缺氧和过度通气对严重颅脑损伤患者急救人员快速顺序插管后预后的影响。

The impact of hypoxia and hyperventilation on outcome after paramedic rapid sequence intubation of severely head-injured patients.

作者信息

Davis Daniel P, Dunford James V, Poste Jennifer C, Ochs Mel, Holbrook Troy, Fortlage Dale, Size Michael J, Kennedy Frank, Hoyt David B

机构信息

Department of Emergency Medicine, University of California, San Diego, California 92103-8676, USA.

出版信息

J Trauma. 2004 Jul;57(1):1-8; discussion 8-10. doi: 10.1097/01.ta.0000135503.71684.c8.

DOI:10.1097/01.ta.0000135503.71684.c8

PMID:15284540

Abstract

BACKGROUND

An increase in mortality has been documented in association with paramedic rapid sequence intubation (RSI) of severely head-injured patients. This analysis explores the impact of hypoxia and hyperventilation on outcome.

METHODS

Adult severely head-injured patients (Glasgow Coma Scale score of 3-8) unable to be intubated without neuromuscular blockade underwent paramedic RSI using midazolam and succinylcholine; rocuronium was administered after confirmation of tube position. Standard ventilation parameters were used for most patients; however, one agency instituted use of digital end-tidal carbon dioxide (ETCO2) and oxygen saturation (Spo2) monitoring during the trial. Each patient undergoing digital ETCO2/Spo2 monitoring was matched to three historical nonintubated controls on the basis of age, gender, mechanism, and Abbreviated Injury Scale scores for each of six body regions. Logistic regression was used to explore the impact of oxygen desaturation during laryngoscopy and postintubation hypocapnia and hypoxia on outcome. The relationship between hypocapnia and ventilatory rate was explored using linear regression and univariate analysis. In addition, trial patients and controls were compared with regard to mortality and the incidence of "good outcomes" using an odds ratio analysis.

RESULTS

Of the 426 trial patients, a total of 59 had complete ETCO2/Spo2 monitoring data; these were matched to 177 controls. Logistic regression revealed an association between the lowest ETCO2 value and final ETCO2 value and mortality. Matched-controls analysis confirmed an association between hypocapnia and mortality. A statistically significant association between ventilatory rate and ETCO2 value was observed (r = -0.13, p < 0.0001); the median ventilatory rate associated with the lowest recorded ETCO2 value was significantly higher than for all other ETCO2 values (27 mm Hg vs. 19 mm Hg, p < 0.0001). In addition, profound desaturations during RSI and hypoxia after intubation were associated with higher mortality than matched controls. Overall mortality was 41% for trial patients versus 22% for matched controls (odds ratio, 2.51; 95% confidence interval, 1.33-4.72; p = 0.004).

CONCLUSIONS

Hyperventilation and severe hypoxia during paramedic RSI are associated with an increase in mortality.

摘要

背景

已有文献记载，严重颅脑损伤患者接受护理人员快速顺序诱导插管（RSI）后死亡率会升高。本分析探讨低氧血症和过度通气对预后的影响。

方法

成年严重颅脑损伤患者（格拉斯哥昏迷量表评分为3 - 8分），若不使用神经肌肉阻滞剂则无法插管，接受护理人员使用咪达唑仑和琥珀酰胆碱进行的RSI；确认导管位置后给予罗库溴铵。大多数患者采用标准通气参数；然而，在试验期间，一个机构开始使用数字呼气末二氧化碳（ETCO2）和血氧饱和度（Spo2）监测。根据年龄、性别、受伤机制以及六个身体部位各自的简明损伤量表评分，将每例接受数字ETCO2/Spo2监测的患者与三名历史上未插管的对照患者进行匹配。采用逻辑回归分析探讨喉镜检查期间的氧饱和度降低以及插管后低碳酸血症和低氧血症对预后的影响。采用线性回归和单因素分析探讨低碳酸血症与通气率之间的关系。此外，使用比值比分析比较试验患者和对照患者的死亡率及“良好预后”发生率。

结果

426例试验患者中，共有59例有完整的ETCO2/Spo2监测数据；这些患者与177例对照患者进行了匹配。逻辑回归分析显示最低ETCO2值和最终ETCO2值与死亡率之间存在关联。匹配对照分析证实低碳酸血症与死亡率之间存在关联。观察到通气率与ETCO2值之间存在统计学显著关联（r = -0.13，p < 0.0001）；与记录到的最低ETCO2值相关的通气率中位数显著高于所有其他ETCO2值对应的通气率中位数（27 mmHg对19 mmHg，p < 0.0001）。此外，RSI期间严重的氧饱和度降低和插管后低氧血症与高于匹配对照患者的死亡率相关。试验患者的总体死亡率为41%，而匹配对照患者为22%（比值比，2.51；95%置信区间，1.33 - 4.72；p = 0.004）。