John Walsh Centre for Rehabilitation Research, Kolling Institute, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.
Trauma Department, Royal North Shore Hospital, Sydney, New South Wales, Australia.
Emerg Med Australas. 2019 Dec;31(6):967-973. doi: 10.1111/1742-6723.13290. Epub 2019 Apr 9.
Evidence-based management for patients with acute traumatic spinal cord injury (TSCI) in the ED has a critical impact on long-term outcomes. Acute hypotension post-injury may compromise spinal cord perfusion and extend neurological damage. Published guidelines recommend mean arterial blood pressure (BP) maintenance between 85 and 90 mmHg for 7 days post-injury; the extent to which this is followed in Australia is unknown.
Prospective observational study of patients ≥16 years with TSCI, treated at 48 hospitals across two Australian states. Mean arterial BPs were recorded in the Ambulance, and ED arrival and discharge. Patients' medical records documented treatment provided (intravenous fluids, vasopressors or both) for BP augmentation. Hypotension was defined as mean arterial BP <85 mmHg, per the American Association of Neurological Surgeons guidelines.
The 208 patients with TSCI in the present study were more likely to receive BP augmentation if they experienced direct transport to a Spinal Cord Service hospital (OR 5.57, 95% CI 2.32-10.11), had a cervical level injury (OR 2.32, 95% CI 1.01-5.5) or were hypotensive on ED arrival (OR 2.42, 95% CI 1.34-4.39). Of the 112 patients who were hypotensive, 71 (63.4%) received treatment for this; however, the majority (76%) remained hypotensive on discharge.
Hypotensive patients' post-TSCI experienced heterogeneous ED care discordant with published guidelines; varying by hospital type. Specialist care and more severe injury increased likelihood of guideline adherence. Lack of adherence may influence patient outcomes. Level 1 evidence is needed along with consistent guideline implementation and clinician training to likely improve TSCI management and outcomes.
在急诊科对急性创伤性脊髓损伤（TSCI）患者进行循证管理对长期结果具有关键影响。损伤后急性低血压可能会影响脊髓灌注并延长神经损伤。已发表的指南建议在损伤后 7 天内维持平均动脉血压（BP）在 85 至 90mmHg 之间；但在澳大利亚，这一建议的遵循程度尚不清楚。
对 2 个澳大利亚州的 48 家医院治疗的年龄≥16 岁的 TSCI 患者进行前瞻性观察性研究。记录患者在救护车、急诊科到达和离开时的平均动脉血压。患者的病历记录了用于血压升高的治疗方法（静脉输液、血管加压药或两者兼用）。根据美国神经外科学会的指南，低血压定义为平均动脉血压<85mmHg。
本研究中 208 例 TSCI 患者更有可能接受 BP 升高治疗，如果他们直接转往脊髓科服务医院（OR 5.57，95%CI 2.32-10.11）、颈段损伤（OR 2.32，95%CI 1.01-5.5）或在急诊科到达时低血压（OR 2.42，95%CI 1.34-4.39）。在 112 例低血压患者中，71 例（63.4%）接受了治疗；然而，大多数患者（76%）在出院时仍低血压。
TSCI 后低血压患者的急诊科治疗存在与已发表指南不一致的异质性；这取决于医院类型。专科治疗和更严重的损伤增加了遵循指南的可能性。不遵守可能会影响患者的结局。需要一级证据，以及一致的指南实施和临床医生培训，以可能改善 TSCI 的管理和结局。
