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【論文摘要】創傷心臟驟停病患LOAD AND GO，GO WHERE？以台灣南部城市為例
【論文摘要】Traumatic Cardiac Arrest Patients: LOAD AND GO, GO WHERE? A Case Study in a Southern Taiwanese City
摘要
研究背景：創傷心臟驟停（Traumatic Cardiac Arrest，TCA）傷患存活率普遍偏低，TCA傷患救治秉持「LOAD AND GO」為目標，卻尚無依據可判斷「GO WHERE ?」。當某個案啟動後送時應抉擇路程3分鐘之一般急救責任醫院或6分鐘之醫學中心，各自有理有據的論點孵育了本次研究契機。本研究以TCA傷患後送時間及急救責任醫院收治等級是否影響存活率，使救護技術員（EMT）面對TCA傷患後送之「就近適當」取捨有據，期以提升TCA傷患存活率。研究方法（或案例描述）：本研究以我國南部某城市EMS資料庫以2010～2016年TCA傷患為對象，以到院前TCA之傷患皆納入範圍，並以到院後恢復自主循環（ROSC）出院作為主要結果。針對後送時間及急救醫院等級（重度、中度及一般）與病患存活率之關聯進行分析。除提供EMT後送TCA傷患之時間敏感度，並分析EMT後送時是否應考量醫院有無具備重大外傷處置能力，或是應予TCA傷患接受初步ALS處置視為目標優先?提供後送選擇得以此為據。研究結果（或案例討論）：研究期間自2010～2016年共計7年資料蒐集1,697例TCA傷患納入本研究。其中，TCA傷患男性佔總數72.6%共計1,232人，而女性則佔27.4%共計465人。TCA傷患全體僅有125人（佔總數7.4%）存活出院，另1,572人（佔總數的92.6%）死亡（圖1）。結果顯示，當後送時間小於15分鐘存活出院為119人（佔存活出院總數的95.2%）；而當時間大於15分鐘存活出院的機率僅為6人（佔存活出院總數的4.8%），兩者之間的差異達到統計學上顯著差異（p<0.05）。此外，我們將急救醫院等級分為重度醫院、中院及一般醫院共3個等級，結果顯示，在重度醫院之ROSC傷患為17人（佔存活總數的13.6%）；中度醫院之ROSC傷患為49人（佔存活總數的39.2%）；一般醫院之ROSC傷患為59人（佔存活總數的47.2%）為佔比最高，已達統計上顯著差異（p<0.05）。但當控制性別及年齡後，15分鐘內送往一般醫院的死亡風險相對於重度醫院是4.592倍（p<0.001），相對於中度醫院是2.235倍（p=0.009），皆達統計上顯著差異。研究結論：經統計，僅針對後送時間仍以「LOAD AND GO」盡速後送預估將有較高存活率。雖結果顯示送往急救醫院等級相對最低之一般醫院卻有較高存活率，但細究其59人中存活出院2人、轉院57人，可推斷病患ROSC後即轉送較高等級醫院繼續救治，難以呈現最終預後存活，亦是本研究資料呈現之限制。當控制性別後所呈現之結果，若案發地點後送時間小於15分鐘且有多家不同收治等級醫院可供選擇之時，倘抉擇醫院收治等級較佳者後送TCA傷患，將大幅抑制其死亡風險，預估會有較高存活的可能。現已運行之電子平板救護派遣系統僅有提示醫院滿載資訊，如增加「後送距離、行車時間預警」將可供EMT參考提升抉擇精準度。另已於我國各地進行小規模實驗之「消防救援車輛優先號誌」裝置，期待未來完整建置後，能夠有效擴展和延伸轉送時間的距離範圍。
並列摘要
Background: The survival rate of Traumatic Cardiac Arrest (TCA) patients is generally low. While approaching care of TCA patient follows the "Load and Go" principle, there is a lack of guidance regarding the specific destination ("Go Where?") for these patients. When initiating the Transport of a TCA patient, the decision must be made between a nearby(3-minutes away)general emergency hospital or a 6-minutes away medical center . Each option has its own theoretical support, thus initiates this study. This research approaches to discuss the impact of TCA patient Transport time and the level of emergency medical facilities on survival rates, facilitating Emergency Medical Technicians (EMTs) to make "nearby and appropriate" decisions about Transportring TCA patients, with the goal of improving their survival rates. This study is based on the EMS database of a southern city in our country, focusing on TCA cases from 2010 to 2016. Patients experiencing TCA before arriving at the hospital were included, and Return of Spontaneous Circulation (ROSC) upon hospital admission was considered the primary outcome. The analysis focused on the relationship between Transport time, emergency hospital level (severe, moderate, and general) and patient survival rates. In addition to provide EMTs with sensitivity to TCA patient Transport time, an analysis was conducted to determine whether EMTs should consider the hospital's capability to manage major trauma during Transport or prioritize initial Advanced Life Support (ALS) interventions for TCA patients. This analysis offers a basis for making informed Transport decisions. Methods (Or case presentation): The study spanned from 2010 to 2016, a total of 1,697 cases of TCA patients were included. Among them, male TCA patients accounted for 72.6% (1,232 individuals), while female patients constituted 27.4% (465 individuals). Out of the total, only 125 TCA patients (7.4%) survived and were discharged, whereas 1,572 individuals (92.6%) deceased (Figure 1). The results showed that when the Transport time was less than 15 minutes, 119 patients (95.2% of the total survivors) survived and were discharged. However, when the Transport time exceeded 15 minutes, the possibility of survival and being discharged decreased significantly to only 6 patients (4.8% of the total survivors), with a statistically significant difference (p<0.05) . Furthermore, the emergency hospitals were categorized into three levels: severe, moderate, and general. The results showed that ROSC patients Transportred to severe level hospitals accounted for 17 individuals (13.6% of the total survivors), in moderate level hospitals for 49 individuals (39.2% of the total survivors), and in general level hospitals for 59 individuals (47.2% of the total survivors), marking the highest proportion and achieving statistical significance (p<0.05) . However, when controlling for gender and age, the risk of death within 15 minutes of Transport to a general level hospital was 4.529 times higher compared to severe level hospitals (p<0.001), and 2.235 times higher compared to moderate level hospitals (p=0.009), both statistically significant . Results (Or Case Discussion): Statistical analysis indicated that focusing solely on Transport time still upholds the principle of "Load and Go," and is associated with higher survival rates. Although the results showed that Transportring to the relatively lower-level general hospital was associated with higher survival rates. Among the 59 survivors, only 2 individuals were discharged, while the remaining 57 were Transportred to higher-level hospitals for further treatments. This suggests that patients are likely to be Transportred to higher-level hospitals after achieving ROSC, making it difficult to demonstrate the final survival outcome. This limitation is also reflected in the study's data presentation. The result after controlling of gender and age, if the Transport time from the incident location is less than 15 minutes and multiple hospitals of varying levels are available, choosing a hospital with a high level care will significantly reduce the risk of death and is expected to increase the possibility of survival. The operating electronic tablet dispatch system nowadays only provides information of hospital capacity. If features such as "Transport distance" and "trip time warnings" are added, the accuracy of EMTs' decision-making can be enhanced. Furthermore, small-scale experiments involving "fire and rescue vehicle priority signal" devices have been conducted nationwide, and it is hoped that after complete implementation, the time of Transportring can be reduced, and the distance can be expanded.