移动监护与急救手术前移在严重胸部创伤急救中的应用

目的 探讨将确定性急救与手术处理前移至基层医院的可行性,以进一步提高危重胸部创伤的救治成功率. 方法 对1998年4月-2008年8月应"120"急救邀请,赴我市基层医院进行院前院内紧急救治的72例严重胸部创伤(AIS≥3)患者的资料进行回顾性分析.分为院前组(院前紧急确定性急救或手术后转回我院)36例和院内组(经院前确定性急救后转回我院手术)36例. 结果 (1)伤后到基层医院时间两组间差异无统计学意义(P>0.05),获确切手术时间院前组显著短于院内组[(3.9±4.1)h比(9.6±8.2)h](P<0.05).(2)院前组失血量、输血量均大于院内组,但差异无统计学意义(P>0.05).(3)ISS值两组差异无统计学意义(P>0.05),RTS值院前组显著低于院内组(P<0.05);院前组总休克发生率显著多于院内组(86.1%比41.7%)(P<0.05).(4)术式:单纯胸腔闭式引流院前组多于院内组(16.7%比5.6%),"胸腔闭式引流+剖胸术"、"胸腔闭式引流+剖腹术"、"胸腔闭式引流+其他"两组间差异无统计学意义,院前组穿透伤"胸腔闭式引流+剖胸术"率是钝性伤的4.8倍,院内组为1.9倍;院前组钝性伤"胸腔闭式引流+剖腹术"率是穿透伤的5倍,院内组为4.5倍.(5)总治愈率95.8%(69/72),院前组中濒死患者8例,生存5例,13.9%(5/36)的院前创伤死亡得以避免. 结论 在伤后"黄金时刻"迅速携带移动监护手术设备,将救命性外科处理前伸至基层医院实施急救或确定性手术后,再安全转送到高级急救中心(医院)进一步救治是安全、有效、可行的,可显著降低严重胸部创伤的院前死亡率.

Mobile intensive care and pre-hospital surgical service for patients with severe thoracic injuries

Objective To explore the feasibility, safety and effectiveness of mobile intensive care and pre-hospital surgical service for patients with severe thoracic injuries so as to further improve success rate of treatment of severe thoracic trauma. Methods A retrospective study was done on the clinical data of 72 patients with severe thoracic injuries (AIS≥3) treated by surgeons from Chongqing Emergency Medical Center (CEMC) from April 1998 to August 2008. The patients were divided into pre-hospital group (n = 36) and in-hospital group (n = 36) according to the time that the definite surgery performed. Results (1) There was no significant statistical difference upon arrival time from scene to primary hospital between two groups (P > 0.05). For patients in pre-hospital group, the time to receive definite surgery was (3.9±4.1) hours, which was significant shorter than (9.6±8.2) hours in in-hospital group (P < 0.05). (2) There were no statistical significant differences upon blood loss volume and blood transfusion volume between two groups (P > 0.05). (3) There was no significant statistical difference upon ISS value between two groups (P > 0.05), but the RTS value of pre-hospital group was significantly lower than that of in-hospital group (P < 0.05). The incidence rate of shock in pre-hospital group was 86.1%, which was significantly higher than 41.7% in in-hospital group (P < 0.05). (4) The percentage of patients who received thoracic close drainage in pre-hospital group was 16.7%, which was significantly higher than 5.6% in in-hospital group. There was no significant statistical difference upon thoracic close drainage plus thoracotomy, thoracic close drainage plus laparotomy and thoracic close drainage plus other operations between two groups. However, the operative rate of thoracic close drainage plus thoracotomy for penetrating injury was 4.8 times higher than that for blunt injury in pre-hospital group, and 1.9 times higher than that for blunt injury in-hospitai group. The operative rate of thoracic close drainage plus laparotomy for blunt injury was 5 times higher than that for penetrating injury in prehospital group, and 4.5 times higher than that for penetrating injury in in-hospital group. The overall survival rate was 95.8% (69/72). Five of eight moribund patients were saved in pre-hospital group, the prevented death rate accounted for 13.9% (5/36) in this group. Conclusions It is flexible, safe and effective to implement mobile intensive care and definite lifesaving surgical interventions for patients with severe thoracic injuries in primary hospitals. After the condition of the patient is stabilized, a quick transportation of the patients to a higher level trauma centers (hospitals) for further treatment may reduce the pre-hospital death rate.