費(fèi) 敏,蔡文偉,高 峰,陳長(zhǎng)水
·論著·
創(chuàng)傷性心搏驟停的流行病學(xué)特征及預(yù)后研究
費(fèi) 敏1*,蔡文偉1,高 峰2,陳長(zhǎng)水3
目的了解創(chuàng)傷性心搏驟停(TCA)的流行病學(xué)特征、預(yù)后情況并探討影響其預(yù)后的因素。方法選取2012年1月—2016年9月浙江省人民醫(yī)院急診科、紹興市急救中心及寧波市急救中心接診的544例院外心搏驟停(OHCA)患者,其中TCA患者186例,非TCA患者358例。參照Utstein模式收集臨床資料,回顧性分析其年齡、性別、發(fā)作地點(diǎn)、被目擊情況、目擊者心肺復(fù)蘇(CPR)、急救反應(yīng)時(shí)間、初始心律、院外除顫、院外氣管插管、院外使用腎上腺素、院外開(kāi)通靜脈通路、自主循環(huán)恢復(fù)(ROSC)、存活入院及存活出院等信息,并比較TCA患者與非TCA患者上述特征及轉(zhuǎn)歸的差異。結(jié)果TCA患者與非TCA患者在年齡、發(fā)作地點(diǎn)、初始心律、院外使用腎上腺素及開(kāi)通靜脈通路等流行病學(xué)特征上差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。非TCA患者與TCA患者的ROSC比較,差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。非TCA患者與TCA患者的存活住院、存活出院比較,差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。被目擊、初始心律為心室停搏、急救反應(yīng)時(shí)間<10 min、目擊者CPR及院外除顫是TCA患者ROSC的影響因素(P<0.05)。結(jié)論TCA與非TCA患者的復(fù)蘇存活率均不高,TCA患者的ROSC率更低,改善院外生存鏈的一系列因素如增加目擊者CPR、院外除顫及減少急救反應(yīng)時(shí)間有助于增加TCA患者的ROSC。
心搏驟停;創(chuàng)傷;流行病學(xué);預(yù)后
心搏驟停(cardiac arrest,CA)是指心臟泵血功能突然停止,全身血液循環(huán)即刻中斷,進(jìn)而導(dǎo)致呼吸停止、腦功能喪失的一種瀕臨死亡狀態(tài),如不立即給予干預(yù),患者將在短時(shí)間內(nèi)死亡[1]。在歐洲,每年大約有50萬(wàn)人發(fā)生CA,而且CA患者的1年生存率很低(<6%)[2]。雖然創(chuàng)傷性心搏驟停(traumatic cardiac arrest,TCA)在院外心搏驟停(out-of-hospital cardiac arrest,OHCA)中所占比例較低[3],但大多數(shù)研究顯示TCA的生存率很低,僅為0~3.7%[4]。對(duì)TCA患者進(jìn)行心肺復(fù)蘇(cardio pulmonary resuscitation,CPR)被很多學(xué)者認(rèn)為是徒勞的,而且浪費(fèi)醫(yī)療及人力資源[5]。因此美國(guó)國(guó)家急救醫(yī)師協(xié)會(huì)和美國(guó)外科醫(yī)師協(xié)會(huì)創(chuàng)傷委員會(huì)于2003年發(fā)布聯(lián)合指南,提出TCA在院外急救時(shí)不予復(fù)蘇或終止復(fù)蘇的建議[6]。但對(duì)這些指南目前存在著爭(zhēng)議,不少研究者認(rèn)為T(mén)CA仍需積極進(jìn)行CPR,這并不都是徒勞的[7-8]。為此,本研究采用多中心、回顧性研究的方法,對(duì)TCA的流行病學(xué)特征及預(yù)后進(jìn)行分析,以期為院外TCA急救方案的制定提供依據(jù)。
1.1 研究對(duì)象 選擇2012年1月—2016年9月浙江省人民醫(yī)院急診科、紹興市急救中心及寧波市急救中心接診的OHCA患者544例,其中TCA患者186例,非TCA(包括心源性疾病、呼吸系統(tǒng)疾病、溺水、電擊及其他原因)患者358例。所有病例均符合CA的診斷標(biāo)準(zhǔn),即突發(fā)意識(shí)不清、呼吸停止或嘆氣樣呼吸、大動(dòng)脈搏動(dòng)消失[9],并被目擊者或院外急救人員復(fù)蘇,然后被轉(zhuǎn)送至醫(yī)療機(jī)構(gòu)。
1.2 研究方法 參照國(guó)際通用Utstein模式[10],采用回顧性分析方法,根據(jù)急救調(diào)度中心記錄、院外急救人員記錄及醫(yī)院記錄收集所有544例OHCA患者的年齡、性別、發(fā)作地點(diǎn)、被目擊情況、目擊者CPR、急救反應(yīng)時(shí)間、初始心律、院外除顫、院外氣管插管、院外使用腎上腺素、院外開(kāi)通靜脈通路、自主循環(huán)恢復(fù)(return of spontaneous circulation,ROSC)、存活入院及存活出院等信息,并比較TCA患者與非TCA患者上述流行病學(xué)特征及轉(zhuǎn)歸的差異。急救反應(yīng)時(shí)間是指從急救中心接到
本文創(chuàng)新點(diǎn):
本文通過(guò)對(duì)186例創(chuàng)傷性心臟驟停(TCA)患者的臨床流行病學(xué)資料進(jìn)行回顧性分析,得出了與美國(guó)國(guó)家急救醫(yī)師協(xié)會(huì)和美國(guó)外科醫(yī)師協(xié)會(huì)創(chuàng)傷委員會(huì)所推薦的學(xué)術(shù)觀點(diǎn)不一致的結(jié)果,并結(jié)合歐洲文獻(xiàn)進(jìn)行討論,認(rèn)為改善院外生存鏈的一系列因素如增加目擊者心肺復(fù)蘇、院外除顫及減少急救反應(yīng)時(shí)間有助于增加TCA患者自主循環(huán)恢復(fù)的結(jié)論。本文雖屬回顧性研究,但樣本量較大,觀察分析指標(biāo)多屬基礎(chǔ)性?xún)?nèi)容,故研究結(jié)果對(duì)臨床實(shí)踐,尤其是院前搶救具有一定參考價(jià)值。
120求救電話至院外急救人員到達(dá)現(xiàn)場(chǎng)所需的時(shí)間[11];初始心律定義為CA發(fā)作后首次被記錄到的心律;以總的ROSC作為評(píng)估TCA患者本次發(fā)作預(yù)后的標(biāo)準(zhǔn)。
2.1 非TCA患者與TCA患者的流行病學(xué)特征比較 非TCA患者與TCA患者的年齡、發(fā)作地點(diǎn)、初始心律、院外使用腎上腺素及院外開(kāi)通靜脈通路情況比較,差異均有統(tǒng)計(jì)學(xué)意義(P<0.05);性別、被目擊、目擊者CPR、急救反應(yīng)時(shí)間、院外除顫及院外氣管插管情況比較,差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05,見(jiàn)表1)。
2.2 非TCA患者與TCA患者的預(yù)后情況比較 非TCA患者與TCA患者的ROSC比較,差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。非TCA患者與TCA患者的存活住院、存活出院比較,差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05,見(jiàn)表2)。
2.3 TCA患者ROSC的單因素分析 單因素分析結(jié)果顯示,被目擊、初始心律為心室停搏、急救反應(yīng)時(shí)間<10 min、目擊者CPR及院外除顫是TCA患者ROSC的影響因素(P<0.05,見(jiàn)表3)。
表1 非TCA患者與TCA患者的流行病學(xué)特征比較
注:TCA=創(chuàng)傷性心搏驟停,CPR=心肺復(fù)蘇;a為t值
表3 TCA患者ROSC的單因素分析(例)
表2 TCA患者與非TCA患者的轉(zhuǎn)歸比較〔n(%)〕
Table2 Comparison the outcomes between TCA and non-TCA patients
組別例數(shù)ROSC存活住院存活出院非TCA35853(148)28(78)3(08)TCA18616(86)11(59)1(05)χ2值425206690151P值003904130697
注:ROSC=自主循環(huán)恢復(fù)
嚴(yán)重創(chuàng)傷已經(jīng)成為發(fā)達(dá)國(guó)家中兒童及44歲以下成年人死亡的主要原因[12],而且TCA的預(yù)后較差,即使幸存下來(lái)也常伴有永久性神經(jīng)功能障礙[13]。因此很多學(xué)者認(rèn)為從合理利用醫(yī)療和人力資源方面考慮,不應(yīng)對(duì)TCA患者進(jìn)行復(fù)蘇,特別是在野外和面對(duì)群體性創(chuàng)傷事件時(shí)[5]。美國(guó)兩大協(xié)會(huì)關(guān)于高級(jí)創(chuàng)傷生命支持的指南中明確建議,對(duì)任何創(chuàng)傷患者如果發(fā)現(xiàn)其“無(wú)自主呼吸、無(wú)脈搏、無(wú)心電活動(dòng)或無(wú)其他生命體征如自主運(yùn)動(dòng)或瞳孔反射”可放棄復(fù)蘇,應(yīng)當(dāng)場(chǎng)宣布死亡[4]。但在很多歐洲國(guó)家,對(duì)于TCA患者也是積極搶救,并予以與非TCA相同級(jí)別的搶救及護(hù)理[14-15]。雖然本研究非TCA患者ROSC比例比TCA患者的高,但存活住院和存活出院無(wú)差異。說(shuō)明對(duì)于TCA患者,也是需要積極搶救的。
ENGDAHL等[16]發(fā)現(xiàn)TCA跟其他CA在流行病學(xué)特征上有明顯區(qū)別,如年齡、發(fā)作地點(diǎn)和初始心律。這與本研究結(jié)果相類(lèi)似,除此之外本研究還發(fā)現(xiàn)在院外處置方面,院外急救人員更多地予以TCA患者開(kāi)通靜脈通路,而使用腎上腺素較非TCA患者少。而其他方面,如性別、被目擊、目擊者CPR、急救反應(yīng)時(shí)間、院外除顫、院外氣管插管方面均沒(méi)有差異。
本研究中TCA與非TCA患者總體生存率均處于較低水平,與具有成熟發(fā)達(dá)急救醫(yī)療系統(tǒng)的國(guó)家差距較大[17]。以總ROSC作為評(píng)估TCA患者本次發(fā)作預(yù)后的標(biāo)準(zhǔn),對(duì)各項(xiàng)可能影響ROSC的因素進(jìn)行χ2檢驗(yàn)后發(fā)現(xiàn),有幾項(xiàng)院外生存鏈的因素在TCA救治過(guò)程中沒(méi)有被完全貫徹。極低的目擊者CPR率(2.2%)和院外除顫率(4.3%)是本次的主要發(fā)現(xiàn)。影響OHCA患者預(yù)后最重要的因素是從CA發(fā)生到開(kāi)始CPR的時(shí)間,如果沒(méi)有目擊者的話生存率就會(huì)非常低,因此目擊者CPR在院外生存鏈中起了關(guān)鍵作用。本研究發(fā)現(xiàn)目擊者CPR可明顯改善TCA的預(yù)后,這與國(guó)外的報(bào)道相一致[18-19]。而本研究發(fā)現(xiàn)TCA最常發(fā)作的場(chǎng)所為工作場(chǎng)所(37.6%),現(xiàn)場(chǎng)有目擊者的比例為56.8%,如何大力普及CPR知識(shí)、開(kāi)展公眾CPR培訓(xùn)及推廣公眾CPR技能,對(duì)提高TCA的生存率影響甚大。另一方面,CA患者的室顫或室速如能被早期發(fā)現(xiàn),生存的機(jī)會(huì)就能增加5~10倍[20]。每延遲1 min除顫,存活出院的機(jī)會(huì)就會(huì)下降10%~12%[21]。由于主要與低血容量和低氧有關(guān),所以TCA中出現(xiàn)心室停搏明顯多于非TCA,而心室停搏因其無(wú)法除顫、預(yù)后極差而稱(chēng)被認(rèn)為是一個(gè)可宣布死亡的心律[22]。本研究發(fā)現(xiàn)初始心律如為心室停搏,則能出現(xiàn)ROSC的比例就明顯減少。雖然在TCA中發(fā)生心室顫動(dòng)或室性心動(dòng)過(guò)速的比例不及非TCA,但本研究也發(fā)現(xiàn)院外除顫能增加ROSC的比例,改善預(yù)后。因此對(duì)于TCA的復(fù)蘇,不僅要積極針對(duì)原發(fā)病,改善低血容量及低氧,防止部分心室顫動(dòng)或室性心動(dòng)過(guò)速惡化為心室停搏,而且還要早期識(shí)別、早期發(fā)現(xiàn)心室顫動(dòng)或室性心動(dòng)過(guò)速,以及時(shí)除顫。
急救反應(yīng)時(shí)間是本研究中發(fā)現(xiàn)的另一個(gè)影響TCA患者ROSC比例的因素,特別是在目擊者CPR率較低的情況下,大部分TCA的復(fù)蘇都依賴(lài)于院外急救人員到達(dá)現(xiàn)場(chǎng)后才完成。急救反應(yīng)時(shí)間的長(zhǎng)短是評(píng)價(jià)一個(gè)城市或地區(qū)急救醫(yī)療系統(tǒng)是否完善或高效的重要指標(biāo)[23]。參考中國(guó)醫(yī)院管理委員會(huì)急救中心(站)管理委員分會(huì)制定的應(yīng)小于10 min(特大型城市除外)的標(biāo)準(zhǔn)[11],本研究發(fā)現(xiàn)急救反應(yīng)時(shí)間<10 min的TCA患者其ROSC比例明顯高于>10 min的患者,這說(shuō)明縮短院外急救反應(yīng)時(shí)間對(duì)改善TCA的預(yù)后至關(guān)重要。
控制出血和補(bǔ)充容量是嚴(yán)重創(chuàng)傷患者復(fù)蘇的兩個(gè)關(guān)鍵點(diǎn),然而受限于院外急救時(shí)有限的人力、處置手段、血制品及復(fù)蘇液體量,即使院外急救人員及時(shí)開(kāi)通靜脈通路、建立高級(jí)氣道(如氣管插管),均無(wú)法明顯改善預(yù)后。對(duì)于腎上腺素是否能作為T(mén)CA患者搶救時(shí)的一線用藥,向來(lái)存在著很大爭(zhēng)議,本研究未發(fā)現(xiàn)院外使用腎上腺素能明顯改善預(yù)后,可能的原因是原本希望使用腎上腺素來(lái)提升外周血壓從而保證重要臟器的血供,但對(duì)于TCA來(lái)說(shuō)有增加出血量的風(fēng)險(xiǎn)[24]。
綜上所述,TCA患者在年齡、發(fā)作地點(diǎn)、初始心律、院外使用腎上腺素及開(kāi)通靜脈通路等流行病學(xué)特征上不同于非TCA患者,兩者在轉(zhuǎn)歸上沒(méi)有明顯區(qū)別,故對(duì)于TCA患者仍需積極復(fù)蘇;本研究發(fā)現(xiàn)TCA生存率不高,改善院外生存鏈的一系列因素如增加目擊者CPR、院外除顫及減少急救反應(yīng)時(shí)間有助于增加TCA患者的ROSC比例。當(dāng)然,本研究也有局限性:LOCKEY等[14]研究顯示TCA患者的生存率還與創(chuàng)傷機(jī)制相關(guān),但對(duì)研究采用的Utstein模式里并不包括創(chuàng)傷的機(jī)制或受傷部位等信息,也無(wú)法通過(guò)創(chuàng)傷嚴(yán)重評(píng)分來(lái)評(píng)估病情,有待于今后進(jìn)一步研究。
作者貢獻(xiàn):費(fèi)敏負(fù)責(zé)研究設(shè)計(jì)與實(shí)施、資料整理、撰寫(xiě)論文、成文并對(duì)文章負(fù)責(zé);蔡文偉、高峰、陳長(zhǎng)水負(fù)責(zé)數(shù)據(jù)采集與匯總。
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EpidemiologicalCharacteristicsandOutcomeofTraumaticCardiacArrest
FEIMin1*,CAIWen-wei1,GAOFeng2,CHENChang-shui3
ObjectiveTo investigate the epidemiological characteristics and outcomes of traumatic cardiac arrest(TCA) and to analyze the factors associated with outcomes.MethodsFive hundred and forty-four patients(186 with TCA and 358 with non-TCA) with out-of-hospital cardiac arrest(OHCA) who
treatment in Department of Emergency,Zhejiang Provincial People′s Hospital,Shaoxing Emergency Medical Service Center and Ningbo Emergency Medical Service Center from January 2012 to September 2016 were enrolled.All the clinical data including age,sex,location of arrest,bystanders,bystander CPR,EMS response time,initial rhythm,pre-hospital defibrillation,pre-hospital intubation,pre-hospital epinephrine administration,pre-hospital vascular access,return of spontaneous circulation(ROSC),survival to hospital admission and survival to hospital discharge were collected from the files of the patients and were documented according to the Utstein style template and analyzed retrospectively.The above characteristics and outcomes between TCA patients and non-TCA patients were compared.ResultsThe age distribution,location of arrest,types of initial rhythm,prevalence of pre-hospital administration of epinephrine and pre-hospital vascular access differed significantly between TCA patients and non-TCA patients(P<0.05).TCA patients were less likely to have ROSC compared with the non-TCA patients(P<0.05).Both groups presented similar survival rate to hospital admission as well as survival rate to hospital discharge(P>0.05).Witnessed by bystanders,ventricular asystole as the initial rhythm,EMS response time <10 min,bystander CPR and pre-hospital defibrillation were associated factors for achieving successful ROSC in TCA patients(P<0.05).ConclusionThe rates of survival after receiving resuscitation were low in both TCA and non-TCA patients.And the TCA patients had lower rate of ROSC than non-TCA patients.Improving the factors associated with out-of-hospital chain of survival,such as increase of bystander CPR and availability of pre-hospital defibrillation,and reduction of EMS response time will contribute to increasing the rate of ROSC in TCA patients.
Cardiac arrest;Trauma;Epidemiology;Outcome
1.310014 浙江省杭州市,浙江省人民醫(yī)院急診科
2.312000 浙江省紹興市,紹興市急救中心
3.315020 浙江省寧波市,寧波市急救中心
*通信作者:費(fèi)敏,主治醫(yī)師;E-mail:fammy2001@163.com
R 541.78
A
10.3969/j.issn.1007-9572.2017.31.015
費(fèi)敏,蔡文偉,高峰,等.創(chuàng)傷性心搏驟停的流行病學(xué)特征及預(yù)后研究[J].中國(guó)全科醫(yī)學(xué),2017,20(31):3907-3911.[www.chinagp.net]
FEI M,CAI W W,GAO F,et al.Epidemiological characteristics and outcome of traumatic cardiac arrest[J].Chinese General Practice,2017,20(31):3907-3911.
1.DepartmentofEmergency,ZhejiangProvincialPeople′sHospital,Hangzhou310014,China
2.ShaoxingEmergencyMedicalServiceCenter,Shaoxing312000,China
3.NingboEmergencyMedicalServiceCenter,Ningbo315020,China
*Correspondingauthor:FEIMin,Attendingdoctor;E-mail:fammy2001@163.com
2017-05-10;
2017-08-17)
(本文編輯:殷麗剛)