计算机断层扫描证实的创伤性脑损伤患者的插管模式及预后

Intubation patterns and outcomes in patients with computed tomography-verified traumatic brain injury.

作者信息

Vandromme Marianne J, Melton Sherry M, Griffin Russell, McGwin Gerald, Weinberg Jordan A, Minor Michael, Rue Loring W, Kerby Jeffrey D

机构信息

Department of Surgery, Section of Trauma, Burns, and Surgical Critical Care, University of Alabama at Birmingham, Birmingham, Alabama 35294, USA.

出版信息

J Trauma. 2011 Dec;71(6):1615-9. doi: 10.1097/TA.0b013e31822a30a1.

DOI:10.1097/TA.0b013e31822a30a1

PMID:21841511

Abstract

BACKGROUND

Studies evaluating traumatic brain injury (TBI) patients have shown an association between prehospital (PH) intubation and worse outcomes. However, previous studies have used surrogates, e.g., Glasgow Coma Scale (GCS) score ≤8 and Abbreviated Injury Severity Scale (AIS) score ≥3, which may overestimate the true presence of TBI. This study evaluated the impact of PH intubation in patients with PH GCS score ≤8 and radiographically proven TBI.

METHODS

Trauma patients routed to a Level I trauma center over a 3-year period with blunt injury and PH GCS score ≤8 were included. PH and in-hospital records were linked and head computed tomography scans were assigned a Marshall Score (MS). Patients with TBI (MS >1) were categorized into groups based on intubation status (PH, emergency department [ED], and no intubation). Comparisons were made using analysis of variance and χ statistics. Mortality differences, crude and adjusted risk ratios (RRs), and 95% confidence intervals (CIs) were calculated using proportions hazards modeling.

RESULTS

Of 334 patients with PH GCS score ≤8, 149 (50%) had TBI by MS. Among the TBI patients, 42.7% of patients were PH intubated, 47.7% were ED intubated, and 9.4% were not intubated during the initial resuscitation. Intubated patients had lower ED GCS score (PH: 4.1 and ED: 5.9 vs. 14.0; p < 0.0001) compared with patients not intubated. Also PH intubated patients had higher mean Injury Severity Score (38.0 vs. 33.7 vs. 23.5, p < 0.001) when compared with ED intubated and nonintubated patients. None of the nonintubated patients had a MS >2. Mortality for TBI patients who required PH intubation was 46.9% and 41.4% among ED-intubated patients. The crude RR of mortality for PH compared with ED intubation was 1.13 (95% CI, 0.68-1.89), and remained nonsignificant (RR, 0.68; 95% CI, 0.36-1.19) when adjusted for key markers of injury severity.

CONCLUSIONS

Patients with PH GCS score ≤8 and proven TBI had a high overall rate of intubation (>90%). PH intubation seems to be a marker for more severe injury and conveyed no increased risk for mortality over ED intubation.

摘要

背景

评估创伤性脑损伤（TBI）患者的研究表明，院前（PH）插管与更差的预后相关。然而，以往的研究使用了替代指标，如格拉斯哥昏迷量表（GCS）评分≤8和简明损伤严重程度量表（AIS）评分≥3，这可能高估了TBI的实际存在情况。本研究评估了PH GCS评分≤8且经影像学证实为TBI的患者进行PH插管的影响。

方法

纳入3年内因钝性损伤且PH GCS评分≤8而被送往一级创伤中心的创伤患者。将PH记录与院内记录进行关联，并对头计算机断层扫描分配马歇尔评分（MS）。TBI患者（MS>1）根据插管状态（PH、急诊科[ED]和未插管）分为几组。使用方差分析和χ统计进行比较。使用比例风险模型计算死亡率差异、粗风险比（RR）和调整风险比以及95%置信区间（CI）。

结果

在334例PH GCS评分≤8的患者中，149例（50%）经MS诊断为TBI。在TBI患者中，42.7%的患者在院前进行了插管，47.7%在急诊科进行了插管，9.4%在初始复苏期间未插管。与未插管患者相比，插管患者的急诊科GCS评分较低（院前：4.1，急诊科：5.9 vs. 14.0；p<0.0001）。此外，与急诊科插管和未插管患者相比，院前插管患者的平均损伤严重程度评分更高（38.0 vs. 33.7 vs. 23.5，p<0.001）。没有未插管患者的MS>2。需要院前插管的TBI患者死亡率为46.9%，急诊科插管患者死亡率为41.4%。与急诊科插管相比，院前插管的粗死亡率RR为1.13（95%CI，0.68-1.89），在调整损伤严重程度关键指标后仍无统计学意义（RR，0.68；95%CI，0.36-1.19）。