Expert consensus on the evaluation and diagnosis of combat injuries of the Chinese People's Liberation Army

The accurate assessment and diagnosis of combat injuries are the basis for triage and treatment of combat casualties. A consensus on the assessment and diagnosis of combat injuries was made and discussed at the second annual meeting of the Professional Committee on Disaster Medicine of the Chinese People's Liberation Army(PLA). In this consensus agreement, the massive hemorrhage, airway, respiration, circulation and hypothermia(MARCH) algorithm, which is a simple triage and rapid treatment and field triage score, was recommended to assess combat casualties during the first-aid stage, whereas the abbreviated scoring method for combat casualty and the MARCH algorithm were recommended to assess combat casualties in level Ⅱ facilities. In level Ⅲ facilities, combined measures, including a history inquiry, thorough physical examination, laboratory examination, X-ray, and ultrasound examination, were recommended for the diagnosis of combat casualties. In addition, corresponding methods were recommended for the recognition of casualties needing massive transfusions, assessment of firearm wounds, evaluation of mangled extremities, and assessment of injury severity in this consensus.

Study of intra-abdominal hypertension prevalence and awareness level among experienced ICU medical staff

Background:Intra-abdominal hypertension(IAH) is a disease with high morbidity and mortality among critically ill patients.The study's objectives were to explore the prevalence of IAH and physicians' awareness of the 2013 World Society of Abdominal Compartment Syndrome(WSACS) guidelines in Chinese intensive care units(ICUs).Methods:A cross-sectional study of four ICUs in Southwestern China was conducted from June 17 to August 2,2014.Adult patients admitted to the ICU for more than 24 h,with bladder catheter but without obvious intravesical pressure(IVP) measurement contraindications,were recruited.Intensivists with more than 5 years of ICU working experience were also recruited.Epidemiological information,potential IAH risk factors,IVP measurements and questionnaire results were recorded.Results:Forty-one patients were selected.Fifteen(36.59%) had IVP?12mm Hg.SOFA(Sequential Organ Failure Assessment) hepatic and neurological sub-scores were utilized as independent predictors for IAH via logistic backward analysis.Thirty-seven intensivists participated in the survey(response rate:80.43%).The average score of each center was less than 35 points.All physicians believed the IAH prevalence in their departments was no more than 20.00%.A significant negative correlation was observed between the intensivists' awareness of the 2013 WSACS guidelines and the IAH prevalence in each center(r=-0.975,P=0.025).Conclusion:The prevalence and independent predictors of IAH among the surveyed population are similar to the reports in the literature.Intensivists generally have a low awareness of the 2013 WSACS guidelines.A systematic guideline training program is vital for improving the efficiency of the diagnosis and treatment of IAH.

Cross-sectional study of the educational background and trauma knowledge of trainees in the “China trauma care training” program

Background:Since the trauma knowledge of trauma providers correlates with the outcomes of injured patients,this study aims to assess the socio-demographic characteristics and levels of trauma knowledge of trainees in the China trauma care training(CTCT)program in addition to their post-course test results to provide support for the development of trauma care training programs and trauma systems in China.Methods:A cross-sectional study was conducted by collecting demographic information,hospital-related information and trauma knowledge of the trainees from 19 regions in China.All participants were assessed by questionnaires collecting the socio-demographic data,the trauma care knowledge levels and the information of the hospitals.Results:There were 955 males(78.9%)and 256 females(21.1%)enrolled.Among them,854 were physicians(70.5%),357 were registered nurses(29.5%).In addition,64 of them also played an administrative role in the hospitals(5.3%).The score of the trainees who were members of the emergency department staff(72.59±14.13)was the highest among the scores of all the personnel surveyed,followed by those of the trainees from the intensive care unit(ICU)(71.17±12.72),trauma surgery department(67.26±13.81),orthopedics department(70.36±14.48),general surgery department(69.91±14.79)and other departments(69.93±16.91),P=0.031.The score of the professors(73.09±15.05)was higher than those of the associate professors(72.40±14.71),lecturers(70.07±14.25)and teaching assistants(67.58±15.16),P<0.0001.The score of the individuals who attended experts’trauma lectures(72.22±14.45)was higher than that of individuals who did not attend the lectures(69.33±15.17),P=0.001.The mean scores before and after the training were 71.02±14.82 and 84.24±13.77,respectively,P<0.001.The mean score of trauma knowledge after the training of trainees from different provinces and with different educational backgrounds was higher than that before the training,with a statistically significant difference(P<0.05).Conclusions:The level of trauma knowledge of trauma care providers was associated with their department,professional position and previous participation in related academic conferences.Trauma care experience and participation in academic lectures and training program including CTCT may effectively improve individuals’level of trauma knowledge.

Effect of intra-abdominal volume increment on kidneys in minipigs with intra-abdominal hypertension after hemorrhagic shock and resuscitation

Background: To investigate the effect of intra-abdominal volume increment(IAVI) on intra-abdominal hypertension(IAH) in the kidneys.Methods: Eight minipigs were successfully established as IAH models and were randomly divided into two groups: the IAVI group and the sham-operated group. The intravesical pressure, inferior vena cava pressure and urine volume were measured before shock, 2 h after IAH, and 22 h after surgery, respectively. The following indices were measured: serum creatinine, urea nitrogen, renal cortical thickness, ratio of abdominal anteroposterior diameter/transverse diameter, renal thickness, diameter of the renal sinus and the wet/dry ratio of renal tissues.Results: The intravesical pressure(IVP) of the 8 minipig IAH models was calculated to be 21.16±4.63 mmHg. There was a significant increase in the abdominal anteroposterior diameter/transverse diameter ratio. The minipigs in the IAVI group survived during the observational period, whereas 2 minipigs died at 18 h and 20 h in the sham-operated group. Twenty-two hours after surgery, the animals in the IAVI group displayed increased urinary volume(UV) and decreased Cr and Ur and remarkable decreases of VP and IVCP. After IAH, the renal cortical thickness and the renal thickness increased significantly. The renal wet/dry ratio in the sham-operated group was higher than that in the IAVI group.Conclusion: IAVI helps to control renal dysfunction after IAH, which may be related to lowering the intra-abdominal pressure, thus alleviating renal edema and blood stasis.

An online survey of non-compressible torso hemorrhage:training is needed

Hemorrhage is the leading cause of combat deaths,which is a primary lesson learned from modern warfare.[1]If temporary hemostasis is not available,the mortality of non-compressible torso hemorrhage(NCTH),a potentially preventable death(PPD),is as high as 85.5%.[2]

Chinese expert consensus on echelons treatment of thoracic injury in modern warfare

The emergency treatment of thoracic injuries varies of general conditions and modern warfare. However, there are no unified battlefield treatment guidelines for thoracic injuries in the Chinese People's Liberation Army(PLA). An expert consensus has been reached based on the epidemiology of thoracic injuries and the concept of battlefield treatment combined with the existing levels of military medical care in modern warfare. Since there are no differences in the specialized treatment for thoracic injuries between general conditions and modern warfare, first aid, emergency treatment, and early treatment of thoracic injuries are introduced separately in three levels in this consensus. At Level Ⅰfacilities, tension pneumothorax and open pneumothorax are recommended for initial assessment during the first aid stage. Re-evaluation and further treatment for hemothorax, flail chest, and pericardial tamponade are recommended at Level Ⅱ facilities. At Level Ⅲ facilities, simple surgical operations such as emergency thoracotomy and debridement surgery for open pneumothorax are recommended. The grading standard for evidence evaluation and recommendation was used to reach this expert consensus.

Effect of SAM junctional tourniquet on respiration when applied in the axilla: A swine model

Purpose:SAM junctional tourniquet(SJT)has been applied to control junctional hemorrhage.However,there is limited information about its safety and efficacy when applied in the axilla.This study aims to investigate the effect of SJT on respiration when used in the axilla in a swine model.Methods:Eighteen male Yorkshire swines,aged 6-month-old and weighing 55-72 kg,were randomized into 3 groups,with 6 in each.An axillary hemorrhage model was established by cutting a 2 mm transverse incision in the axillary artery.Hemorrhagic shock was induced by exsanguinating through the left carotid artery to achieve a controlled volume reduction of 30% of total blood volume.Vascular blocking bands were used to temporarily control axillary hemorrhage before SJT was applied.In Group I,the swine spontaneously breathed,while SJT was applied for 2 h with a pressure of 210 mmHg.In Group II,the swine were mechanically ventilated,and SJT was applied for the same duration and pressure as Group I.In Group III,the swine spontaneously breathed,but the axillary hemorrhage was controlled using vascular blocking bands without SJT compression.The amount of free blood loss was calculated in the axillary wound during the 2 h of hemostasis by SJT application or vascular blocking bands.After then,a temporary vascular shunt was performed in the 3 groups to achieve resuscitation.Pathophysiologic state of each swine was monitored for 1 h with an infusion of 400 mL of autologous whole blood and 500 mL of lactated ringer solution.Tb and T0 represent the time points before and immediate after the 30% volume-controlled hemorrhagic shock,respectively.T30,T60,T90 and T120,denote 30,60,90,and 120 min after T0(hemostasis period),while T150,and T180 denote 150 and 180 min after T0(resuscitation period).The mean arterial pressure and heart rate were monitored through the right carotid artery catheter.Blood samples were collected at each time point for the analysis of blood gas,complete cell count,serum chemistry,standard coagulation tests,etc.,and thromboelastography was conducted subsequently.Movement of the left hemidiaphragm was measured by ultrasonography at Tb and T0 to assess respiration.Data were presented as mean±standard deviation and analyzed using repeated measures of two-way analysis of variance with pairwise comparisons adjusted using the Bonferroni method.All statistical analyses were processed using GraphPad Prism software.Results:Compared to Tb,a statistically significant increase in the left hemidiaphragm movement at T0 was observed in Groups I and II(bothp<0.001).In Group III,the left hemidiaphragm movement remained unchanged(p=0.660).Compared to Group I,mechanical ventilation in Group II significantly alleviated the effect of SJT application on the left hemidiaphragm movement(p<0.001).Blood pressure and heart rate rapidly increased at T0 in all three groups.Respiratory arrest suddenly occurred in Group I after T120,which required immediate manual respiratory assistance.PaO_(2) in Group I decreased significantly at T120,accompanied by an increase in PaCO_(2)(both p<0.001vs.Groups II and III).Other biochemical metabolic changes were similar among groups.However,in all 3 groups,lactate and potassium increased immediately after 1 min of resuscitation concurrent with a drop in pH.The swine in Group I exhibited the most severe hyperkalemia and metabolic acidosis.The coagulation function test did not show statistically significant differences among three groups at any time point.However,D-dimer levels showed a more than 16-fold increase from T120 to T180 in all groups.Conclusion:In the swine model,SJT is effective in controlling axillary hemorrhage during both spontaneous breathing and mechanical ventilation.Mechanical ventilation is found to alleviate the restrictive effect of SJT on thoracic movement without affecting hemostatic efficiency.Therefore,mechanical ventilation could be necessary before SJT removal.

Chinese Trauma Surgeon Association for management guidelines of vacuum sealing drainage application in abdominal surgeries-Update and systematic review

Vacuum sealing drainage (VSD) is frequently used in abdominal surgeries. However, relevant guidelines are rare. Chin ese Trauma Surge on Associati on orga nized a committee composed of 28 experts across China in July 2017, aiming to provide an evidence-based recommendation for the application of VSD in abdominal surgeries.Eleven questions regarding the use of VSD in abdominal surgeries were addressed:(1) which type of materials should be respectively chosen for the intraperitoneal cavity, retroperitoneal cavity and superficial incisions?(2) Can VSD be preventively used for a high-risk abdominal incision w让h primary suture?(3) Can VSD be used in severely contaminated/infected abdominal surgical sites?(4) Can VSD be used for temporary abdominal cavity closure under some special conditions such as severe abdominal trauma, infection, liver transplantation and intra-abdominal volume increment in abdominal compartment syndrome?(5) Can VSD be used in abdominal organ inflammation, injury, or postoperative drainage?(6) Can VSD be used in the treatment of intestinal fistula and pancreatic fistula?(7) Can VSD be used in the treatment of intra-abdominal and extra-peritoneal abscess?(8) Can VSD be used in the treatment of abdominal wall wounds, wound cavity, and defects?(9) Does VSD in crease the risk of bleeding?(10) Does VSD increase the risk of intestinal wail injury?(11) Does VSD increase the risk of peritoneal adhesion? Focusing on these questions, evidence-based recommendations were given accordingly. VSD was strongly recommended regarding the questions 2-4. Weak recommendations were made regarding questions 1 and 5-11. Proper use of VSD in abdominal surgeries can lower the risk of infection in abdominal incisions with primary suture, treat severely contaminated/infected surgical sites and facilitate temporary abdominal cavity closure.

Current trauma care system and trauma care training in China

损伤是威胁生活的现代疾病。结果能被成本效率、迅速的损伤照顾仅仅优化，它除了损伤照顾系统的造成分裂的革新开始必要能力和概念的革命的改进。根据来自发达国家的经验，系统的损伤照顾训练在损伤照顾上是归纳和改进的奠基石，例如进展损伤生活支持(ATLS ) 。当前，医院前紧急情况医疗服务(他们) 是在中国的健康服务的基础结构的必要元素之一，它对损伤照顾系统也基本。在此，有独立知识产权权利的训练的中国损伤照顾(CTCT ) 被开始了并且由中国损伤外科医生协会发射了也在损伤照顾的地里扩大新概念和技术在惯例增强通常接受得好的标准化协议。这篇文章考察损伤照顾系统以及训练的损伤照顾的当前的地位。

Prevalence and diagnosis rate of intra-abdominal hypertension in critically ill adult patients： A single-center cross-sectional study

Purpose： To investigate the prevalence and diagnosis rate of intra-abdominal hypertension （IAH） in a mixed-population intensive care unit （ICU）, and to investigate the knowledge of ICU staff regarding the guidelines published by the World Society of Abdominal Compartment Syndrome （WSACS） in 2013. Methods： A one-day cross-sectional study based on the WSACS 2013 guidelines was conducted in the general ICU of a tertiary teaching hospital in Chongqing, China. The included patients were divided into intravesical pressure （IVP） measured group and IVP unmeasured group. The epidemiologic data were recorded, and potential IAH risk factors （RFs） were collected based on the guidelines. IVP measurements were conducted by investigators every 4 h and the result was compared to that measured by the ICU staff to evaluate the diagnosis rate. Besides, a questionnaire was used to investigate the understanding of the guidelines among ICU staff. Results： Thirty-two patients were included, 14 in the IVP measured group and 18 in the IVP unmeasured group. The prevalence of IAH during the survey was 15.63% （5/32）, 35.71% （5/14） in IVP measured group. Only one case of IAH had been diagnosed by the ICU physician and the diagnosis rate was as low as 20.00%. Logistic regression analysis showed that sequential organ failure assessment （SOFA） score was an independent RF for IAH （OR： 1.532, 95Yg CI： 1.029-2.282, p- 0.036. Fourteen doctors and 5 nurses were investigated and the response rate was 67.86%. The average scores of the doctors and nurses were 27.14 ± 20.16 and 16.00 ± 8.94 respectively. None of them had studied the WSACS 2013 guidelines thoroughly. Conclusion： Patients with a higher SOFA score has a higher incidence of IAH. The IAH prevalence in 14 ICU patients with indwelling catheter was 35.71%. Strengthening the wide and rational use of WSACS guideline is important to improve the diagnosis of IAH.

Management of non-compressible torso hemorrhage:An update

With the widespread adoption of advanced tourniquets,the mortality rate of limb wound hemorrhage has decreased significantly,and non-compressible torso hemorrhage has gradually occupied the leading position of potentially preventable death,both in military and civilian circumstances.With the emergence of novel hemostatic devices and materials,strategies for the management of non-compressible torso hemorrhage have changed significantly.This review summarizes the current treatment strategies and types of equipment for non-compressible torso hemorrhage and suggests future research directions,hoping to provide a comprehensive review for the medical personnel and researchers engaging in this field.

Effect of retension sutures on abdominal pressure after abdominal surgery

PurposeTo 在未来的队学习包括了的腹的外科 patients.MethodsThis 在腹的压力和手术后的预后上评估保留缝术的效果进入弹跳的病人从 2014 年 5 月 15 日的医院到 2014 年 10 月 11 日。57 个病人的一个总数被注册，包括在在非保留缝术组的 U 类型保留缝术组，在断断续续的保留缝术组的 17 个病人，和 22 个病人的 18 个病人。为腹的创伤裂开的人口统计的数据，临床的数据和风险因素被记录。intraoperatively，膀胱压力(IVP ) 外科手术前地被监视并且四天手术后地。另外，腹的创伤裂开和感染的发生在操作以后的 14 天是 recorded.ResultsDuring 操作， IVP 减少了然后增加；它在它的最低 1 ? 在操作的开始以后的 h (5.3 ? mmHg 吗？？

Risk factors associated with the progression of extra-axial hematoma in the original frontotemporoparietal site after contralateral decompressive surgery in traumatic brain injury patients

Purpose:To introduced our experience with progressive extra-axial hematoma(EAH)in the original frontotemporoparietal(FTP)site after contralateral decompressive surgery(CDS)in traumatic brain injury patients and discuss the risk factors associated with this dangerous situation.Methods:This retrospective study was conducted on 941 patients with moderate or severe TBI treated in Daping Hospital,Army Medical University,Chongqing,China in a period over 5 years(2013e2017).Only patients with bilateral lesion,the contralateral side being the dominant lesion,and decompressive surgery on the contralateral side conducted firstly were included.Patients were exclude if(1)they underwent bilateral decompression or neurosurgery at the original location firstly;(2)although surgery was performed first on the contralateral side,surgery was done again at the contralateral side due to rebleeding or complications;(3)patients younger than 18 years or older than 80 years;and(4)patients with other significant organ injury or severe disorder or those with abnormal coagulation profiles.Clinical and radiographic variables reviewed were demographic data,trauma mechanisms,neurological condition assessed by Glasgow coma scale(GCS)score at admission,pupil size and reactivity,use of mannitol,time interval from trauma to surgery,Rotterdam CT classification,type and volume of EAH,presence of a skull fracture overlying the EAH,status of basal cistern,size of midline shift,associated brain lesions and types,etc.Patients were followed-up for at least 6 months and the outcome was graded by Glasgow outcome scale(GOS)score as favorable(scores of 4e5)and unfavorable(scores of 1e3).Student's t-test was adopted for quantitative variables while Pearson Chi-squared test or Fisher's exact test for categorical variables.Multivariate logistic regression analysis was also applied to estimate the significance of risk factors.Results:Initially 186 patients(19.8%)with original impact locations at the FTP site and underwent surgery were selected.Among them,66 met the inclusion and exclusion criteria.But only 50 patients were included because the data of the other 16 patients were incomplete.Progressive EAH developed at the original FTP site in 11 patients after the treatment of,with an incidence of 22%.Therefore the other 39 patients were classified as the control group.Multivariate logistic regression analysis showed that both the volume of the original hematoma and the absence of an apparent midline shift were significant predictors of hematoma progression after decompressive surgery.Patients with fracture at the original impact site had a higher incidence of progressive EAH after CDS,however this factor was not an important predictor in the multivariate model.We also found that patients with progressive EAH had a similar favorable outcome with control group.Conclusion:Progressive EAH is correlated with several variables,such as hematoma volumes10 mL at the original impact location and the absence of an apparent midline shift(<5 mm).Although progressive EAH is devastating,timely diagnosis with computed tomography scans and immediate evacuation of the progressive hematoma can yield a favorable result.

Comment on the ＂fatal accident due to anti-personnel ARGES EM01 rifle grenade explosion＂

爆炸成为了战斗伤亡的死亡的最普通的原因之一。我在其死亡的原因是 355 g 步枪手榴弹的意外表示并且考察了强风损害的临床的途径和策略的尸体的一个案例上做了一个评价。