Newgard Craig D, Rudser Kyle, Hedges Jerris R, Kerby Jeffrey D, Stiell Ian G, Davis Daniel P, Morrison Laurie J, Bulger Eileen, Terndrup Tom, Minei Joseph P, Bardarson Berit, Emerson Scott
Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon, USA.
J Trauma. 2010 Feb;68(2):452-62. doi: 10.1097/TA.0b013e3181ae20c9.
It remains unclear whether the American College of Surgeons Committee on Trauma (ACSCOT) "step 1" field physiologic criteria could be further restricted without substantially sacrificing sensitivity. We assessed whether more restrictive physiologic criteria would improve the specificity of this triage step without missing high-risk patients.
We analyzed an out-of-hospital, consecutive patient, prospective cohort of injured adults >or=15 years collected from December 1, 2005, to February 28, 2007, by 237 emergency medical service agencies transporting to 207 acute care hospitals in 11 sites across the United States and Canada. Patients were included based on ACSCOT field decision scheme physiologic criteria systolic blood pressure <or=90, respiratory rate <10 or >29 breaths/min, Glasgow Coma Scale score <or=12, or field intubation. Seven field physiologic variables and four additional demographic and mechanism variables were included in the analysis. The composite outcome was mortality (field or in-hospital) or hospital length of stay >2 days.
Of 7,127 injured persons, 6,259 had complete outcome information and were included in the analysis. There were 3,631 (58.0%) persons with death or LOS >2 days. Using only physiologic measures, the derived rule included advanced airway intervention, shock index >1.4, Glasgow Coma Scale <11, and pulse oximetry <93%. Rule validation demonstrated sensitivity 72% (95% confidence interval: 70%-74%) and specificity 69% (95% confidence interval: 67%-72%). Inclusion of demographic and mechanism variables did not significantly improve performance measures.
We were unable to omit or further restrict any ACSCOT step 1 physiologic measures in a decision rule practical for field use without missing high-risk trauma patients.
美国外科医师学会创伤委员会（ACSCOT）的“第一步”现场生理标准是否可以在不显著牺牲敏感性的情况下进一步限制，目前尚不清楚。我们评估了更严格的生理标准是否会提高这一分诊步骤的特异性，同时又不会遗漏高危患者。
我们分析了一个院外连续患者的前瞻性队列，该队列由237个紧急医疗服务机构从2005年12月1日至2007年2月28日收集，这些机构将受伤成年人（年龄≥15岁）转运至美国和加拿大11个地点的207家急症护理医院。根据ACSCOT现场决策方案的生理标准纳入患者，即收缩压≤90、呼吸频率<10或>29次/分钟、格拉斯哥昏迷量表评分≤12或现场插管。分析中纳入了七个现场生理变量以及另外四个人口统计学和损伤机制变量。复合结局为死亡（现场或院内）或住院时间>2天。
在7127名受伤者中，6259人有完整的结局信息并纳入分析。有3631人（58.0%）死亡或住院时间>2天。仅使用生理指标时，推导得出的规则包括高级气道干预、休克指数>1.4、格拉斯哥昏迷量表<11以及脉搏血氧饱和度<93%。规则验证显示敏感性为72%（95%置信区间：70%-74%），特异性为69%（95%置信区间：67%-72%）。纳入人口统计学和损伤机制变量并未显著改善性能指标。
我们无法在适用于现场使用的决策规则中省略或进一步限制任何ACSCOT第一步的生理指标，同时又不遗漏高危创伤患者。
