Osterwalder Joseph J
Emergency Department, Cantonal Hospital, St. Gallen, Switzerland.
J Trauma. 2003 Aug;55(2):355-61. doi: 10.1097/01.TA.0000034231.94460.1F.
The role of prehospital basic life support as opposed to prehospital advanced life support and the best qualifications for emergency personnel are controversial. Our objective was to establish whether the prehospital deployment of emergency physicians (EPs) rather than emergency medical technicians (EMTs) decreased mortality in blunt polytrauma patients.
In a prospective, observational cohort study conducted between 1990 and 1996, we used the A Severity Characterization of Trauma score to compare the actual mortality with the predicted mortality in 71 blunt polytrauma patients, 63 treated by EMTs alone and 8 treated also by anesthetic nurses. The same comparison was conducted in 196 blunt polytrauma patients treated by EPs together with EMTs or paramedics. Multivariate logistic regression analysis was conducted to test for any confounding factors and bias, and for the identification of factors associated with mortality. Inclusion criteria were blunt trauma at a minimum of two body sites, an Injury Severity Score of 8 or more, and direct admission to our trauma center.
The mortality in patients treated by EPs was 11.2% (22 of 196) and was statistically not significantly lower than the 14.1% calculated for the patients treated without EP involvement (10 of 71). In the group treated by EPs, there were 1.3 (95% confidence interval [CI], -5.9-8.5), or 6%, fewer deaths than would have been expected on the basis of the results of the Major Trauma Outcome Study (p = 0.734). In contrast, in the group treated without EP involvement, there were 3.4 (95% CI, -0.2-7), or 34%, more deaths than predicted (p = 0.066). This trend was confirmed by multivariate logistic regression, which showed a significant mortality odds ratio of 37 (95% CI, 2-749) for the EMT group as compared with the EP group.
In contrast with the deployment of EPs, care of blunt polytrauma patients by EMTs showed a statistical trend to a higher mortality than predicted and also a significantly higher risk of mortality. It is likely that the consistent deployment of EPs for moderate to severe blunt polytrauma in our catchment area might prevent between 0% and 23% of all deaths from blunt polytrauma or, in absolute terms, up to 1 death per year or 0 to 9.9 per 100 patients treated by an EP instead of an EMT.
与院前高级生命支持相比，院前基础生命支持的作用以及急救人员的最佳资质存在争议。我们的目的是确定院前部署急诊医师（EP）而非急诊医疗技术员（EMT）是否能降低钝性多发伤患者的死亡率。
在1990年至1996年进行的一项前瞻性观察队列研究中，我们使用创伤严重程度特征评分将71例钝性多发伤患者的实际死亡率与预测死亡率进行比较，其中63例仅由EMT治疗，8例还由麻醉护士治疗。对196例由EP与EMT或护理人员共同治疗的钝性多发伤患者进行了同样的比较。进行多因素逻辑回归分析以检验任何混杂因素和偏倚，并确定与死亡率相关的因素。纳入标准为至少两个身体部位的钝性创伤、损伤严重程度评分为8分或更高，以及直接入住我们的创伤中心。
由EP治疗的患者死亡率为11.2%（196例中的22例），在统计学上并不显著低于未由EP参与治疗的患者计算出的14.1%（71例中的10例）。在由EP治疗的组中，死亡人数比根据重大创伤结局研究结果预期的少1.3例（95%置信区间[CI]，-5.9 - 8.5），即少6%（p = 0.734）。相比之下，在没有EP参与治疗的组中，死亡人数比预测的多3.4例（95% CI，-0.2 - 7），即多34%（p = 0.066）。多因素逻辑回归证实了这一趋势，显示EMT组与EP组相比，死亡率优势比显著为37（95% CI，2 - 749）。
与部署EP相比，EMT对钝性多发伤患者的护理显示出死亡率高于预测的统计学趋势，且死亡风险也显著更高。在我们的服务区域，持续部署EP用于中重度钝性多发伤可能预防0%至23%的钝性多发伤死亡，或者绝对而言，每年最多预防1例死亡，或每100例由EP而非EMT治疗的患者中预防0至9.9例死亡。
