- 學位論文
小兒外傷住院患者其嚴重度及受傷型態與成人之差異，及小兒嚴重外傷之早期預測因子 —高雄醫學大學附設醫院八年經驗的回溯性橫斷式分析
Epidemiologic Differences between Pediatric and Adult Trauma Patients, and Early Predictive Factors of Severe Trauma in Children: An 8-year Retrospective Cross-Sectional Study in Kaohsiung Medical University Hospital
摘要
前言：在台灣，有關小兒外傷患者的流行病學，治療方式和死亡率的信息有限。創傷的所造成的負擔可從生理負荷到經濟負荷，而現今出生率下降的時代，這可能是嚴重的負面影響。因此，了解小兒創傷的流行病學，治療方式和死亡率非常重要。所以，我們進行了一項大規模的觀察性研究，以深入了解高雄地區，小兒外傷人、時、地的流行病學，治療模式和死亡率趨勢；並探討小兒嚴重外傷之早期預測因子。 材料方法：在研究期間，我們使用高雄醫學大學附設醫院外傷登錄資料庫（KMUH Trauma Registry Data Bank）在2011年至2018年之間的數據。該資料庫收集了與患者有關的信息，例如患者人口資料，到院前的醫療狀況，生命體徵，各式外傷量表，和住院後死亡率。所有年齡小於18歲的小兒創傷住院患者均納入，選擇同時間18-64歲的成人做為對照組。將患者分為四個年齡組：0-5歲，6-12歲，13-17歲，和18-64歲。對於結果，則是使用Wilcoxon檢定，卡方檢定，費雪精確檢定，羅吉斯迴歸，受試者操作特徵曲線。在所有統計分析中，統計顯著性定義為雙向p值<0.0017。 結果：在性別分佈上，均以男性居多(比例為57~72 %)。在學齡兒童及青少年，男性受傷的風險則是有顯著較成人高(AOR各為1.37及1.73)。在受傷機轉中，學齡前及學齡兒童最常見的為墜落(各為49.26%及49.30%)；青少年則和成人相似，是車禍(各為65.30%及60.37%)。格拉斯哥昏迷指數小於8分的風險，學齡前及學齡兒童，則顯著低於心成人(AOR=0.48 and 0.25)。在受傷部位，各年齡層兒童和成人相比，大多數有顯著差異。外傷嚴重度分數、新式外傷嚴重度分數、改良式外傷指數的分組，學齡前及學齡兒童其嚴重程度均比成人顯著的低，而青少年和成人則沒有顯著差異。絕大部份的外傷都是非蓄意的(90~99%)。學齡前兒童最常發生傷害的地點為家中(51.58%)；學齡兒童，青少年及成人則是街道(各為33.94%、68.22%、63.48%)。住院後的死亡率，學齡前兒童及學齡兒童均比成人顯著性的低(AOR各為0.22及0.23)；青少年和成人比，則沒有差異。對於小兒嚴重外傷(ISS ≥20)的預測因子，在校正年齡分組，性別，及部份顯著的單變項因子後，有顯著意義的有格拉斯哥昏迷指數分組，頭頸部外傷，顏面外傷，胸部外傷，和腹部骨盆外傷。 結論：在高雄，兒童的外傷有特定的年齡和特定的機轉。這對於為在高雄的兒童制定重點傷害預防方案具有重要意義。雖然小兒的受傷嚴重程度較成人低，但針對不同年齡的小兒族群，我們必需採取特殊的衛生政策及治療計劃。早期發現外傷相關危險因子，可以給予這些病人更積極的治療。
並列摘要
Background: In Taiwan, there is limited information on the epidemiology, treatment, and mortality of pediatric trauma patients. The burden of trauma ranges from physical to economic issues. In the current era of decreasing birth rates, this may be a serious negative effect. Therefore, it is important to understand the epidemiology, treatment, and mortality of trauma in children. Therefore, we conducted an observational study to gain an insight into the epidemiology, treatment, and mortality trends and analyze the risk factors of pediatric trauma in Kaohsiung. Material and Methods: We used data from the Kaohsiung Medical University Hospital Trauma Registry Data Bank from 2011 to 2018. The database contains information we needed. All trauma patients younger than 18 years of age were included, and adults aged 18-64 years were selected as the control group at the same time. The patients were divided into four age groups: 0-5 year-old, 6-12 year-old, 13-17 year-old, and 18-64 year-old. For the results, Wilcoxon test, Chi-square test, Fisher's exact test, multiple logistic regression, and receiver operating characteristic curve were used. In all statistical analyses, statistical significance was defined as a two-way p-value <0.0017. Results: There are men in majority in all age groups (proportions are 57~72 %). The most common mechanism in preschool and school-age children is fall (49.26% and 49.30%) while the traffic accident is the most in adolescents and adults (65.30% and 60.37%). In GCS ≤8, children younger than 12 years old are significantly lower than adults (AOR=0.48 and 0.25). Children have significant differences compared with adults in the injured anatomic regions. In the groups of ISS, NISS, and RTS, the severity in preschool and school-age children are significantly lower than in adults while there was no significant difference between adolescents and adults in these three groups (ISS, NISS, RTS). The vast majority of trauma is unintentional (90~99%). The most common place for preschool children to be injured is at home (51.58%) while school-age children, adolescents and adults are on the streets (33.94%, 68.22%, 63.48%). Mortality rates after admission were significantly lower in preschool and school-age children than adults (AOR=0.22 and 0.23), but there was no difference between adolescents and adults. For the predictors of severe trauma (ISS ≥20) in children, there are significant in GCS groups, injured anatomic areas, including head and neck, face, thorax, and abdomen/pelvis after adjustment with age groups, sex, and other significant univariates. Conclusion: In Kaohsiung, there are specific mechanisms in different age groups in pediatric trauma. It is important to us to make prevention program for children. Early detection of trauma-related risk factors can give these patients more aggressive treatment.
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