From the Department of Anaesthesiology and Pain Medicine (J.K., A.S., S.S.), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Emergency Medical Service (D.H.), German Red Cross, Reutlingen, Germany; Faculty of Medicine (D.H.), University Tübingen, Tübingen, Germany; Department of Anaesthesiology and Intensive Care Medicine (B.W.B.), University Hospital of Cologne, Köln, Germany; Clinical Trials Unit (CTU) Bern (A.L., O.S.), University of Bern, Bern, Switzerland; and Emergency Department (M.B.), University of Düsseldorf, Düsseldorf, Germany.
J Trauma Acute Care Surg. 2019 Oct;87(4):978-989. doi: 10.1097/TA.0000000000002444.
As trauma is one of the leading causes of death worldwide, there is great potential for reducing mortality in trauma patients. However, there is continuing controversy over the benefit of deploying emergency medical systems (EMS) physicians in the prehospital setting. The objective of this systematic review and meta-analysis is to assess how out-of-hospital hospital management of severely injured patients by EMS teams with and without physicians affects mortality.
PubMed and Google Scholar were searched for relevant articles, and the search was supplemented by a hand search. Injury severity in the group of patients treated by an EMS team including a physician had to be comparable to the group treated without a physician. Primary outcome parameter was mortality. Helicopter transport as a confounder was accounted for by subgroup analyses including only the studies with comparable modes of transport. Quality of all included studies was assessed according to the Cochrane handbook.
There were 2,249 publications found, 71 full-text articles assessed, and 22 studies included. Nine of these studies were matched or adjusted for injury severity. The odds ratio (OR) of mortality was significantly lower in the EMS physician-treated group of patients: 0.81; 95% confidence interval (CI): 0.71-0.92. When analysis was limited to the studies that were adjusted or matched for injury severity, the OR was 0.86 (95% CI, 0.73-1.01). Analyzing only studies published after 2005 yielded an OR for mortality of 0.75 (95% CI, 0.64-0.88) in the overall analysis and 0.81 (95% CI, 0.67-0.97) in the analysis of adjusted or matched studies. The OR was 0.80 (95% CI, 0.65-1.00) in the subgroup of studies with comparable modes of transport and 0.74 (95% CI, 0.53-1.03) in the more recent studies.
Prehospital management of severely injured patients by EMS teams including a physician seems to be associated with lower mortality. After excluding the confounder of helicopter transport we have shown a nonsignificant trend toward lower mortality.
Systematic review and meta-analysis, level III.
创伤是全球导致死亡的主要原因之一，因此降低创伤患者死亡率的潜力巨大。然而，在院前环境中部署急救医疗服务（EMS）医生的益处仍存在争议。本系统评价和荟萃分析的目的是评估由 EMS 团队管理的严重创伤患者的院外医院管理，是否会影响死亡率，以及这些团队是否有医生。
在 PubMed 和 Google Scholar 上搜索相关文章，并通过手工搜索进行补充。接受 EMS 团队治疗的患者中，包括医生的组的损伤严重程度必须与未接受医生治疗的组的损伤严重程度相匹配。主要结局参数是死亡率。通过亚组分析，仅包括具有可比运输方式的研究，考虑了直升机运输的混杂因素。根据 Cochrane 手册评估所有纳入研究的质量。
共发现 2249 篇文献，评估了 71 篇全文文章，纳入了 22 项研究。其中 9 项研究对损伤严重程度进行了匹配或调整。在接受 EMS 医生治疗的患者中，死亡率的优势比（OR）显著降低：0.81；95%置信区间（CI）：0.71-0.92。当分析仅限于对损伤严重程度进行调整或匹配的研究时，OR 为 0.86（95%CI，0.73-1.01）。仅分析 2005 年后发表的研究，总体分析中死亡率的 OR 为 0.75（95%CI，0.64-0.88），调整或匹配研究的 OR 为 0.81（95%CI，0.67-0.97）。在具有可比运输方式的亚组研究中，OR 为 0.80（95%CI，0.65-1.00），在较新的研究中，OR 为 0.74（95%CI，0.53-1.03）。
由包括医生在内的 EMS 团队对严重创伤患者进行院前管理似乎与死亡率降低有关。在排除直升机运输的混杂因素后，我们发现死亡率呈下降趋势，但无统计学意义。
系统评价和荟萃分析，III 级。
