臺灣博碩士論文加值系統

研究動機與目的

重大外傷是全世界意外死亡的主要原因，自2000年以來，每年造成超過 120 萬人死亡，是世界各地緊急醫療救護與公共衛生領域共同的重要課題。對於這些嚴重外傷患者，往往仰賴當地緊急醫療服務系統提供急救處置及後送，尤其同為時間急症的重大外傷，在第一時間判斷傷患是否需要接受外傷中心之確切治療，從而採行適當的送醫選擇，往往為救護從業人員帶來極大的挑戰，如果將輕症送往外傷中心（過度檢傷）將產生醫療資源的浪費或排擠到真正需要的傷病患；另若將嚴重傷患送往就近沒有高層級外傷照護之醫療機構，可能耽誤了治療時機而造成可避免的死亡與失能。然而，在如此重要的課題上，目前應用在我國社區中的檢傷分流建議大部分仍是直接採納來自北美的指標或者尚未有具體的規劃，同時，長期以來，在亞洲地區的相關研究尚顯不足。

因此，我們針對亞洲地區透過緊急救護系統送醫之成年外傷患者，基於救護人員於現場所記錄的生命徵象、評估的外傷情況以及患者抵達醫院後的外傷嚴重度診斷與預後狀態，探討以下兩項主題：（一）檢驗到院前重大外傷患者檢傷工具的適用性；（二）評估以現場昏迷指數的運動反應（GCS-M）取代格拉斯哥昏迷量表（GCS）總分，作為檢傷指標的可行性。

重要研究方法

研究採回溯性世代研究設計（retrospective cohort study），首先檢驗源自於北美到院前現場檢傷指標（Field Triage Scheme, FTS）中步驟1：生理狀態 （physiologic status, P）及步驟2：解剖損傷（anatomical injury, A），在亞洲社區中辨識出外傷患者嚴重度之準確性，並微調生理標準（P），檢驗改良後的指標在辨識不同年齡組高風險外傷患者的表現；此外，我們比較現場測得傷患的GCS總分和GCS-M分別預測患者死亡和嚴重殘疾的接收者操作特徵曲線下面積（AUROCs），並針對有創傷性腦損傷（Traumatic Brain Injury, TBI）和無TBI的患者分別進行分析與比較。

研究結果

生理和解剖標準辨識重大外傷（外傷嚴重度評分 ≥ 16）的敏感度和特異度分別為80.6%和58.5%。改良後的指標敏感度增加但特異度降低，這種變化在年輕組更加顯著。

研究群體30天內死亡為1.04%，GCS和GCS-M的AUROC分別為0.917（0.887–0.946）和0.907（0.875–0.938），p值為0.155。不良功能預後的發生率為12.4%，GCS和GCS-M的AUROC分別為0.617（0.597–0.637）和0.613（0.593–0.633），p值為0.616。有（或無）TBI之次群體分析中，GCS與GCS-M預測30天內死亡及不良功能預後能力一致。

研究結論

簡化現場檢傷指標（sFTS）僅使用生理和解剖標準對亞洲成年外傷患者整體表現尚可接受，sFTS在年齡的極端值表現均不理想。然而，調整生理標準並加入休克指數可以提高對重傷患者，特別是年輕組的敏感度。此外，院前環境中，現場評估的GCS-M在預測外傷患者（無論是否有TBI）的30天內死亡和不良功能預後方面，與GCS具有可比性。綜上所述，對於亞洲地區的外傷患者，特別是年輕群體，現行的檢傷指標需要進一步改善以提高其敏感度及特異性，而改良後的生理標準和休克指數的加入展現了其潛在價值。此外，GCS-M作為評估工具的可比性顯示出其在院前環境中的應用價值，亦支持在前述生理標準中以GCS-M取代GCS。本研究的結果，將有助於我國建構本土化的重大外傷現場檢傷準則，建議未來的研究繼續探討和驗證這些調整，以期在實務操作中持續進步。

Background and Objectives

Major trauma is a leading cause of accidental death worldwide, accounting for over 1.2 million fatalities annually since 2000. It remains a critical issue within the fields of emergency medical services and public health globally. These serious injuries often depend on the swift response of local emergency medical systems to provide immediate treatment and determine the necessity for transporting to trauma centers. This presents a significant challenge for emergency personnel, who must make rapid transport decisions. Over triage, or the unnecessary transportation of minor injuries to trauma centers, can waste medical resources and potentially divert care away from those in true need. Conversely, under triage, which is the insufficient identification of serious injuries, resulting in their transport to facilities without high-level trauma care, can lead to preventable deaths and disabilities. Despite the importance of this issue, current triage guidelines in community settings within our country largely adopt indicators from North America or lack specific planning. Moreover, related research in the Asian context is scarce.

This study addresses adult trauma patients transported by emergency medical systems in Asia, focusing on two main objectives: (1) examining the applicability of prehospital triage tools for major trauma, and (2) evaluating the feasibility of substituting the motor response component of the Glasgow Coma Scale (GCS-M) for the total GCS score as a triage indicator.

Methods

Using a retrospective cohort study design, the first part of this research assesses the accuracy of identifying trauma severity in the Asian community using Steps 1 (physiologic status, P) and 2 (anatomical injury, A) from the North American prehospital Field Triage Scheme (FTS). We examined the performance of simplified FTS (sFTS) in all age groups and fine-tuned physiological criteria to improve sFTS performance in identifying high-risk trauma patients in different age groups. The second part of the study compared the AUROCs of GCS and GCS-M for predicting 30-day mortality and poor functional outcomes and analyzed separately for patients with and without traumatic brain injury (TBI).

Results

The sensitivity and specificity of physiological and anatomical criteria for identifying major trauma were 80.6% and 58.5%, respectively. The modified criteria showed increased sensitivity but decreased specificity, with more significant changes in younger age groups.

The overall 30-day mortality rate was 1.04%. The AUROCs and 95% confidence intervals for prediction were GCS: 0.917 (0.887–0.946) vs. GCS-M:0.907 (0.875–0.938), p = 0.155. The secondary outcome for poor functional outcome (MRS ≥4) was 12.4% and the AUROCs and 95% confidence intervals for prediction were GCS: 0.617 (0.597–0.637) vs. GCS-M: 0.613 (0.593–0.633), p = 0.616. Subgroup analyses showed consistent discrimination abilities between GCS and GCS-M for patients with or without TBI.

Conclusion

The simplified field triage scheme (sFTS), using only physiological and anatomical criteria, performs acceptably overall for adult trauma patients in Asia but shows suboptimal performance at the extremes of age. Adjusting the physiological criteria and incorporating the shock index can improve sensitivity, particularly for younger patients. Moreover, in the prehospital setting, GCS-M is comparable to GCS in predicting 30-day mortality and poor functional outcomes in trauma patients, regardless of TBI status. These findings highlight the need to refine current triage guidelines to enhance sensitivity and specificity for Asian trauma patients, particularly for younger populations. The study supports the potential value of incorporating GCS-M into triage criteria and provides a basis for developing localized major trauma triage guidelines. Future research should continue to explore and validate these adjustments for practical implementation.

​​目錄(Contents)
中文摘要 i
英文摘要(Abstract in English) iv
圖目次 xi
表目次 xi
縮寫表 xiii
第 1 章 緒論 1
1.1 研究動機 1
1.2 研究目的 4
1.3 研究重要性 4
第 2 章 文獻回顧 6
2.1 到院前重大外傷檢傷指標之現況與趨勢 6
2.2 到院前重大外傷檢傷準確性探討 11
2.3 以GCS-M取代GCS總分作為檢傷指標之可行性 13
第 3 章 整體研究架構 17
3.1 研究概念與問題討論 17
3.2 第一個子研究：調整生理標準對不同年齡族群重大外傷的檢傷效能分析 17
3.3 第二個子研究：比較GCS與GCS-M對外傷患者30天內死亡及功能性預後的預測能力 17
3.4 重要性與應用 18
第 4 章 調整生理標準對不同年齡族群重大外傷的檢傷效能分析 19
4.1 緒論 19
4.2 研究方法 19
4.2.1 研究假說 19
4.2.2 研究對象 20
4.2.3 自變項與依變項定義 20
4.2.4 研究設計 21
4.2.5 統計分析 22
4.3 研究結果 25
4.3.1 納入標準與患者特徵 25
4.3.2 sFTS及改良後sFTS的預測值 28
4.4 討論 36
4.4.1 生理標準和解剖標準的sFTS在亞洲成年族群中整體表現 36
4.4.2 單一指標之敏感度及特異性 39
4.4.3 sFTS調整生理指標後之檢傷能力表現 40
4.4.4 研究限制 42
4.5 小結 44
第 5 章 比較GCS與GCS-M對外傷患者30天內死亡及功能性預後的預測能力 46
5.1 緒論 46
5.2 研究方法 47
5.2.1 研究假說 47
5.2.2 研究對象 47
5.2.3 研究自變項與依變項定義 47
5.2.4 研究設計 48
5.2.5 統計分析 49
5.3 研究結果 50
5.3.1 納入標準與患者特徵 50
5.3.2 GCS 和 GCS-M 對死亡和不良功能預後之預測力比較 55
5.4 討論 62
5.4.1 GCS 與GCS-M預測臨床相關結果表現 62
5.4.2 GCS 與GCS-M於次群體中預測臨床相關結果之能力 66
5.4.3 GCS≤13與GCS-M<6對臨床相關結果之預測能力及應用 67
5.4.4 研究限制 68
5.5 小結 69
第 6 章 綜合討論 71
第 7 章 結論與展望 73
7.1 結論 73
7.2 展望 73
第 8 章 參考文獻 76
附錄(Appendix) 88
未納入分析案例特徵 88

圖目次
圖 1 1台灣事故傷害標準化死亡率 1
圖 4 1 sFTS研究對象流程圖 26
圖 4 2各年齡之各種檢傷標準的敏感度樣條函數曲線圖 30
圖 4 3各年齡之各種檢傷標準的特異性之樣條函數曲線圖 30
圖 5 1 GCS及GCS-M研究對象流程圖 50
圖 5 2 GCS和GCS-M對於所有患者（a,b）、TBI患者(c,d)及非TBI患者(e,f)之30天死亡（30-day Mortality）和不良功能預後（MRS ≥4）AUROC 58
圖 5 3 GCS和GCS-M邏輯回歸模型對於所有患者之30天死亡（30-day Mortality）和不良功能預後（MRS ≥4）AUROC 58

表目次
表 2 1傷患者現場檢傷指標（Guidelines for field triage of injured patients — United States, 2011） 6
表 4 1預測值的定義與計算 24
表 4 2研究對象特徵比較 27
表 4 3 按年齡分層的sFTS† 對重大外傷的敏感度（SEN）及特異性（SPE） 33
表 4 4按年齡分層的改良後sFTS† 與改良後sFTS + SI > 0.8對重大外傷的敏感度（SEN）及特異性（SPE） 34
表 4 5按年齡分層的sFTS、改良後sFTS與改良後sFTS + SI† > 0.8對重大外傷預測值一覽表 35
表 4 6 過去研究對於AVPU與GCS之對照表 43
表 5 1 30天內死亡患者特徵比較 52
表 5 2不良功能預後患者特徵比較 54
表 5 3 GCS和GCS-M對於所有患者、TBI患者及非TBI患者之30天死亡（30-day Mortality）和不良功能預後（MRS ≥4）AUROC比較表 56
表 5 4不同GCS和GCS-M分層對30天死亡的預測值 60
表 5 5不同GCS和GCS-M分層對不良功能結果（MRS ≥4）的預測值 61
表 5 6 到院前GCS預測臨床相關結果研究比較表 63

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