【作者】 李辉；

【导师】 马岳峰；

【作者基本信息】 浙江大学 ， 急诊医学， 2012， 硕士

【摘要】 引言在国内,创伤是导致死亡的第五大原因。据统计,我国每年因创伤导致的死亡人数高达75万,因创伤致残的患者超过500万,并且还在以每年约10万的人数增加。每年仅因交通事故导致的死亡人数就超过25万人,并且是15-44岁年龄段人群首要的死亡原因。随着机动车保有量的持续增加,以道路交通事故为主的创伤事件有持续增加的趋势。近年来,我国在创伤急救的各个方面,包括在院前急救,院内救治方面都取得了很大的进步,但关于现阶段创伤发生的流行病学特征以及不同等级医院在创伤的院前及院内各环节创伤救治方面的现状还缺乏相关的信息。本次研究试图通过对浙江省10家医院创伤发生的流行病学调查以及救治现状的分析来揭示现阶段我省创伤发生的一般规律和目前创伤救治可能存在的问题,通过探究创伤死亡的相关影响因素以及评价临床创伤救治效率,为进一步提高创伤评估和救治成功率提供参考。第一部分浙江省创伤流行病学及救治情况分析目的通过调查浙江省多家医院创伤患者的流行病学特征以及院前和院内救治情况,揭示我省现阶段的创伤流行病学特征,并分析创伤救治过程中可能存在的问题,为提高我省的创伤的诊治和防范水平提供依据。方法通过专用调查网站,回顾性地收集了浙江省10家不同等级医院2009年1月1日至12月31日急诊科首诊的创伤患者的病历资料,收集了院前急救、急诊室及ICU三个阶段共100余项信息,并根据患者的伤情严重程度进行评分,包括损伤严重度评分,新损伤严重度评分,修正的创伤评分等。所有数据均通过统计软件SPSS18.0进行分析处理。结果在2009年1月1日至2009年12月31日间,10家医院急诊科首诊并收治入院的创伤患者共5503例,排除重复及无效的调查表后最终得到5464例,其中男性3967例,占72.6%。平均年龄为44.16±17.71,范围为0-103岁。绝大部分为钝性伤患者,占95.14%。最常见的受伤原因为车祸伤,占56.59%,其次为高处坠落伤(12.77%)。创伤最高发的职业是农民,占62.9%。最常见的受伤部位为头面部,占44.45%。患者的平均ISS评分为13.54±14.38。创伤发生的高峰时间段为7点到20点。65.4%的患者院前时间短于1小时,约5%的患者急诊室滞留时间超过2小时。共有1641例进入ICU接受治疗,占总数的30.1%。最终死亡253人,死亡率为4.6%。结论创伤最常见的致病原因仍为道路交通伤害,并以青壮年男性为主,头面部是最常见的创伤部位。创伤的院前急救和院内救治均和国外相比存在较大的差距,加强道路交通安全宣传,合理配置院前急救资源,缩短院前急救时间,加强创伤急救系统各环节的衔接以及ICU内的生命支持和病情评估,有助于改善创伤患者的预后。第二部分浙江省创伤患者死亡危险因素分析目的分析现阶段创伤急救系统中导致创伤患者死亡的危险因素并探讨改进创伤急救及降低创伤患者死亡率的措施。方法通过对浙江省8家医院2009年创伤患者信息的回顾性收集,结合创伤急救的院前及院内救治各个环节,选择可能导致患者死亡的相关因素,通过单因素和多因素logistic回归分析方法,得到导致创伤患者死亡的独立危险因素。结果共有3659名患者纳入了本次研究,其中死亡226人,死亡率为6.18%。单因素分析结果提示：年龄、创伤机制、ISS评分、GCS评分、专业现场急救、转送途中气管插管、转送途中清创止血、入院时低血压、昏迷、急诊室胸腔闭式引流、急诊手术、ICU内中心静脉压监测和ICu内机械通气和患者死亡相关(p<0.05)。多因素logistic回归分析提示,GCS评分(OR=0.69；95%CI：0.66-0.72)；ISS评分(OR=2.79；95%CI：1.59-4.89)；机械通气(OR=2.85；95%CI：1.89-4.28);失血性休克(OR=3.81；95%CI：2.20-6.60)；年龄(OR=1.03；95%CI：1.02-1.04)是患者死亡的独立危险因素,有效的专业现场急救(OR=0.62；95%CI：0.42-0.91)为保护因素。结论患者的伤情严重程度和年龄是影响患者结局的重要因素。加强院前急救,早期稳定患者伤情以及合理使用ICU内监护设施有助于进一步降低创伤救治的死亡率。第三部分浙江省多家医院的创伤救治评价目的通过TRISS评分计算浙江省多家医院2009年创伤患者的生存概率,将创伤救治数据与MTOS做比对,评价我省目前医疗机构创伤救治的现状并为临床提供参考。方法回顾性分析了浙江省5家三级医院2009年急诊科首诊的创伤患者共2193名。收集了人口统计学资料,创伤机制,受伤原因等信息,并通过计算患者进入急诊室时的ISS评分、RTS评分得到TRISS评分。通过计算M值以及标准化W统计的方法比较实际生存率和期望生存率,评价我省的创伤救治的现状。结果在所纳入的2193名创伤患者中,平均年龄为44.39岁,其中男性1661人占75.74%。最常见的受伤原因为车祸伤,其次为高处坠落伤。TRISS预测死亡率为13.22%,实际死亡率为9.75%。对于总体患者,M=0.80,提示与MTOS伤情差别显著。Ws=2.15,95%CI(Ws)：1.54-2.77,说明与生存率显著高于MTOS;此外,附属医院和三甲医院的创伤患者生存率都显著高于MTOS,而三乙医院和MTOS之间无显著差别。结论研究所纳入的5家医院的整体创伤救治能力优于MTOS,这和近年来我国的创伤急救领域的快速发展有关。然而不同等级医院之间在创伤救治方面仍有较大的差距。TRISS系数较为陈旧是导致其高估本次研究创伤死亡率的重要原因,建立我国的创伤数据库,得到适用于本地人群的TRISS系数有助于推动创伤评估和对创伤预后的研究。更多还原

【Abstract】 IntroductionTrauma is the fifth leading cause of death in China. Each year, about750,000deaths was caused by trauma and the disabled were more than5million, this number is expected to increase100,000each year. With the fast increasing number of vehicles, the traumatic events dominated in traffic crash have a tendency to increase steadily. In recent years, the trauma emergency medicine, including pre-hospital and hospital treatment, has been improved greatly. However, the current state of trauma epidemiology and trauma care performance of hospitals in different levels is not clear enough. The aim of present study was trying to explore the general rule of trauma happening and the problems may existed in present trauma system through the epidemiology study in10hospitals in Zhejiang province. The present study also analyzed the factors associated with trauma death and evaluated the trauma care performance in Zhejiang province in order to provide references to improve the success rate of trauma evaluation and treatment. Part I An analysis of trauma epidemiology and management of patients in Zhejiang provinceObjective:To identify the trauma epidemiology and current state of trauma care performance in pre-hospital and hospital stage through the epidemiology investigation in10hospitals in Zhejiang province. Discuss the problems may existed in trauma care and provide basis for the improvement of trauma care and prevention.Methods:A dedicated survey website was established, the data of multiple trauma in the hospitals from Jan1st to Dec31in2009was collected retrospectively. The information in pre-hospital, emergency room, ICU and operating room, was collected, and trauma scores including injury severity score etc. was calculated based on the injury severity. All the data was analyzed using SPSS18.0.Results:In the study period, a total of5503patients were collected in our database. Finally5464patients were enrolled in the final analysis after remove the replicate and invalid data. Among them, male makes up more than70percent. Finally,253patients died, the mortality rate is4.6%.The average age is44.16±17.71, most of the injury mechanism was blunt (95.14%). The most common reason of injury is traffic crash (56.69%) and fall from height (12.77%) takes second place. Most of the patients were fanner, head and face is the most common injury location. The average ISS score is13.54±14.38. The peak period of injury happened is between7am to8pm.65.4%of the patients get into the hospital in one hour. However, about5%patients had emergency length of stay more than2hours and1641patients had been transferred to ICU.Conclusion:The most common reason of injury is traffic crash. The majority of trauma victims are male adult and head-face is the most frequent injury area. The pre-hospital and hospital trauma care has many disadvantages compare with the western countries. Enhance the traffic safety publicity, allocate the pre-hospital emergency resources rationally, shorten the pre-hospital time, improve the links of trauma emergency services and strengthen trauma evaluation in ICU may benefit the outcomes of trauma patients. Part Ⅱ A multivariate analysis of trauma mortality in Zhejiang provinceObjective:To explore the risk factors of mortality in trauma patients and the way to improve trauma emergency service.Methods:Retrospectively review the data of trauma patients in8hospitals in Zhejiang province in2009and choosing possible variables related to the mortality of patients based on pre-hospital and hospital stage of trauma emergency, find the independent risk factors through univariate and multivariate analysis.Results:A total of3659patients were enrolled in this study.226trauma patients died and the mortality rate is6.18%. Following factors were related to mortality significantly after the univariate analysis:Age, trauma mechanism, injury severity score, Glasgow coma scale, coma on the scene, professional emergency treatment on the scene, intubation in the ambulance, debridement and hemostasis in the ambulance, low blood pressure at admission, closed drainage of pleural cavity, emergency operation, CVP monitoring in ICU, mechanical ventilation in ICU. After the multivariate analysis, six factors were independently related to the mortality as following:Glasgow coma scale (OR=0.69;95%CI:0.66-0.72), injury severity score (OR=2.79;95%CI:1.59-4.89), mechanical ventilation (OR=2.85;95%CI:1.89-4.28), low blood pressure at admission (OR=3.81;95%CI:2.20-6.60), age and professional emergency treatment on the scene (OR=0.62;95%CI:0.42-0.91)Conclusion:It has a great significance to investigate the risk factors of mortality for trauma patients. Severity of trauma and age were independently associated with the outcome of trauma. Besides, improve pre-hospital care, stabilize the trauma patients in early phase and use the monitoring equipments rationally in ICU may decrease the mortality further. PartⅢ An evaluation of the trauma care performance in Zhejiang province:a multi-hospital studyObjective:The objective of present study was to apply TRISS methodology to evaluate the trauma care performance of the hospitals in Zhejiang province and provide reference for clinical practice.Methods:A total of2193trauma patients were retrospectively collected in the5tertiary hospitals in Zhejiang province. Relevant information was collected, including demographic data, trauma mechanism, causes of injury, etc. The TRISS score was got though the calculation of ISS and RTS at the admission of emergency department. We compared our data with MOTS through the calculation of M value, standardized W statistic and its95%confidence interval to evaluate the trauma care performance.Results:In the study group, the average age was44.39years, among them,1661patients were male (75.74%). The most common reason of injury is traffic accident and the second is fall injury. The mortality rate according to the TRISS is13.22%, higher than the actual mortality rate9.75%. For all the patients, M=0.80, Ws=2.15,95%CI for Ws:1.54-2.77, indicating survival rate was significantly higher than MTOS. Besides, the survival rate of affiliated hospital and class A grade three hospital were also significantly higher than MTOS. The survival rate between class B grade three hospital and MTOS was not statistically significant.Conclusion:The average trauma care performance was outperformed than MTOS and this may associated with the development of trauma emergency system in recent years. However, the hospitals in different level still vary greatly in trauma treatment. TRISS overestimate the mortality in present patient group, this may associated with its old coefficients. Setting up the local trauma database and renew coefficients of TRISS may improve its predicting ability.更多还原