Joint Trauma System, Defense Health Agency, Fort Sam Houston, TX.
Armed Forces Medical Examiner System, Defense Health Agency, Dover AFB, DE.
Ann Surg. 2024 Jan 1;279(1):1-10. doi: 10.1097/SLA.0000000000005787. Epub 2023 Jan 2.
To examine time from injury to initiation of surgical care and association with survival in US military casualties.
Although the advantage of trauma care within the "golden hour" after an injury is generally accepted, evidence is scarce.
This retrospective, population-based cohort study included US military casualties injured in Afghanistan and Iraq, January 2007 to December 2015, alive at initial request for evacuation with maximum abbreviated injury scale scores ≥2 and documented 30-day survival status after injury. Interventions: (1) handoff alive to the surgical team, and (2) initiation of first surgery were analyzed as time-dependent covariates (elapsed time from injury) using sequential Cox proportional hazards regression to assess how intervention timing might affect mortality. Covariates included age, injury year, and injury severity.
Among 5269 patients (median age, 24 years; 97% males; and 68% battle-injured), 728 died within 30 days of injury, 68% within 1 hour, and 90% within 4 hours. Only handoffs within 1 hour of injury and the resultant timely initiation of emergency surgery (adjusted also for prior advanced resuscitative interventions) were significantly associated with reduced 24-hour mortality compared with more delayed surgical care (adjusted hazard ratios: 0.34; 95% CI: 0.14-0.82; P = 0.02; and 0.40; 95% CI: 0.20-0.81; P = 0.01, respectively). In-hospital waits for surgery (mean: 1.1 hours; 95% CI; 1.0-1.2) scarcely contributed ( P = 0.67).
Rapid handoff to the surgical team within 1 hour of injury may reduce mortality by 66% in US military casualties. In the subgroup of casualties with indications for emergency surgery, rapid handoff with timely surgical intervention may reduce mortality by 60%. To inform future research and trauma system planning, findings are pivotal.
探讨美国军事伤员从受伤到开始接受外科治疗的时间及其与生存的关系。
尽管一般认为受伤后在“黄金一小时”内进行创伤救治具有优势，但相关证据却很少。
本回顾性基于人群的队列研究纳入了 2007 年 1 月至 2015 年 12 月在阿富汗和伊拉克受伤的美国军事伤员，这些伤员在最初请求撤离时存活，最大简明损伤评分≥2，并记录了受伤后 30 天的生存状态。干预措施：（1）将伤员活着移交给外科团队，（2）开始第一次手术，将其作为时间相关协变量（从受伤到干预的时间流逝）进行分析，采用序贯 Cox 比例风险回归来评估干预时机如何影响死亡率。协变量包括年龄、受伤年份和损伤严重程度。
在 5269 例患者中（中位年龄为 24 岁；97%为男性；68%为战斗伤），728 例在受伤后 30 天内死亡，68%在 1 小时内死亡，90%在 4 小时内死亡。只有在受伤后 1 小时内完成交接，并及时进行紧急手术（也调整了先前的高级复苏干预），与更延迟的手术治疗相比，与 24 小时死亡率降低显著相关（校正后的危险比：0.34；95%CI：0.14-0.82；P=0.02；0.40；95%CI：0.20-0.81；P=0.01）。手术前的院内等待时间（平均：1.1 小时；95%CI：1.0-1.2）几乎没有影响（P=0.67）。
在受伤后 1 小时内将伤员迅速移交给外科团队，可能会使美国军事伤员的死亡率降低 66%。在需要紧急手术的伤员亚组中，迅速交接并及时进行手术干预，可能会使死亡率降低 60%。为了为未来的研究和创伤系统规划提供信息，这些发现至关重要。
