并非所有院前时间都是等同的：现场时间对死亡率的影响。
Not all prehospital time is equal: Influence of scene time on mortality.
作者信息
Brown Joshua B, Rosengart Matthew R, Forsythe Raquel M, Reynolds Benjamin R, Gestring Mark L, Hallinan William M, Peitzman Andrew B, Billiar Timothy R, Sperry Jason L
机构信息
From the Division of Trauma and General Surgery (J.B.B., M.R.R., R.M.F., B.R.R., 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 (M.L.G., W.M.H.), Department of Surgery, University of Rochester Medical Center, Rochester, New York.
出版信息
J Trauma Acute Care Surg. 2016 Jul;81(1):93-100. doi: 10.1097/TA.0000000000000999.
BACKGROUND
Trauma is time sensitive, and minimizing prehospital (PH) time is appealing. However, most studies have not linked increasing PH time with worse outcomes because raw PH times are highly variable. It is unclear whether specific PH time patterns affect outcomes. Our objective was to evaluate the association of PH time interval distribution with mortality.
METHODS
Patients transported by emergency medical services in the Pennsylvania trauma registry from 2000 to 2013 with a total PH time (TPT) of 20 minutes or longer were included. TPT was divided into three PH time intervals: response, scene, and transport time. The number of minutes in each PH time interval was divided by TPT to determine the relative proportion each interval contributed to TPT. A prolonged interval was defined as any one PH interval contributing equal to or greater than 50% of TPT. Patients were classified by prolonged PH interval or no prolonged PH interval (all intervals < 50% of TPT). Patients were matched for TPT, and conditional logistic regression determined the association of mortality with PH time pattern, controlling for confounders. PH interventions were explored as potential mediators, and PH triage criteria used identify patients with time-sensitive injuries.
RESULTS
There were 164,471 patients included. Patients with prolonged scene time had increased odds of mortality (odds ratio, 1.21; 95% confidence interval, 1.02-1.44; p = 0.03). Prolonged response, transport, and no prolonged interval were not associated with mortality. When adjusting for mediators including extrication and PH intubation, prolonged scene time was no longer associated with mortality (odds ratio, 1.06; 95% confidence interval, 0.90-1.25; p = 0.50). Together, these factors mediated 61% of the effect between prolonged scene time and mortality. Mortality remained associated with prolonged scene time in patients with hypotension, penetrating injury, and flail chest.
CONCLUSION
Prolonged scene time is associated with increased mortality. PH interventions partially mediate this association. Further study should evaluate whether these interventions drive increased mortality because they prolong scene time or by another mechanism, as reducing scene time may be a target for intervention.
LEVEL OF EVIDENCE
Prognostic/epidemiologic study, level III.
背景
创伤具有时间敏感性，尽量缩短院前（PH）时间很有意义。然而，大多数研究并未将增加的PH时间与更差的预后联系起来，因为原始的PH时间差异很大。尚不清楚特定的PH时间模式是否会影响预后。我们的目的是评估PH时间间隔分布与死亡率之间的关联。
方法
纳入2000年至2013年宾夕法尼亚创伤登记处由紧急医疗服务运送的患者，其总PH时间（TPT）为20分钟或更长。TPT分为三个PH时间间隔：响应时间、现场时间和转运时间。每个PH时间间隔的分钟数除以TPT，以确定每个间隔对TPT的相对贡献比例。延长间隔定义为任何一个PH间隔占TPT的比例等于或大于50%。患者按延长的PH间隔或无延长的PH间隔（所有间隔<TPT的50%）进行分类。对患者的TPT进行匹配，并通过条件逻辑回归确定死亡率与PH时间模式之间的关联，同时控制混杂因素。探讨PH干预作为潜在的中介因素，并使用PH分诊标准识别有时间敏感性损伤的患者。
结果
共纳入164471例患者。现场时间延长的患者死亡几率增加（比值比，1.21；95%置信区间，1.02 - 1.44；p = 0.03）。响应时间延长、转运时间延长和无延长间隔与死亡率无关。在调整包括解救和PH插管等中介因素后，现场时间延长与死亡率不再相关（比值比，1.06；95%置信区间，0.90 - 1.25；p = 0.50）。这些因素共同介导了现场时间延长与死亡率之间效应的61%。在低血压、穿透伤和连枷胸患者中，死亡率仍与现场时间延长相关。
结论
现场时间延长与死亡率增加相关。PH干预部分介导了这种关联。进一步的研究应评估这些干预措施是否因延长现场时间或通过另一种机制导致死亡率增加，因为缩短现场时间可能是一个干预靶点。
证据水平
预后/流行病学研究，III级。
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