Davidson Anders J, Ferencz Sarah-Ashley E, Sosnov Jonathan A, Howard Jeffrey T, Janak Jud C, Chung Kevin K, Stewart Ian J
60th Clinical Investigation Facility, Travis Air Force Base, United States; University of California Davis Department of Surgery, United States.
San Antonio Military Medical Center, United States; Uniformed Services University of the Health Sciences, United States.
Burns. 2018 Mar;44(2):298-304. doi: 10.1016/j.burns.2017.07.023. Epub 2017 Aug 31.
The effect of presenting hypertension is poorly studied in combat casualties. We hypothesized that elevated mean arterial pressure (MAP) on presentation to combat hospitals would be associated with poor outcomes.
Data was obtained from the Department of Defense Trauma Registry and the Armed Forces Medical Examiner System. Variables analyzed included presenting vital signs to Role II-III military theater hospital, demographic variables, injury severity score (ISS), location and mechanism of injury, presence of traumatic brain injury (TBI), acute kidney injury (AKI), and mortality. Patients were stratified by decile of MAP and logistic regression analysis was employed to adjust for confounders.
A total of 4072 subjects injured from February 2002 to February 2011 were identified. Compared to patients in the middle deciles of presenting MAP, patients in the highest and lowest MAP deciles were the only groups that demonstrated a higher mortality on univariate analysis (OR 2.06, 95% CI 1.16-2.31 and OR 2.86, 95% CI 1.76-4.67, respectively), and this relationship persisted after adjustment for ISS, HR, temperature, presence of burn injury, TBI, and AKI. Burn injury was associated with mortality in the full multivariate analysis. However, further analysis limited to patients without burn injury did not demonstrate an association between high MAP and mortality (OR 0.84, 95% CI 0.36-1.99; p=0.70). Conversely, when limited to patients with burn injury, high MAP was associated with mortality (OR 3.78, 95% CI 1.74-8.20; p=0.001).
The relationship between mortality and presenting MAP appears to be U-shaped, demonstrating increased mortality in the lowest and highest deciles. However, mortality in the highest MAP decile appears to be limited to casualties with associated burn injury, even after adjustment for TBI, AKI, and ISS, which takes into account the severity of the burn injury. Physicians should recognize that burn patients presenting with an elevated MAP are at an increased risk for poor outcomes.
III.
对战时伤员中出现高血压的影响研究较少。我们假设，前往战地医院时平均动脉压（MAP）升高与不良预后相关。
数据取自美国国防部创伤登记处和武装部队法医系统。分析的变量包括前往二级至三级军事战区医院时的生命体征、人口统计学变量、损伤严重程度评分（ISS）、损伤部位和机制、创伤性脑损伤（TBI）、急性肾损伤（AKI）以及死亡率。患者按MAP十分位数分层，并采用逻辑回归分析来调整混杂因素。
共确定了2002年2月至2011年2月期间受伤的4072名受试者。与MAP处于中间十分位数的患者相比，MAP处于最高和最低十分位数的患者是单因素分析中仅有的死亡率较高的组（分别为OR 2.06，95%CI 1.16 - 2.31和OR 2.86，95%CI 1.76 - 4.67），在对ISS、心率、体温、烧伤、TBI和AKI进行调整后，这种关系仍然存在。在全多因素分析中，烧伤与死亡率相关。然而，进一步分析仅限于无烧伤患者时，未显示高MAP与死亡率之间存在关联（OR 0.84，95%CI 0.36 - 1.99；p = 0.70）。相反，当仅限于有烧伤患者时，高MAP与死亡率相关（OR 3.78，95%CI 1.74 - 8.20；p = 0.001）。
死亡率与就诊时MAP之间的关系似乎呈U形，在最低和最高十分位数时死亡率增加。然而，即使在对TBI、AKI和ISS进行调整后（该调整考虑了烧伤严重程度），最高MAP十分位数的死亡率似乎仅限于伴有烧伤的伤员。医生应认识到，MAP升高的烧伤患者预后不良的风险增加。
三级
