- 學位論文
基礎救命術在心跳停止病患社區層面之研究：可近性、效用性及現場終止急救原則之適用性
Study on Basic Life Support for Cardiac Arrest in Community: Accessibility, Effectiveness, and Applicability of Termination-of-Resuscitation Rules
摘要
社區中猝死病患之急救，是世界各地緊急醫療救護與公共衛生領域共同的重要課題。對於這些到院前心跳停止 (out-of-hospital cardiac arrest) 的病患，如果沒有及時獲得旁觀者提供基礎救命術 (basic life support) 的協助，包括施予心肺復甦術 (cardiopulmonary resuscitation; CPR) 及使用自動體外去顫器 (automated external defibrillator; AED) 急救，將很難有長期存活的機會。然而，在如此重要的課題上，目前應用在我國社區中基礎救命術的建議大部分仍是直接採納來自北美或歐洲國家的報告。長期以來，本土研究付之闕如。 其實我國緊急醫療救護系統的組成與西方國家並不相同，此外文獻回顧亦顯示我國的社區中猝死病患其重要的流行病學特徵與西方國家有相當的差異，例如較低的可去顫心律 (shockable rhythm) 以及有接受旁觀者心肺復甦術的比率。因此，我們針對基礎救命術在我國心跳停止病患社區層面之議題，進行了關於下列三個主題的系列研究： (1) 旁觀者心肺復甦術的可近性，(2) 不同方式的基礎救命術的效益性，與 (3) 現場終止急救原則之適用性。 第一個研究採橫斷式設計 (cross-sectional design) 以檢視社會因素 (social determinants) 和接受旁觀者心肺復甦的機會的相關性。在此所指之社會因素係以該年度平均房價與平均家戶所得作為該社區社會經濟狀況 (socioeconomic status) 的代表。第二個研究是以隨機對照試驗 (randomized control trial) 檢驗兩種不同方式的基礎救命術：「先胸外按壓」與「先心律分析」，在低可電擊心律社區猝死病患急救的效果。第三個研究採世代研究設計 (cohort study) 以檢視源自於北美、組合多項現場基礎救命術相關變項的「終止急救」(termination-of-resuscitation; TOR) 原則，在我國社區中是否仍能準確預測社區猝死病患的存活、以及增加緊急醫療救護系統的效率。 研究結果有三項重要發現。第一，居住在本研究所定義之台北市較低社會經濟社區之民眾，發生院外猝死時較少接受旁觀者心肺復甦術，而且存活預後較差。提高當地民眾對猝死病患的辨識度及接受簡單急救訓練的比率可能有助提昇旁觀者心肺復甦術。提高線上派遣員對報案電話中猝死病患的辨識度也是一重要可行的方法。第二，針對社區猝死病患，現場急救人員先進行十循環CPR或先進行AED分析，其穩定心跳恢復率與長期存活率並無差異，但在穩定心跳恢復的病患中存活出院的比例以先接受十循環CPR方式者較高。考量我國社區猝死病患急救相關流行病學，先進行十循環CPR應為可行之道。第三，歐美發展並驗證成為目前急救指引所稱的「通用TOR原則」在台北市資料庫驗證時雖能有效減少不必要的醫院後送，但並無法達到與國外一樣的高準確性，無論在各種病患與施救者的組合下，都會有大於百分之一的機會將可長期存活的病患誤判成無法存活者。 本系列研究的結果，將目前關於基本救命術在社區層面之醫學實證與我國目前現況接軌，能作為日後公共衛生及緊急醫療相關領域政策制定時的重要參考。
並列摘要
Out-of-hospital cardiac arrest (OHCA) is a public health problem of paramount importance all over the world. Many lives and life-years were lost because prompt basic life support (BLS), including bystander cardiopulmonary resuscitation (CPR) and defibrillation, is not provided in the community. Besides, currently most of the recommendation in BLS applied in our community was adopted from the western countries. Characteristics of OHCAs and composition of emergency medical service (EMS) in Taipei were different from the western sites. Therefore, we conducted a series of studies in three important issues with the knowledge gaps, including (1) the accessibility of bystander-initiated CPR, (2) effectiveness of different BLS pattern, and (3) the screening of salvageable patients for hospital transport. There were three studies included in the series. The first study is a cross-sectional design to assess the association between social determinant and chances of receiving bystander-initiated CPR for patients with cardiac arrest in community. We used the average of real estate price and hosehold income to surrogate the socioeconomic status (SES) of the community. The second study was a randomized control trial to determine the effectiveness of different patterns of BLS (compression first” (CF) versus “analyze first” (AF) strategies) in community of low prevalence of shockable rhythms. The third study was a cohort study to evaluate the applicability of rules for termination of resuscitation (TOR) and to determine whether BLS-TOR rules acceptable as the universal rule in a mixed-tire EMS as in Taipei. The first study revealed that patients who experienced an OHCA in low-SES areas of the city were less likely to receive bystander CPR, and demonstrated worse survival outcomes. The information could guide targeted community training to promote bystander CPR. In the second study, in Taipei City, a population with low rates of shockable rhythms and bystander CPR, there were no differences in sustained return of spontaneous circulation (ROSC) between compressions first vs. analyze first strategy. Considering the EMS operation situation, a period of CPR for up to 10 cycles by paramedic prior to rhythm analysis could be a feasible strategy in this Asian community. In the third study, ALS- and BLS-TOR rules performed well in decreasing unnecessary transport of OHCA patients, and BLS-TOR rule has better performance comparing to ALS TOR rule under all provider combinations in an area with a mixed-tier response EMS system. However, because greater than 1% of those lived would be misclassified as non-survivor by current TOR rules, implementation in this community or other areas with similar characteristics should be cautious. This series of studies provided informative knowledge to current scientific gaps, and would have implication for improving the basic life support for patients with cardiac arrest in our own community.
參考文獻
延伸閱讀
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