Not all prehospital time is equal: Influence of scene time on mortality
Not all prehospital time is equal: Influence of scene time on mortality
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DOI：
10.1097/ta.0000000000000999
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发表时间：
2016-07-01
影响因子：
3.4
通讯作者：
Sperry, Jason L.
中科院分区：
文献类型：
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作者：
Brown, Joshua B.;Rosengart, Matthew R.;Sperry, Jason L.
背景：创伤是时间敏感的，尽量减少院前(PH)时间是很有吸引力的。然而，大多数研究都没有将增加PH时间与更差的结果联系起来，因为原始PH时间是高度可变的。目前尚不清楚具体的PH时间模式是否会影响结果。我们的目的是评估PH时间间隔分布与死亡率的关系。方法：纳入2000年至2013年宾夕法尼亚州创伤登记处急诊医疗服务运送的总PH时间(TPT)为20分钟或更长的患者。TPT被分为三个PH时间间隔：响应时间、场景时间和运输时间。每个PH时间间隔中的分钟数除以TPT，以确定每个时间间隔对TPT的相对贡献比例。延长的间期被定义为任何一个PH间期，其贡献等于或大于TPT的50%。按PH间期延长或无PH间期延长(所有间期均为TPT的50%)进行分组。患者的TPT匹配，条件Logistic回归确定死亡率与PH时间模式的关联，控制混杂因素。研究人员将PH干预作为潜在的调节因素，并使用PH分类标准来确定时间敏感性损伤的患者。结果：共有164,471名患者。现场时间延长的患者死亡率增加(优势比为1.21；95%可信区间为1.02-1.44；p=0.03)。反应时间延长、运输时间延长和间隔时间不延长与死亡率无关。调整包括拔管和插管在内的中介因素后，延长的现场时间不再与死亡率相关(优势比1.06；95%可信区间0.90-1.25；p=0.50)。这些因素加在一起，在延长现场时间和死亡率之间的影响中起到了61%的作用。在低血压、穿透性损伤和连枷胸患者中，死亡率仍然与现场时间延长有关。PH干预部分地调节了这种联系。进一步的研究应该评估这些干预是否因为延长了现场时间或通过另一种机制而导致死亡率增加，因为减少现场时间可能是干预的目标。《创伤急救外科杂志》2016；81：93-100。版权所有(C)2016 Wolters Kluwer Health，Inc.保留所有权利。)
BACKGROUND: Trauma is time sensitive, and minimizing prehospital (PH) time is appealing. However, most studies have not linked increasing PH time with worse outcomes because raw PH times are highly variable. It is unclear whether specific PH time patterns affect outcomes. Our objective was to evaluate the association of PH time interval distribution with mortality.METHODS: Patients transported by emergency medical services in the Pennsylvania trauma registry from 2000 to 2013 with a total PH time (TPT) of 20 minutes or longer were included. TPT was divided into three PH time intervals: response, scene, and transport time. The number of minutes in each PH time interval was divided by TPT to determine the relative proportion each interval contributed to TPT. A prolonged interval was defined as any one PH interval contributing equal to or greater than 50% of TPT. Patients were classified by prolonged PH interval or no prolonged PH interval (all intervals < 50% of TPT). Patients were matched for TPT, and conditional logistic regression determined the association of mortality with PH time pattern, controlling for confounders. PH interventions were explored as potential mediators, and PH triage criteria used identify patients with time-sensitive injuries.RESULTS: There were 164,471 patients included. Patients with prolonged scene time had increased odds of mortality (odds ratio, 1.21; 95% confidence interval, 1.02-1.44; p = 0.03). Prolonged response, transport, and no prolonged interval were not associated with mortality. When adjusting for mediators including extrication and PH intubation, prolonged scene time was no longer associated with mortality (odds ratio, 1.06; 95% confidence interval, 0.90-1.25; p = 0.50). Together, these factors mediated 61% of the effect between prolonged scene time and mortality. Mortality remained associated with prolonged scene time in patients with hypotension, penetrating injury, and flail chest.CONCLUSION: Prolonged scene time is associated with increased mortality. PH interventions partially mediate this association. Further study should evaluate whether these interventions drive increased mortality because they prolong scene time or by another mechanism, as reducing scene time may be a target for intervention. (J Trauma Acute Care Surg. 2016; 81: 93-100. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.)