探討急診院內死亡病人的死因與生命徵象變化的關係

Abstract

研究背景: 根據過去的研究，發生院內心跳停止的病人通常在心跳停止前可以觀察到生命徵象有不正常的變化，而這些臨床上的警訊提供我們機會去避免這樣的悲劇發生。以死亡的原因去分析，心因性院內心跳停止的病人比起非心因性患者，有比較好的預後。過去的研究，針對心跳停止前預兆（尤指生命徵象的變化）與院內心跳停止原因間的關係卻沒有被提及。 研究方法: 我們藉由回溯性世代研究（病歷回顧）的方式，在台灣省台北市的一家醫學中心，收集兩年來在急診發生院內心跳停止的病人記錄。在死前預兆的部分，主要記錄病人心跳停止前的生命徵象，其中包括體溫、脈搏、呼吸速率、血壓、血氧濃度及意識狀態。其他包括病人特徵，健康照護體系相關變項，心跳停止事件相關變項及預後變項也一併記錄。 在病人死因的部分，則分成心因性與非心因性死亡。我們利用邏輯式迴歸的逐步迴歸方式去評估這些心跳停止前預兆與死因是否存在相關性。針對院內心跳停止病人的預後情形也會做相關的評估，並從死因的分類去做預後比較。 研究結果: 共有155位成年人納入我們的研究，平均年齡為72.4±16歳，62%為男性，29.7%為心因性院內心跳停止病人。相較於非心因性院內心跳停止的病人，心因性病人有以下臨床特徵：來診主訴為胸痛(OR: 5.46; 95% CI, 1.46-20.4)，過去病史有冠狀動脈疾病(OR: 5.14; 95% CI, 1.95-13.6)及心律不整(OR: 6.86; 95% CI, 2.3-20.4)，初始心電圖有ST段改變(OR: 4.17; 95% CI, 1.5-11.6)及心跳停止時心律為可電擊心律(OR: 6.04; 95% CI, 1.27-28.8。每個記錄生命徵象的時段中，心因性死亡病人在死前預兆部分，比起非心因性死亡病人有較佳的意識狀態。在預後部分，相較於非心因性心跳停止病人，心因性病人生存至住院的預後較佳（OR: 2.76; 95%CI, 1.1-6.96）。 研究結論: 心因性院內心跳停止病人心跳停止前生命徵象的變化比起非心因性的病人，往往較不明顯。臨床上，可能會錯過早期介入的時機。我們可以利用病人本身的臨床特徵，早期預判可能較易發生心因性院內心跳停止的病人，改變監測策略，進而提昇院內心跳停止病人的預後。

Background: Patients with in-hospital cardiac arrest (IHCA) often exhibit abnormal vital signs before the arrest, and these warning signs may afford the chance to prevent the catastrophic event. The cardiac IHCA had less mortality than non-cardiac IHCA. The associations between antecedents to IHCA and causes of IHCA have not been well documented. Methods: We conducted a retrospective cohort study at emergency department (ED) in a tertiary medical center in Taipei city, Taiwan for 2 years. The antecedents, vital signs before IHCA, were recorded by four time duration before IHCA. All other events and variables were recorded using the Utstein style for IHCA. We measured the association between the changes of antecedents and causes of IHCA. The outcome of IHCA, including return of spontaneous circulation (ROSC), survival to hospital, survival to discharge, and functional neurological outcome were also measured. Results: Of 155 IHCA adults (mean age 72.4±16 years, 62% men), 29.7% suffered cardiac IHCA at ED. The patients with chest pain (OR: 5.46; 95% CI, 1.46-20.4)，previous medical history with coronary artery disease (OR: 5.14; 95% CI, 1.95-13.6) and arrhythmia (OR: 6.86; 95% CI, 2.3-20.4)，ST segment changes in initial electrocardiography (ECG)(OR: 4.17; 95% CI, 1.5-11.6) and arrest rhythms with ventricular fibrillation / pulseless ventricular tachycardia (OR: 6.04; 95% CI, 1.27-28.8) would be likely to suffer cardiac IHCA. Among the antecedents (vital signs), the cardiac IHCA patients had favorable mental status in each time duration before IHCA. The survival to hospital was better in cardiac IHCA patients (OR: 2.76; 95%CI, 1.1-6.96). Conclusions: Antecedents in cardiac IHCA patients may be more obscured than non-cardiac, and we may miss the right time to resuscitate these patients who may have better outcome. By clinical characteristics, we may identify the possible cardiac IHCA patients, and improved the outcome by adjusting the monitor strategy for these patients.