- 學位論文
高齡嚴重頭部外傷病患出院一年預後之相關因素探討
Factors Related to the One-Year Outcome of Older Adults with Severe Head Injury
摘要
研究目的：本研究主要探討65歲以上嚴重頭部外傷老人，其出院後一年的恢復狀況，及其相關因素。 研究方法：本研究設計採回溯性次級資料分析設計，研究對像為醫師診斷為嚴重頭部外傷，嚴重度分數≧16分、且建議開腦的65歲以上病患。資料來自於2009年1月至2015年9月期間某區域教學醫院病患病歷、醫院電腦資訊病歷匯總系統、疾病分類系統、及外傷個管師統計數據。所收集之資料，以SPSS 18版套裝軟體進行資料整理與統計檢定。 研究結果：研究對象142人，男性88人(62%)，女性54人(38%)，平均年齡76.6歲 (SD=6.6)。頭部受傷主因有車禍73人（51.4%），跌倒69人（48.6%）。頭部外傷情況人數依次為硬膜下血腫 (SDH) 122人、顱內出血(ICH) 82人、蜘蛛膜下出血(SAH) 71人、硬腦膜外血腫(EDH) 11人；單純頭部外傷41人(28.9%)，多重頭部外傷101人(71.1%)；昏迷指數平均5.4分(SD=1.9分)；外傷嚴重度指數平均24.3分(SD=9.2分)。接受開腦手術104人 (73.2%)，拒絕開腦手術38人(26.8%)。出院當中21人(14.8%)有肺炎，18人(12.7%)有泌尿道感染，出院時存活人數 72 (50.7%），死亡人數 70（49.3%）。出院當時狀況分為預後良好和預後差兩組，16人 (11.3%) 預後佳，預後差126人 (88.7%)。有接受手術者預後比拒絕手術預後好 (x2 = 6.6, p =.01)，拒絕開腦者的38人只有2人存活且預後差。此外，兩組的其他人口學變項或腦外傷有關變項均無統計上顯著差異。出院一年後有60人存活，16人(26.7%)預後佳，44人(73.3%)預後差需要依賴別人照顧其生活。一年後狀況預後佳或預後差與住院時是否有肺炎(x2 = 5.8, p =.02) 、泌尿道感染(x2 = 4.1, p <.05)、出院當時狀況(x2 =46.1, p<.001)有統計上的顯著相關。在行動、飲食、語言三種生活能力當中，有 16人(26.7%) 可獨立行動或輔具協助，17人(28.3%) 飲食能力可獨立或一些協助，23人(38.3%) 語言恢復良好。行動能力和飲食能力與住院時是否有肺炎或泌尿道感染(x2 = 2.8, p=.01)、出院當時狀況(x2 =28.6, p<.001)有統計上的顯著相關。語言能力的恢復除了和肺炎(x2 = 2.8, p=.01)、泌尿道感染(x2 = 5.3, p=.03)、出院當時狀況(x2 =26.0, p<.001)、還和頭部外傷嚴重度 (x2 =-2.1, p=.04)有統計上的顯著相關。 結論：老年人發生嚴重頭部外傷常導致嚴重殘障、植物人與死亡。在這個研究，醫師建議開刀且接受開腦者，有較高存活率，且預後有27.6%的機會可恢復獨立生活。住院中感染的併發症也是影響一年後恢復的重要原因，所以醫療照護者應該要嚴格感染控制，減少病人肺炎和泌尿道感染機會。病人出院前也鹰教導病人和居家照顧者預防肺炎和泌尿道感染。
並列摘要
Purpose: This study examines factors related to the outcome of older adults with severe head injury after one year. Methods: A retrospective secondary data analysis was used in the study. Data was collected from the hospital medical information summary system, the disease classification system, trauma statistics, and patient medical records of a regional teaching hospital between January 2009 and September 2015. Patients who were 65 and older, diagnosed with severe head injury (Injury Severity Score > 16), and advised to have brain surgery were included in the study. Results: The mean age of the 142 subjects, 88 men (62%) and 54 women (38%), was 76.6 (SD = 6.6). Head trauma was caused by car accidents for 73 patients (51.4%) and by falls for 69 patients (48.6%). Among the subjects, 122 experienced subdural hematoma (SDH), 82 intracranial hemorrhage (ICH), 71 subarachnoid hemorrhage (SAH), and 11 epidural hemorrhage (EDH). Forty-one patients (28.9%) had simple head injury and 101 patients had multiple head injuries. The mean Glasgow Coma Scale score was 5.4 (SD = 1.9), and the mean Injury Severity Score was 24.3 (SD = 9.2). Thirty patients (26.8%) rejected brain surgery and 104 patients (73.2%) underwent brain surgery. During hospitalization, 21 (14.8%) had pneumonia and 18 (12.7%) had urinary tract infections (UTI). Among 142 patients, 70 (49.3%) died and 72 (50.7%) survived, with 16 patients (11.3%) classified as having good prognosis and 126 (88.7%) as having poor prognosis. After being discharged from the hospital, those who underwent brain surgery had better prognosis than those who refused surgery (x2 = 6.6, p =.01). Among the 38 who refused surgery, only 2 survived and their prognosis were poor. All other demographic and head injury related variables were not significantly different between the poor prognosis group and the good prognosis group. Twelve of the treated patients died within a year after being discharged from the hospital. Among the 60 surviving patients, 44 (73.3%) did not have self-care abilities, and 16 (26.7%) were in good condition. With regard to these abilities, 16 (26.7%) had mobility, 17 (28.3%) ate independently or with minor assistance, and 23 (38.3%) had good verbal ability. The good mobility and eating groups were significantly different from the poor groups in incidence of pneumonia and UTI (x2 = 2.8, p=.01) during their hospitalization, and their condition when discharged from the hospital (x2 =28.6, p<.001). Verbal ability also correlated with pneumonia (x2 = 2.8, p=.01), UTI (x2 = 5.3, p=.03), condition when discharged from the hospital (x2 =26.0, p<.001), and severity of head injury (x2 =-2.1, p=.04). Conclusion: Elderly people with severe head injuries often face disability, a vegetative state, or death. In this study, those who underwent head surgery had higher survival rates, and 27.6% of those who survived were able to live independently after one year. Since pneumonia and UTI correlated with patient prognosis, health care providers should adhere closely to infection control policies and teach patients to prevent pneumonia and UTI at home.