创伤中心介入过晚：未使用院前止血带的严重肢体创伤增加了失血性休克导致的死亡。
The trauma center is too late: Major limb trauma without a pre-hospital tourniquet has increased death from hemorrhagic shock.
作者信息
Scerbo Michelle H, Holcomb John B, Taub Ethan, Gates Keith, Love Joseph D, Wade Charles E, Cotton Bryan A
机构信息
From the Center for Translational Injury Research (CeTIR) (M.H.S., J.B.H., C.E.W., B.A.C.), Department of Surgery (M.H.S., J.B.H., E.T., J.D.L., C.E.W., B.A.C.), and Department of Emergency Medicine (K.G.), The University of Texas Health Science Center, Houston, Texas; and Life Flight, Memorial Hermann Hospital, Houston, Texas (J.D.L.).
出版信息
J Trauma Acute Care Surg. 2017 Dec;83(6):1165-1172. doi: 10.1097/TA.0000000000001666.
BACKGROUND
To date, no civilian studies have demonstrated that pre-hospital (PH) tourniquets improve survival. We hypothesized that late, trauma center (TC) tourniquet use would increase death from hemorrhagic shock compared to early (PH) placement.
METHODS
All patients arriving to a Level 1, urban TC between October 2008 and January 2016 with a tourniquet placed before (T-PH) or after arrival to the TC (T-TC) were evaluated. Cases were assigned the following designations: indicated (absolute indication [vascular injury requiring repair/ligation, operation within 2 hours for extremity injury, or traumatic amputation] or relative indication [major musculoskeletal/soft tissue injury requiring operation 2-8 hours after arrival, documented large blood loss]) or non-indicated. Outcomes were death from hemorrhagic shock, physiology upon arrival to the TC, and massive transfusion requirements. After univariate analysis, logistic regression was carried out to assess independent predictors of death from hemorrhagic shock.
RESULTS
A total of 306 patients received 326 tourniquets for injuries to 157 upper and 147 lower extremities. Two hundred eighty-one (92%) had an indication for placement. Seventy percent of patients had a blunt mechanism of injury. T-TC patients arrived with a lower systolic blood pressure (SBP, 101 [86, 123] vs. 125 [100, 145] mm Hg, p < 0.001), received more transfusions in the first hour of arrival (55% vs. 34%, p = 0.02), and had a greater mortality from hemorrhagic shock (14% vs. 3.0%, p = 0.01). When controlling for year of admission, mechanism of injury and shock upon arrival (SBP ≤90 mm Hg or HR ≥120 bpm or base deficit ≤ 4) indicated T-TC had a 4.5-fold increased odds of death compared to T-PH (OR 4.5, 95% CI 1.23-16.4, p = 0.02).
CONCLUSIONS
Waiting until TC arrival to control hemorrhage with a tourniquet was associated with worsened blood pressure and increased transfusion within the first hour of arrival. In routine civilian trauma patients, delaying to T-TC was associated with 4.5-fold increased odds of mortality from hemorrhagic shock.
LEVEL OF EVIDENCE
Level IV.
背景
迄今为止，尚无民用研究表明院前（PH）止血带能提高生存率。我们假设，与早期（PH）使用止血带相比，在创伤中心（TC）较晚使用止血带会增加因失血性休克导致的死亡。
方法
对2008年10月至2016年1月期间抵达一级城市创伤中心且在抵达创伤中心之前（T-PH）或之后（T-TC）使用了止血带的所有患者进行评估。病例被指定为以下类别：有指征（绝对指征[血管损伤需要修复/结扎、肢体损伤后2小时内手术或外伤性截肢]或相对指征[主要肌肉骨骼/软组织损伤需要在抵达后2 - 8小时手术，记录有大量失血]）或无指征。观察指标为失血性休克导致的死亡、抵达创伤中心时的生理状况以及大量输血需求。单因素分析后，进行逻辑回归以评估失血性休克导致死亡的独立预测因素。
结果
共有306例患者因157例上肢和147例下肢损伤接受了326次止血带治疗。281例（92%）有使用止血带的指征。70%的患者为钝性损伤机制。T-TC组患者抵达时收缩压较低（收缩压，101[86, 123] vs. 125[100, 145] mmHg，p < 0.001），抵达后第一小时接受输血更多（55% vs. 34%，p = 0.02），且因失血性休克导致的死亡率更高（14% vs. 3.0%，p = 0.01）。在控制入院年份、损伤机制和抵达时的休克情况（收缩压≤90 mmHg或心率≥120次/分钟或碱缺失≤4）后，表明T-TC组与T-PH组相比，失血性休克导致死亡的几率增加了4.5倍（比值比4.5，95%可信区间1.23 - 16.4，p = 0.02）。
结论
等到创伤中心时才用止血带控制出血与抵达后第一小时内血压恶化和输血增加有关。在常规民用创伤患者中，延迟至T-TC使用止血带与失血性休克导致死亡的几率增加4.5倍有关。
证据级别
四级。
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