心脏穿透伤各临床时期患者的生存分析

Survival Analysis of Victims with Different Stages of with Penetrating Cardiac Trauma

目的分析心脏穿透伤(PCT)各临床时期患者的伤情及治疗措施对预后的影响,以改进救治措施和提高成功率。方法回顾性分析遂宁市中心医院和华西医院等21家医院133例心脏穿透伤患者的临床资料,其中男124例,女9例;年龄27.4±9.9岁。按患者到达急诊室时的伤情分为亚临床期组(35例)、临床期组(79例)和濒死期组(19例)。将影响伤情演变及预后的有关因素20项作为影响患者死亡的危险因素。采用Kaplan-Meier法比较3组患者伤后72h生存率,用log-rank法比较3组患者的生存过程,筛选影响患者预后的伤情特征和医疗干预措施。结果 3组患者伤后72h生存率差异有统计学意义(P<0.05),亚临床期组患者生存率最高(88.60%)。log-rank检验结果显示,各组PCT患者生存过程的差异有统计学意义(χ2=24.570,P=0.000)。影响预后的伤情特征包括年龄大(χ2=65.578,P=0.003)、器官损伤定级(OIS)高(χ2=10.718,P=0.005)、急诊室修订创伤评分(RTS)(χ2=88.637,P=0.000)和手术室麻醉时RTS低(χ2=90.889,P=0.000)等8个因素;影响预后的医疗干预措施包括心包腔探查(χ2=7.976,P=0.005)、手术室开胸(χ2=15.832,P=0.000)等4个因素。而性别、心包穿刺等因素对患者预后的影响差异无统计学意义(P>0.05)。结论急诊室内处于不同临床时期的PCT患者伤后生存过程不同,应分类救治不同的伤情类型和损伤程度患者,根据PCT患者在急诊室内所处的不同病程分期,选择相应的急救手术方式。

Objectives To investigate predictors of physiologic disturbance and anatomical lesions resulting from penetrating cardiac trauma （PCT）, which can influence prognosis, and to formulate a special principle for early treatment of PCT so as to improve the prognosis of sufferers. Methods We analyzed clinical records of 133 patients with PCT in 21 hospitals, including Suining Central Hospital and West China Hospital. There were 124 males and 9 females, with an average age of 27. 4 ＋ 9. 9 years. The patients were divided into three groups, including a subclinic group （n=35）, a clinic group （n=79）, and an agonal phase group （n=19）. Survival analysis was applied to 20 selected predictors, which included patient features and medical intervention measures. Survival and 72-hour survival rates of the three groups were analyzed and compared by the Kaplan-Meier and log rank tests. Results The Kaplan Meier test indicated there was a statistically significant difference in 72-hour survival rates among the three groups （P〈0.05）. The 72-hour survival rate in the subelinic group was the highest, at 88. 60/00. There was a significant difference in survival among the three groups by log rank test （x2 -24. 570, P = 0. 000）. Statistical differences were also found among the three groups in eight physiologic disturbance predictive factors such as eld age（x2 =65. 578, P= 0. 003）, organ injury scaling （OIS, X2= 10. 718, P=0. 005）, revised trauma score （RTS） in emergency room （RTS, x2 =88. 637,P=0.000）, RTS in operation room （x2 =90. 889,P=0. 000）et al, and in four predictive risk factors such as pericardial checking via subxiphoid window or wound extension（x2= 7. 976, P = 0. 005）, and operating room thoracotomy （X2= 15. 832, P=O. 000）. There was no statistical difference in predictive factors such as gender and pericardial centesis （P〈0.05）. Conclusions The survival rates of PCT patients vary among clinical stages. PCT patients should be treated differently according to the type and severity of their injuries. Surgical treatment of PCT patients in emergency rooms should be adapted to the posttraumatic phase of PCT.