基于证据的国家创伤分诊协议改进：格拉斯哥昏迷评分与格拉斯哥昏迷评分运动子量表。
Evidence-based improvement of the National Trauma Triage Protocol: The Glasgow Coma Scale versus Glasgow Coma Scale motor subscale.
机构信息
From the Division of General Surgery and Trauma (J.B.B., R.M.F., A.B.P., T.R.B., J.L.S.), Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and Division of Acute Care Surgery (N.A.S., M.L.G.), Department of Surgery, University of Rochester Medical Center, Rochester, New York.
出版信息
J Trauma Acute Care Surg. 2014 Jul;77(1):95-102; discussion 101-2. doi: 10.1097/TA.0000000000000280.
BACKGROUND
Ideal triage uses simple criteria to identify severely injured patients. Glasgow Coma Scale motor (GCSm) may be easier for field use and was considered for the National Trauma Triage Protocol (NTTP). This study evaluated performance of the NTTP if GCSm is substituted for the current GCS score ≤ 13 criterion.
METHODS
Subjects in the National Trauma Data Bank undergoing scene transport were included. Presence of NTTP physiologic (Step 1) and anatomic (Step 2) criteria was determined. GCSm score ≤ 5 was defined as a positive criterion. Trauma center need (TCN) was defined as Injury Severity Score (ISS) > 15, intensive care unit admission, urgent operation, or emergency department death. Test characteristics were calculated to predict TCN. Area under the curve was compared between GCSm and GCS scores, individually and within the NTTP. Logistic regression was used to determine the association of GCSm score ≤ 5 and GCS score ≤ 13 with TCN after adjusting for other triage criteria. Predicted versus actual TCN was compared.
RESULTS
There were 811,143 subjects. Sensitivity was lower (26.7% vs. 30.3%), specificity was higher (95.1% vs. 93.1%), and accuracy was similar (66.1% vs. 66.3%) for GCSm score ≤ 5 compared with GCS score ≤ 13. Incorporated into the NTTP Steps 1 + 2, GCSm score ≤ 5 traded sensitivity (60.4% vs. 62.1%) for specificity (67.1% vs. 65.7%) with similar accuracy (64.2% vs. 64.2%) to GCS score ≤ 13. There was no difference in the area under the curve between GCSm score ≤ 5 and GCS score ≤ 13 when incorporated into the NTTP Steps 1 + 2 (p = 0.10). GCSm score ≤ 5 had a stronger association with TCN (odds ratio, 3.37; 95% confidence interval, 3.27-3.48; p < 0.01) than GCS score ≤ 13 (odds ratio, 3.03; 95% confidence interval, 2.94-3.13; p < 0.01). GCSm had a better fit of predicted versus actual TCN than GCS at the lower end of the scales.
CONCLUSION
GCSm score ≤ 5 increases specificity at the expense of sensitivity compared with GCS score ≤ 13. When applied within the NTTP, there is no difference in discrimination between GCSm and GCS. GCSm score ≤ 5 is more strongly associated with TCN and better calibrated to predict TCN. Further study is warranted to explore replacing GCS score ≤ 13 with GCSm score ≤ 5 in the NTTP.
LEVEL OF EVIDENCE
Prognostic study, level III.
背景
理想的分诊使用简单的标准来识别严重受伤的患者。格拉斯哥昏迷量表运动（GCSm）可能更便于现场使用，并被考虑用于国家创伤分诊协议（NTTP）。本研究评估了如果将目前的 GCS 评分≤13 标准替换为 GCSm 评分≤5 的情况下 NTTP 的性能。
方法
纳入国家创伤数据库中接受现场转运的患者。确定是否存在 NTTP 生理（第 1 步）和解剖（第 2 步）标准。GCSm 评分≤5 定义为阳性标准。创伤中心需求（TCN）定义为损伤严重程度评分（ISS）>15、入住重症监护病房、紧急手术或急诊死亡。计算预测 TCN 的测试特征。分别比较 GCSm 和 GCS 评分在 NTTP 中的曲线下面积，并进行比较。使用逻辑回归确定 GCSm 评分≤5 和 GCS 评分≤13 与 TCN 之间的关联，调整其他分诊标准后。比较预测与实际 TCN。
结果
共有 811,143 名患者。与 GCS 评分≤13 相比，GCSm 评分≤5 的敏感性（26.7%比 30.3%）较低，特异性（95.1%比 93.1%）较高，准确性（66.1%比 66.3%）相似。纳入 NTTP 步骤 1+2 后，GCSm 评分≤5 的特异性（67.1%比 65.7%）高于敏感性（60.4%比 62.1%），准确性（64.2%比 64.2%）与 GCS 评分≤13 相似。纳入 NTTP 步骤 1+2 后，GCSm 评分≤5 和 GCS 评分≤13 的曲线下面积之间无差异（p=0.10）。GCSm 评分≤5 与 TCN 的相关性（优势比，3.37；95%置信区间，3.27-3.48；p<0.01）强于 GCS 评分≤13（优势比，3.03；95%置信区间，2.94-3.13；p<0.01）。与 GCS 相比，GCSm 在量表的较低端更能准确地预测 TCN。
结论
与 GCS 评分≤13 相比，GCSm 评分≤5 增加了特异性，同时降低了敏感性。当应用于 NTTP 时，GCSm 和 GCS 之间的区分度没有差异。GCSm 评分≤5 与 TCN 的相关性更强，对 TCN 的预测更准确。需要进一步研究以探讨在 NTTP 中用 GCSm 评分≤5 替代 GCS 评分≤13。
证据水平
预后研究，III 级。
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