Chinese expert consensus on clinical treatment of adult patients with severe traumatic brain injury complicated by corona virus disease 2019 (version 2023) / 中华创伤杂志

The condition of patients with severe traumatic brain injury (sTBI) complicated by corona virus 2019 disease (COVID-19) is complex. sTBI can significantly increase the probability of COVID-19 developing into severe or critical stage, while COVID-19 can also increase the surgical risk of sTBI and the severity of postoperative lung lesions. There are many contradictions in the treatment process, which brings difficulties to the clinical treatment of such patients. Up to now, there are few clinical studies and therapeutic norms relevant to sTBI complicated by COVID-19. In order to standardize the clinical treatment of such patients, Critical Care Medicine Branch of China International Exchange and Promotive Association for Medical and Healthcare and Editorial Board of Chinese Journal of Trauma organized relevant experts to formulate the Chinese expert consensus on clinical treatment of adult patients with severe traumatic brain injury complicated by corona virus infection 2019 ( version 2023) based on the joint prevention and control mechanism scheme of the State Council and domestic and foreign literatures on sTBI and COVID-19 in the past 3 years of the international epidemic. Fifteen recommendations focused on emergency treatment, emergency surgery and comprehensive management were put forward to provide a guidance for the diagnosis and treatment of sTBI complicated by COVID-19.

Experts consensus on the management of delirium in critically ill patients / 中华内科杂志

To establish the experts consensus on the management of delirium in critically ill patients.A special committee was set up by 15 experts from the Chinese Critical Hypothermia-Sedation Therapy Study Group.Each statement was assessed based on the GRADE (Grading of Recommendations Assessment,Development,and Evaluation) principle.Then the Delphi method was adopted by 36 experts to reassess all the statements.(1) Delirium is not only a mental change,but also a clinical syndrome with multiple pathophysiological changes.(2) Delirium is a form of disturbance of consciousness and a manifestation of abnormal brain function.(3) Pain is a common cause of delirium in critically ill patients.Analgesia can reduce the occurrence and development of delirium.(4) Anxiety or depression are important factors for delirium in critically ill patients.(5) The correlation between sedative and analgesic drugs and delirium is uncertain.(6) Pay attention to the relationship between delirium and withdrawal reactions.(7) Pay attention to the relationship between delirium and drug dependence/ withdrawal reactions.(8) Sleep disruption can induce delirium.(9) We should be vigilant against potential risk factors for persistent or recurrent delirium.(10) Critically illness related delirium can affect the diagnosis and treatment of primary diseases,and can also be alleviated with the improvement of primary diseases.(11) Acute change of consciousness and attention deficit are necessary for delirium diagnosis.(12) The combined assessment of confusion assessment method for the intensive care unit and intensive care delirium screening checklist can improve the sensitivity of delirium,especially subclinical delirium.(13) Early identification and intervention of subclinical delirium can reduce its risk of clinical delirium.(14) Daily assessment is helpful for early detection of delirium.(15) Hopoactive delirium and mixed delirium are common and should be emphasized.(16) Delirium may be accompanied by changes in electroencephalogram.Bedside electroencephalogram monitoring should be used in the ICU if conditions warrant.(17) Pay attention to differential diagnosis of delirium and dementia/depression.(18) Pay attention to the role of rapid delirium screening method in delirium management.(19) Assessment of the severity of delirium is an essential part of the diagnosis of delirium.(20) The key to the management of delirium is etiological treatment.(21) Improving environmental factors and making patient comfort can help reduce delirium.(22) Early exercise can reduce the incidence of delirium and shorten the duration of delirium.(23) Communication with patients should be emphasized and strengthened.Family members participation can help reduce the incidence of delirium and promote the recovery of delirium.(24) Pay attention to the role of sleep management in the prevention and treatment of delirium.(25) Dexmedetomidine can shorten the duration of hyperactive delirium or prevent delirium.(26) When using antipsychotics to treat delirium,we should be alert to its effect on the heart rhythm.(27) Delirium management should pay attention to brain functional exercise.(28) Compared with non-critically illness related delirium,the relief of critically illness related delirium will not accomplished at one stroke.(29) Multiple management strategies such as ABCDEF,eCASH and ESCAPE are helpful to prevent and treat delirium and improve the prognosis of critically ill patients.(30) Shortening the duration of delirium can reduce the occurrence of long-term cognitive impairment.(31) Multidisciplinary cooperation and continuous quality improvement can improve delirium management.Consensus can promote delirium management in critically ill patients,optimize analgesia and sedation therapy,and even affect prognosis.

Clinical effects of damage control surgery in treatment of severe craniocerebral injury combined with multiple extremity fractures / 中华创伤杂志

Objective To investigate the effects of damage control surgery (DCS) in the treatment of severe craniocerebral injury patients combined with multiple extremity fractures.Methods The clinical data of 128 patients with severe craniocerebral injury[Glasgow coma scale (GCS) scored 3-8] combined with multiple extremity fractures admitted from May 2011 to August 2015 were retrospectively analyzed by case-control study.There were 81 males and 47 females,with an average age of 37.3 years (range,19-77 years).The patients were treated with intracranial pressure monitoring in addition to the common administration.The patients were subdivided into two groups:87 patients treated with DCS concept as damage control group and 41 patients treated with non-DCS routine concept as control group.The DCS group received craniotomy and fracture fixation operation in stage Ⅰ with selective operation of open reduction and internal fixation.The control group received craniotomy and open reduction and internal fixation in stage Ⅰ.The postoperative intracranial pressure,operation duration,intraoperative blood loss,hospital stay and prognosis [Glasgow outcome scale (GOS)] were analyzed statistically.Results No intracranial infection was found in all patients during the treatment process.In damage control group,the postoperative intracranial pressure was normal in 44 cases (51％),which was significantly better than that in control group [8 cases (20％)] (P ＜ 0.05).In damage control group,operation duration [(150.1 ± 12.4)minutes],intraoperative blood loss [(270.6 ± 15.3)ml],and hospital stay [(29.7 ± 9.3) days] were significantly shortened compared with control group,whose operation duration,intraoperative blood loss and hospital stay were (270.6 ± 9.8) minutes,(460.2 ± 17.5) ml,and (34.4 ± 6.2) days,respectively (P ＜ 0.05).The GOS rating of damage control group (70％) was notably higher than that in control group (42％) (P ＜ 0.05).Conclusion For severe craniocerebral injury patients combined with multiple extremity fractures,the application of DCS contributes to control of postoperative intracranial pressure,which can also shorten the duration of hospitalization and improve prognosis.

The clinical research of multi-target lateral puncture combined with intracranial pressure monitoring in treatment of basal ganglia hypertensive cerebral hemorrhage / 中国医师进修杂志

Objective To compare the clinical efficacy of multi-target lateral puncture combined with intracranial pressure monitoring in treatment of basal ganglia hypertensive cerebral hemorrhage. Methods Sixty-six patients of basal ganglia hypertensive cerebral hemorrhage, with bleeding volume over 40 ml were divided into experimental group (36 cases) and control group (30 cases) by random digits table method. Patients in experimental group underwent multi-target puncture combined with routine intracerebroventricular treatment of intracranial pressure monitoring,and patients in control group underwent frontotemporal craniotomy and small hematoma decompressive craniotomy. The operation time, length of stay, hematoma evacuation rate, catheter drainage time, total amount of mannitol, Glasgow Coma Scale (GCS) scores 3 days after treatment, complication rate and 3-month Glasgow Outcome Scale (GOS) scores were recorded and compared between two groups. Results The operation time, length of stay, hematoma evacuation rate 1 day after treatment, and total amount of mannitol in experimental group were significantly lower than those in control group: (67.5±8.0) min vs. (109.3±9.6) min, (18.6±4.2) min vs. (23.3±5.9) min, (59.7±9.2)% vs. (80.4±11.6)%, (668.6±83.5) g vs. (1 430.4±107.1) g, P0.05). The GOS scores in experimental group: 5 points (9 cases), 4 points (10 cases), 3 points (8 cases), 2 points(5 cases), and 1 point(4 cases). The GOS scores in control group: 5 points (4 cases), 4 points (4 cases), 3 points (7 cases), 2 points (9 cases), and 1 point (6 cases). Long curative effect in experimental group was better than that in control group (Z =2.318, P =0.020). The incidence of intracranial air in experimental group was significantly higher than that in control group: 27.8%(10/36) vs. 3.3%(1/30), P0.05). Conclusions Multi-target lateral puncture combined with intracranial pressure monitoring in treatment of basal ganglia hypertensive cerebral hemorrhage has more advantages, including less trauma, wide surgical indications, short operation time and hospital stay, less postoperative mannitol, and decreased mortality rate. For older, patients with organ dysfunction, and patients who can not tolerate craniotomy, it is an effective treatment, and worthy of promotion.

Clinical application of ventricular intracranial pressure monitoring in severe craniocerebral trauma / 中华创伤杂志

Objective To investigate the clinical value of ventricular intracranial pressure monitoring in treatment of severe craniocerebral trauma with high intracranial pressure.Methods A retrospective analysis was conducted on forty cases of severe craniocerebral trauma with GCS score of 3-5 undergone bilateral decompressive craniectomy from October 2010 to January 2012.The patients were divided into three groups:Group A (12 cases received craniotomy after the placement of ventricular intracranial pressure probe) ; Group B (15 cases had craniotomy ahead of the probe placement) ; control group (13 cases had probe placement alone).Intracranial pressure control,dose and duration of administration of dehydrator and prognosis were compared among groups.Results Groups A and B showed a better result in aspects of controlling intracranial pressure within 15 mm Hg,dose and duration of mannitol treatment,and prognosis,as compared with control group (P ＜ 0.05).Furthermore,Group A had seven cases of severe disability or in vegetable state,but only three cases in Group B (P ＜ 0.05).Conclusion Ventricular intracranial pressure monitoring can effectively reduce intracranial pressure,raise treatment success rate and decline the use of mannitol in management of severe craniocerebral trauma.

Some Important Aspects in Medical Education / 中华医学教育探索杂志

Nowadays,in order to cultivate a great number of high-quality clinicians,on students it is essential for medical university to strengthen education of humanities,excite aspiration for innovating,cultivate innovation ability and teach the modern medical knowledge with science and rational method.The author has given his reasons and made suggestions for the opinion in the article.