Mans Stefan, Reinders Folmer Eline, de Jongh Mariska A C, Lansink Koen W W
Trauma Centre Brabant, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands.
Department of Surgery, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands.
Injury. 2016 Jan;47(1):26-31. doi: 10.1016/j.injury.2015.09.020. Epub 2015 Oct 9.
Several studies have suggested that severely injured patients should be transported directly to a trauma centre bypassing the nearest hospital. However, the evidence remains inconclusive. The purpose of this study was to examine the benefits in terms of mortality of direct transport to a trauma centre versus primary treatment in a level II or III centre followed by inter hospital transfer to a trauma centre for severely injured patients without Traumatic Brain Injury (TBI).
We used the regional trauma registry and included all patients with an Injury Severity Score (ISS) >15 and an Abbreviated Injury Score <4 for head injury. We adjusted for survival bias by including "potential transfers": patients who died at the nearest hospitals before transportation to a trauma centre.
A total of 439 patients was included. The majority of patients (349/439, 79%) was transported directly to the level I trauma centre (direct group). The transferred group was formed by the remaining 90 patients, of whom 81 were transferred to the level I trauma centre after initial stabilisation elsewhere and 9 patients died in the emergency room before transfer to a level 1 trauma centre could occur. There were no significant differences in baseline and injury characteristics between the groups. Overall, 60 patients died in-hospital including 41 of the 349 patients (12%) in the direct group and 19 of the 90 patients (21%) in the transferred group. Nine of the 19 deaths in the transferred group were ascribed to potential transfers. After adjusting for prehospital Revised Trauma Score (RTS) and ISS, the odds ratio of death was 2.40 (95%CI: 1.07-5.40) for patients in the transfer group. When potential transfer patients were excluded from the analysis, the adjusted odds ratio of death was 1.14 (95%CI: 0.43-3.01).
After adjusting for survivor bias by including potential transfers, the results of this study suggest a lower risk of death for patients who are directly transported to a level I trauma centre than for patients who receive primary treatment in a level II or III centre and are transferred to a trauma centre. However, this finding was only significant when adjusting for survival bias and therefore we conclude that it is still uncertain if there is a lower risk of death for patients who are transported directly to a level I trauma centre.
多项研究表明，重伤患者应绕过最近的医院直接转运至创伤中心。然而，证据仍不确凿。本研究的目的是探讨对于无创伤性脑损伤（TBI）的重伤患者，直接转运至创伤中心与在二级或三级中心进行初步治疗后再转至创伤中心相比，在死亡率方面的益处。
我们使用了区域创伤登记系统，纳入了所有损伤严重度评分（ISS）>15且头部损伤简明损伤评分<4的患者。我们通过纳入“潜在转运者”来调整生存偏倚：即在转运至创伤中心之前在最近医院死亡的患者。
共纳入439例患者。大多数患者（349/439，79%）直接转运至一级创伤中心（直接组）。转运组由其余90例患者组成，其中81例在其他地方初步稳定后转至一级创伤中心，9例在转至一级创伤中心之前在急诊室死亡。两组之间的基线和损伤特征无显著差异。总体而言，60例患者在医院死亡，包括直接组349例患者中的41例（12%）和转运组90例患者中的19例（21%）。转运组19例死亡中有9例归因于潜在转运者。在调整院前修正创伤评分（RTS）和ISS后，转运组患者的死亡比值比为2.40（95%CI：1.07 - 5.40）。当在分析中排除潜在转运患者时，调整后的死亡比值比为1.14（95%CI：0.43 - 3.01）。
通过纳入潜在转运者调整生存偏倚后，本研究结果表明，直接转运至一级创伤中心的患者比在二级或三级中心接受初步治疗后再转至创伤中心的患者死亡风险更低。然而，这一发现仅在调整生存偏倚时具有显著性，因此我们得出结论，直接转运至一级创伤中心的患者死亡风险是否更低仍不确定。
