DiRusso Stephen M, Sullivan Thomas, Risucci Donald, Nealon Peter, Slim Michel
Department of Surgery, New York Medical College, Westchester Medical Center, Valhalla, New York 10595, USA.
J Trauma. 2005 Jul;59(1):84-90; discussion 90-1. doi: 10.1097/01.ta.0000171462.28379.f3.
Recently, evidence has shown that intubation in the field may not improve or may even adversely affect outcomes. Our objective was to analyze outcomes in pediatric intubated trauma patients using a large national pediatric trauma registry.
The patient population was derived from the last phase of the National Pediatric Trauma Registry, comprising admissions from 1994 through 2002. Intubated patients were identified, as was their place of intubation: in the field, at a hospital that was not a trauma center, and at a trauma center. Risk stratification was performed for mortality using logistic regression models and variables available at presentation to the emergency room. Odds ratio and variable significance were calculated from the logistic regression model. The percentage of patients discharged to home and an abnormal Functional Independence Measure at hospital discharge examined functional outcome of survivors.
There were a total of 50,199 patients, 5460 (11.6%) of whom were intubated (1,930 in the field, 1,654 in the hospital, and 1,876 in a trauma center). Unadjusted mortality rates for intubated patients were as follows: field, 38.5%; hospital, 16.7%; and trauma center, 13.2% (all different, p < 0.05). The developed logistic regression model had an area under the receiver operating characteristic curve of 0.98. Compared with nonintubated patients, the odds ratio for field intubation, for non-trauma center, and for trauma center intubation was 14.4, 5.8, and 4.8, respectively (significantly different field vs. either hospital). The actual (observed) death rate was significantly higher than predicted in those intubated in the field. Stratification of injury by New Injury Severity Score or degree of head injury showed that this difference extended from mild to severe (e.g., odds ratio for New Injury Severity Score < 15 field vs. trauma center intubation, 12.3; odds ratio for none or moderate head injury, 5.1). Similar results were obtained for functional outcome in the survivors.
Field intubation is an independent strong negative predictor of survival or good functional outcome despite adjustment for severity of injury. Although not causal, the magnitude of these differences should lead to future controlled studies of pediatric trauma field intubations.
最近，有证据表明现场插管可能不会改善甚至可能对预后产生不利影响。我们的目的是使用一个大型的国家儿童创伤登记系统分析儿童创伤插管患者的预后情况。
患者群体来自国家儿童创伤登记系统的最后阶段，包括1994年至2002年期间的入院患者。确定插管患者及其插管地点：现场、非创伤中心医院和创伤中心。使用逻辑回归模型和急诊室就诊时可用的变量对死亡率进行风险分层。从逻辑回归模型计算比值比和变量显著性。出院回家的患者百分比和出院时功能独立性测量异常情况用于检查幸存者的功能结局。
共有50199例患者，其中5460例（11.6%）进行了插管（现场1930例、医院1654例、创伤中心1876例）。插管患者的未调整死亡率如下：现场38.5%；医院16.7%；创伤中心13.2%（均有差异，p<0.05）。所建立的逻辑回归模型的受试者工作特征曲线下面积为0.98。与未插管患者相比，现场插管、非创伤中心插管和创伤中心插管的比值比分别为14.4、5.8和4.8（现场与任何一家医院相比均有显著差异）。现场插管患者的实际（观察到的）死亡率显著高于预测值。按新损伤严重度评分或头部损伤程度对损伤进行分层显示，这种差异从轻度到重度均存在（例如，新损伤严重度评分<15时现场插管与创伤中心插管的比值比为12.3；无头部损伤或中度头部损伤时的比值比为5.1）。幸存者的功能结局也得到了类似结果。
尽管对损伤严重程度进行了调整，但现场插管仍是生存或良好功能结局的一个独立的强负性预测因素。虽然并非因果关系，但这些差异的程度应促使未来对儿童创伤现场插管进行对照研究。
