From the Carver College of Medicine (C.T.), Division of Acute Care Surgery, Department of Surgery (M.L., C.G., D.A.S.), and College of Public Health (J.T.), University Iowa, Iowa.
J Trauma Acute Care Surg. 2023 Feb 1;94(2):248-257. doi: 10.1097/TA.0000000000003841. Epub 2022 Nov 18.
Worse outcomes following injuries are more likely in rural versus urban areas. In 2001, our state established an inclusive trauma system to improve mortality. In 2015, the trauma system had a consultation visit from the American College of Surgeons' Committee on Trauma, who made several recommendations. We hypothesized that continued maturation of this system would lead to more laparotomies prior to transfer to a higher level of care and better outcomes.
Our trauma registry was queried to identify all patients transferred between January 1, 2010, and December 31, 2020, who underwent laparotomy either before transfer or within 4 hours of arrival. The preconsultation (2010-2015) and postconsultation periods (2016-2020) were compared. Categorical and continuous variables were compared using χ2 and Mann-Whitney U tests, respectively.
We included 213 patients; 63 had laparotomy before transfer and 150 within 4 hours after transfer. Age, injury severity scores, systolic blood pressure, and mechanism of injury were not different between periods. Proportions of laparotomy before and after transfer and outcomes (mortality, hospital length of stay, intensive care unit length of stay, ventilator days) were also similar (p = 0.368 for laparotomy, p = 0.840, 0.124, 0.286, 0.822 for outcomes). Compared with the preconsultation period, the proportion of laparotomy performed before transfer for severe injuries (abdominal Abbreviated Injury Scale score >3) significantly increased postconsultation (57.1% vs. 30.6%, p = 0.011). Incidence of damage-control laparotomies (43.9% vs. 23.6%; p = 0.020) and transfusion of plasma and platelets (33.6% vs. 13.2%; p < 0.001, 22.4% vs. 8.5%, p = 0.007, respectively) significantly increased.
Identification and surgical stabilization of critical patients at the non-Level I facilities prior to transfer, as well as blood product use and damage-control techniques, improved postconsultation, suggesting a shift in the approaches to surgical stabilization and resuscitation efforts in our trauma system.
Therapeutic/Care Management; Level IV.
农村地区的创伤患者预后比城市地区差。2001 年，我们州建立了一个包容性的创伤系统，以提高死亡率。2015 年，创伤系统接受了美国外科医师学院创伤委员会的咨询访问，该委员会提出了一些建议。我们假设，该系统的持续成熟将导致在转至更高层级的治疗前，更多患者接受剖腹术治疗，从而获得更好的预后。
我们查询了创伤登记系统，以确定 2010 年 1 月 1 日至 2020 年 12 月 31 日期间转诊的所有患者，这些患者在转诊前或转诊后 4 小时内行剖腹术治疗。比较了咨询前（2010-2015 年）和咨询后（2016-2020 年）两个时期。分别采用卡方检验和曼-惠特尼 U 检验比较分类变量和连续变量。
共纳入 213 例患者；63 例在转诊前接受剖腹术治疗，150 例在转诊后 4 小时内接受剖腹术治疗。两个时期的年龄、创伤严重程度评分、收缩压和损伤机制无差异。转诊前和转诊后剖腹术的比例以及结局（死亡率、住院时间、重症监护病房住院时间、呼吸机使用天数）也相似（剖腹术的 p = 0.368，结局的 p = 0.840、0.124、0.286、0.822）。与咨询前相比，咨询后严重损伤（腹部损伤严重程度评分 >3）患者在转诊前接受剖腹术的比例显著增加（57.1%比 30.6%，p = 0.011）。损伤控制性剖腹术（43.9%比 23.6%；p = 0.020）和血浆与血小板输注（33.6%比 13.2%；p < 0.001，22.4%比 8.5%；p = 0.007）的发生率显著增加。
在转诊前，非 1 级创伤中心对危急患者进行识别和外科稳定，以及使用血液制品和损伤控制性技术，改善了咨询后的治疗效果，这表明我们的创伤系统在外科稳定和复苏努力方面的方法发生了转变。
治疗/护理管理；IV 级。
