Sloan Edward P, Koenigsberg Max, Weir W Brad, Clark James M, O'Connor Robert, Olinger Michael, Cydulka Rita
1Department of Emergency Medicine,University of Illinois at Chicago,Chicago,IllinoisUSA.
2Advocate Illinois Masonic Medical Center,Chicago,IllinoisUSA.
Prehosp Disaster Med. 2015 Feb;30(1):54-61. doi: 10.1017/S1049023X14001174. Epub 2014 Dec 15.
Optimal emergent management of traumatic hemorrhagic shock patients requires a better understanding of treatment provided in the prehospital/Emergency Medical Services (EMS) and emergency department (ED) settings. Hypothesis/Problem Described in this research are the initial clinical status, airway management, fluid and blood infusions, and time course of severely-injured hemorrhagic shock patients in the EMS and ED settings from the diaspirin cross-linked hemoglobin (DCLHb) clinical trial.
Data were analyzed from 17 US trauma centers gathered during a randomized, controlled, single-blinded efficacy trial of a hemoglobin solution (DCLHb) as add-on therapy versus standard therapy.
Among the 98 randomized patients, the mean EMS Glasgow Coma Scale (GCS) was 10.6 (SD = 5.0), the mean EMS revised trauma score (RTS) was 6.3 (SD = 1.9), and the mean injury severity score (ISS) was 31 (SD = 17). Upon arrival to the ED, the GCS was 20% lower (7.8 (SD = 5.3) vs 9.7 (SD = 6.3)) and the RTS was 12% lower (5.3 (SD = 2.0) vs 6.0 (SD = 2.1)) than EMS values in blunt trauma patients (P < .001). By ED disposition, 80% of patients (78/98) were intubated. Rapid sequence intubation (RSI) was utilized in 77% (60/78), most often utilizing succinylcholine (65%) and midazolam (50%). The mean crystalloid volume infused was 4.2 L (SD = 3.4 L), 80% of which was infused within the ED. Emergency department blood transfusion occurred in 62% of patients, with an average transfused volume of 1.2 L (SD = 2.0 L). Blunt trauma patients received 2.1 times more total fluids (7.4 L vs 3.5 L, < .001) and 2.4 times more blood (2.4 L vs 1.0 L, P < .001). The mean time of patients taken from injury site to operating room (OR) was 113 minutes (SD = 87 minutes). Twenty-one (30%) of the 70 patients taken to the OR from the ED were sent within 60 minutes of the estimated injury time. Penetrating trauma patients were taken to the OR 52% sooner than blunt trauma patients (72 minutes vs 149 minutes, P < .001).
Both GCS and RTS decreased prior to ED arrival in blunt trauma patients. Intubation was performed using RSI, and crystalloid infusion of three times the estimated blood loss volume (L) and blood transfusion of the estimated blood loss volume (L) were provided in the EMS and ED settings. Surgical intervention for these trauma patients most often occurred more than one hour from the time of injury. Penetrating trauma patients received surgical intervention more rapidly than those with a blunt trauma mechanism.
创伤性失血性休克患者的最佳紧急处理需要更好地了解在院前/紧急医疗服务（EMS）和急诊科（ED）所提供的治疗。本研究中描述的假设/问题是来自双阿司匹林交联血红蛋白（DCLHb）临床试验的严重受伤失血性休克患者在EMS和ED环境中的初始临床状态、气道管理、液体和血液输注以及时间进程。
分析了在美国17个创伤中心收集的数据，这些数据来自一项随机、对照、单盲的血红蛋白溶液（DCLHb）作为附加治疗与标准治疗的疗效试验。
在98例随机分组的患者中，EMS的格拉斯哥昏迷量表（GCS）平均为10.6（标准差=5.0），EMS修订创伤评分（RTS）平均为6.3（标准差=1.9），平均损伤严重程度评分（ISS）为31（标准差=17）。到达急诊科时，钝性创伤患者的GCS比EMS时低20%（7.8（标准差=5.3）对9.7（标准差=6.3）），RTS比EMS时低12%（5.3（标准差=2.0）对6.0（标准差=2.1））（P<.001）。根据急诊科处置情况，80%的患者（78/98）进行了插管。77%（60/78）的患者采用了快速顺序诱导插管（RSI），最常用的是琥珀酰胆碱（65%）和咪达唑仑（50%）。输注的晶体液平均量为4.2L（标准差=3.4L），其中80%在急诊科输注。62%的患者在急诊科接受了输血，平均输血量为1.2L（标准差=2.0L）。钝性创伤患者接受的总液体量多2.1倍（7.4L对3.5L，P<.001），输血量多2.4倍（2.4L对1.0L，P<.001）。患者从受伤部位到手术室（OR）的平均时间为113分钟（标准差=87分钟）。从急诊科送往手术室的70例患者中有21例（30%）在估计受伤时间的60分钟内被送去。穿透性创伤患者比钝性创伤患者早52%被送往手术室（72分钟对149分钟，P<.001）。
钝性创伤患者在到达急诊科之前GCS和RTS均下降。采用RSI进行插管，在EMS和ED环境中输注了估计失血量3倍体积（L）的晶体液和估计失血量（L）的血液。这些创伤患者的手术干预大多在受伤后1小时以上进行。穿透性创伤患者比钝性创伤机制的患者接受手术干预更快。
