Department of Traumatology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia.
Eur J Trauma Emerg Surg. 2020 Aug;46(4):873-878. doi: 10.1007/s00068-019-01139-9. Epub 2019 May 6.
Prehospital guidelines stratify and manage patients with Glasgow Coma Scale (GCS) less than nine and any sign of head injury as affected by severe traumatic brain injury (STBI). We hypothesized that this group of patients is so inhomogeneous that uniform treatment guidelines cannot be advocated.
Patients (2005-2012) with prehospital GCS below nine and abbreviated injury scale head and neck above two were identified from trauma registry. Patients with acute lethal injuries, isolated neck injuries, extubated within 24 h or transferred interhospitally were excluded. Patients were dichotomized based on the worst prehospital GCS (recorded before sedatives) into two groups: GCS 3-5 and GCS 6-8. These were statistically compared using univariate analysis.
The GCS 3-5 group (99 patients) when compared with the GCS 6-8 group (49 patients) had shorter prehospital times (63 vs. 79 min; p < 0.05), more frequent episodes of both hypoxia (30.3% vs. 7.7%; p < 0.05) and hypotension (26.7% vs. 6.4%; p < 0.05), more often required craniectomy (15.1% vs. 4.0%; p = 0.05) and higher mortality (33.3% vs. 2%; p < 0.05). In the GCS 3-5 group, prehospital endotracheal intubation was attempted more often (57.5% vs. 28.6%, p < 0.05) and was more often successful (39.3% vs. 10.2%; p = 0.05). Length of stay in ICU did not differ.
STBI patients are fundamentally different based on whether their initial GCS falls into 3-5 or 6-8 category. Recommendations from trials investigating trauma patients with GCS less than nine as one group should be translated with caution to clinical practice.
院前指南对格拉斯哥昏迷量表（GCS）评分小于 9 分且有任何头部受伤迹象的患者进行分层和管理，这些患者受严重创伤性脑损伤（STBI）的影响。我们假设这组患者非常不同，因此不能提倡统一的治疗指南。
从创伤登记处确定院前 GCS 评分低于 9 分且损伤严重程度评分头颈部大于 2 的患者。排除有急性致命性损伤、单纯颈部损伤、24 小时内拔管或院内转科的患者。根据院前记录的最差 GCS（镇静前），将患者分为两组：GCS 3-5 组和 GCS 6-8 组。使用单变量分析对两组进行统计学比较。
与 GCS 6-8 组（49 例）相比，GCS 3-5 组（99 例）的院前时间更短（63 分钟 vs. 79 分钟；p<0.05），缺氧（30.3% vs. 7.7%；p<0.05）和低血压（26.7% vs. 6.4%；p<0.05）的发作更频繁，更常需要开颅术（15.1% vs. 4.0%；p=0.05），死亡率更高（33.3% vs. 2%；p<0.05）。在 GCS 3-5 组中，院前气管插管的尝试更频繁（57.5% vs. 28.6%，p<0.05），成功率更高（39.3% vs. 10.2%；p=0.05）。ICU 住院时间无差异。
根据初始 GCS 是否落入 3-5 或 6-8 类别，STBI 患者存在根本差异。从临床试验中获得的针对 GCS 评分低于 9 分的创伤患者的建议，应谨慎转化为临床实践。
