血压降低会使年长创伤患者陷于高风险


  【24drs.com】研究者在美国外科学会第98届年度临床研讨会中报告指出,如果年长者到创伤中心就诊时、到院前收缩压(PHSBP)低于110 mmHg的话,死亡率风险显著增加。
  
  研究者建议需进行研究,以确认疾病管制中心(CDC)用于PHSBP低于110 mmHg的年长病患送往创伤中心之分流指引,是否需从四步骤的建议变更为一步骤的适应症。
  
  根据芝加哥Advocate Illinois Masonic医学中心的Juan Santiago医师表示,预估到了2025年时,约有三分之一的创伤病患是年长者,因此,了解年长创伤病患的风险因素益发重要。
  
  CDC目前的现场创伤分流准则指出,若病患的PHSBP低于90 mmHg时则送往创伤中心,不过,这个2011年版指引的四步骤建议包括一项备注:65岁以上者的PHSBP低于110 mmHg可能会有休克。
  
  为了评估PHSBP是否是受伤年长者的死亡率风险标记,研究者检视了2010年的全国创伤资料库的资料,以确认PHSBP在这群病患的范围与死亡率风险。
  
  他们依据PHSBP将66,762名65岁以上病患分类:低于90 mmHg (n= 1296人)、90-99 mmHg (n= 1414人)、100-109 mmHg (n= 2857人)、110-119 mmHg (n= 4817人)、120-129 mmHg (n= 6656人)、130-39 mmHg (n= 9169人)以及140 mmHg以上(n= 40,556人)。
  
  整体死亡率风险为5.6% (n= 3724人),不过,死亡率风险随PHSBP降低而增加。
PHSBP分组(mm Hg)死亡率风险(%)胜算比P P值
90-9913.52.73<.0001
100-1098.41.58<.0001
110-1196.21.12<.064
120-1295.30.95<.33
130-1394.50.78<.0001
≧1404.80.69<.0001

  此外,相较于PHSBP大于109 mmHg者,PHSBP小于等于109 mmHg者使用呼吸器的时间显著增加、住院期间较久、住在加护病房的期间也较久。
  
  同样来自Advocate Illinois Masonic医学中心的资深作者Richard Fantus医师表示,年长者的生理储备能量不同,年长者的小创伤也可能会导致显著的发病与死亡。
  
  肯塔基州路易斯维尔大学的J.David Richardson医师指分流准则的重要性在于「试图让适当的病患在适当时间送抵适当院所」,不过,年长病患的问题在于他们不要到其它地方。
  
  资料来源:http://www.24drs.com/professional/list/content.asp?x_idno=6950&x_classno=0&x_chkdelpoint=Y
  

Low BP May Put Elderly Trauma Patients at High Risk

By Lara C. Pullen, PhD
Medscape Medical News

October 11, 2012 (Chicago, Illinois) — Elderly people who present to a trauma center with a prehospital systolic blood pressure (PHSBP) below 110 mm Hg are at significantly increased risk for mortality, researchers reported here at the American College of Surgeons 98th Annual Clinical Congress.

They suggest that research should be done to determine whether the Centers for Disease Control and Prevention (CDC) triage guidelines for an elderly patient with a PHSBP below 110 mm Hg should be elevated from a step 4 recommendation to a step 1 indicator for transport to a trauma center.

It is expected that by 2025, approximately one third of trauma patients will be elderly, according to lead author Juan Santiago, MD, from the Advocate Illinois Masonic Medical Center in Chicago. Therefore, understanding the risk factors for elderly trauma patients will become increasingly important.

Current field trauma triage criteria from the CDC call for the transport of patients to a trauma center if PHSBP is below 90 mm Hg. However, the step 4 recommendation in the 2011 guidelines includes a notation that a PHSBP below 110 mm Hg could indicate shock in patients 65 years and older.

To evaluate whether PHSBP is a marker for mortality risk in the injured elderly, the researchers examined 2010 entries in the National Trauma Databank to determine PHSBP range and the risk for mortality in this patient population.

They stratified the 66,762 patients who 65 years or older according to PHSBP: below 90 mm Hg (n = 1296), 90 to 99 mm Hg (n = 1414), 100 to 109 mm Hg (n = 2857), 110 to 119 mm Hg (n = 4817), 120 to 129 mm Hg (n = 6656), 130 to 139 mm Hg (n = 9169), and 140 mm Hg or higher (n = 40,556).

The overall mortality rate was 5.6% (n = 3724); however, mortality risk increased with decreasing PHSBP.

Mortality Risk by PHSBP Group
PHSBP Group (mm Hg) Mortality Rate (%) Odds Ratio P Value
90 to 99 13.5 2.73 <.0001
100 to 109 8.4 1.58 <.0001
110 to 119 6.2 1.12 <.064
120 to 129 5.3 0.95 <.33
130 to 139 4.5 0.78 <.0001
?140 4.8 0.69 <.0001


Moreover, patients whose PHSBP was 109 mm Hg or lower, compared with those whose PHSBP was above 109 mm Hg, spent significantly more time on a ventilator, had a longer stay in the hospital, and spent more time in the intensive care unit.

Senior author Richard Fantus, MD, who is also from the Advocate Illinois Masonic Medical Center, told Medscape Medical News that "older people don't have the same physiologic reserve.... Lesser injuries in an elderly individual can result in significant morbidity and mortality."

J. David Richardson, MD, FACS, from the University of Louisville in Kentucky, described the importance of triage criteria for "trying to get the right patient to the right place at the right time." He pointed out, however, that "the problem with elderly patients is that they don't want to go somewhere else."

Dr. Santiago, Dr. Fantus, and Dr. have disclosed no relevant financial relationships.

American College of Surgeons (ACS) 98th Annual Clinical Congress: Poster 230. Presented October 3, 2012.

    



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