Lui Felix, Gormley Paula, Sorrells Donald L, Biffl Walter L, Kurkchubasche Arlet G, Tracy Thomas F, Luks Francois I
Division of Pediatric Surgery, Brown Medical School and Hasbro Children's Hospital, Providence, RI 02905, USA.
J Pediatr Surg. 2005 Jan;40(1):103-6. doi: 10.1016/j.jpedsurg.2004.09.029.
BACKGROUND/PURPOSE: Optimal trauma care requires an attending pediatric surgeon to head a trauma team for the most severely injured patients. Recently, the American College of Surgeons-Committee on Trauma has added "Glasgow Coma Scale (GCS) <8" and "airway compromise" to the existing anatomical and physiological criteria for immediate attending presence. This report analyzes the outcome of children who met these isolated criteria and were treated before the change in guidelines was made.
The trauma registry of this level I trauma center was queried for all pediatric patients with GCS <8 or airway compromise. Age, sex, initial GCS, Revised Trauma Score, Injury Severity Score, outcome, and probability of survival (TRISS methodology) were recorded. The subgroup of patients for whom an attending surgeon was not immediately present was further analyzed.
Over a 5-year period, 2895 trauma patients (aged 0-16 years) were admitted. One hundred fifteen patients had a GCS <8 and/or airway compromise. In 61 cases, an attending surgeon was not present upon patient arrival. Of these patients, 24 died (group D), 15 were discharged to a rehabilitation facility (group R), and 22 were discharged home (group H). Ten patients with a probability of survival of lower than 0.5 survived. Only 4 of the 24 patients who died had a probability of survival of >0.5 (mean, 0.697). All 4 had an Injury Severity Score >25 and a GCS < or =4. All deaths were reviewed through a quality improvement program and were deemed nonpreventable by objective reviewers. Patient outcome was not affected by the presence or absence of an attending surgeon upon patient arrival.
Outcome of severely injured children with GCS <8 or airway compromise met and, in some cases, exceeded expectations of survival according to the TRISS methodology. The lack of immediate attending surgeon's presence does not appear to have negatively influenced the outcome in these children. Based on this series, there is no evidence to justify mandatory immediate presence of an attending surgeon for these 2 criteria alone.
背景/目的：最佳创伤护理需要一名主治儿科外科医生领导创伤团队来治疗伤势最严重的患者。最近，美国外科医师学会创伤委员会已将“格拉斯哥昏迷量表（GCS）<8”和“气道受损”纳入现有的立即需要主治医生在场的解剖学和生理学标准。本报告分析了符合这些单独标准且在指南变更之前接受治疗的儿童的治疗结果。
查询该一级创伤中心的创伤登记处，获取所有GCS<8或气道受损的儿科患者信息。记录年龄、性别、初始GCS、修订创伤评分、损伤严重度评分、治疗结果和生存概率（创伤和损伤严重度评分系统方法）。对主治外科医生未立即到场的患者亚组进行进一步分析。
在5年期间，收治了2895例创伤患者（年龄0至16岁）。115例患者GCS<8和/或气道受损。61例患者到达时主治外科医生不在场。这些患者中，24例死亡（D组），15例出院至康复机构（R组），22例出院回家（H组）。10例生存概率低于0.5的患者存活。死亡的24例患者中只有4例生存概率>0.5（平均0.697）。所有4例患者损伤严重度评分>25且GCS≤4。通过质量改进计划对所有死亡病例进行了审查，客观评审人员认为所有死亡均无法预防。患者到达时主治外科医生在场与否并不影响治疗结果。
GCS<8或气道受损的重伤儿童的治疗结果，在某些情况下，达到并超过了创伤和损伤严重度评分系统方法预期的生存水平。主治外科医生未立即到场似乎并未对这些儿童的治疗结果产生负面影响。基于本系列研究，没有证据表明仅依据这两条标准就必须要求主治外科医生立即到场。
