Ito Kaori, Nakazawa Kahoko, Nagao Tsuyoshi, Chiba Hiroto, Miyake Yasufumi, Sakamoto Tetsuya, Fujita Takashi
Division of Acute Care Surgery, Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan.
Trauma Surg Acute Care Open. 2019 Feb 22;4(1):e000269. doi: 10.1136/tsaco-2018-000269. eCollection 2019.
It is not mandatory for Japanese trauma centers to have an operating room (OR) and OR team available 24 hours a day/7 days a week. Therefore, emergency laparotomy/thoracotomy is performed in the emergency department (ED). The present study was conducted to assess the safety of this practice.
The data were reviewed from 88 patients who underwent emergency trauma laparotomy and/or thoracotomy performed by our acute care surgery group during the period from April 2013 to December 2017. Operation was performed in the ED for 43 of 88 patients (51%, ED group), and in the OR for 45 of 88 patients (49%, OR group). The perioperative outcomes of the two groups were compared.
Compared with the OR group, the ED group had a higher Injury Severity Score (30±15 vs. 13±10, p<0.01), greater incidence of blunt trauma (74% (32/43) vs. 36% (16/45), p<0.01), larger volume of red blood cell transfusion (18±18 units vs. 5±10 units, p<0.01), higher incidence of new-onset shock after sedation among patients who received sedation in the ED (59% (17/29) vs. 25% (6/24), p<0.01), and higher in-hospital mortality rate (49% (21/43) vs. 0, p<0.01). All five patients who underwent laparotomy followed by thoracotomy died in the ED; none of these patients underwent preoperative placement of resuscitative endovascular balloon occlusion of the aorta (REBOA). Of the 21 patients in the ED group who died, 17 (81%) died immediately postoperatively; furthermore, 12 of the 22 patients who survived (55%) were not in shock prior to operation.
Emergency trauma laparotomy and/or thoracotomy outcomes were related to injury severity. The resources for trauma operations in the ED seemed suboptimal. The outcome of trauma operations may be improved by reviewing the protocols for anesthetic care, and by the usage of REBOA rather than aortic cross-clamping.
IV.
日本的创伤中心并非必须每天24小时、每周7天配备手术室（OR）及手术团队。因此，急诊剖腹术/开胸术在急诊科（ED）进行。本研究旨在评估这种做法的安全性。
回顾了2013年4月至2017年12月期间由我们的急性护理手术团队进行的88例急诊创伤剖腹术和/或开胸术患者的数据。88例患者中有43例（51%，急诊组）在急诊科进行手术，88例患者中有45例（49%，手术室组）在手术室进行手术。比较两组的围手术期结果。
与手术室组相比，急诊组的损伤严重程度评分更高（30±15 vs. 13±10，p<0.01），钝性创伤发生率更高（74%（32/43）vs. 36%（16/45），p<0.01），红细胞输注量更大（18±18单位 vs. 5±10单位，p<0.01），在急诊科接受镇静的患者中，镇静后新发休克的发生率更高（59%（17/29）vs. 25%（6/24），p<0.01），住院死亡率更高（49%（21/43）vs. 0，p<0.01）。所有5例先进行剖腹术再进行开胸术的患者均在急诊科死亡；这些患者均未在术前进行主动脉内复苏球囊阻断术（REBOA）。急诊组21例死亡患者中，17例（81%）术后立即死亡；此外，22例存活患者中有12例（55%）在手术前未处于休克状态。
急诊创伤剖腹术和/或开胸术的结果与损伤严重程度有关。急诊科的创伤手术资源似乎并不理想。通过审查麻醉护理方案以及使用REBOA而非主动脉交叉钳夹术，可能会改善创伤手术的结果。
IV级。
