Witt Cordelie E, Linnau Ken F, Maier Ronald V, Rivara Frederick P, Vavilala Monica S, Bulger Eileen M, Arbabi Saman
From the Harborview Injury Prevention and Research Center (C.E.W., R.V.M., F.P.R., M.S.V., E.M.B., S.A.), University of Washington, Seattle, Washington; Department of Surgery (C.E.W., R.V.M., E.M.B., S.A.), Harborview Medical Center, University of Washington, Seattle, Washington; Department of Radiology (K.F.L.), Harborview Medical Center, University of Washington, Seattle, Washington; Department of Pediatrics (F.P.R.), Harborview Medical Center, University of Washington, Seattle, Washington; and Department of Anesthesiology and Pain Medicine (M.S.V.), Harborview Medical Center, University of Washington, Seattle, Washington.
J Trauma Acute Care Surg. 2017 Apr;82(4):733-741. doi: 10.1097/TA.0000000000001386.
The objectives of this study were to assess current variability in management preferences for blunt trauma patients with pericardial fluid, and to identify characteristics associated with operative intervention for patients with pericardial fluid on admission computed tomography (CT) scan.
This was a mixed-methods study of blunt trauma patients with pericardial fluid. The first portion was a research survey of members of the Eastern Association for the Surgery of Trauma conducted in 2016, in which surgeons were presented with four clinical scenarios of blunt trauma patients with pericardial fluid. The second portion of the study was a retrospective evaluation of all blunt trauma patients 14 years or older treated at our Level I trauma center between January 1, 2010, and November 1, 2015, with pericardial fluid on admission CT scan.
For the survey portion of our study, 393 surgeons responded (27% response rate). There was significant variability in management preferences for scenarios depicting trace pericardial fluid on CT with concerning hemodynamics, and for scenarios depicting hemopericardium intraoperatively. For the separate retrospective portion of our study, we identified 75 blunt trauma patients with pericardial fluid on admission CT scan. Seven underwent operative management; six of these had hypotension and/or electrocardiogram changes. In multivariable analysis, pericardial fluid amount was a significant predictor of receiving pericardial window (relative risk for one category increase in pericardial fluid amount, 3.99, 95% confidence interval, 1.47-10.81) but not of mortality.
There is significant variability in management preferences for patients with pericardial fluid from blunt trauma, indicating a need for evidence-based research. Our institutional data suggest that patients with minimal to small amounts of pericardial fluid without concerning clinical findings may be observed. Patients with moderate to large amounts of pericardial fluid who are clinically stable with normal hemodynamics may also appear appropriate for observation, although confirmation in larger studies is needed. Patients with hemodynamic instability should undergo operative exploration.
Therapeutic/care management study, level IV.
本研究的目的是评估目前对于心包积液钝性创伤患者管理偏好的变异性，并确定入院计算机断层扫描（CT）显示心包积液患者手术干预相关的特征。
这是一项针对心包积液钝性创伤患者的混合方法研究。第一部分是2016年对外科创伤东部协会成员进行的一项研究调查，向外科医生展示了心包积液钝性创伤患者的四种临床情景。研究的第二部分是对2010年1月1日至2015年11月1日在我们的一级创伤中心接受治疗、入院CT扫描有心包积液的所有14岁及以上钝性创伤患者进行回顾性评估。
对于我们研究的调查部分，393名外科医生做出了回应（回应率为27%）。对于CT显示微量心包积液且血流动力学异常的情景，以及术中显示心包积血的情景，管理偏好存在显著变异性。对于我们研究的单独回顾部分，我们确定了75名入院CT扫描有心包积液的钝性创伤患者。7例接受了手术治疗；其中6例有低血压和/或心电图改变。在多变量分析中，心包积液量是接受心包开窗术的重要预测因素（心包积液量每增加一个类别，相对风险为3.99，95%置信区间为1.47 - 10.81），但不是死亡率的预测因素。
对于钝性创伤心包积液患者的管理偏好存在显著变异性，这表明需要进行基于证据的研究。我们机构的数据表明，心包积液量少且无相关临床发现的患者可以进行观察。心包积液量中等至大量且血流动力学正常、临床稳定的患者似乎也适合观察，尽管需要更大规模的研究予以证实。血流动力学不稳定的患者应进行手术探查。
治疗/护理管理研究，四级。
