Davis Daniel P, Stern Jessica, Sise Michael J, Hoyt David B
Department of Emergency Medicine, Division of Trauma, University of California-San Diego, CA92103-8946, USA.
J Trauma. 2005 Aug;59(2):486-90. doi: 10.1097/00005373-200508000-00037.
The San Diego Paramedic Rapid Sequence Intubation (RSI) Trial documented an increase in mortality after paramedic RSI, with hyperventilation identified as a contributing factor in a small subgroup analysis. Here we explore factors affecting outcome in the entire cohort of patients undergoing paramedic RSI to confirm previous findings. This also represents a synthesis of findings from previous analyses
Adult trauma patients with severe head injury (Glasgow Coma Scale score, 3-8) who could not be intubated without RSI were prospectively enrolled in the trial. This analysis excluded patients without traumatic brain injury (head/neck abbreviated injury score <2 or failure to meet Major Trauma Outcome Study criteria) or death in the field or within 30 minutes of arrival. Each remaining trial patient was matched to two nonintubated historical controls from the county trauma registry based on: age, sex, mechanism, abbreviated injury scores for each body system, and Injury Severity Score. Logistic regression, cohort analysis, mean least squares regression, and discordant group analysis were used to explore the impact of various factors on outcome.
Of the 426 trial patients, 352 met inclusion criteria for this analysis and were hand-matched to 704 controls. Trial patients and controls were identical with regard to all matching variables. Mortality was increased in RSI patients versus matched controls (31.8 versus 23.7%; odds ration, 1.5; 95% confidence interval, 1.1-2.0; p < 0.01). Hyperventilation was associated with an increase in mortality, whereas transport by aeromedical crews after paramedic RSI was associated with improved outcomes. The reported incidence of aspiration pneumonia was higher for the RSI patients.
Paramedic RSI was associated with an increase in mortality compared with matched historical controls. The association between hyperventilation and mortality was confirmed. In addition, patients transported by helicopter after paramedic RSI had improved outcomes. Paramedic RSI did not seem to prevent aspiration pneumonia.
圣地亚哥护理人员快速顺序诱导插管（RSI）试验记录了护理人员进行RSI后死亡率增加，在一项小型亚组分析中，过度通气被确定为一个促成因素。在此，我们探讨影响接受护理人员RSI的所有患者结局的因素，以证实先前的研究结果。这也代表了先前分析结果的综合。
前瞻性纳入了严重颅脑损伤（格拉斯哥昏迷量表评分3 - 8分）且不进行RSI就无法插管的成年创伤患者。该分析排除了无创伤性脑损伤（头/颈简略损伤评分<2或未达到重大创伤结局研究标准）或在现场或到达后30分钟内死亡的患者。根据年龄、性别、受伤机制、每个身体系统的简略损伤评分和损伤严重程度评分，将其余每位试验患者与来自县创伤登记处的两名未插管的历史对照进行匹配。使用逻辑回归、队列分析、平均最小二乘回归和不一致组分析来探讨各种因素对结局的影响。
426名试验患者中，352名符合本分析的纳入标准，并与704名对照进行了手工匹配。试验患者和对照在所有匹配变量方面均相同。与匹配的对照相比，RSI患者的死亡率增加（31.8%对23.7%；优势比，1.5；95%置信区间，1.1 - 2.0；p < 0.01）。过度通气与死亡率增加相关，而护理人员进行RSI后由空中医疗机组转运与结局改善相关。RSI患者报告的吸入性肺炎发生率更高。
与匹配的历史对照相比，护理人员进行RSI与死亡率增加相关。过度通气与死亡率之间的关联得到证实。此外，护理人员进行RSI后通过直升机转运的患者结局得到改善。护理人员进行RSI似乎并未预防吸入性肺炎。
