手术时间对躯干枪伤低血压患者死亡率的影响：黄金10分钟。
Effect of time to operation on mortality for hypotensive patients with gunshot wounds to the torso: The golden 10 minutes.
作者信息
Meizoso Jonathan P, Ray Juliet J, Karcutskie Charles A, Allen Casey J, Zakrison Tanya L, Pust Gerd D, Koru-Sengul Tulay, Ginzburg Enrique, Pizano Louis R, Schulman Carl I, Livingstone Alan S, Proctor Kenneth G, Namias Nicholas
机构信息
From the Ryder Trauma Center, DeWitt Daughtry Family Department of Surgery (J.P.M., J.J.R., C.A.K., C.J.A., T.L.Z., G.D.P., E.G., L.R.P., C.I.S., A.S.L., K.G.P., N.N.), University of Miami Miller School of Medicine, Miami, Florida; Department of Public Health Sciences (J.P.M., J.J.R., T.K.S.), University of Miami Miller School of Medicine, Miami, Florida.
出版信息
J Trauma Acute Care Surg. 2016 Oct;81(4):685-91. doi: 10.1097/TA.0000000000001198.
INTRODUCTION
Timely hemorrhage control is paramount in trauma; however, a critical time interval from emergency department arrival to operation for hypotensive gunshot wound (GSW) victims is not established. We hypothesize that delaying surgery for more than 10 minutes from arrival increases all-cause mortality in hypotensive patients with GSW.
METHODS
Data of adults (n = 309) with hypotension and GSW to the torso requiring immediate operation from January 2004 to September 2013 were retrospectively reviewed. Patients with resuscitative thoracotomies, traumatic brain injury, transfer from outside institutions, and operations occurring more than 1 hour after arrival were excluded. Survival analysis using multivariate Cox regression models was used for comparison. Hazard ratios (HRs) and 95% confidence intervals (CIs) are reported. Statistical significance was considered at p ≤ 0.05.
RESULTS
The study population was aged 32 ± 12 years, 92% were male, Injury Severity Score was 24 ± 15, systolic blood pressure was 81 ± 29 mm Hg, Glasgow Coma Scale score was 13 ± 4. Overall mortality was 27%. Mean time to operation was 19 ± 13 minutes. After controlling for organ injury, patients who arrived to the operating room after 10 minutes had a higher likelihood of mortality compared with those who arrived in 10 minutes or less (HR, 1.89; 95% CI, 1.10-3.26; p = 0.02); this was also true in the severely hypotensive patients with systolic blood pressure of 70 mm Hg or less (HR, 2.67; 95% CI, 0.97-7.34; p = 0.05). The time associated with a 50% cumulative mortality was 16 minutes.
CONCLUSIONS
Delay to the operating room of more than 10 minutes increases the risk of mortality by almost threefold in hypotensive patients with GSW. Protocols should be designed to shorten time in the emergency department. Further prospective observational studies are required to validate these findings.
LEVEL OF EVIDENCE
Therapeutic study, level IV.
引言
在创伤治疗中，及时控制出血至关重要；然而，对于低血压枪伤（GSW）患者，从急诊科就诊到手术的关键时间间隔尚未确定。我们假设，从就诊起延迟手术超过10分钟会增加低血压GSW患者的全因死亡率。
方法
回顾性分析2004年1月至2013年9月期间309例因躯干低血压性GSW需要立即手术的成人患者的数据。排除接受复苏性开胸手术、创伤性脑损伤、从外部机构转入以及就诊后1小时以上进行手术的患者。使用多变量Cox回归模型进行生存分析以作比较。报告风险比（HRs）和95%置信区间（CIs）。p≤0.05时认为具有统计学意义。
结果
研究人群年龄为32±12岁，92%为男性，损伤严重程度评分为24±15，收缩压为81±29 mmHg，格拉斯哥昏迷量表评分为13±4。总死亡率为27%。平均手术时间为19±13分钟。在控制器官损伤后，与在10分钟或更短时间内到达手术室的患者相比，10分钟后到达手术室的患者死亡可能性更高（HR，1.89；95%CI，1.10 - 3.26；p = 0.02）；收缩压70 mmHg或更低的严重低血压患者也是如此（HR，2.67；95%CI，0.97 - 7.34；p = 0.05）。与50%累积死亡率相关的时间为16分钟。
结论
对于低血压GSW患者，延迟到手术室超过10分钟会使死亡风险增加近两倍。应制定方案以缩短在急诊科的时间。需要进一步的前瞻性观察研究来验证这些发现。
证据级别
治疗性研究，IV级。
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