影響急診室內心跳停止病人之預後因子

Factors Associated With the Outcome of In-Hospital Cardiac Arrest in Emergency Department

王安怡(An-Yi Wang)

指導教授 ： 蔡行瀚

臺北醫學大學/公共衛生暨營養學院/傷害防治學研究所/碩士(2015年)

摘要

背景
在急診室內發生院內心跳停止事件對健康會造成極重大的不良結果，然而相關文獻針對發生在急診室內之預後研究較少，因此本研究希望探討影響急診室內心跳停止病人之相關預後因子。
目的
探討在傳統預後因子中，加入查爾森共病指標及改良式早期預警評分於心跳停止病人之預後模型中是否能提供最為預後參考。
方法
本研究為回溯世代研究，研究期間於2011年02月至2013年07月於北部醫學中心急診內執行，收集非創傷來源之病人在急診期間發生院內心跳停止事件，收錄病人基本資料、查爾森共病指標、改良式早期預警評分、心跳停止事件變項依Utstein style模式收集。
結果
在30個月研究期間中，每月平均來診人次為9073.1次，共70.5%為非創傷性；總共234位病人平均年齡67.0±15.1歲在急診期間發生院內心跳停止事件，141(60.3%)位病人為男性；169(72.2%)恢復自發性循環、52(22.2%)存活出院；心跳停止之所記錄到之心臟節律最多為無脈搏性電氣活動(128/234, 54.7%)、其次為無收縮心搏停止(74/234, 31.6%)、可電擊心律(心室顫動、無脈搏性心室頻脈)最少(32/234, 13.7%)，心因性原因佔32.9%。
在多變數分析中，院內心跳停止發生在重症區有較高機率恢復自發性循環(勝算比2.46;95%信賴區間[1.34-4.51], p<0.05)；查爾森共病指標分數越低及在心跳停止前30分鐘所偵測之改良式早期預警評分越低為預測存活出院之重要之獨立因子；比較檢傷時與在心跳停止前30分鐘所偵測之改良式早期預警評分在死亡組中增加的趨勢較高。
結論
適當監測重症病人之生命徵象不只可以預防院內心跳停止事件，進而能夠改善其預後，改良式早期預警評分改變可以幫助臨床醫護人員在心跳停止發生前辨認病人惡化之趨勢，並且也能夠用以預測心跳停止之預後，當病人分數增加應盡早給予適當治療，對於年長、多重共病者可與其討論關於緩和式醫療，避免無效醫療加重病人痛苦。

關鍵字

院內心跳停止、查爾森共病指標、改良式早期預警評分

並列摘要

Background:
In emergency department (ED), in-hospital cardiac arrest (IHCA) is the most catastrophic adverse outcome. However, detailed information about IHCA in ED is little. The aim of the study is to evaluate factors associated with the outcome of adult IHCA in a crowded ED.
Objective:
To evaluate whether the traditional risk factors with adding on Charlson Comorbidity Index and Modified Early Warning Score (MEWS) can be used to predict the outcome of IHCA
Methods:
This was a retrospective cohort study during February 2011 to July 2013 at an urban, 2000-bed tertiary medical center in Taiwan. Non-traumatic adult patients who experienced in-hospital cardiac arrest during ED stays were registered. Data regarding patients’ characteristics, Charlson Comorbidity Score, MEWS score before events, mode of arrest and outcome details were extracted followed Utstein style.
Results:
During the 30-month period, there were 9073.1 patient-visits per month with 70.5% non-traumatic cause. 234 patients aged 67.0±15.1 years suffered IHCA during ED stays, and 141(60.3%) were male. 169(72.2%) achieved return of spontaneous circulation (ROSC) and 52(22.2%) survived to discharge. Pulseless electric activity (PEA) was the most common primary rhythm (128/234, 54.7%), asystole was second (74/234, 31.6%), and pulseless VT/Vf was the least 32/234(13.7%). Cardiac etiology accounts for 32.9%.
In multivariate analysis, IHCA events occurred at critical care unit had higher chance to achieve ROSC (odds ratio, 2.46; 95% confidence interval [1.34-4.51], p<0.05). Lower Charlson Comorbidity Score and lower MEWS score 0.5 hours before IHCA are two independent variables to predict survival to discharge. MEWS score change between initial records at triage and 0.5 hours before IHCA increased more in mortality group.
Conclusions:
Well-monitored of critical ill patients is important not only in prevention; moreover, it can also improve IHCA outcome. MEWS score change helps to identify patient in deterioration before IHCA event, and also could be used to predict the outcome of IHCA. Prompt treatment should be initiated earlier, and we also need to discuss with families about palliative care especially in elderly, multiple comorbidities.

並列關鍵字

In-hospital Cardiac Arrest, Charlson Comorbidity Index, Modified Early Warning Score, Emergency Department

參考文獻

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