Unit of Clinical Epidemiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy.
National Centre for Healthcare Research and Pharmacoepidemiology,, University of Milano-Bicocca, Milan, Italy.
World J Emerg Surg. 2023 Jan 4;18(1):2. doi: 10.1186/s13017-022-00472-6.
A structured approach involves systematic management of trauma patients. We aim to conduct an overview of reviews about the clinical efficacy and safety of structured approach (i.e., primary and secondary survey) by guideline checklist compared to non-structured approach (i.e. clinical examination); moreover, routine screening whole-body computer tomography (WBCT) was compared to non-routine WBCT in patients with suspected major trauma.
We systematically searched MEDLINE (PubMed), EMBASE and Cochrane Database of Systematic Reviews up to 3 May 2022. Systematic reviews (SRs) that investigated the use of a structured approach compared to a non-structured approach were eligible. Two authors independently extracted data, managed the overlapping of primary studies belonging to the included SRs and calculated the corrected covered area (CCA). The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.
We included nine SRs investigating two comparisons in stable trauma patients: structured approach vs non-structured approach (n = 1) and routine WBCT vs non-routine WBCT (n = 8). The overlap of included primary studies was generally high across outcomes (CCA ranged between 20.85 and 42.86%) with some discrepancies in the directions of effects across reviews. The application of a structured approach by checklist may improve adherence to guidelines (e.g. Advanced Trauma Life Support) during resuscitation and might lead to a reduction in mortality among severely injured patients as compared to clinical examination (Adjusted OR 0.51; 95% CI 0.30-0.89; p = 0.018; low certainty of evidence). The use of routine WBCT seems to offer little to no effects in reducing mortality and time spent in emergency room or department, whereas non-routine WBCT seems to offer little to no effects in reducing radiation dose, intensive care unit length of stay (LOS) and hospital LOS (low-to-moderate certainty of evidence).
The application of structured approach by checklist during trauma resuscitation may improve patient- and process-related outcomes. Including non-routine WBCT seems to offer the best trade-offs between benefits and harm. Clinicians should consider these findings in the light of their clinical context, the volume of patients in their facilities, the need for time management, and costs.
结构化方法涉及对创伤患者进行系统管理。我们旨在通过指南检查表对结构化方法（即初级和次级检查）与非结构化方法（即临床检查）的临床疗效和安全性进行综述，此外，还比较了疑似严重创伤患者常规全身计算机断层扫描（WBCT）与非常规 WBCT。
我们系统地检索了 MEDLINE（PubMed）、EMBASE 和 Cochrane 系统评价数据库，截至 2022 年 5 月 3 日。有资格入选的系统评价（SRs）调查了使用结构化方法与非结构化方法的比较。两名作者独立提取数据，管理属于纳入 SRs 的主要研究的重叠，并计算校正涵盖面积（CCA）。使用推荐评估、制定和评估（GRADE）方法评估证据的确定性。
我们纳入了 9 项关于稳定创伤患者的 2 项比较的 SRs：结构化方法与非结构化方法（n=1）和常规 WBCT 与非常规 WBCT（n=8）。各研究结果的重叠率通常较高（CCA 范围在 20.85%至 42.86%之间），但各综述的效果方向存在一些差异。与临床检查相比，应用检查表的结构化方法可能会提高复苏过程中对指南（如高级创伤生命支持）的依从性，并且可能会降低严重受伤患者的死亡率（调整后的 OR 0.51；95%CI 0.30-0.89；p=0.018；低确定性证据）。常规 WBCT 的使用似乎在降低死亡率和急诊室或科室停留时间方面几乎没有效果，而非常规 WBCT 的使用在降低辐射剂量、重症监护病房住院时间（LOS）和住院 LOS 方面几乎没有效果（低至中度确定性证据）。
在创伤复苏过程中应用检查表的结构化方法可能会改善患者和过程相关的结果。包括非常规 WBCT 似乎在获益和危害之间取得了最佳的权衡。临床医生应根据其临床背景、医疗机构的患者数量、时间管理需求和成本考虑这些发现。
