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中华卫生应急电子杂志 ›› 2020, Vol. 06 ›› Issue (06) : 350 -355. doi: 10.3877/cma.j.issn.2095-9133.2020.06.006

所属专题: 文献

论著

急诊内科昏迷患者的临床分析
冯小鹏1,(), 谢昭鑫1, 张艳玲1   
  1. 1. 516003 广东惠州,惠州市第一人民医院急诊内科
  • 收稿日期:2019-12-02 出版日期:2020-12-18
  • 通信作者: 冯小鹏

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

Xiaopeng Feng1,(), Zhaoxin Xie1, Yanling Zhang1   

  1. 1. Department of Emergency, First People’s Hospital in Huizhou, Huizhou 516003, China
  • Received:2019-12-02 Published:2020-12-18
  • Corresponding author: Xiaopeng Feng
  • About author:
    Corresponding author: Feng Xiaopeng, Email:
引用本文:

冯小鹏, 谢昭鑫, 张艳玲. 急诊内科昏迷患者的临床分析[J]. 中华卫生应急电子杂志, 2020, 06(06): 350-355.

Xiaopeng Feng, Zhaoxin Xie, Yanling Zhang. Patients with impaired consciousness in the Department of Emergency: a clinical study[J]. Chinese Journal of Hygiene Rescue(Electronic Edition), 2020, 06(06): 350-355.

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.

表1 424例不明原因昏迷患者的三间分布
表2 424例不明原因昏迷患者入院严重程度评估
表3 424例不明原因昏迷患者的病因分析
表4 424例不明原因昏迷患者的短期转归
表5 424例不明原因昏迷患者的最终转归
1
Kanich W, Brady WJ, Huff JS,et al.Alteredmental status:evaluation and etiology in the ED[J].Am J Emerg Med,2002,20(7): 613-617.
2
Martikainen K, Seppä K, Viita P,et al.Transientloss of consciousness as reason for admission to primary health care emergency room[J].Scand J Prim Health Care,2003,21(1): 61-64.
3
Horsting MW, Franken MD, Meulenbelt J,et al.The etiology and outcome of non-traumatic coma in critical care:a systematic review[J].BMC Anesthesiol,2015,15: 65.
4
Bjorkman J, Hallikainen J, Olkkola KT,et al.Epidemiology and aetiology of impaired level of consciousness in prehospital nontrauma patients in an urban setting[J].Eur J Emerg Med,2016,23(5): 375-380.
5
Braun M, Schmidt WU, Möckel M,et al.Coma of unknown origin in the emergency department:implementation of an in-house management routine[J].Scand J Trauma Resusc Emerg Med,2016,24: 61.
6
Howard BM, Kornblith LZ, Conroy AS,et al.The found down patient:a western trauma association multicenter study[J].J Trauma Acute Care Surg,2015,79(6): 976-982.
7
Mistry B, Stewart De Ramirez S, Kelen G,et al.Accuracy and reliability of emergency department triage using the emergency severity index:an international multicenter assessment[J].Ann Emerg Med,2018,71(5): 581-587.
8
Wuerz RC, Travers D, Gilboy N,et al.Implementation and refinement of the emergency severity index[J].Acad Emerg Med,2001,8(2): 170-176.
9
Tanabe P, Gilboy N, Travers DA.Emergency severity index version 4:clarifying common questions[J].J Emerg Nurs,2007,33(2): 182-185.
10
Edlow JA, Rabinstein A, Traub SJ,et al.Diagnosis of reversible causes of coma[J].Lancet,2014,384(9959): 2064-2076.
11
Forsberg S, Hojer J, Enander C,et al.Coma and impaired consciousness in the emergency room:characteristics of poisoning versus other causes[J].Emerg Med J,2009,26(2): 100-102.
12
Weiss N, Regard L, Vidal C,et al.Causes of coma and their evolution in the medical intensive care unit[J].J Neurol,2012,259(7): 1474-1477.
13
Forsberg S, Höjer J, Ludwigs U,et al.Metabolic vs structural coma in the ED - an observational study[J].Am J Emerg Med,2012,30(9): 1986-1990.
14
Lown DJ, Knott J, Rechnitzer T,et al.Predicting short-term and long-term mortality in elderly emergency patients admitted for intensive care[J].Crit Care Resusc,2013,15(1): 49-55.
15
Forsberg S, Höjer J, Ludwigs U.Prognosis in patients presenting with non-traumatic coma[J].J Emerg Med,2012,42(3): 249-253.
16
Mirhaghi A, Heydari A, Mazlom R,et al.Reliability of the emergency severity index:metaanalysis[J].Sultan Qaboos Univ Med J,2015,15(1): e71-e77.
17
van de Beek D, Cabellos C, Dzupova O,et al.ESCMID guideline:diagnosis and treatment of acute bacterial meningitis[J].Clin Microbiol Infect,2016,22(Suppl 3): S37-S62.
18
Soar J, Nolan JP, Böttiger BW,et al.European resuscitation council guidelines for resuscitation2015:section 3. Adult advanced life support[J].Resuscitation,2015,95: 100-114
19
ATLS Subcommittee,American College of Surgeons’ Committee on Trauma,International ATLS working group.American College of Surgeons’Committee on Trauma;International ATLS working group:Advanced trauma life support(ATLS®):the ninth edition[J].J Trauma Acute Care Surg,2013,74(5): 1363-1366.
20
Ntaios G, Bornstein NM, Caso V,et al.The European stroke organisation guidelines:astandard operating procedure[J].Int J Stroke,2015,10(Suppl A100): 128-135.
21
Bernhard M, Becker TK, Nowe T,et al.Introduction of a treatment algorithm can improve the early management of emergency patients in the resuscitation room[J].Resuscitation,2007,73(3): 362-373.
22
Bekelis K, Marth NJ, Wong K,et al.Primary stroke center hospitalization for elderly patients with stroke:implications for case fatality and travel times[J].JAMA Intern Med,2016,176(9): 1361-1368.
23
Lichtman JH, Jones SB, Leifheit-Limson EC,et al.30-day mortality and readmission after hemorrhagic stroke among Medicare beneficiaries in joint commission primary stroke center-certified and noncertified hospitals[J].Stroke,2011,42(12): 3387-3391.
24
Goodacre S, Nicholl J, Dixon S,et al.Randomised controlled trial and economic evaluation of a chest pain observation unit compared with routine care[J].BMJ,2004,328(7434): 254.
25
Hoang V, Nuwer MR.Changes in emergency department coverage for the neurologist[J].Neurol Clin Pract,2013,3(4): 334-340.
26
Moore SA, Wijdicks EF.The acutely comatose patient:clinical approach and diagnosis[J].Semin Neurol,2013,33(2): 110-20.
27
Hansen CK, Fisher J, Joyce NR,et al.A prospective evaluation of indications for neurological consultation in the emergency department[J].Int J Emerg Med,2015,8(1): 74.
28
Huff JS, Stevens RD, Weingart SD,et al.Emergency neurological life support:approach to the patient with coma[J].Neurocrit Care,2012,17(suppl 1): S54-S59.
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