Department of Emergency and Critical Care Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8509, Japan.
High Care Unit, Wakayama Medical University Hospital, 811-1, Kimiidera, Wakayama, 641-8510, Japan.
BMC Emerg Med. 2021 Nov 13;21(1):136. doi: 10.1186/s12873-021-00530-3.
Early routine intubation in motor-complete cervical spinal cord injury (CSCI) above the C5 level is a conventional protocol to prevent unexpected respiratory exacerbation (RE). However, in the context of recent advances in multidisciplinary respiratory management, the absolute indication for intubation in patients with CSCI based on initial neurologic assessment is controversial because of the drawbacks of intubation. This study aimed to redetermine the most important predictor of RE following CSCI after admission without routine intubation among patients admitted with motor-complete injury and/or injury above the C5 level to ensure timely intubation.
We performed a retrospective review of patients with acute traumatic CSCI admitted to our hospital without an initial routine intubation protocol from January 2013 to December 2017. CSCI patients who developed RE (defined as unexpected emergent intubation for respiratory resuscitation) were compared with those who did not. Baseline characteristics and severity of trauma data were collected. Univariate analyses were performed to compare treatment data and clinical outcomes between the two groups. Further, multivariate logistic regression was performed with clinically important independent variables: motor-complete injury, neurologic level above C5, atelectasis, and copious airway secretion (CAS).
Among 58 patients with CSCI, 35 (60.3%) required post-injury intubation and 1 (1.7%) died during hospitalization. Thirteen (22.4%) had RE 3.5 days (mean) post-injury; 3 (37.5%) of eight patients with motor-complete CSCI above C5 developed RE. Eleven of the 27 (40.7%) patients with motor-complete injury and five of the 22 (22.7%) patients with neurologic injury above C5 required emergency intubation at RE. Three of the eight CSCI patients with both risk factors (motor-complete injury above C5) resulted in emergent RE intubation (37.5%). CAS was an independent predictor for RE (odds ratio 7.19, 95% confidence interval 1.48-42.72, P = 0.0144) in multivariate analyses.
Timely intubation post-CSCI based on close attention to CAS during the acute 3-day phase may prevent RE and reduce unnecessary invasive airway control even without immediate routine intubation in motor-complete injury above C5.
早期对 C5 以上完全性颈髓损伤（CSCI）患者进行常规插管以预防意外呼吸恶化（RE）是一种常规方案。然而，在多学科呼吸管理的最新进展背景下，基于初始神经评估对 CSCI 患者进行插管的绝对适应证存在争议，因为插管存在弊端。本研究旨在重新确定在没有常规插管方案的情况下，对于入院时表现为完全性损伤和/或 C5 以上损伤的 CSCI 患者，在确保及时插管的前提下，确定急性外伤性 CSCI 患者住院后发生 RE 的最重要预测因素。
我们对 2013 年 1 月至 2017 年 12 月期间我院收治的急性外伤性 CSCI 患者进行了回顾性研究，这些患者在入院时没有采用初始常规插管方案。将发生 RE（定义为因呼吸复苏需要紧急插管）的 CSCI 患者与未发生 RE 的患者进行比较。收集基线特征和创伤严重程度数据。采用单变量分析比较两组患者的治疗数据和临床结局。进一步，采用多变量逻辑回归分析具有临床意义的独立变量：完全性损伤、C5 以上神经水平、肺不张和大量气道分泌物（CAS）。
在 58 例 CSCI 患者中，35 例（60.3%）在受伤后需要进行气管插管，1 例（1.7%）在住院期间死亡。13 例（22.4%）在受伤后 3.5 天（平均）发生 RE；8 例 C5 以上完全性 CSCI 患者中有 3 例（37.5%）发生 RE。27 例完全性损伤患者中有 11 例（40.7%）和 22 例神经损伤患者以上患者中有 5 例（22.7%）在发生 RE 时需要紧急插管。8 例具有这两个危险因素（C5 以上完全性损伤）的 CSCI 患者中有 3 例（37.5%）导致紧急 RE 插管。多变量分析中，CAS 是 RE 的独立预测因素（比值比 7.19，95%置信区间 1.48-42.72，P=0.0144）。
在急性 3 天阶段密切关注 CAS 的情况下，对 CSCI 患者进行及时插管可能预防 RE，并减少不必要的有创性气道控制，即使在 C5 以上完全性损伤患者中不立即进行常规插管也是如此。
