循环优先 - 现在是时候质疑创伤 ABC 护理顺序了；美国创伤外科学会多中心试验。
Circulation first - the time has come to question the sequencing of care in the ABCs of trauma; an American Association for the Surgery of Trauma multicenter trial.
机构信息
1Trauma, Emergency surgery and Critical Care, Virginia Commonwealth University, 417 N 11th St, Richmond, VA 23298, Richmond, VA 23298-0454 USA.
2University of California San Francisco, San Francisco, USA.
出版信息
World J Emerg Surg. 2018 Feb 5;13:8. doi: 10.1186/s13017-018-0168-3. eCollection 2018.
BACKGROUND
The traditional sequence of trauma care: Airway, Breathing, Circulation (ABC) has been practiced for many years. It became the standard of care despite the lack of scientific evidence. We hypothesized that patients in hypovolemic shock would have comparable outcomes with initiation of bleeding treatment (transfusion) prior to intubation (CAB), compared to those patients treated with the traditional ABC sequence.
METHODS
This study was sponsored by the American Association for the Surgery of Trauma multicenter trials committee. We performed a retrospective analysis of all patients that presented to trauma centers with presumptive hypovolemic shock indicated by pre-hospital or emergency department hypotension and need for intubation from January 1, 2014 to July 1, 2016. Data collected included demographics, timing of intubation, vital signs before and after intubation, timing of the blood transfusion initiation related to intubation, and outcomes.
RESULTS
From 440 patients that met inclusion criteria, 245 (55.7%) received intravenous blood product resuscitation first (CAB), and 195 (44.3%) were intubated before any resuscitation was started (ABC). There was no difference in ISS, mechanism, or comorbidities. Those intubated prior to receiving transfusion had a lower GCS than those with transfusion initiation prior to intubation (ABC: 4, CAB:9, = 0.005). Although mortality was high in both groups, there was no statistically significant difference (CAB 47% and ABC 50%). In multivariate analysis, initial SBP and initial GCS were the only independent predictors of death.
CONCLUSION
The current study highlights that many trauma centers are already initiating circulation first prior to intubation when treating hypovolemic shock (CAB), even in patients with a low GCS. This practice was not associated with an increased mortality. Further prospective investigation is warranted.
TRIAL REGISTRATION
IRB approval number: HM20006627. Retrospective trial not registered.
背景
传统的创伤救治顺序：气道、呼吸、循环（ABC）已经实施了多年。尽管缺乏科学证据，但它已成为护理标准。我们假设，与按照传统 ABC 顺序治疗的患者相比，失血性休克患者在开始插管（CAB）之前开始出血治疗（输血）会有类似的结果。
方法
这项研究由美国创伤外科学会多中心试验委员会赞助。我们对 2014 年 1 月 1 日至 2016 年 7 月 1 日期间因院前或急诊科低血压和需要插管而被送往创伤中心的所有疑似失血性休克患者进行了回顾性分析。收集的数据包括人口统计学特征、插管时间、插管前后生命体征、输血开始与插管相关的时间以及结局。
结果
在符合纳入标准的 440 名患者中，245 名（55.7%）先接受静脉血制品复苏（CAB），195 名（44.3%）在开始任何复苏前进行插管（ABC）。ISS、机制或合并症无差异。与输血开始前插管的患者相比，在接受输血前插管的患者的 GCS 更低（ABC：4，CAB：9，=0.005）。尽管两组死亡率都很高，但无统计学差异（CAB 组 47%，ABC 组 50%）。在多变量分析中，初始 SBP 和初始 GCS 是死亡的唯一独立预测因素。
结论
本研究强调，许多创伤中心在治疗失血性休克（CAB）时已经在插管前首先开始循环（CAB），即使患者 GCS 较低。这种做法与死亡率增加无关。需要进一步前瞻性研究。
试验注册
IRB 批准号：HM20006627。回顾性试验未注册。
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