Analysis of effects and strategy of long-distance transportation before hospital in 256 patients with craniocerebral hemorrhage
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摘要: 目的 分析研究颅脑出血患者院前长距离转运的效果和危险因素，有针对性的加强救治措施，以求为急救人员转运此类患者提供指导，提高转运成功率。方法 回顾调查2016年1月—2020年12月期间256例颅脑出血患者由郊区医院长距离转运到市区三甲医院的流行病学特点和转运效果，将转运到目标医院时患者生命体征较转院前无明显改变的定为病情稳定组(n=175)，转运到目标医院前患者生命体征恶化或出现严重并发症的定为病情恶化组(n=81)。单因素分析筛查出危险因素，通过多因素logistic回归分析法评价危险因素与病情变化的相关性。结果 长距离转院的颅脑出血患者途中总体病情恶化率为31.6%(81/256)，这其中59.3%为创伤性颅脑出血。恶化风险较高的患者为内囊/基底核区出血(25.9%)，脑挫裂伤(24.7%)，脑干出血(19.8%)和蛛网膜下腔出血(17.3%)。出血原因、出血部位、格拉斯哥昏迷量表(GCS)评分≤8分、出血量≥30 mL、发病到转院时间 < 2 h、转院前指氧饱和度 < 90%、目标医院距离远、转院前高血压是转院途中病情恶化的危险因素(P< 0.05)，转院前导尿和应用止血药物是病情稳定的保护因素(P< 0.05)。结论 出血原因(创伤性)、出血部位(内囊/基底核区、脑挫裂伤、脑干和蛛网膜下腔)、GCS评分≤8分、出血量≥30 mL、发病到转院时间 < 2 h、转院前指氧饱和度 < 90%、目标医院距离远、转院前高血压会增加长距离转运恶化风险，不可盲目转院。脑干出血患者长距离转院获益极低，不建议急性期转院。长距离转院前应给予导尿和应用止血药物。转院途中如果出现病情恶化指标应给予急救处理或就近就能力重新选择目标医院，如在转院前既已存在恶化指标应暂缓转院，以免增加转运途中的死亡风险。Abstract: Objective To analyze and study the effects and risk factors of long distance transport in patients with craniocerebral hemorrhage, and to strengthen the treatment measures in order to provide guidance for emergency personnel to transport such patients and improve the success rate of transport.Methods We investigated the epidemiological characteristics and effects of 256 cases of craniocerebral hemorrhage from January 2016 to December 2020 who were transported from suburban hospitals to a grade Ⅲ level A hospital in urban areas. The patients with vital signs were classified as stable group(n=175) and the patients with deterioration of vital signs or serious complications were classified as deterioration group(n=81). Risk factors from univariate analysis were screened, and the association of risk factors and disease changes was assessed by multivariate logistic regression analysis.Results The overall deterioration rate of patients was 31.6%(81/256), of which 59.3% due to traumatic craniocerebral. The high risks of deterioration were internal capsule/basal node hemorrhage(accounted for 25.9%), cerebral contusion(accounted for 24.7%), cerebral stem hemorrhage(accounted for 19.8%) and subarachnoid hemorrhage(accounted for 17.3%). Causes of bleeding, blood sites, Glasgow Coma Scale(GCS) score ≤ 8, amounts of bleeding ≥ 30 mL, time interval from onset to arriving in hospital < 2 h, hospital oxygen saturation < 90%, long target hospital distance, prehospital hypertension were risk factors for deterioration(P< 0.05), while prehospital catheterization and application of hemostatic drugs were protective factors for stability(P< 0.05).Conclusion Causes of bleeding, the bleeding sites(inner capsule/basal segment region, brain contusion, brainstem, and subarachnoid cavity), GCS score ≤ 8, amount of bleeding ≥ 30 mL, time interval from onset to arriving in hospital < 2 h, finger oxygen saturation < 90% before transfer, long target hospital distance, hypertension increases the risk of long-distance transfer deterioration. In these circumstances, patients cannot be blindly transferred. Long-distance transfer to hospital in patients with brainstem bleedingseldom brings benefits, and acute phase transfer is not recommended. Urinary catheterization and hemostatic drugs should be given before long-distance transfer. If the deterioration index of the condition occured on the way to the hospital, first aid should be treated or the target hospital should be re-selected nearby. If there were already existing deterioration indexes before hospitalizing, the transfer should be postponed, so as not to increase the risk of death on the way.
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Key words:
- cerebral hemorrhage /
- risk factors /
- transfer /
- pre-hospital care
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表 1 颅脑出血转院患者流行病学分析及转运危险因素的单因素分析
例(%) 因素 稳定组(n=175) 恶化组(n=81) t/χ2 P 性别 0.34 0.564 男 123(70.3) 54(66.7) 女 52(29.7) 27(33.3) 年龄/岁 0.303 0.647 ＜60 131(74.9) 58(71.6) ≥60 44(25.1) 23(28.4) 出血原因 18.031a) < 0.001 创伤性 55(34.3) 48(59.3) 自发性 118(64.6) 32(39.5) 血液病/服用华法林 2(1.1) 1(1.2) 出血部位 27.643a) < 0.001 蛛网膜下腔 78(30.5) 14(17.3) 硬膜下 10(3.9) 3(3.7) 硬膜外 11(4.3) 5(6.2) 脑挫裂伤 23(9.0) 20(24.7) 内囊/基底核区 102(39.8) 21(25.9) 脑室 4(1.6) 1(1.2) 小脑 7(2.7) 1(1.2) 脑干 21(8.2) 16(19.8) 格拉斯哥昏迷量表(GCS)/分 12.835 < 0.001 ≤8 106(41.4) 52(64.2) ＞8 150(58.6) 29(35.8) 出血量/mL 6.358 0.012 ≥30 171(66.8) 66(81.5) ＜30 85(33.2) 15(18.5) 首诊来院方式 2.499 0.134 自来医院 77(30.1) 32(39.5) 救护车来院 179(69.9) 49(60.5) 发病到转院时间/h 13.296 < 0.001 ＜2 93(36.6) 48(59.3) ≥2 163(63.7) 33(40.7) 转院前指氧饱和度/% 10.435 0.001 ＜90 55(21.5) 32(60.5) ≥90 201(78.5) 49(39.5) 目标医院距离/km 50±8.6 68±9.1 6.028 0.014 转院前血压/mmHgb) 10.257 0.001 收缩压 133.3±7.2 196.2±12.4 舒张压 85.5±6.7 107.4±5.5 转院前气管插管 1.634 0.223 是 20(7.8) 3(3.7) 否 236(92.2) 78(96.3) 转院前导尿 6.963 0.01 是 125(48.8) 26(32.1) 否 131(51.2) 55(67.9) 应用止血药物 6.077 0.018 是 171(66.8) 31(38.3) 否 85(33.2) 50(61.7) 注：a)为Fisher确切概率; b)1 mmHg=0.133 kPa。 
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表 2 颅脑出血转院患者途中病情恶化危险因素的多因素logistic回归分析
因素 B SE Wald χ2 P OR 95%置信区间 下限 上限 出血原因 0.503 0.163 9.656 0.002 1.653 1.205 2.805 出血部位 0.910 0.351 6.721 0.010 2.496 1.248 4.977 GCS评分≤8分 1.164 0.462 6.339 0.012 3.204 1.294 7.931 出血量≥30 mL 1.406 0.584 5.795 0.016 4.073 1.025 6.403 发病到转院时间 < 2 h 0.875 0.309 6.623 0.010 1.336 1.064 4.351 指氧饱和度 < 90% 0.893 0.308 8.374 0.004 2.441 1.334 6.463 目标医院距离 0.039 0.014 7.774 0.005 1.040 1.013 1.069 转院前高血压 1.011 0.426 5.632 0.018 2.749 1.192 6.336 转院前导尿 -0.132 0.454 8.631 0.003 0.263 0.108 0.641 应用止血药物 -1.604 0.512 10.112 0.001 0.196 0.072 0.533
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