Davis Daniel P, Hoyt David B, Ochs Mel, Fortlage Dale, Holbrook Troy, Marshall Lawrence K, Rosen Peter
Department of Emergency Medicine, UC San Diego, CA 92103-8676, USA.
J Trauma. 2003 Mar;54(3):444-53. doi: 10.1097/01.TA.0000053396.02126.CD.
To evaluate the effect of paramedic rapid sequence intubation (RSI) on outcome in patients with severe traumatic brain injury.
Adult major trauma victims were prospectively enrolled over two years using the following inclusion criteria: Glasgow Coma Scale (GCS) 3-8, suspected head injury by mechanism or physical examination, transport time > 10," and inability to intubate without RSI. Midazolam and succinylcholine were administered before laryngoscopy; rocuronium was given after tube placement was confirmed using physical examination, capnometry, syringe aspiration, and pulse oximetry. The Combitube was used as a salvage airway device. For this analysis, trial patients were excluded for absence of a head injury (Head/Neck AIS score < 2), failure to fulfill major trauma outcome study criteria, unsuccessful intubation or Combitube insertion, or death in the field or in the resuscitation suite within 30" of arrival. Each study patient was hand matched to three nonintubated historical controls from our trauma registry using the following parameters: age, sex, mechanism of injury, trauma center, and AIS score for each body system. Controls were excluded for Head/Neck AIS defined by a c-spine injury or death in the field or in the resuscitation suite within 30" of arrival. chi 2, odds ratios, and logistic regression were used to investigate the impact of RSI on the primary outcome measures of mortality and incidence of a "good outcome," defined as discharge to home, rehabilitation, psychiatric facility, jail, or signing out against medical advice.
A total of 209 trial patients were hand matched to 627 controls. The groups were similar with regard to all matching parameters, admission vital signs, frequency of specific head injury diagnoses, and incidence of invasive procedures. Mortality was significantly increased in the trial cohort versus controls for all patients (33.0% versus 24.2%, p < 0.05) and in those with Head/Neck AIS scores of 3 or greater (41.1% versus 30.3%, p < 0.05). The incidence of a "good outcome" was lower in the trial cohort versus controls (45.5% versus 57.9%, p < 0.01). Factors that may have contributed to the increase in mortality include transient hypoxia, inadvertent hyperventilation, and longer scene times associated with the RSI procedure.
Paramedic RSI protocols to facilitate intubation of head-injured patients were associated with an increase in mortality and decrease in good outcomes versus matched historical controls.
评估护理人员快速顺序诱导插管（RSI）对重度创伤性脑损伤患者预后的影响。
采用以下纳入标准，对成年严重创伤患者进行了为期两年的前瞻性研究：格拉斯哥昏迷量表（GCS）评分为3 - 8分，根据受伤机制或体格检查怀疑有头部损伤，转运时间>10分钟，且若无RSI则无法插管。在喉镜检查前给予咪达唑仑和琥珀酰胆碱；在通过体格检查、二氧化碳波形图、注射器抽吸和脉搏血氧饱和度确认导管置入后给予罗库溴铵。联合双腔气道导管用作挽救气道装置。在本次分析中，试验患者若不存在头部损伤（头部/颈部简明损伤定级标准[AIS]评分<2）、未达到严重创伤预后研究标准、插管或插入联合双腔气道导管未成功、或在到达后30分钟内在现场或复苏室死亡，则被排除。使用以下参数将每位研究患者与我们创伤登记处的三名未插管的历史对照进行手动匹配：年龄、性别、损伤机制、创伤中心以及每个身体系统的AIS评分。对照若因颈椎损伤定义的头部/颈部AIS评分或在到达后30分钟内在现场或复苏室死亡则被排除。使用卡方检验、优势比和逻辑回归来研究RSI对主要结局指标死亡率和“良好结局”发生率的影响，“良好结局”定义为出院回家、康复机构、精神病院、监狱或违反医嘱自行出院。
共209例试验患者与627例对照进行了手动匹配。两组在所有匹配参数、入院生命体征、特定头部损伤诊断频率和侵入性操作发生率方面相似。在所有患者中，试验队列的死亡率显著高于对照组（33.0%对24.2%，p<0.05），在头部/颈部AIS评分为3或更高的患者中也是如此（41.1%对30.3%，p<0.05）。试验队列的“良好结局”发生率低于对照组（45.5%对57.9%，p<0.01）。可能导致死亡率增加的因素包括短暂缺氧、无意的过度通气以及与RSI操作相关的更长现场时间。
与匹配的历史对照相比，护理人员用于促进头部受伤患者插管的RSI方案与死亡率增加和良好结局减少相关。
