急诊内科昏迷患者的临床分析

Patients with impaired consciousness in the Department of Emergency:a clinical study

目的分析急诊内科不明原因昏迷患者的三间分布、病因构成及对预后的影响。方法选择2016年9月至2018年8月进入惠州市第一人民医院急诊内科以"急性昏迷"为主诉,且无明确诊断及可以解释昏迷原因的424例患者为研究对象,进行回顾性病例分析研究。纳入患者男性:女性为1∶1.16,统计分析患者的三间分布、确诊手段、最终确诊病因及预后情况。结果不明原因的昏迷主要发生于中老年、乡村人群,且高发于春冬季。88%的患者最终在住院期间确诊,主要是通过脑部影像学检查[23.1%(98/424)]、结合体格检查的检验结果[25.0%(106/424)]来完成确诊。最常见急诊不明原因昏迷的病因是:脑血管疾病[24.1%(102/424)]、感染[14.2%(60/424)]、中毒[9.0%(38/424)]、癫痫发作[8%(34/424)]、代谢性疾病[7.1%(30/424)]、精神性疾病[6.1%(26/424)]等。92.0%(390/424)的急诊不明原因昏迷患者在入院时的急诊严重指数(ESI)分级为1~3级,格拉斯评分(GCS)以轻度昏迷为主:13~14分[29.7%(126/424)]、15分[32.6%(138/424)]。患者死于诊室的病死率为1.4%(6/424)。出院后仍需继续治疗如康复训练占35.4%(150/424),在养老院继续治疗占11.1%(47/424)。结论急性昏迷的病因诊断谱广且患者死亡风险高,脑血管疾病是其最常见的病因。ESI分级和GCS评分可帮助识别大多数死亡高位风险的患者。为明确诊断,神经系统检查如脑部影像学检查、体格检查和实验室检验等必不可少。跨学科协作对于提高急诊昏迷患者的病因诊断效率和准确率是有益的。

Objective To analyze the causes of acute impaired consciousness in patients in an internal emergency department(ED).Methods We analyzed all patients who were admitted to the ED of a tertiary hospital with the dominating symptom of"sudden onset unconsciousness"within 2 years(September 2016 until August2017).Patients with a clear diagnosis at arrival that explained the altered state of consciousness or other dominating symptoms at the time of arrival were not included.Results A total of 424 patients were analyzed.In 88%of the patients,a final diagnosis could be established in the ED.Most common causes for unconsciousness were cerebrovascular diseases(24.1%),infections(14.2%),epileptic seizures(12%),psychiatric diseases(6.1%),metabolic causes(7.1%),intoxications(9%),transient global amnesia(5.2%)and cardiovascular causes(4.2%).The diagnoses were predominantly established by physical examination in combination with computed tomography(23.1%)and by the results of laboratory testing(25%).In-hospital mortality was 11%,and 59%of all patients were discharged with a Glasgow Outcome Score of 2-4.Conclusions This analysis demonstrates a large variety of etiologies in patients with unknown unconsciousness of acute onset who are admitted to an ED.As neurological diagnoses are among the most common etiologies,neurological qualification is required in the ED,and availability of diagnostics such as cerebral imaging is indispensable and recommended as an early step in a standardized clinical approach.