两种评分法在评估急诊抢救室患者预后的效果对比探讨

目的分析两种评分法在评估急诊抢救室患者预后的效果对比。方法选取2013年1月至2014年6月我院急诊抢救室收治的急危重症患者376例,均进行SIRS评分及MEWS评分评估,并统计24小时患者死亡例数。结果 188例患者共死亡32例,死亡患者及存活患者在性别比和年龄等方面均无统计学意义(P0.05)。存活患者SIRS评分及MEWS评分分别为(2.74±1.22)分及(1.88±1.01)分;死亡患者SIRS评分及MEWS评分分别为(3.82±1.44)分及(4.89±1.34)分。死亡患者SIRS评分和MEWS评分均高于存活患者,且差异具有统计学意义(P0.05)。MEWS评分敏感度显著性高于SIRS评分(P0.05)。结论在评估急诊抢救室患者预后方面SIRS评分及MEWS评分均为有效方法,但MEWS评分效果优于SIRS评分。     

氨溴索注射液对急性肺损伤患者保护作用的研究

目的 探讨氨溴索对急性肺损伤患者预后的影响,对进一步发展至急性呼吸窘迫综合征（ARDS）的作用.方法 选择77例病情程度基本相同的急性肺损伤患者作为研究对象,随机分为氨溴索治疗组38例,常规治疗组39例.比较治疗7天后两组患者动脉血气的差异;比较两组患者的预后,包括ARDS发生率、病死率、存活患者的住院时间、SIRS评分及肺损伤评分.结果 治疗7天后两组患者动脉血气分析指标均有明显改善（P〈0.01）,氨溴索治疗组比常规治疗组改善更明显（P〈0.01）;氨溴索治疗组患者ARDS发生率（28.95%）低于常规治疗组（53.85%）（P〈0.05）,氨溴索治疗组存活患者的SIRS评分（1.71±1.61）低于常规治疗组（2.73±1.41）（P〈0.05）;肺损伤评分（0.24±0.16）明显低于常规治疗组（0.79±0.21）,住院时间（14.01±7.16）天,明显短于常规治疗组（19.14±6.25）天（均P〈0.01）.结论氨溴索对急性肺损伤有保护作用,可降低急性肺损伤患者ARDS的发生率,缩短患者住院时间,改善预后.     

简化小儿危重病例评分法在手足口病患儿中的应用

目的探讨简化小儿危重病例评分法在手足口病患儿中的应用。方法对160例手足口病患儿于入院时,入院后24、72h采用简化小儿危重病例评分法进行病情评分,根据评分分值分为非危重、病情危重和极危重患儿,并采取相应的一级护理、重点护理和特别护理,观察3种评分分值患儿的预后。结果 160例手足口病患儿中,非危重病例93例(58.13%),无1例死亡;危重病例52例(33.50%),死亡2例,病死率3.85%;极危重病例15例(8.37%),死亡5例,病死率33.33%。结论简化小儿危重病例评分法能帮助判断手足口病患儿的病情及预后,对指导临床治疗和护理具有重要意义。     

尿蛋白定性与ICU 危重患者预后的相关性研究

目的:探讨尿蛋白定性结果在ICU危重症患者病情和预后的预测价值。方法:对2008年1月～2011年5月我院ICU收治的190例患者,按照尿蛋白定性分为尿蛋白阴性组和尿蛋白定性阳性组,分别比较两组患者的肾功能不全、多器官功能衰竭、病死率及APACHE II评分,并进一步分析尿蛋白含量与上述指标的关系。结果:190例患者尿蛋白定性为阳性的为124例患者,阴性的66例患者,经过比较发现ARF发生率、MODS发生率、病死率,APACHE II评分,阳性组患者均明显高于阴性组患者,差异有显著的统计学意义(P<0.01);并且经过比较发现ARF发生率、MODS发生率、病死率,APACHE II评分不同组尿蛋白阳性组之间差异有显著的统计学意义(P<0.01),随着尿蛋白+的增加,ARF发生率、MODS发生率、病死率、APACHE II评分逐渐增加。结论:尿蛋白定性能很好的预测ICU危重患者肾功能不全、多器官功能衰竭和死亡的发生,反应患者病情的严重程度。     

老年重症肺炎患者机械通气后短期预后的相关影响因素分析

目的：探讨分析该疾病患者短期预后的相关影响因素。方法：对120例老年重症肺炎机械通气患者的临床资料进行回顾性分析,采用Logistic回归分析法,对老年重症肺炎患者的机械通气后的病死率与并发症的相关因素进行分析。结果：病死率为29．17％,经回归分析后,病死率与心力衰竭、电解质紊乱与酸碱失衡、肝功能衰竭以及呼吸衰竭等因素有关（P〈0．05）;而与循环衰竭、胃肠损害（消化道出血异常）以及气胸等因素无关（P〉0．05）;影响患者短期预后的独立预测因素包括：高急性生理与慢性健康评分（APACHEII）、高急性生理学评分（APS）、低格拉斯哥昏迷（GCS）评分以及低白蛋白水平。结论：老年重症肺炎患者机械通气后,能够引起心力衰竭等症状,影响患者短期预后情况的重要因素。     

“胃气”对成年人重症肺炎预后的影响

目的探讨中医“得胃气者生”的理论对重症肺炎预后的影响及在临床的应用。方法对本院2001～2007年收治住院的重症肺炎患者76例进行回顾性分析,统计患者消化道症状,计算患者所需能量和实际补充能量,将患者分为营养治疗不充分组（A组）和营养治疗充分组（B组）,并观察两组的临床效果及预后。结果A组32例,病死21例,生存11例,病死率65．62％;B组44例．病死15例,生存29例,病死率34．09％。A组和B组的病死率比较差异具有统计学意义（P〈0．005）。病程中各组病人根据食欲、进食情况,分为得“胃气”组（食欲、进食增加组）和失“胃气”组（食欲、进食无增加组）,前者病死率明显低于后者,差异具有统计学意义（P〈0．005）。治疗后B组消化道症状改善较A组明显,差异具有统计学意义（P〈0．005）。结论重症肺炎失“胃气”者（食欲差、进食少、营养补充不充分者）预后差．病死率高;而得“胃气”者（充分补充营养、治疗中食欲、进食增加者）抢救成功率高,病死率低。病程中出现食欲和进食增加者预后较好．印正了中医“得胃气者生”的理论,为重症肺炎患者重视营养支持和固护胃气的治疗提供理论依据。     

多模态MRI、CT多期增强扫描联合D-二聚体对重症急性胰腺炎的预后评价作用分析

摘要 目的：分析多模态MRI、CT增强扫描联合D-二聚体对重症急性胰腺炎（SAP）的预后评价作用。方法：收集2018年7月至2021年12月于我院诊治的85例SAP患者的影像学及临床资料。所有患者入院48小时内均接受多模态MRI及CT多期增强扫描检查,入院24小时内完善D-二聚体测定,分析多模态MRI、CT多期增强扫描、D-二聚体单独及联合应用对SAP患者预后的评价效能。结果：（1）经MRSI评分,低分组52例,高分组33例,低分组住院天数、病死率低于高分组（P<0.05）;（2）经MCTSI评分,低分组42例,高分组43例,低分组住院天数、病死率低于高分组（P<0.05）;（3）以2 mg/L为界,D-二聚体低水平组39例,高水平组46例,低水平组住院天数、病死率低于高水平组（P<0.05）;（4）MRSI评分、MCTSI评分、D-二聚体水平预测SAP预后的ROC曲线下面积（AUC）分别为：0.804、0.738、0.810,三种方式均能有效预测SAP的死亡,且D-二聚体水平> MRSI评分>MCTSI评分;（5）多模态MRI、CT多期增强扫描联合D-二聚体诊断SAP的灵敏度为94.77%,特异度为92.58%,均高于多模态MRI、CT多期增强扫描、D-二聚体三种方法单独诊断以及两两结合诊断（P<0.05）。结论：多模态MRI、CT多期增强扫描联合D-二聚体共同检查可提高SAP诊断的灵敏度及特异度,有助于提高对患者预后评估的准确率。     

集束化护理在急诊危重患者多管道维护中的应用

目的探讨集束化护理在急诊危重患者多管道维护中的应用效果。方法选择2016年1月~2017年1月在我院急诊科同时留置4条以上管道的241例危重患者为研究对象,随机分为对照组和观察组,对照组患者给予常规多管道维护护理,观察组患者予以集束化管道护理干预,比较两组患者的护理效果。结果两组患者经护理干预后,观察组患者的生存质量评分明显高于对照组,组间比较差异有统计学意义(P0.05);两组患者的护理效果比较,对照组的总有效率为78.33%,观察组为96.69%,组间比较差异有统计学意义(P0.05)。结论在急诊抢救室危重患者多管道维护中应用集束化护理干预,可有效提升患者治疗结局的总有效率,提升生存质量评分,取得满意的护理效果,值得推广。     

乳酸和APACHEⅡ评分在评估老年脓毒症患者预后中的应用

目的：研究乳酸和急性生理学及慢性健康状况评分（APACHE Ⅱ评分）对老年脓毒症患者预后的评估作用。方法：老年脓毒症患者96例,按照入院时血乳酸值分成升高者60例,乳酸正常者36例,比较两组的病死率、休克、机械通气和MODS发生率、APACHE Ⅱ评分的区别;根据APACHE Ⅱ评分（〈15、15～24、≥25）分为3组,比较每组患者的病情和预后区别。结果：乳酸升高组老年脓毒症患者的机械通气、休克发生率、MODS发生率、APACHE Ⅱ评分明显大于乳酸正常组（P〈0.05）,病死率明显上升（28.3%vs 2.7%）,（P=0.005）;随着APACHE Ⅱ评分增高,患者病情逐渐加重,休克发生率和住院病死率明显升高,（P〈0.05）,患者乳酸水平也明显增高（P〈0.05）。结论：血乳酸和APACHE Ⅱ评分都可以评估老年脓毒症患者病情严重和预后,两者升高提示预后差。     

脓毒性脑病的预警因素分析

目的：研究脓毒性脑病（SE）和无脑病者（NE）的预警因素。方法：分析我院ICU2004．1-2006、9收治的117例脓毒症病人的临床资料及相关检查结果,对比分析两组病人的住院时间、病死率、血培养、血压、白细胞计数（WBC）、血小板计数（PLT）、K＋、Ca2＋、游离钙（iCa2＋）、谷丙转氨酶（ALT）、谷草转氨酶（AST）、白蛋白、球蛋白、总胆红素（TBIL）、直接胆红素（DBIL）、肌酐（SCr）、尿素氮（BUN）、C反应蛋白（CRP）、血糖（BS）、胆固醇、甘油三脂（TG）、PaCO2、CT／MRI、APACHEII评分的差别。结果：52例SE患者的APACHEII评分、病死率、血培养阳性率、ALT、AST、SCr、BUN、PaCO2与65例NE比较差异有统计学意义（P〈0．05）;鲍曼不动杆菌和金黄色葡萄球菌为脓毒症病人感染率最高的革兰阳性菌和阴性菌,分别为18．49％和13．70％,两组感染病原菌和感染率均不一样;10例sE患者头部CT／MRI有微小脓肿和组织水肿等阳性表现,而NE组均无阳性表现;APACHEII评分与脓毒症的病死率相关,相关系数为r=0．541,而且两组病人APACHEII评分不同,病死率也不一样,21-25分段SE组病死率要高于NE组（P=0,001）。结论：APACHEII评分、血培养、ALT、AST、SCr、BUN、PaCO2对诊断和鉴别诊断SE具有重要意义,调整BS、SCr、ALT、BUN、iCa2＋、白蛋白水平对预防脓毒症发生SE有益。     

ISS与APACHEⅡ评分对急诊多发伤患者伤情评估的价值分析

目的:探讨损伤严重程度计分法(Injuryseverityscore,ISS)和慢性健康评分(Acute physiology and chronic health evaluation scoreⅡ,APACHEⅡ)评分对急诊多发伤患者伤情评估的应用价值。方法:将我院自2016年6月至2019年6月急诊收治的多发伤患者85例作为研究对象,分别使用ISS和APACHEⅡ评分,追踪患者住院期间的伤情严重程度和预后情况。结果:急诊多发伤患者入院时ISS评分和APACHEⅡ评分越高,患者ICU收住率和死亡率越高,患者预后越差(P0.05);死亡的急诊多发伤患者ISS评分和APACHE-Ⅱ评分均明显高于存活组(P0.05)。ISS评分预测急诊多发伤患者死亡的灵敏度为87.06%,特异性为85.88%,APACHE-Ⅱ评分预测急诊多发伤患者死亡的灵敏度和特异性分别为88.24%和87.06%,差异无统计学意义(P0.05),两者联合预测急诊多发伤患者死亡的灵敏度为95.29%,特异性为94.12%,均优于单独预测(P0.05)。结论:ISS评分和APACHE-Ⅱ评分能够较为准确的评估急诊多发伤患者的病情严重程度,对患者预后具有较好的预测价值,两者结合使用的应用价值更高。     

改良HEART评分法对急诊胸痛患者分层治疗的指导价值研究

目的:研究改良HEART评分法对急诊胸痛患者分层治疗的指导价值。方法:选择我院急诊科收治的急性胸痛患者197例,根据疾病分为心源性胸痛组(n=132)和非心源性胸痛组(n=65),所有患者均行改良HEART评分和传统HEART评分,并根据评分进行危险分层,比较患者去向,建立受试者工作特征(ROC)曲线,评价HEART评分对危险分层和预后预测的价值。结果:心源性胸痛组改良HEART评分和常规HEART评分均高于非心源性胸痛组,两组改良HEART评分和常规HEART评分比较差异有统计学意义(P0.05)。改良HEART评分低危者100%未住院,中危62.71%住院,高危住院、入ICU的构成比例为73.17%、36.59%;HEART评分低危11.11%住院,中危住院、入ICU的构成比例为57.38%、6.56%,高危住院、入ICU的构成比例为68.57%、31.43%,差异有统计学意义(P0.05)。改良HEART评分用于对心源性胸痛患者分层的AUC值为0.916,敏感度为0.883,明显高于HEART评分的0.831和0.765。结论:改良HEART评分法可提高急诊胸痛患者分层的准确性,对指导患者去向和治疗价值较高。     

Triage: a working solution to overcrowding in the emergency department

Recently, emergency departments across the continent have become crowded with patients requiring non-urgent care. To alleviate this situation at The Hospital for Sick Children in Toronto, receptionists in the emergency department direct patients requiring urgent care to the emergency room and those requiring non-urgent care to a screening clinic (triage). During a two-month period, 13,551 patients visited the emergency department. The triage receptionist sent 8368 patients to the emergency room and 5183 to the screening clinic. About 45% of patients visiting the emergency room had suffered accidents and injuries, and 19% had respiratory illness; 15% of patient visits resulted in admission to hospital. In contrast to this, 49% of patients sent to the screening clinic had respiratory illness and 18% had infective disease; less than 1% of patients needed hospitalization.     

Improving the care of patients with major trauma in the accident and emergency department.

OBJECTIVE--To determine whether improvement in the care of victims of major trauma could be made by using the revised trauma score as a triage tool to help junior accident and emergency doctors rapidly identify seriously injured patients and thereby call a senior accident and emergency specialist to supervise their resuscitation. DESIGN--Comparison of results of audit of management of all seriously injured patients before and after these measures were introduced. SETTING--Accident and emergency department in an urban hospital. PATIENTS--All seriously injured patients (injury severity score greater than 15) admitted to the department six months before and one year after introduction of the measures. RESULTS--Management errors were reduced from 58% (21/36) to 30% (16/54) (p less than 0.01). Correct treatment rather than improvement in diagnosis or investigation accounted for almost all the improvement. CONCLUSIONS--The management of seriously injured patients in the accident and emergency department can be improved by introducing two simple measures: using the revised trauma score as a triage tool to help junior doctors in the accident and emergency department rapidly identify seriously injured patients, and calling a senior accident and emergency specialist to supervise the resuscitation of all seriously injured patients. IMPLICATIONS--Care of patients in accident and emergency departments can be improved considerably at no additional expense by introducing two simple measures.     

急诊科护士正念度与心理弹性和职业倦怠的相关性分析

为了探讨急诊科护士正念度与心理弹性和职业倦怠的相关性,本研究采用整群抽样法对34名急诊科护士进行问卷调查,所有护士均接受一般状况调查表、五因子正念度问卷(FFMQ)、Conner-Davidson心理弹性量表(CD-RISC)简化版和职业倦怠问卷修订版(MBI-GS)调查。结果表明,急诊科护士情绪耗竭、去人性化、个人成就感的得分分别为(16.25±8.27)分、(16.84±9.17)分、(26.83±9.05)分。急诊科护士FFMQ得分(99.91±8.14)分,项目均分(2.56±0.57)分。急诊科护士CD-RISC得分(69.14±7.43)分,项目均分(2.77±0.54)分。初步结论表明,急诊科护士职业倦怠感严重,正念度与急诊科护士的心理弹性呈正相关,与职业倦怠感呈负相关,通过正念训练提高心理弹性可影响急诊科护士的职业倦怠感。     

Pentraxin 3 (PTX3) Is Associated with Severe Sepsis and Fatal Disease in Emergency Room Patients with Suspected Infection: A Prospective Cohort Study

Background

Early diagnostic and prognostic stratification of patients with suspected infection is a difficult clinical challenge. We studied plasma pentraxin 3 (PTX3) upon admission to the emergency department in patients with suspected infection.

Methods

The study comprised 537 emergency room patients with suspected infection: 59 with no systemic inflammatory response syndrome (SIRS) and without bacterial infection (group 1), 67 with bacterial infection without SIRS (group 2), 54 with SIRS without bacterial infection (group 3), 308 with sepsis (SIRS and bacterial infection) without organ failure (group 4) and 49 with severe sepsis (group 5). Plasma PTX3 was measured on admission using a commercial solid-phase enzyme-linked immunosorbent assay (ELISA).

Results

The median PTX3 levels in groups 1–5 were 2.6 ng/ml, 4.4 ng/ml, 5.0 ng/ml, 6.1 ng/ml and 16.7 ng/ml, respectively (p<0.001). The median PTX3 concentration was higher in severe sepsis patients compared to others (16.7 vs. 4.9 ng/ml, p<0.001) and in non-survivors (day 28 case fatality) compared to survivors (14.1 vs. 5.1 ng/ml, p<0.001). A high PTX3 level predicted the need for ICU stay (p<0.001) and hypotension (p<0.001). AUC^ROC in the prediction of severe sepsis was 0.73 (95% CI 0.66–0.81, p<0.001) and 0.69 in case fatality (95% CI 0.58–0.79, p<0.001). PTX3 at a cut-off level for 14.1 ng/ml (optimal cut-off value for severe sepsis) showed 63% sensitivity and 80% specificity. At a cut-off level 7.7 ng/ml (optimal cut-off value for case fatality) showed 70% sensitivity and 63% specificity in predicting case fatality on day 28.In multivariate models, high PTX3 remained an independent predictor of severe sepsis and case fatality after adjusting for potential confounders.

Conclusions

A high PTX3 level on hospital admission predicts severe sepsis and case fatality in patients with suspected infection.     

556例多发伤患者的急诊救治临床分析

目的探讨多发伤患者的救治策略。方法回顾分析我科2000年1月至2008年5月急诊抢救的556例多发伤患者的临床资料。结果 16例患者经抢救无效死亡,死亡率2.88%;其余患者均经紧急抢救及行必要实验室检查,病情稳定,好转率达97.12%。平均抢救时间为(1.37±1.05)h。结论强化多发伤的急诊科早期救治,树立创伤急救"黄金1 h"观念,是提高多发伤患者生存率及降低死亡率的关键。     

肌钙蛋白I和肌红蛋白在急性心肌梗死患者血清中的变化特点及其诊断价值

目的:探讨肌钙蛋白I、CKMB的即时检测技术在急诊科心肌梗死患者中的应用及其临床意义。方法:研究对象为2012年10月至2013年8月于我急诊科急诊的急性心肌梗死患者,按就诊时间分为对照组和实验组。对照组患者采用常规化验室检测肌钙蛋白I、CKMB,实验组采用急诊科即时检测方法检测肌钙蛋白I、CKMB。对比两组患者从就诊到确诊的时间、住院天数、治愈率、心功能不全发生率和死亡率。结果:实验组患者的确诊时间为(25.5±5.6)min,住院天数为(9.89±1.5)天,治愈率为80.8%,心功能不全发生率为15.4%。对照组患者的确诊时间为(66.8±10.0)min,住院天数为(12.6±2.5)天,治愈率为56.0%,心功能不全发生率为32.0%P均.0.05,有统计学意义。两组患者死亡率分别为12%和3.8%,无明显差异。结论:对心肌梗死患者采用肌钙蛋白I、CKMB的即时检测对于提高患者治愈率,减少确诊时间和住院时间,降低心功能不全发生率有很大帮助。     

Risk factors for hospitalization among adults with asthma: the influence of sociodemographic factors and asthma severity

Background

The morbidity and mortality from asthma have markedly increased since the late 1970s. The hospitalization rate, an important marker of asthma severity, remains substantial.

Methods

In adults with health care access, we prospectively studied 242 with asthma, aged 18–50 years, recruited from a random sample of allergy and pulmonary physician practices in Northern California to identify risk factors for subsequent hospitalization.

Results

Thirty-nine subjects (16%) reported hospitalization for asthma during the 18-month follow-up period. On controlling for asthma severity in multiple logistic regression analysis, non-white race (odds ratio [OR], 3.1; 95% confidence interval [CI], 1.1–8.8) and lower income (OR, 1.1 per $10,000 decrement; 95% CI, 0.9–1.3) were associated with a higher risk of asthma hospitalization. The severity-of-asthma score (OR, 3.4 per 5 points; 95%, CI 1.7–6.8) and recent asthma hospitalization (OR, 8.3; 95%, CI, 2.1–33.4) were also related to higher risk, after adjusting for demographic characteristics. Reliance on emergency department services for urgent asthma care was also associated with a greater likelihood of hospitalization (OR, 3.2; 95% CI, 1.0–9.8). In multivariate analysis not controlling for asthma severity, low income was even more strongly related to hospitalization (OR, 1.2 per $10,000 decrement; 95% CI, 1.02–1.4).

Conclusion

In adult asthmatics with access to health care, non-white race, low income, and greater asthma severity were associated with a higher risk of hospitalization. Targeted interventions applied to high-risk asthma patients may reduce asthma morbidity and mortality.     

The Association of Longitudinal and Interpersonal Continuity of Care with Emergency Department Use,Hospitalization, and Mortality among Medicare Beneficiaries

Background

Continuity of medical care is widely believed to lead to better health outcomes and service utilization patterns for patients. Most continuity studies, however, have only used administrative claims to assess longitudinal continuity with a provider. As a result, little is known about how interpersonal continuity (the patient''s experience at the visit) relates to improved health outcomes and service use.

Methods

We linked claims-based longitudinal continuity and survey-based self-reported interpersonal continuity indicators for 1,219 Medicare beneficiaries who completed the National Health and Health Services Use Questionnaire. With these linked data, we prospectively evaluated the effect of both types of continuity of care indicators on emergency department use, hospitalization, and mortality over a five-year period.

Results

Patient-reported continuity was associated with reduced emergency department use, preventable hospitalization, and mortality. Most of the claims-based measures, including those most frequently used to assess continuity, were not associated with reduced utilization or mortality.

Conclusion

Our results indicate that the patient- and claims-based indicators of continuity have very different effects on these important health outcomes, suggesting that reform efforts must include the patient-provider experience when evaluating health care quality.