出處：WebMD醫學新聞
March 27, 2009 —根據登載於3月24日Lancet期刊線上搶先版的多中心回溯研究結果，對於多重創傷的病患，於初期照護中加入全身電腦斷層(CT)掃描可以顯著增加存活機率。
德國慕尼黑大學醫院的Stefan Huber-Wagner與德國創傷協會、多重創傷工作小組的同仁寫道，使用全身CT評估初步創傷的創傷中心數量日漸增加。沒有證據認為使用全身CT對重大創傷的病患結果有任何效果，因此我們比較鈍性創傷病患接受與未接受全身CT者之間的存活可能性。
研究者使用德國創傷協會的登記資料，確認4,621名鈍性創傷病患接受全身或者非全身CT的結果。根據創傷嚴重指數(TRISS)、修訂版傷害嚴重度分類(RISC)評分、標準化死亡率比率(SMR/死亡率紀錄與預估死亡率之比值)，計算存活可能性。
在4,621名病患中，1,494人(32%)接受全身CT。全部病患有3,364人(73%)是女性。平均年紀為42.6 ± 20.7歲，平均傷害嚴重度分數為29.7 ± 13·0。根據TRISS，接受全身CT之病患的SMR為0.745 (95%信心區間[CI]為0.633 - 0.859) ，接受非全身CT之病患則為1.023(95% CI, 0.909 - 1.137) (P<.001)。
根據RISC分數，接受全身CT之病患的SMR為0.865 (95% CI, 0.774 - 0.956)，接受非全身CT之病患則為1.034 (95% CI, 0.959 - 1.109) (P=.017)。根據TRISS，死亡率相對風險降低(RRR)值為25% (95% CI, 14% - 37%)、根據RISC分數則為13% (95% CI, 4% - 23%)。即使校正醫院等級、創傷年份、潛在中心效果等多變項之後，全身CT是預測存活的一個獨立因素(P≦.002)。為了預防1件死亡，根據TRISS，需要掃描17人，根據RISC，需要掃描32人。
研究作者寫道，將全身CT整合到初期創傷照護，可顯著增加多重創傷病患的存活可能性。建議將全身CT作為多重創傷病患初期復甦期的標準診斷方法。
研究限制包括，屬於回溯設計；創傷登記上有漏失資料，只有49%病患可以計算TRISS，有89%病患可以計算RISC；還未確定全身CT的明確規範；缺乏有關參與醫院的差異資料，例如CT掃描器的位置、從創傷中心移到CT室的運送時間；缺乏有關CT規範或者完成進階創傷生命支持原則的資料；各中心之間對於創傷等級可能有所差異；可能有其他疏失之處。
研究作者結論表示，儘管有這些限制，我們的結果顯示，使用全身CT可以顯著增加嚴重創傷病患的存活可能性。根據我們的發現，我們建議將全身CT整合到嚴重創傷病患的初期復甦期，作為標準與基本的診斷方法。
德國創傷協會創傷登記有部份係接受Deutsche Forschungsgemeinschaft Ne 385/5支持， Novo Nordisk A/S 支持本研究。研究作者宣告沒有相關財務關係。
Lancet. 線上登載於2009年3月24日。
Whole-Body CT May Improve Survival for Patients With Polytrauma
Medscape Medical News
March 27, 2009 — For patients with polytrauma, integrating whole-body computed tomography (CT) scan into early trauma care significantly increases the probability of survival, according to the results of a retrospective, multicenter study reported in the March 24 Online First issue of The Lancet.
"The number of trauma centres using whole-body CT for early assessment of primary trauma is increasing," write Stefan Huber-Wagner, from Munich University Hospital in Munich, Germany, and colleagues from the Working Group on Polytrauma of the German Trauma Society. "There is no evidence to suggest that use of whole-body CT has any effect on the outcome of patients with major trauma. We therefore compared the probability of survival in patients with blunt trauma who had whole-body CT during resuscitation with those who had not."
The investigators used the data recorded in the trauma registry of the German Trauma Society to determine survival outcomes for 4621 patients with blunt trauma who received whole-body or non–whole-body CT. Survival probability was calculated according to the trauma and injury severity score (TRISS), revised injury severity classification (RISC) score, and standardized mortality ratio (SMR, ratio of recorded to expected mortality).
Of the 4621 patients, 1494 (32%) underwent whole-body CT. Of these patients, 3364 (73%) were men. Mean age was 42.6 ± 20.7 years, and mean injury-severity score was 29.7 ± 13·0. Based on TRISS, SMR was 0.745 (95% confidence interval [CI], 0.633 - 0.859) for patients who underwent whole-body CT vs 1.023 (95% CI, 0.909 - 1.137) for those who underwent non–whole-body CT (P?
Based on the RISC score, SMR was 0.865 (95% CI, 0.774 - 0.956) for patients who underwent whole-body CT vs 1.034 (95% CI, 0.959 - 1.109) for those who underwent non–whole-body CT (P?=?.017). Relative risk reduction (RRR) in mortality rate based on TRISS was 25% (95% CI, 14% - 37%) vs 13% (95% CI, 4% - 23%) based on RISC score. Whole-body CT was an independent predictor for survival (P???.002), even after multivariate adjustment for hospital level, year of trauma, and potential center effects. To prevent 1 death, the number needed to scan was 17 based on TRISS and 32 based on RISC calculation.
"Integration of whole-body CT into early trauma care significantly increased the probability of survival in patients with polytrauma," the study authors write. "Whole-body CT is recommended as a standard diagnostic method during the early resuscitation phase for patients with polytrauma."
Limitations of this study include retrospective design; missing data in the trauma registry, allowing calculations of TRISS in only 49% and RISC score in 89% of patients; clear protocol for or against whole-body CT not clearly defined; lack of data about structural differences of the participating hospitals, such as the location of the CT scanner and transportation times between the trauma room and CT suite; lack of data about CT protocols or implementation of the principles of advanced trauma life support; potentially different intercenter consistency in grading injuries; and possible residual confounding.
"Despite these limitations, our results indicate that the probability of survival for patients with major trauma can be significantly increased by use of whole-body CT," the study authors conclude. "On the basis of our findings, we recommend that whole-body CT should be integrated into the early resuscitation phase of severely injured patients as a standard and basic diagnostic method."
The trauma registry of the German Trauma Society (Deutsche Gesellschaft fur Unfallchirurgie) was partly funded by the Deutsche Forschungsgemeinschaft Ne 385/5 and Novo Nordisk A/S, supported this study. The study authors have disclosed no relevant financial disclosures.
Lancet. Published online March 24, 2009. |
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