Härtl Roger, Gerber Linda M, Iacono Laura, Ni Quanhong, Lyons Kerry, Ghajar Jamshid
Department of Neurological Surgery, Weill Medical College of Cornell University, and the Brain Trauma Foundation, New York, New York 10021, USA.
J Trauma. 2006 Jun;60(6):1250-6; discussion 1256. doi: 10.1097/01.ta.0000203717.57821.8d.
Prehospital management of traumatic brain injury (TBI) and trauma system development and organization are aspects of TBI care that have the potential to significantly impact patient outcome. This multi-center study was conducted to explore the effect of prehospital management decisions on early mortality after severe TBI.
This report is based on 1449 patients with severe TBI (GCS<9) treated at 22 trauma centers enrolled in a New York State quality improvement (QI) program between 2000 and 2004. The prehospital data collected on these patients include time of injury, time of arrival to the trauma center, mode of transport, type of EMS provider, direct or indirect transport, blood pressure and pulse oximetry values, GCS score, pupillary assessment, and airway management procedures.
After exclusion criteria were applied, a total of 1,123 patients were eligible for analysis. The majority of patients were male (75%) with a mean age of 36 years. After controlling for arterial hypotension, age, pupillary status, and initial GCS score, direct transport was found to result in significantly lower mortality than indirect transport. Transport mode, time to admission, and prehospital intubation were not found to be related to 2-week mortality.
The present study provides class II evidence that demonstrates a 50% increase in mortality associated with indirect transfer of TBI patients. Patients with severe TBI should be transported directly to a Level I or Level II trauma center with capabilities as delineated in the Guidelines for the Prehospital Management of Traumatic Brain Injury, even if this center may not be the closest hospital.
创伤性脑损伤（TBI）的院前管理以及创伤系统的发展与组织是TBI护理的重要方面，有可能对患者的预后产生重大影响。本多中心研究旨在探讨院前管理决策对重度TBI患者早期死亡率的影响。
本报告基于2000年至2004年间在纽约州质量改进（QI）项目中登记的22个创伤中心治疗的1449例重度TBI患者（格拉斯哥昏迷量表[GCS]<9）。收集的这些患者的院前数据包括受伤时间、到达创伤中心的时间、运输方式、急救医疗服务提供者类型、直接或间接运输、血压和脉搏血氧饱和度值、GCS评分、瞳孔评估以及气道管理程序。
应用排除标准后，共有1123例患者符合分析条件。大多数患者为男性（75%），平均年龄36岁。在控制动脉低血压、年龄、瞳孔状态和初始GCS评分后，发现直接运输导致的死亡率显著低于间接运输。未发现运输方式、入院时间和院前插管与2周死亡率相关。
本研究提供了II类证据，表明TBI患者间接转运的死亡率增加了50%。重度TBI患者应直接转运至具备《创伤性脑损伤院前管理指南》中所规定能力的I级或II级创伤中心，即使该中心可能不是最近的医院。
