On-scene times for trauma patients in West Yorkshire.

OBJECTIVE: To assess whether length of time on-scene in patients with major injury was associated with severity of injury or with abnormal on-scene physiology. METHODS: A retrospective analysis of a convenience sample of patients in whom prehospital on-scene times were entered onto the regional major trauma database. On-scene times of patients were analysed to assess whether ultimate injury severity score or on scene physiology measurements affected times. This was undertaken by examining subgroups of patients with similar injury severity or physiological measurements by Wilcoxon-Mann-Whitney testing and comparing 95% confidence intervals of the mean on-scene times. RESULTS: The mean on-scene time for 111 non-entrapped patients was 26 minutes (95% confidence interval 23.5 to 28.6). Patients with injury severity score of > 15, with a Glasgow coma scale of < 13, and with an abnormal pulse spent significantly less time on-scene than less severely injured or physiologically deranged patients. CONCLUSIONS: Paramedics have the ability to recognise patients with severe injury and reduce on-scene times. On-scene times were consistently long throughout all subgroups of major trauma patients.     

On-scene time in advanced trauma life support by anaesthesiologists.

OBJECTIVES: Severe injury is the leading cause of death among the young. Trauma systems have improved management of the severely injured and increased survival rates, but there is no level-1 evidence of advanced prehospital trauma care. Advanced prehospital trauma care prolongs on-scene time, which may imply a risk of significant delay in definitive trauma care. The aim of this study was to evaluate on-scene time and influence of (1) the presence of an anaesthesiologist on-scene, (2) prehospital intubation, (3) entrapment, and (4) injury severity. METHODS: A cohort of registry-based patients brought to Aarhus Trauma Centre. Data were consecutively reported. On-scene time was defined as the time from vehicle arrival to departure. Severe injury is defined by an injury severity score >15. The study was conducted over the period 1998-2000; only patients brought primarily to the trauma centre were included. Statistical tests used include chi, Kruskal-Wallis, Wilcoxon's rank sum and Spearman's rho. RESULTS: Seven hundred and forty-one patients triaged to Aarhus Trauma Centre from which we obtained all information in 596 cases constituted the study group. In 472 cases, an anaesthesiologist was present. On-scene times, median and 95% confidence interval, were as follows: entire study group (n=596) 15.5 min (15-17); ambulance only: 14.0 min (12-15); anaesthesiologist present, no intubation, no entrapment: 15.0 min (14-16); intubation, no entrapment: 21.5 min (16-27); entrapment, no intubation: 21.5 min (17-25); both intubation and entrapment: 22.0 min (16-36). CONCLUSION: The presence of an anaesthesiologist prolonged the median on-scene time by 1 min and in cases of prehospital intubation by 7.5 min. This result was no different from the prolongation caused by entrapment.     

Efficacy of the presence of an emergency physician in prehospital major trauma care: A nationwide cohort study in Japan

PurposeThe beneficial effect of the presence of an emergency physician in prehospital major trauma care is controversial. The aim in this study is to assess whether an emergency physician on scene can improve survival outcome of critical trauma patients.MethodsThis retrospective cohort study was conducted by using nationwide trauma registry data between 2004 and 2013 in Japan. Severe trauma patients (injury severity score (ISS) ≥ 16) who were transported directly to the hospital from the injury site were included in our analysis. Patients who were predicted to be untreatable (abbreviated injury score (AIS) = 6 and/or cardiopulmonary arrest at least one time before hospital arrival) were excluded. Participants were divided into either a physician or paramedics group based on the prehospital practitioner. The primary outcome was survival rate at discharge. Multivariable logistic regression analysis was performed to compare the outcome with adjustment for age, gender, ISS, cause of injury, and pre-hospital vital signs.ResultsA total of 30,283 patients were eligible for the selection criteria (physician: 1222, paramedics: 29,061). Overall, 172 patients (14.1%) died in the physician group compared to 3508 patients (12.1%) in the paramedics group. Patients in the physician group had higher ISSs than those in the paramedics group. In multivariable logistic regression, the physician group had an odds ratio (OR) of 1.16 (95% confidence interval (CI) = 0.97 to 1.40, p = 0.11) for in-hospital survival.ConclusionsOur results failed to show a difference in survival at discharge between non-physician-staffed ambulances and physician-staffed ambulances.     

The Time Cost of Prehospital Intubation andIntravenous Access in Trauma Patients

Objectives. The prehospital management of trauma patients remains controversial. Little is known about the time each procedure contributes to the on-scene duration, andthis information would be helpful in prioritizing which procedures to perform in the prehospital setting. We sought to estimate the contribution of procedures to on-scene duration focusing on intubation andestablishment of intravenous (IV) access. Methods. Data were provided by the Office of Emergency Planning andResponse at the Mississippi Department of Health. Real-time prehospital patient-level data are collected by emergency medical services (EMS) providers for all 9-1-1 calls statewide. Linear regression was performed to determine the overall additional time for an average procedure andto calculate marginal increases in on-scene time associated with the establishment of IV access andwith endotracheal intubation. Analyses were performed using Stata 9. Results. During 2001–2005, 192,055 prehospital runs were made for trauma patients. 121,495 (63%) included prehospital procedures. Average on-scene duration for those runs was 15:24 (minutes:seconds). On average, each procedure was associated with an addition of 1 minute to the on-scene duration (95% confidence interval [CI]: 58–62 seconds). A scene involving the establishment of IV access was 5:04 longer, while one involving tracheal intubation was 2:36 longer. Conclusions. We estimate the marginal increase in on-scene duration associated with the performance of an average procedure, establishment of IV access, andendotracheal intubation. There are policy andplanning implications for the time trade-off of prehospital procedures, especially discretionary ones.     

The effect of prehospital transport time on the mortality from traumatic injury

OBJECTIVE: To test the hypothesis that a prehospital time threshold (PhTT) exists that when exceeded, significantly increases the mortality of trauma patients transported directly from the scene of injury to a trauma center rather than to the closest hospital. DESIGN: Review of data contained within the Illinois Trauma Registry encompassing the period from fall 1989 through spring 1991. PARTICIPANTS: A total of 5,215 injured persons with an Injury Severity Score (ISS) > 10, cared for in an Illinois level-I or -II trauma center outside of the city of Chicago. MEASUREMENTS: Injury severity expressed as ISS, scene time (ST), transport time (TrT), total emergency medical services time (TEMST), and outcome were determined for each patient. Patients were stratified into groups on the basis of ISS. RESULTS: Patient outcomes were significantly different statistically between ISS groups (p < 0.001, chi 2). Mean ST and TEMST, but not TrT, were significantly different statistically between ISS groups (p < 0.001, analysis of variance). Lower ISS was associated with longer times. Mean ST, TrT, and TEMST were significantly different statistically between survivors and nonsurvivors (p < 0.001, two-sample t-tests). Survival was associated with longer times. Each of the mean times remained significantly different between survivors and nonsurvivors after controlling for severity of injury (p < 0.001, two-way analysis of variance). CONCLUSION: No PhTT beyond which time patient transport to the closest hospital would have decreased mortality was identifiable, because no prehospital time < 90 minutes exerted a significant adverse effect upon survival.     

Does Prehospital Time Influence Clinical Outcomes in Severe Trauma Patients?: A Cross Sectional Study

Objective: Prehospital time potentially impacts clinical outcomes in severely injured trauma patients. The importance of individual components, including scene and response time, however, is controversial. Our objective was to determine the impact of prehospital times on survival in severely injured patients. Methods: We reviewed injured trauma patients enrolled in a Korean EMS trauma registry during 2012. Severe trauma patients were defined as having either a “V” or lower in the AVPU system, a systolic blood pressure ≤90mmHg, or respiratory rate <10 or >29. Patients with Injury Severity Scores(ISS) < 9 were excluded. Patients were categorized by scene time into 4 groups as follows: <3 minutes, 3–6 minutes, 6–9 minutes, and ≥9 minutes and by prehospital time as follows: <16 minutes, 16–24 minutes, 24–32 minutes, and ≥32 minutes. The primary outcome was in-hospital mortality. Multiple linear regression analysis was used to adjust for possible confounders. Results: A total of 2,257 eligible patients were analyzed. Scene time was <3 minutes in 220 (9.7%), 3–6 in 865 (38.3%), 6–9 in 587 (26.0%), and ≥9 in 585 (25.9%). In-hospital mortality was 396 (17.5%). Compared to a scene time 6 to 9 minutes, mortality was higher as the scene time decreased: odds ratio (OR) = 1.3(3 to <6), OR = 1.9(0 to <3). Mortality was slightly decreased as prehospital time increased, OR = 1.0(16 to <24), OR = 0.9(24 to <32), OR = 0.7(≥32). Conclusion: Longer prehospital times did not increase mortality in severely injured trauma patients in Korea. Furthermore, longer scene times were associated with lower mortality.     

Road traffic accidents with vehicular entrapment: incidence of major injuries and need for advanced life support.

Road traffic accidents (RTAs) with entrapment are perceived as a challenge to emergency systems because of the severity of the ensuing traumas and the inherent complexity of the rescue procedures. To clarify these two aspects this prospective cohort study enrolling 244 entrapped trauma patients was conducted by a Regional Medical Helicopter Service. Forty-six victims (18.9%) were found dead, 101 (51%) of the 198 patients who reached the hospital alive had an injury severity score (ISS) > or = 16. The use of seat belts was associated with lower trauma severity. Out of the 101 severely traumatized patients (ISS > or = 16), 46 (42.6%) were intubated at road side, 12 required decompression of a tension pneumothorax on the scene and in 15 cases a pneumothorax was drained during the early intrahospital phase. Thirty-six (34.7%) patients had the first systolic blood pressure (SBP) < or = 90 mmHg and were then aggressively infused: in 75% of these cases, the SBP on arrival at the emergency department increased. The first SBP was significantly correlated with mortality. There was no correlation of extrication time, total rescue time and mortality. Fourteen patients (13.9%) died during hospitalization. These data demonstrate that a high percentage of entrapped patients require advanced life support (ALS), including on scene intubation and chest decompression. Aggressive field resuscitation and immediate transport to a level 1 trauma centre is associated with a mortality lower than that predicted by TRISS in spite of the prolonged prehospital time.     

H ELICOPTER T RANSPORT OF P EDIATRIC VERSUS A DULT T RAUMA P ATIENTS

Objective: Conflicting reports exist regarding the appropriate utilization of helicopter transport for victims of trauma. It has been suggested that adult patients are more severely injured compared with pediatric patients when transported by helicopter. The purpose of this study was to determine whether injury severity and survival probability in pediatric trauma patients were similar to those for adults when helicopter transport was utilized at a suburban trauma center. Methods: The authors conducted a retrospective review of all trauma patients transported by helicopter from the accident scene. Patients were identified from the Christiana Care Health System trauma registry from January 1995 to November 1999. Pediatric patients were defined as those aged 15 years and younger. Data collected were utilized to determine injury severity score (ISS), revised trauma score (RTS), and survival probability. Results: Nine hundred sixty-nine patients were transported; 143 were pediatric. There was no statistical difference noted in ISS (14.21 adult, 12.76 pediatric; p = 0.1506) and RTS (7.23 adult, 7.31 pediatric; p = 0.1832). Mean length of stay was less for the pediatric group (7.5 days adult, 5.2 days pediatric; p = 0.008). Survival probabilities were likewise similar for the two groups, yet the difference met statistical significance (0.92 adult, 0.95 pediatric; p = 0.03). Conclusion: Pediatric patients transported from the accident scene by helicopter have similar ISSs and RTSs compared with adults. These data suggest that prehospital selection criteria for the two groups are similar.     

Helicopter transport of pediatric versus adult trauma patients

Objective: Conflicting reports exist regarding the appropriate utilization of helicopter transport for victims of trauma. It has been suggested that adult patients are more severely injured compared with pediatric patients when transported by helicopter. The purpose of this study was to determine whether injury severity and survival probability in pediatric trauma patients were similar to those for adults when helicopter transport was utilized at a suburban trauma center. Methods: The authors conducted a retrospective review of all trauma patients transported by helicopter from the accident scene. Patients were identified from the Christiana Care Health System trauma registry from January 1995 to November 1999. Pediatric patients were defined as those aged 15 years and younger. Data collected were utilized to determine injury severity score (ISS), revised trauma score (RTS), and survival probability. Results: Nine hundred sixty-nine patients were transported; 143 were pediatric. There was no statistical difference noted in ISS (14.21 adult, 12.76 pediatric; p = 0.1506) and RTS (7.23 adult, 7.31 pediatric; p = 0.1832). Mean length of stay was less for the pediatric group (7.5 days adult, 5.2 days pediatric; p = 0.008). Survival probabilities were likewise similar for the two groups, yet the difference met statistical significance (0.92 adult, 0.95 pediatric; p = 0.03). Conclusion: Pediatric patients transported from the accident scene by helicopter have similar ISSs and RTSs compared with adults. These data suggest that prehospital selection criteria for the two groups are similar. PREHOSPITAL EMERGENCY CARE 2002;6:306-308     

Scene disposition and mode of transport following rural trauma: a prospective cohort study comparing patient costs

This prospective cohort study was performed from 1994 to 1996 to compare the impact of scene disposition on prehospital and hospital costs incurred by rural trauma patients transported to a trauma center by helicopter or ground ambulance. The study included all rural adult injury victims who arrived at the tertiary trauma center by ambulance within 24 h of injury. Inclusion criteria consisted of inpatient admission or death in the emergency department, and any traumatic injury except burns. Data collected included mortality, mode of transport, Injury Severity Score (ISS), and costs from impact to discharge or death. Of 105 study patients, 52 initially went to a rural hospital, while 53 went directly to the trauma center. There was no significant difference in survival in the two groups. The ISS was significantly higher for patients taken directly to the trauma center from the scene. The ISS of trauma patients transported from the rural hospital was highest for patients sent by ground transport. The prehospital transport costs were significantly more for patients transported to a rural hospital first. The costs incurred at the trauma center were highest for those patients transported directly from the scene. Many severely injured patients were initially transported to a rural hospital rather than directly to the trauma center. At both the scene and rural hospital, consistent use of triage criteria appeared to be lacking in determining the severity of injury, appropriate destination, and mode of transport for trauma patients. Since no significant difference in prehospital helicopter and ground transport costs was demonstrated, the decision on mode of transport should be in the best interest of patient care.     

Automatic acoustic gunshot sensor technology’s impact on trauma care

IntroductionAs cities nation-wide combat gun violence, with less than 20% of shots fired reported to police, use of acoustic gunshot sensor (AGS) technology is increasingly common. However, there are no studies to date investigating whether these technologies affect outcomes for victims of gunshot wounds (GSW). We hypothesized that the AGS technology would be associated with decreased prehospital transport time.MethodsAll GSW patients from 2014 to 2016 were collected from our institutional registry and cross-referenced with local police department data regarding times and locations of AGS alerts. Each GSW incident was categorized as related or unrelated to an AGS alert. Admission data, trauma outcomes, and prehospital time were then compared.ResultsWe analyzed 731 patients. Of these, 192 were AGS-related (26%) and 539 were not (74%). AGS-related patients were more likely to be female (p < 0.01), have a higher injury severity score (ISS) (p < 0.01), and require an operation (p = 0.03). Ventilator days (p < 0.05) and hospital length of stay (p < 0.01) was greater in the AGS cohort. Mortality, however, did not differ between groups (p = 0.5). On multivariable analysis, both total prehospital time and on-scene time were lower in the AGS group (p < 0.01).ConclusionOur study suggests reduced transport times, decreased prehospital and emergency medical service on-scene times with AGS technology. Additionally, despite higher ISS and use of more hospital resources, mortality was similar to non-AGS counterparts. The potential of AGS technology to further decrease prehospital times in the urban setting may provide an opportunity to improve outcomes in trauma patients with penetrating injuries.     

Longer Prehospital Time was not Associated with Mortality in Major Trauma: A Retrospective Cohort Study

Objective: The objective of this study was to determine the association between prehospital time and outcomes in adult major trauma patients, transported by ambulance paramedics. Methods: A retrospective cohort study of major trauma patients (Injury Severity Score >15) attended by St John Ambulance paramedics in Perth, Western Australia, who were transported to hospital between January 1, 2013 and December 31, 2016. Inverse probability of treatment weighting (IPTW) using the propensity score was performed to limit selection bias and confounding. The primary outcome was 30-day mortality and the secondary outcome was the length of hospital stay (LOS) for 30-day survivors. Multivariate logistic and log-linear regression analyses with IPTW were used to determine if prehospital time of more than the one hour (from receipt of the emergency call to arrival at hospital) or any individual prehospital time interval (response, on-scene, transport, or total time) was associated with 30-day mortality or LOS. Results: A total of 1,625 major trauma patients were included and 1,553 included in the IPTW sample. No significant association between prehospital time of one hour and 30-day mortality was found (adjusted odds ratio 1.10, 95% confidence interval (CI) 0.71–1.69). No association between any individual prehospital time interval and 30-day mortality was identified. In the 30-day survivors, one-minute increase of on-scene time was associated with 1.16 times (95% CI 1.03–1.31) longer LOS. Conclusion: Longer prehospital times were not associated with an increased likelihood of 30-day mortality in major trauma patients transported to hospital by ambulance paramedics. We found no evidence to support the hypothesis that prehospital time longer than one hour resulted in an increased risk of 30-day mortality. However, longer on-scene time was associated with longer hospital LOS (for 30-day survivors). Our recommendation is that prehospital care is delivered in a timely fashion and delivery of the patient to hospital is reasonably prompt.     

Examining emergency medical services' prehospital transport times for trauma patients during COVID-19

IntroductionLonger prehospital times were associated with increased odds for survival in trauma patients. The purpose of this study was to determine how the COVID-19 pandemic affected emergency medical services (EMS) prehospital times for trauma patients.MethodsThis retrospective cohort study compared trauma patients transported via EMS to six US level I trauma centers admitted 1/1/19–12/31/19 (2019) and 3/16/20–6/30/20 (COVID-19). Outcomes included: total EMS pre-hospital time (dispatch to hospital arrival), injury to dispatch time, response time (dispatch to scene arrival), on-scene time (scene arrival to scene departure), and transportation time (scene departure to hospital arrival). Fisher's exact, chi-squared, or Kruskal-Wallis tests were used, alpha = 0.05. All times are presented as median (IQR) minutes.ResultsThere were 9400 trauma patients transported by EMS: 79% in 2019 and 21% during the COVID-19 pandemic. Patients were similar in demographics and transportation mode. Emergency room deaths were also similar between 2019 and COVID-19 [0.6% vs. 0.9%, p = 0.13].There were no differences between 2019 and during COVID-19 for total EMS prehospital time [44 (33, 63) vs. 43 (33, 62), p = 0.12], time from injury to dispatch [16 (6, 55) vs. 16 (7, 77), p = 0.41], response time [7 (5, 12) for both groups, p = 0.27], or on-scene time [16 (12−22) vs. 17 (12,22), p = 0.31]. Compared to 2019, transportation time was significantly shorter during COVID-19 [18 (13, 28) vs. 17 (12, 26), p = 0.01].ConclusionThe median transportation time for trauma patients was marginally significantly shorter during COVID-19; otherwise, EMS prehospital times were not significantly affected by the COVID-19 pandemic.     

严重创伤患者中急性创伤性凝血病与深静脉血栓形成关系探讨

目的 研究创伤患者下肢深静脉血栓(DVT)形成的危险因素,并探讨急性创伤性凝血病(ATC)与DVT形成的关系.方法 回顾性收集上海交通大学附属第六人民医院急性创伤急救中心EICU 2014年1月至12月收治的创伤患者资料,记录年龄、性别、体质量指数、创伤严重度评分(ISS)、创伤机制、损伤部位、入院时国际标准化比率(INR)、DVT发生率等指标.根据INR将患者分为凝血病组和非凝血病组(对照组),比较两组间DVT的发生率.结果 入选创伤患者200例,60例(30％)患者出现ATC,87例(43.5％)患者发生DVT.凝血病组DVT发生率显著高于非凝血病组(71.7％ vs.31.4％,P＜0.01).Logistic回归分析结果显示凝血病组DVT发生率是非凝血病组的5.74倍(OR=5.74,95％ CI:2.80 ～ 11.74,P＜0.01).在次危重(9≤ISS＜ 16)患者中,凝血病组DVT发生率的增加更加显著(OR=9.80,95％ CI:2.09～45.90,P=0.004).同时脊髓损伤(OR=4.96,95％ CI:1.17～ 20.95,P=0.029)和下肢长骨骨折(OR=4.80,95％ CI:1.70～13.5,P=0.003)是下肢DVT形成的独立危险因素.结论 伤后24 h内收住EICU的严重创伤患者,ATC的发病率较高.伴有ATC的创伤患者下肢DVT的发病率显著增加,尤其在次危重组(9≤ISS＜ 16)患者中更为明显.同时脊髓损伤和下肢长骨骨折是下肢DVT形成的独立危险因素.     

Emergency department at the cutting edge.

OBJECTIVE: This paper reviews the experience of penetrating chest trauma over a 3-year period in one UK emergency department. METHODS: A retrospective review was performed of patients assessed in the emergency department resuscitation room between 1 January 2002 and 31 December 2005. Patients with penetrating chest trauma, either isolated or in combination with other injuries, were included. A Medline search was performed using the terms 'chest', 'trauma' and 'penetrating'. RESULTS: A total of 120 patients presented with penetrating chest trauma. Ninety-two percent were male. Ninety-six percent (115) of the patients survived to hospital discharge. Seventy-eight percent of the patients presented at night (20.00 and 8.00 h). A single wound accounted for 52% (63) of patients, multiple wounds 43% (52) with 2% (two) gun-shot wounds and 3% (three) impalings. The mean prehospital time of patients in cardiac arrest was 42 min with a mean on-scene time of 24 min. The mean prehospital time for patients undergoing formal emergency surgery was 39 min with a mean on-scene time of 16 min. Twenty-three patients required one or more tube thoracostomies to be performed in the emergency department and six underwent emergency department thoracotomy. Sixteen patients required immediate formal emergency surgery for haemorrhage control. CONCLUSION: Penetrating chest trauma contributes significantly to our trauma workload with a high proportion of patients sustaining life-threatening injuries requiring immediate intervention. Significant prehospital delays occur. Overall mortality of 4.2% is comparable with that of a major American case series. Further education and protocol development is required to ensure that prehospital and emergency department management of these patients reflects the latest evidence-based guidelines.     

Pelvic fractures: an analysis of factors affecting prehospital triage and patient outcome

Using an established prehospital regional triage protocol, 175 patients sustaining fractures of the pelvis were managed in a level one trauma center during a 38-month interval. The majority of injuries (51.7%) were caused by motor vehicle accidents and involved an average trauma score (TS) of 13 and an average injury severity score (ISS) of 24. The overall mortality was 16%; 43.5% had open fractures, 13.2% had closed fractures, and 30.6% had been in pedestrian accidents. Significant risk factors for mortality were age, blood pressure on admission, associated injuries, and the presence of an open pelvic fracture. It appears that TS alone is not reliable in prehospital triage of patients with pelvic fractures. Age and mechanism of injury may better identify the patient at risk for morbidity and mortality.     

急诊危重患者急性肾损伤发生的危险因素分析

目的:调查急诊抢救室患者急性肾损伤（acute kindey injury,AKI）的发生率并探讨相关危险因素。方法:采用回顾性队列研究方法,纳入2018年9~12月经由本院抢救室收治的患者,根据患者入院后7 d内是否发生AKI,将患者分为AKI组和非AKI组。收集患者入抢救室时的人口学特征、APACHE Ⅱ评分、是否使用肾脏毒性药物、24 h液体出入量及院内生存时间等相关指标。使用多因素Logistic回归分析AKI发生的危险因素。使用COX回归研究AKI的发生对患者住院生存率的影响,并分析AKI严重程度对患者死亡风险的影响。结果:纳入急诊抢救室的患者238例,其中108例发生AKI（45.4%）,AKI 1期83例（34.9%）,AKI 2~3期25例（10.5%）。APACHE Ⅱ评分>13分[ OR=1.11,95% CI（1.07~1.16）, P<0.01],应用血管活性药[ OR=2.20,95% CI（1.08~4.49）, P=0.03],糖尿病（ OR=2.33,95% CI（1.23~4.42）, P=0.01）,24 h入量>3 L（ OR=3.10,95% CI（1.17~8.25）, P=0.02）是发生AKI的独立危险因素。多因素COX回归校正APACHE Ⅱ评分和年龄后,AKI仍是急诊抢救室患者死亡的独立危险因素,且AKI严重程度显著增加急诊患者死亡风险[AKI1期 HR=1.45,95% CI（1.08~2.03）, P=0.04; AKI2-3期 HR=3.15,95% CI（1.49~4.81）, P=0.03]。 结论:急诊抢救室患者中AKI的发生较常见。APACHE Ⅱ评分>13分,应用血管活性药,糖尿病,24 h入量>3 L是发生AKI的独立危险因素。随着AKI严重程度的增加,死亡风险增加。     

急诊危重患者急性肾损伤发生的危险因素分析

目的:调查急诊抢救室患者急性肾损伤（acute kindey injury,AKI）的发生率并探讨相关危险因素。方法:采用回顾性队列研究方法,纳入2018年9~12月经由本院抢救室收治的患者,根据患者入院后7 d内是否发生AKI,将患者分为AKI组和非AKI组。收集患者入抢救室时的人口学特征、APACHE Ⅱ评分、是否使用肾脏毒性药物、24 h液体出入量及院内生存时间等相关指标。使用多因素Logistic回归分析AKI发生的危险因素。使用COX回归研究AKI的发生对患者住院生存率的影响,并分析AKI严重程度对患者死亡风险的影响。结果:纳入急诊抢救室的患者238例,其中108例发生AKI（45.4%）,AKI 1期83例（34.9%）,AKI 2~3期25例（10.5%）。APACHE Ⅱ评分>13分[ OR=1.11,95% CI（1.07~1.16）, P<0.01],应用血管活性药[ OR=2.20,95% CI（1.08~4.49）, P=0.03],糖尿病（ OR=2.33,95% CI（1.23~4.42）, P=0.01）,24 h入量>3 L（ OR=3.10,95% CI（1.17~8.25）, P=0.02）是发生AKI的独立危险因素。多因素COX回归校正APACHE Ⅱ评分和年龄后,AKI仍是急诊抢救室患者死亡的独立危险因素,且AKI严重程度显著增加急诊患者死亡风险[AKI1期 HR=1.45,95% CI（1.08~2.03）, P=0.04; AKI2-3期 HR=3.15,95% CI（1.49~4.81）, P=0.03]。 结论:急诊抢救室患者中AKI的发生较常见。APACHE Ⅱ评分>13分,应用血管活性药,糖尿病,24 h入量>3 L是发生AKI的独立危险因素。随着AKI严重程度的增加,死亡风险增加。     

Admission hypothermia and outcome after major trauma

OBJECTIVE: Uncontrolled exposure hypothermia is believed to be deleterious in the setting of major trauma. Prevention of hypothermia in the injured patient is currently practiced in both prehospital and in-hospital settings. However, this standard is based on studies of limited patient series that were not designed to identify the independent relationship between hypothermia and mortality. Recent studies suggest that therapeutically applied hypothermia may benefit selected patient subsets. The goal of this study was to evaluate the independent association between admission hypothermia and mortality after major trauma, with adjustment for clinical confounders. DESIGN: Retrospective analysis of a statewide trauma registry. The primary outcome was death at hospital discharge. The key exposure was hypothermia, defined as body temperature /=16 yrs of age for the years 2000-2002. Transferred patients were excluded. Patients were excluded if temperature or route of temperature measurement was not known. Both the full cohort and a subset with isolated severe head injury were evaluated. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 38,520 patients, 1,921 (5.0%) were hypothermic at admission. Admission hypothermia was independently associated with increased odds of death in both the full cohort (odds ratio, 3.03; 95% confidence interval, 2.62-3.51) and the subset with isolated severe head injury (2.21; 1.62-3.03), with adjustment for age, severity and mechanism of injury, and route of temperature measurement. CONCLUSIONS: Admission hypothermia is independently associated with increased adjusted odds of death after major trauma. The increase in mortality is not completely attributable to physiologic presentation or injury pattern or severity.