急性冠脉综合征院前急救现状调查及分析
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摘要
目的随着《2005国际心肺复苏和心血管急救指南》的颁布,急性冠脉综合征的院前急救治疗方案在全世界急诊领域学者中取得了较为一致的认可。本次研究拟通过对我国ACS院前急救进行调查,并对ACS院前治疗效果进行多中心的比较研究,了解目前我国ACS院前救治的综合水平、我国ACS院前急救对《2005国际心肺复苏和心血管急救指南》中关于ACS院前急救的依从性、四种院前急救模式之间的差异以及影响ACS院前急救治疗效果的因素。
方法采用目标人群的横断面研究的流行病学调查方法,用自制的急性冠脉综合征院前救治效果调查表收集资料,根据对中南大学附属海口医院急诊科的预调查结果来估计本次研究所需的样本量。从2009年10月至2010年3月在全国范围的四种急救模式中抽取13家单位,共收集符合研究条件的病例272例,有效表格260例。所以原始数据收集表格均经专业培训的院前医师填写,统一进行数据的处理和分析。
结果①本组研究院前急救出车距离以10Km为轴线呈正态分布,呼救反应时间以8min为轴线呈正态分布。在ACS院前初步处置中,应用阿司匹林比例为10.2%、应用镇静镇痛药物的比例为3.9%、应用硝酸酯类药物的比例为61.3%,应用院前心电图的比例为71.4%。②本组研究四种急救模式的比较中,指挥型和依托型在出车距离的比较有显著差异(4.3±2.1 vs 11.6±31.0,P<0.05)。指挥型和院前型、依托型在呼救反应时间的比较有显著差异(22.2±37.3 vs 65.6±51.7,75.1±84.9,P<0.05)。指挥型和独立性、依托型在呼救到达时间的比较有显著差异(9.8±1.1 vs 7.9±3.5,7.6±6.4,P<0.05)。在建立静脉通道上,独立型(100%)、院前型(100%)与指挥型(37.9%)、依托型(71.2%)之间比较有显著差异(P<0.001)。在应用阿司匹林上,院前型(24.6%)与其他三型(10%,4.2%,4.5%)比较有显著差异(P<0.001)。在应用硝酸酯上,独立型(80%)与院前型(52.3%)、依托型(53%)比较有显著差异(P<0.001)。在应用院前心电图上,独立型(89.7%)、院前型(89.2%)与指挥型(64.2%)、依托型(56.1%)之间比较有显著差异(P<0.001)。③在ACS院前治疗效果的观察中,ACS院前急救的总有效率为48%。心脏骤停后持续自主循环恢复比例为10.5%。给予硝酸酯类药的有效率为62.4%,给予镇静镇痛药物的有效率为80%。在治疗效果的多因素回归分析中,独立型急救模式、给予硝酸酯类药物和口服给药进入回归方程,有显著差异(P<0.05)。
结论①本组研究ACS的院前急救在正确危险分级、应用阿司匹林、镇静镇痛药物、硝酸酯类药物和院前心电图方面对《2005心肺复苏和心血管急救指南》中关于ACS院前初步处置的依从性不高。②本组研究四种院前急救模式的比较中,独立型在ACS的院前急救中的治疗效果最好,院前型的现场初步处置做的最好。③本组研究在对ACS的院前救治中,给予硝酸酯类药物和口服给药方式对治疗效果的帮助最大。
Objective With the promulgation of Guideline 2005 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, the treatment protocols of pre-hospital care of patients with ACS are generally approved by scholars in the emergency field in the world. This study is to investigate the pre-hospital care of patients with ACS in China, and perform a multicenter comparative study on the therapeutic effect of pre-hospital care of patients with ACS to further investigate the current comprehensive level of pre-hospital care of patients with ACS in China, and understand the compliance of pre-hospital care for patients with ACS required in the Guideline 2005 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, the difference between four patterns of pre-hospital care as well as the factors affecting the therapeutic effect of pre-hospital care for patients with ACS.
Methods An epidemiological survey of target population-based cross-sectional study was performed, and self-designed questionnaire for the therapeutic effect of pre-hospital care of patients with ACS was used to collect data, then the required sample size in this study was evaluated according to the pre-survey results of Department of Emergency, the Affiliated Haikou Hospital of Central South University. A total of 13 hospitals were selected from four patterns of pre-hospital care in China from October 2009 to March 2010,272 cases matching the research conditions and 260 valid tables were collected, data were processed and analyzed together.
Results 1. In this study, the distance of ambulance driving showed a mormal distribution with 10 km served as the axial ray, and the reaction time for first aid also showed a mormal distribution with 8 min served as the axial ray. In the preliminary pre-hospital therapy of patients with ACS, the percentages of using Aspirin, sedative drugs and Nitrate were 10.2%, 3.9% and 61.3% respectively, and the percentage of applying pre-hospital ECG was 71.4%.2. Comparison of four pre-hospital care patterns suggested that directive pattern showed significant difference in the distance of ambulance driving compared with that of dependent pattern (4.3±2.1 vs 11.6±31.0, P<0.05). The directive pattern showed a significant difference in reaction time for first aid compared with that of pre-hospital pattern and dependent pattern (22.2±37.3 vs 65.6±51.7, 75.1±84.9, P<0.05). The directive pattern showed a significant difference in the arrival time for first aid compared with that of independent pattern and dependent pattern (9.8±1.1 vs 7.9±3.5,7.6±6.4, P＜0.05). The establishments of intravenous access of independent pattern, pre-hospital pattern, directive pattern and dependent pattern were 100%,100%,37.9% and 71.2% respectively, they showed a significant difference (P＜0.001). The percentages of using Aspirin of pre-hospital pattern and the other three patterns were 24.6%,10%,4.2% and 4.5% respectively, they showed a significant difference (P＜0.001). The percentages of using Nitrate of independent pattern, pre-hospital pattern and dependent pattern were 80%,52.3% and 53% respectively, they showed a significant difference (P＜0.001). The percentages of applying ECG of independent pattern, pre-hospital pattern, directive pattern and dependent pattern were 89.7%,89.2%,64.2% and 56.1% respectively, they showed a significant difference (P＜0.001).3. Results of the pre-hospital therapeutic effect of ACS indicated that the effective rate of the total therapeutic effect of pre-hospital care of patients with ACS was 48%, and the percentage of sustainable return of spontaneous circulation after cardiac arrest was 10.5%, and the effective rates of using Nitrate and sedative drugs were 62.4% and 80% respectively. Multivariate regression analysis of therapeutic effect suggested that the independent pattern, using Nitrate and oral administration entered the regression equation, they showed a significant difference (P<0.05).
Conclusions 1. In this study, the compliance of correct risk classification, using Aspirin, sedative drugs and Nitrate, and applying ECG in the preliminary pre-hospital therapy of patients with ACS required in the Guideline 2005 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care is low.2. Comparison of four patterns of pre-hospital care suggests that independent pattern has the best therapeutic effect in the pre-hospital care of patients with ACS, and pre-hospital pattern has best preliminary therapy.3. In the pre-hospital care of patients with ACS, using Nitrate and oral administration show the best benefit for the therapeutic effect.
方法采用目标人群的横断面研究的流行病学调查方法,用自制的急性冠脉综合征院前救治效果调查表收集资料,根据对中南大学附属海口医院急诊科的预调查结果来估计本次研究所需的样本量。从2009年10月至2010年3月在全国范围的四种急救模式中抽取13家单位,共收集符合研究条件的病例272例,有效表格260例。所以原始数据收集表格均经专业培训的院前医师填写,统一进行数据的处理和分析。
结果①本组研究院前急救出车距离以10Km为轴线呈正态分布,呼救反应时间以8min为轴线呈正态分布。在ACS院前初步处置中,应用阿司匹林比例为10.2%、应用镇静镇痛药物的比例为3.9%、应用硝酸酯类药物的比例为61.3%,应用院前心电图的比例为71.4%。②本组研究四种急救模式的比较中,指挥型和依托型在出车距离的比较有显著差异(4.3±2.1 vs 11.6±31.0,P<0.05)。指挥型和院前型、依托型在呼救反应时间的比较有显著差异(22.2±37.3 vs 65.6±51.7,75.1±84.9,P<0.05)。指挥型和独立性、依托型在呼救到达时间的比较有显著差异(9.8±1.1 vs 7.9±3.5,7.6±6.4,P<0.05)。在建立静脉通道上,独立型(100%)、院前型(100%)与指挥型(37.9%)、依托型(71.2%)之间比较有显著差异(P<0.001)。在应用阿司匹林上,院前型(24.6%)与其他三型(10%,4.2%,4.5%)比较有显著差异(P<0.001)。在应用硝酸酯上,独立型(80%)与院前型(52.3%)、依托型(53%)比较有显著差异(P<0.001)。在应用院前心电图上,独立型(89.7%)、院前型(89.2%)与指挥型(64.2%)、依托型(56.1%)之间比较有显著差异(P<0.001)。③在ACS院前治疗效果的观察中,ACS院前急救的总有效率为48%。心脏骤停后持续自主循环恢复比例为10.5%。给予硝酸酯类药的有效率为62.4%,给予镇静镇痛药物的有效率为80%。在治疗效果的多因素回归分析中,独立型急救模式、给予硝酸酯类药物和口服给药进入回归方程,有显著差异(P<0.05)。
结论①本组研究ACS的院前急救在正确危险分级、应用阿司匹林、镇静镇痛药物、硝酸酯类药物和院前心电图方面对《2005心肺复苏和心血管急救指南》中关于ACS院前初步处置的依从性不高。②本组研究四种院前急救模式的比较中,独立型在ACS的院前急救中的治疗效果最好,院前型的现场初步处置做的最好。③本组研究在对ACS的院前救治中,给予硝酸酯类药物和口服给药方式对治疗效果的帮助最大。
Objective With the promulgation of Guideline 2005 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, the treatment protocols of pre-hospital care of patients with ACS are generally approved by scholars in the emergency field in the world. This study is to investigate the pre-hospital care of patients with ACS in China, and perform a multicenter comparative study on the therapeutic effect of pre-hospital care of patients with ACS to further investigate the current comprehensive level of pre-hospital care of patients with ACS in China, and understand the compliance of pre-hospital care for patients with ACS required in the Guideline 2005 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, the difference between four patterns of pre-hospital care as well as the factors affecting the therapeutic effect of pre-hospital care for patients with ACS.
Methods An epidemiological survey of target population-based cross-sectional study was performed, and self-designed questionnaire for the therapeutic effect of pre-hospital care of patients with ACS was used to collect data, then the required sample size in this study was evaluated according to the pre-survey results of Department of Emergency, the Affiliated Haikou Hospital of Central South University. A total of 13 hospitals were selected from four patterns of pre-hospital care in China from October 2009 to March 2010,272 cases matching the research conditions and 260 valid tables were collected, data were processed and analyzed together.
Results 1. In this study, the distance of ambulance driving showed a mormal distribution with 10 km served as the axial ray, and the reaction time for first aid also showed a mormal distribution with 8 min served as the axial ray. In the preliminary pre-hospital therapy of patients with ACS, the percentages of using Aspirin, sedative drugs and Nitrate were 10.2%, 3.9% and 61.3% respectively, and the percentage of applying pre-hospital ECG was 71.4%.2. Comparison of four pre-hospital care patterns suggested that directive pattern showed significant difference in the distance of ambulance driving compared with that of dependent pattern (4.3±2.1 vs 11.6±31.0, P<0.05). The directive pattern showed a significant difference in reaction time for first aid compared with that of pre-hospital pattern and dependent pattern (22.2±37.3 vs 65.6±51.7, 75.1±84.9, P<0.05). The directive pattern showed a significant difference in the arrival time for first aid compared with that of independent pattern and dependent pattern (9.8±1.1 vs 7.9±3.5,7.6±6.4, P＜0.05). The establishments of intravenous access of independent pattern, pre-hospital pattern, directive pattern and dependent pattern were 100%,100%,37.9% and 71.2% respectively, they showed a significant difference (P＜0.001). The percentages of using Aspirin of pre-hospital pattern and the other three patterns were 24.6%,10%,4.2% and 4.5% respectively, they showed a significant difference (P＜0.001). The percentages of using Nitrate of independent pattern, pre-hospital pattern and dependent pattern were 80%,52.3% and 53% respectively, they showed a significant difference (P＜0.001). The percentages of applying ECG of independent pattern, pre-hospital pattern, directive pattern and dependent pattern were 89.7%,89.2%,64.2% and 56.1% respectively, they showed a significant difference (P＜0.001).3. Results of the pre-hospital therapeutic effect of ACS indicated that the effective rate of the total therapeutic effect of pre-hospital care of patients with ACS was 48%, and the percentage of sustainable return of spontaneous circulation after cardiac arrest was 10.5%, and the effective rates of using Nitrate and sedative drugs were 62.4% and 80% respectively. Multivariate regression analysis of therapeutic effect suggested that the independent pattern, using Nitrate and oral administration entered the regression equation, they showed a significant difference (P<0.05).
Conclusions 1. In this study, the compliance of correct risk classification, using Aspirin, sedative drugs and Nitrate, and applying ECG in the preliminary pre-hospital therapy of patients with ACS required in the Guideline 2005 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care is low.2. Comparison of four patterns of pre-hospital care suggests that independent pattern has the best therapeutic effect in the pre-hospital care of patients with ACS, and pre-hospital pattern has best preliminary therapy.3. In the pre-hospital care of patients with ACS, using Nitrate and oral administration show the best benefit for the therapeutic effect.
引文
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[1]2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation.2005,112(24).
[2]Steven M. Meeting the treat of weapons of mass destruction terrorism:toward a broader conception of consequence management. Military Medicine,2001,28(4):13-18.
[3]赵炜.急救医疗服务体系在突发灾害中的紧急救援作用.中国急救医学,2003,23(5)：314-315.
[4]韦波,杨起,刘德诚.科学构建区域性应急医疗救治体系.中国公共卫生,2006,22(3)267-268.
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