From the Division of Pediatric Surgery (M.M.W., A.J.C., B.B., N.A.H., M.A.J.), Doernbecher Children's Hospital, Oregon Health Science University; Department of Pediatric Trauma (E.T.O.), Randall Children's Hospital; Department of Anesthesiology (B.G.M., M.C.A.), Division of Trauma (F.J.C.J.), Legacy Emanuel Medical Center; and Division of Pediatric Surgery (M.A.J.), Randall Children's Hospital, Portland, Oregon.
J Trauma Acute Care Surg. 2018 Oct;85(4):659-664. doi: 10.1097/TA.0000000000001908.
BACKGROUND: Expediting evaluation and intervention for severely injured patients has remained a mainstay of advanced trauma care. One technique, direct to operating room (DOR) resuscitation, for selective adult patients has demonstrated decreased mortality. We sought to investigate the application of this protocol in children. METHODS: All DOR pediatric patients from 2009 to 2016 at a pediatric Level I trauma center were identified. Direct to OR criteria included penetrating injury, chest injuries, amputations, significant blood loss, cardiopulmonary resuscitation, and surgeon discretion. Demographics, injury patterns, interventions, and outcomes were analyzed. Observed mortality was compared with expected mortality, calculated using Trauma Injury Severity Score methodology, with two-tailed t tests, and a p value less than 0.5 was considered significant. RESULTS: Of 2,956 total pediatric trauma activations, 82 (2.8%) patients (age range, 1 month to 17 years) received DOR resuscitation during the study period. The most common indications for DOR were penetrating injuries (62%) and chest injuries (32%). Forty-four percent had Injury Severity Score (ISS) greater than 15, 33% had Glasgow Coma Scale (GCS) score of 8 or less, and 9% were hypotensive. The most commonly injured body regions were external (66%), head (34%), chest (30%), and abdomen (27%). Sixty-seven (82%) patients required emergent procedural intervention, most commonly wound exploration/repair (35%), central venous access (22%), tube thoracostomy (19%), and laparotomy (18%). Predictors of intervention were ISS greater than 15 (odds ratio, 14; p = 0.013) and GCS < 9 (odds ratio = 8.5, p = 0.044). The survival rate to discharge for DOR patients was 84% compared with an expected survival of 79% (Trauma Injury Severity Score) (p = 0.4). The greatest improvement relative to expected mortality was seen in the subgroup with penetrating trauma (84.5% vs 74.4%; p = 0.002). CONCLUSION: A selective policy of resuscitating the most severely injured children in the OR can decrease mortality. Patients suffering penetrating trauma with the highest ISS, and diminished GCS scores have the greatest benefit. Trauma centers with appropriate resources should evaluate implementing similar policies. LEVEL OF EVIDENCE: Diagnostic tests or criteria, level II.
背景：加快对严重受伤患者的评估和干预一直是高级创伤护理的基础。对于选择性成人患者，一种称为直接进入手术室（DOR）复苏的技术已证明可降低死亡率。我们试图研究该方案在儿童中的应用。
方法：在一家儿科一级创伤中心，确定了 2009 年至 2016 年所有 DOR 儿科患者。DOR 标准包括穿透性损伤、胸部损伤、截肢、大量失血、心肺复苏和外科医生的判断。分析了人口统计学、损伤模式、干预措施和结果。使用创伤损伤严重程度评分方法观察死亡率与预期死亡率进行比较，采用双尾 t 检验，p 值小于 0.5 认为有统计学意义。
结果：在 2956 例总儿科创伤激活中，82 例（2.8%）患者（年龄 1 个月至 17 岁）在研究期间接受了 DOR 复苏。最常见的 DOR 指征是穿透性损伤（62%）和胸部损伤（32%）。44%的患者损伤严重程度评分（ISS）大于 15，33%的患者格拉斯哥昏迷评分（GCS）为 8 或更低，9%的患者低血压。受伤最常见的身体部位是外部（66%）、头部（34%）、胸部（30%）和腹部（27%）。67 例（82%）患者需要紧急手术干预，最常见的干预措施是伤口探查/修复（35%）、中心静脉通路（22%）、胸腔引流（19%）和剖腹手术（18%）。ISS 大于 15（优势比，14；p = 0.013）和 GCS < 9（优势比= 8.5，p = 0.044）是干预的预测因素。与 DOR 患者的出院生存率（84%）相比，预计生存率（79%）（创伤损伤严重程度评分）为 0.4。在穿透性创伤亚组中，相对于预期死亡率，改善程度最大（84.5% vs 74.4%；p = 0.002）。
结论：在手术室对伤势最严重的儿童进行有选择的复苏可以降低死亡率。ISS 最高、GCS 评分最低的穿透性创伤患者获益最大。有适当资源的创伤中心应评估实施类似政策。
证据水平：诊断试验或标准，二级。
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