血壓降低會使年長創傷患者陷於高風險


  【24drs.com】研究者在美國外科學會第98屆年度臨床研討會中報告指出,如果年長者到創傷中心就診時、到院前收縮壓(PHSBP)低於110 mmHg的話,死亡率風險顯著增加。
  
  研究者建議需進行研究,以確認疾病管制中心(CDC)用於PHSBP低於110 mmHg的年長病患送往創傷中心之分流指引,是否需從四步驟的建議變更為一步驟的適應症。
  
  根據芝加哥Advocate Illinois Masonic醫學中心的Juan Santiago醫師表示,預估到了2025年時,約有三分之一的創傷病患是年長者,因此,瞭解年長創傷病患的風險因素益發重要。
  
  CDC目前的現場創傷分流準則指出,若病患的PHSBP低於90 mmHg時則送往創傷中心,不過,這個2011年版指引的四步驟建議包括一項備註:65歲以上者的PHSBP低於110 mmHg可能會有休克。
  
  為了評估PHSBP是否是受傷年長者的死亡率風險標記,研究者檢視了2010年的全國創傷資料庫的資料,以確認PHSBP在這群病患的範圍與死亡率風險。
  
  他們依據PHSBP將66,762名65歲以上病患分類:低於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)。
  
  整體死亡率風險為5.6% (n= 3724人),不過,死亡率風險隨PHSBP降低而增加。
PHSBP分組(mm Hg)死亡率風險(%)勝算比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,相較於PHSBP大於109 mmHg者,PHSBP小於等於109 mmHg者使用呼吸器的時間顯著增加、住院期間較久、住在加護病房的期間也較久。
  
  同樣來自Advocate Illinois Masonic醫學中心的資深作者Richard Fantus醫師表示,年長者的生理儲備能量不同,年長者的小創傷也可能會導致顯著的發病與死亡。
  
  肯塔基州路易斯維爾大學的J.David Richardson醫師指分流準則的重要性在於「試圖讓適當的病患在適當時間送抵適當院所」,不過,年長病患的問題在於他們不要到其他地方。
  
  資料來源: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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