revealed a significantly higher incidence of DMA in trauma patients (18.6%) and during cardiopulmonary resuscitation (16.7%) than in the remaining patient group (9.8%). Intubation failed significantly more often in trauma (3.9%) than in the remaining patient group (1.1%). CONCLUSION: When compared to studies on laryngoscopy performed in the operating room, this study demonstrated a higher incidence of difficult and failed laryngoscopy, DAM, and high laryngeal grade views when patients were managed in a prehospital setting by anaesthesia trained physicians.     

广州市2001年至2010年突发群体事件院前急救分析

目的 分析2001年至2010年10年间广州市院前急救中突发群体事件的类型、特点及发展趋势.方法 从广州市急救医疗指挥中心数据库中获取广州市2001年至2010年突发群体事件全部数据,对其进行统计学分析.结果 2001年至2010年广州市急救中心共记录突发群体事件累计6 807起,导致26 749人受伤和917人死亡.在各类意外事件中,车祸无论从发生数量、伤患者数和死亡人数在各类突发事件中都居首位(分别占49.80％、55.29％和61.72％),其次为斗殴、火灾和中毒.车祸的发生数量和伤患者数呈上升趋势.2008年至2010年,大型突发群体事件在不同级别的突发群体事件中占76.65％.结论 车祸是广州市近10年来突发群体事件中导致伤亡的主要原因,车祸的事件数量、伤患者数都呈上升趋势.在各级别的突发事件中,大型突发事件是造成主要伤亡的级别.因此,有必要完善相应的应急预案,加强医护人员专业培训,定期开展突发群体事件医疗救援模拟演练.     

Improving the handover of complex trauma patients by implementing a standardised process

BackgroundPatient handover continues to be an international health priority in the prevention of patient harm. Transitioning patients from the intensive care unit (ICU) to the ward is complex, particularly for trauma patients, due to the multifaceted aspects of their care requirements as a result of multiple injuries and different speciality teams.Objectives/aimTo design, implement, and evaluate the efficacy of a standardised handover process and tool for the transfer of ICU trauma patients.MethodsA multimethod before/after study design was used. This included observations before and after an implemented transfer process and semistructured interviews with ICU and ward nurses caring for trauma patients. Comparisons were made of data before and after the intervention.ResultsEleven patient handovers were observed, and 21 nurses (11 from the ICU and 10 from the ward) were interviewed. Patients and family members were included during the handover following the intervention (n = 0/10 [0%] vs n = 4/11 [36%]) and the ward nurses were asked if they had any concerns (n = 5/10 [50%] vs n = 10/11 [91%]). Improvements in patient observations handed over were reported following the intervention. However, omissions remained in some key areas including patient introduction, patient identity, fluid balance, and allergies/alerts. Thematic analysis of interviews revealed that the new handover process was perceived advantageous by both ICU and ward nurses because of its structured and comprehensive approach. Identified future improvements included the need for hospital service managers to ensure integration of ICU and ward electronic health record systems.ConclusionPrecise, accurate, and complete handover remains a patient safety concern. Improvements were achieved using a standardised process and handover tool for the transfer of complex trauma patients. Further improvements are required to reduce the failure to hand over essential patient information.     

多发伤的黄金救治时间与救治原则讨论(附212例的急救体会)

目的:探讨多发伤的临床特点和急救处理原则。方法:回顾性分析我院1989年1月~2003年12月收治的212例多发伤的临床急救资料,比较创伤严重程度(ISS)、创伤部位与病死率的关系,评价治疗效果。结果:本组ISS评分≤20分76例,21~30分73例,31~40分46例,41~50分12例,≥51分5例,分别死亡0,1,1,3,3例,每例平均2.78处伤,合并脊柱、四肢伤治疗效果较好,合并胸部、头颅和腹部伤者病死率高,且与ISS评分呈平行关系,分数越高,病死率越高。结论:多发伤病情复杂,诊断困难,变化迅速,病死率高;多发伤的创伤部位、严重程度、急救处理是否正确与及时决定了治疗结果。     

Knowledge gaps in prostate cancer treatment between physicians and clinical nurse specialists

Delphi consultations, a method of gaining consensus by gathering expert opinion, were conducted in order to understand the role of degarelix as a treatment option for advanced hormone‐dependent prostate cancer. During the Delphi consultations, differences were identified between physicians and clinical nurse specialists in terms of their knowledge of therapeutic developments. We argue that disparities in knowledge between physicians and nurse specialists could limit the effectiveness of multi‐disciplinary teams in providing optimal patient care. When such situations arise, communication between patients and nurse specialists, often the patient's primary point of contact, may conflict with information they have received from the physician. This could lead to confusion and uncertainty among patients about whether they are receiving the best possible care. Time and resources should be provided to address the continuing educational needs of nurses, which will ultimately result in the improved care and experience of patients.     

Accurate and continuous measurement of oxygen deficit during haemorrhage in pigs

Objective

Haemorrhagic shock can cause organ failure and high mortality. Uncontrolled bleeding, a predetermined bleeding volume or blood pressure controlled bleeding are traditionally used to study haemorrhagic shock. These models are influenced by compensatory mechanisms preventing accurate knowledge about the severity of cellular insult. We describe the use of a method for continuous measurement of oxygen deficit during haemorrhage in pigs.

Methods

We defined a cumulative oxygen deficit of approximately 100 mL/kg as the primary endpoint for severe haemorrhage. For continuous assessment of oxygen deficit a metabolic monitor (Deltatrac™ II, Datex-Ohmeda Instrumentation Corp., Helsinki, Finland) was used. Data are presented as mean ± SD; ^*P < 0.05 was considered to be significant.

Results

17 out of 22 anaesthetised male pigs achieved a mean cumulative oxygen deficit of 106 ± 3 mL/kg (range: 95–117 mL/kg) by withdrawing an average blood volume of 47 ± 6 mL/kg over 1 h. Mean arterial blood pressure (MAP) fell from 83 ± 19 to 22 ± 7 mmHg (baseline versus shock), heart rate increased from 83 ± 7 to 147 ± 37 min⁻¹. Venous base excess changed from 4.8 ± 2.4 to −12.5 ± 3.4 mmol/L and venous lactate increased from 1.5 ± 0.4 to 13.3 ± 2.4 mmol/L after haemorrhage. Two pigs (11%) died during the haemorrhagic shock phase. The traditional method of assessing haemorrhage (measuring blood volume lost) showed only a poor correlation with heart rate (r = 0.3872; P = 0.1540), MAP (r = 0.3901; P = 0.1505), mixed venous oxygen saturation (svO₂; r = 0.0944; P = 0.7379) or cardiac index (CI; r = 0.2101; P = 0.4523). Cumulative oxygen deficit correlated significantly better with heart rate (r = 0.7175; P = 0.0026), MAP (r = 0.5039; P = 0.0556), svO₂ (r = 0.7084; P = 0.0031) or CI (r = 0.6260; P = 0.0125).

Conclusion

We describe a model to study haemorrhagic shock based on the cumulative oxygen deficit. We believe that the use of a metabolic monitor to measure oxygen deficit in our model represents an improvement on the current available methods to study the effects of haemorrhagic shock.     

Triage Revised Trauma Score change between first assessment and arrival at the hospital to predict mortality

Objective

To assess among seriously injured accident victims whether change of the Triage Revised Trauma Score (T-RTS) between first assessment and arrival at the hospital independently predicts mortality.

Design

Prospective cohort study.

Methods

The study analysed data on 507 trauma patients with multiple injuries and with a Hospital Trauma Index-Injury Severity Score (HTI–ISS) of 16 or higher, who were presented directly by ambulance services to the Accident &; Emergency Department of the University Medical Centre Utrecht (the Netherlands) in 1999 and 2000.

Results

Compared to non-intubated patients whose T-RTS remained unchanged (reference category), the mortality risk was 3.1 times higher [95% confidence interval (CI): 1.5–6.3, p=0.001] for patients with deteriorating T-RTS, 2.9 times higher (95% CI: 1.3–6.5, p<0.001) for patients who had an initially good T-RTS but were nevertheless intubated and 5.7 times higher (95% CI: 3.6–9.0, p<0.001) for patients who had an initially poor T-RTS and were intubated. These associations were independent of factors that could be assumed to have a direct effect on T-RTS, that is intravenous therapy, oxygen administration and being attended to by a mobile medical team at the scene of the accident. Along with T-RTS change, more advanced age was associated with a higher mortality risk.

Conclusion

Intubation and a deteriorating T-RTS between the time of the accident and patient’s arrival at the hospital are powerful independent predictors of mortality after hospitalisation. Together with advanced age, a deteriorating T-RTS should be the main aspect guiding the preclinical procedures.     

院内急救快速反应系统的改进与应用

目的 改进院内急救快速反应系统,构建院内急救“3P”管理模式,并对其应用效果进行评价,为改善院内急救护理管理质量提供参考。 方法 通过查阅文献、急救管理专家组讨论和2轮德尔菲专家函询,确立院内急救“3P”管理模式指标,并于2017年4月—2018年3月应用于临床。结果 2轮函询问卷的有效回收率均为100%,第2轮函询专家的权威系数为0.907,判断依据系数为0.947,熟悉程度系数为0.867,一、二、三级指标重要性的肯德尔和谐系数分别为0.233、0.128和0.272,一、二、三级指标可操作性的肯德尔系数分别为0.211、0.135和0.277,显著性检验均有统计学意义（P<0.05）,最终形成的院内急救“3P”管理模式包含3个一级指标（1P急救技能再培训、2P急救流程再优化、3P急救物资再配置）、13个二级指标和34个三级指标。临床应用后,护士综合急救技能实践考核成绩由应用前的（69.07±4.80）分提高到（85.40±2.68）分;非预期性院内心搏骤停患者急救时启动应急医疗服务系统时间由应用前的（6.12±1.85） min缩短至（1.26±0.60） min,开始心肺复苏时间由应用前的（2.72±1.35） min缩短至（0.78±0.06） min,开始除颤时间由应用前的（8.51±3.12） min缩短至（1.43±0.94） min,急救成功率由应用前的55.56%提高到83.79%,差异均具有统计学意义（P<0.05）。结论 院内急救“3P”管理模式具有较好的可靠性、科学性和实用性,可为医院改善院内急救护理质量提供参考。     

Experiences of coercion in psychiatric care as narrated by patients, nurses and physicians

AIM: The aim of the study was to increase understanding of psychiatric patients', nurses' and physicians' experience of coercion, in relation to their own and the other parties' experiences. METHODS: Seven triads of patient, nurse and physician narrated their experiences of the same coercive event. The 21 interviews were analysed focusing on narrative elements. RESULTS: The nurse and physician narratives revealed that they felt unable to connect with the patients, while the patients told us that they wanted more human contact with nurses and physicians. All three parties expressed the belief that interpersonal relationships and the human contact were important. The nurses and physicians stated that knowing the patient made them feel easier about using coercion and that their actions were less violating for the patient. The patients stated that human contact alleviated their feeling of discomfort and made them feel more secure when subjected to coercion. CONCLUSION: The salient aspect described by all three parts was the importance of human contact and having a mutual relationship. These findings indicate a need for more dialogue between patients and staff. The dialogue should aim at making staff understand patients' feelings better regarding coercion and at informing the patients about the coercive measures.