创伤患者死亡的原因和方式：一项前瞻性多中心西方创伤协会研究。
The why and how our trauma patients die: A prospective Multicenter Western Trauma Association study.
机构信息
From the Department of Surgery (R.A.C., L.Z.K., A.S.C., A.J.R.), Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, California; Department of Surgery (J.P.M., N.N.), University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, Florida; Department of Surgery (D.E.M., A.H.), McGovern Medical School, University of Texas Health Science Center, Houston; Division of Trauma and Acute Care (M.S.T., V.A.), Methodist Dallas Medical Center, Dallas, Texas; Department of Trauma (J.M.H., K.L.L.), Via Christi Health, Kansas University School of Medicine Wichita Campus, Wichita, Kansas; Division of Trauma (J.M.P., J.L.S.R.), Cooper University Hospital, Camden, New Jersey; Department of Surgery (W.L.B.), Scripps Memorial Hospital La Jolla, La Jolla, California; Department of Surgery (M.S.H.), The Queen's Medical Center, The University of Hawaii, Honolulu, Hawaii; Trauma Service (M.J.S., J.B.), Scripps Mercy Hospital, San Diego; Division of Surgical Critical Care and Trauma (G.R., K.I.), Los Angeles County + University of Southern California Medical Center, Los Angeles, California; Department of Surgery (T.J.S., E.C.), University of Colorado Health, Memorial Hospital, Colorado Springs; Department of Surgery (J.A.D., S.G.), University of Colorado Health North, Medical Center of the Rockies, Loveland, Colorado; Department of Surgery (R.C.M.Jr., E.D.P.), University of Colorado School of Medicine, Aurora, Colorado; Department of Trauma and General Surgery (P.J.O., C.F.D.), Abrazo Medical Group, Abrazo West Campus, Goodyear, Arizona; Department of Surgery (A.M.S., E.E.S.), University of Oklahoma, Oklahoma City, Oklahoma; Division of Trauma and Emergency Acute Care Surgery (M.A.W., S.S.), North Memorial Health Hospital, Robbinsdale, Minnesota; Department of Surgery (D.C.C., J.F.C.), Marshfield Clinic, Marshfield, Wisconsin; Department of Surgery (E.E.M., H.B.M.), Denver Health Medical Center, University of Colorado Denver, Denver, Colorado; Department of Surgery (A.R.P., E.A.E.), Medical University of South Carolina, Charleston, South Carolina; Department of Surgery (M.J.C.), Denver Health Medical Center, Denver; and University of Colorado Medical Center (M.J.C.), Aurora, Colorado.
出版信息
J Trauma Acute Care Surg. 2019 May;86(5):864-870. doi: 10.1097/TA.0000000000002205.
BACKGROUND
Historically, hemorrhage has been attributed as the leading cause (40%) of early death. However, a rigorous, real-time classification of the cause of death (COD) has not been performed. This study sought to prospectively adjudicate and classify COD to determine the epidemiology of trauma mortality.
METHODS
Eighteen trauma centers prospectively enrolled all adult trauma patients at the time of death during December 2015 to August 2017. Immediately following death, attending providers adjudicated the primary and contributing secondary COD using standardized definitions. Data were confirmed by autopsies, if performed.
RESULTS
One thousand five hundred thirty-six patients were enrolled with a median age of 55 years (interquartile range, 32-75 years), 74.5% were male. Penetrating mechanism (n = 412) patients were younger (32 vs. 64, p < 0.0001) and more likely to be male (86.7% vs. 69.9%, p < 0.0001). Falls were the most common mechanism of injury (26.6%), with gunshot wounds second (24.3%). The most common overall primary COD was traumatic brain injury (TBI) (45%), followed by exsanguination (23%). Traumatic brain injury was nonsurvivable in 82.2% of cases. Blunt patients were more likely to have TBI (47.8% vs. 37.4%, p < 0.0001) and penetrating patients exsanguination (51.7% vs. 12.5%, p < 0.0001) as the primary COD. Exsanguination was the predominant prehospital (44.7%) and early COD (39.1%) with TBI as the most common later. Penetrating mechanism patients died earlier with 80.1% on day 0 (vs. 38.5%, p < 0.0001). Most deaths were deemed disease-related (69.3%), rather than by limitation of further aggressive care (30.7%). Hemorrhage was a contributing cause to 38.8% of deaths that occurred due to withdrawal of care.
CONCLUSION
Exsanguination remains the predominant early primary COD with TBI accounting for most deaths at later time points. Timing and primary COD vary significantly by mechanism. Contemporaneous adjudication of COD is essential to elucidate the true understanding of patient outcome, center performance, and future research.
LEVEL OF EVIDENCE
Epidemiologic, level II.
背景
历史上，出血被认为是导致早期死亡的主要原因（40%）。然而，尚未对死因（COD）进行严格的实时分类。本研究旨在前瞻性裁决和分类 COD，以确定创伤死亡率的流行病学。
方法
18 家创伤中心在 2015 年 12 月至 2017 年 8 月期间，前瞻性地招募了所有死亡时的成年创伤患者。在死亡后立即，主治医生使用标准化定义对主要和次要 COD 进行裁决。如果进行了尸检，则对数据进行了确认。
结果
共纳入 1536 例患者，中位年龄为 55 岁（四分位距 32-75 岁），74.5%为男性。穿透性机制（n = 412）患者年龄较小（32 岁 vs. 64 岁，p < 0.0001）且更可能为男性（86.7% vs. 69.9%，p < 0.0001）。跌倒最常见的损伤机制（26.6%），其次是枪伤（24.3%）。总体上最常见的原发性 COD 是创伤性脑损伤（TBI）（45%），其次是失血性休克（23%）。TBI 导致 82.2%的患者死亡。钝性损伤患者更可能患有 TBI（47.8% vs. 37.4%，p < 0.0001），穿透性损伤患者更可能患有失血性休克（51.7% vs. 12.5%，p < 0.0001）作为主要 COD。失血性休克是院前（44.7%）和早期 COD（39.1%）的主要原因，而 TBI 是后期最常见的原因。穿透性机制患者死亡更早，有 80.1%的患者在第 0 天死亡（vs. 38.5%，p < 0.0001）。大多数死亡被认为与疾病有关（69.3%），而不是由于限制进一步积极治疗（30.7%）。因放弃治疗而导致的 38.8%的死亡与出血有关。
结论
失血性休克仍然是早期主要的原发性 COD，TBI 导致大多数患者在后期死亡。时间和主要 COD 因机制而异。COD 的同期裁决对于阐明患者结局、中心表现和未来研究的真正理解至关重要。
证据水平
流行病学，II 级。
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