Objective:To evaluate the clinical utility of noninvasive myocardial work (MW) assessment in detecting early left ventricular systolic dysfunction in patients with septic cardiomyopathy (SCM), with the aim of facilitating early diagnosis and reducing mortality.Methods:This prospective observational cohort study enrolled septic patients admitted to the Emergency Intensive Care Unit (EICU) of Lianyungang First People's Hospital between September 2024 and May 2025. Comprehensive clinical data, conventional echocardiographic parameters, and speckle-tracking echocardiography (STE) indices were collected within 24 hours of admission. Patients were categorized into two groups based on global longitudinal strain (GLS): the SCM group (study group) and the non-SCM group (control group). Baseline clinical characteristics, conventional echocardiographic parameters (including left ventricular ejection fraction [LVEF]), and advanced STE-derived myocardial work indices were compared between groups. Pearson correlation analysis was used to assess associations between myocardial work parameters and established functional markers (LVEF and GLS). The diagnostic performance of noninvasive myocardial work parameters for SCM identification was evaluated using receiver operating characteristic (ROC) curve analysis, and areas under the curve (AUC) were calculated and compared.Results:Among the 84 patients included, 42 were assigned to the SCM group and 42 to the non-SCM group. The SCM group exhibited significantly higher heart rate (HR) and high-sensitivity cardiac troponin I (Hs-cTnI) levels compared to controls (all P < 0.05), while other baseline clinical parameters showed no significant differences (all P > 0.05). Cardiac function assessment revealed significantly lower LVEF, GLS, global constructive work (GCW), global work efficiency (GWE), and global work index (GWI) in the SCM group (all P < 0.01). Global wasted work (GWW) was significantly higher in the SCM group ( P < 0.05). Correlation analysis showed significant positive correlations between LVEF and GWI ( r = 0.50), GCW (r = 0.48), and GWE ( r = 0.41) (all P < 0.01). Significant negative correlations were observed between GLS and GWI ( r = –0.81), GCW ( r = –0.71), and GWE ( r = –0.70) (all P < 0.01). ROC analysis demonstrated that myocardial work indices had strong diagnostic value for SCM identification, with GWI showing the highest predictive performance (AUC = 0.863), followed by GCW (AUC = 0.826) and GWE (AUC = 0.793). Conclusions:Noninvasive myocardial work parameters show considerable promise for the early detection of left ventricular systolic dysfunction in SCM patients, providing a novel diagnostic approach for timely clinical confirmation of the condition.
Objective:This study aimed to retrospectively analyze the incidence and influencing factors of tricuspid regurgitation (TR) in the short term after pacemaker lead implantation at the Second Affiliated Hospital of Zhejiang University School of Medicine, so as to provide evidence for understanding pacemaker lead-related TR.Methods:Consecutive patients who underwent single- or dual-chamber permanent pacemaker implantation between June 2019 and December 2023 in the Department of Cardiology were enrolled. General clinical data and relevant parameters were collected. Changes in TR severity before and shortly after the procedure were assessed using echocardiography. TR progression was defined as an increase by one grade or more, and TR improvement as a decrease by one grade or more. Logistic regression analysis was employed to identify factors associated with TR progression.Results:A total of 219 patients were included (128 males, 91 females), with a mean age of 69.7 ± 11.2 years. The median follow-up time was 99 (26, 199) days. TR remained unchanged in 114 patients (52.1%), improved in 46 (21.0%)—including 36 (16.4%) with one-grade reduction, 9 (4.1%) with two-grade reduction, and 1 (0.5%) with three-grade reduction—and progressed in 59 patients (26.9%). Among those with progression, 51 (23.3%) had mild-to-moderate TR worsening by one grade, and 8 (3.7%) had moderate or worse TR worsening by at least two grades. Notably, one case involved lead perforation of the leaflet and two cases had lead impingement. Compared with the non-progression group ( n = 114), pacemaker indication (AV block vs. sick sinus syndrome), baseline left atrial diameter, pulmonary artery systolic pressure (PASP), and the severity of mitral regurgitation (MR) and TR were significantly associated with TR progression or improvement (all P < 0.05). Ordinal logistic regression analysis identified preoperative TR severity [ OR=10.57 (3.77–29.68), P < 0.001] and pacemaker indication [ OR=0.452 (0.222–0.918), P = 0.028] as independent predictors of postoperative TR progression. Patients with AV block were more likely to receive left bundle branch pacing ( P < 0.001), which may contribute to their lower risk of TR. Conclusions:Short-term progression of TR after pacemaker implantation is relatively common, although severe TR remains rare. Preoperative TR severity and pacemaker indication are independent predictors of short-term TR progression. The use of physiological pacing modalities may help reduce the incidence of TR following pacemaker lead implantation.
Objectives:Fluid resuscitation is an important treatment for sepsis. However, the optimal choice of fluid is still controversial. This study aimed to investigate the effect of Sodium Bicarbonate Ringer’s Solution on the outcome of patients with sepsis.Methods:This was a single-center, prospective, randomized controlled clinical study, From July 2021 to June 2023, adult patients with Sepsis who met the diagnostic criteria of Sepsis 3.0 admitted to the Department of Critical Care Medicine of Jiangdu People's Hospital of Yangzhou were randomly assigned to the sodium bicarbonate ringer’s solution group or the normal saline group according to the random number table. Patients received either sodium bicarbonate ringer’s solution or normal saline as fluid for resuscitation and maintenance therapy. Clinicians determined the amount and rate of infusion based on volume assessment. The 30-day mortality, the degradation of endothelial glycocalyx degradation products at multiple time points, the mortality in intensive care unit (ICU), the incidence of major adverse renal events (MAKE30) within 30 days, and other clinical outcomes were compared between the two groups. Enzyme-Linked immunosorbent assay was used to determine the concentration of endothelial glycocalyx coating degradation products in peripheral blood. The count data were analyzed by χ 2 test, and the measurement data were analyzed by independent sample t test. Results:A total of 67 patients who met the inclusion criteria were enrolled during the study (32 patients in the sodium bicarbonate ringer’s solution group and 35 patients in the normal saline group). There were no significant differences in baseline data such as age, gender, underlying diseases, and SOFA score at enrollment between the two groups ( P>0.05).The 30-day mortality (28.1% vs. 40.0%), ICU mortality (15.6% vs. 20.0%) and MAKE30 (31.2% vs. 42.9%) in the sodium bicarbonate ringer’s solution group were lower than those in the normal saline group, but the differences were not statistically significant ( P>0.05). The levels of SCD-1(1317.3±206.9) pg/mL, HA (75.1±24.9) ng/mL and HS (75.6±13.8) ng/mL in the sodium bicarbonate ringer’s solution group were significantly lower than those in the normal saline group [(1514.6±264.9) pg/mL, (96.5±25.4) ng/mL, (85.8±15.8) ng/mL] on the third day (all P<0.05). Conclusion:Although the use of sodium bicarbonate ringer’s solution for resuscitation in sepsis patients cannot significantly reduce the 30-day mortality rate, but significantly reduce the degradation of polysaccharide coating, decrease the occurrence of hyperchloremia and acidosis.
Objective: To investigate and analyze the influencing factors of central venous catheter-associated bloodstream infection in patients with emergency hemorrhagic shock. Methods: According to the inclusion criteria, 249 patients with hemorrhagic shock and central venous catheterization admitted to the emergency department of Shanghai First People's Hospital from June 2016 to June 2022 were retrospectively analyzed, and divided into the infection group (54 cases) and the non-infection group (195 cases) according to whether catheter-related bloodstream infection occurred.Multivariate Logistic regression was used to analyze the relationship between central venous catheter-related bloodstream infection and various influencing factors. The etiological and drug susceptibility test data of peripheral venous blood culture, puncture site samples and catheter tip samples from patients with central venous catheter-associated bloodstream infection were statistically analyzed. Results: There were significant differences in age, catheterization location, ultrasound-guided puncture, APACHE ⅱ score, catheter indwelling time and application of broad-spectrum antibiotics between the infected group and the non-infected group (P<0.05). Staphylococcus epidermidis accounted for 44.4%, Escherichia coli 24.1%, and fungi 11.1% in 54 infected patients. The lowest resistance rate of Gram-positive cocci was to vancomycin (3.4%), followed by tetracycline 34.5%, and the highest resistance rate was to amoxicillin 100.0%. Conclusion: The risk factors of central venous catheter-related bloodstream infection in patients with emergency hemorrhagic shock include advanced age, femoral vein catheterization, non-ultrasound-guided puncture, high APACHE ⅱ score, catheter retention time, and application of broad-spectrum antibiotics. Staphylococcus epidermidis the common pathogen of central venous catheterization related infection in emergency hemorrhagic shock patients.
OBJECTIVES:To establish an early prediction model for acute pancreatitis (AP) complicated with acute kidney injury (AKI) and evaluate its diagnostic value. METHOD:AP patients were recruited from the Emergency Department at Peking University People's Hospital in 2021 and stratified into AKI and control (no AKI) groups. Their clinical data were analyzed. The risk for AKI development was determined using logistic analyses to establish a risk prediction model, whose diagnostic value was analyzed using a receiver operating characteristic curve. RESULTS:There was no significant difference in the basic renal function between the AKI (n = 79) and control (n = 179) groups. The increased triglyceride glucose index (odds ratio [OR], 2.613; 95% confidence interval [CI], 1.324-5.158; P = 0.006), age (OR, 1.076; 95% CI, 1.016-1.140; P = 0.013), and procalcitonin (OR, 1.377; 95% CI, 1.096-1.730, P = 0.006) were associated with AKI development. A model was established for prediction of AKI (sensitivity 79.75%, specificity 96.65%). The area under the receiver operating characteristic curve was 0.856 which was superior to the Ranson, Bedside Index for Severity in AP, and Acute Physiology and Chronic Health Evaluation II scores (0.856 vs 0.691 vs 0.745 vs 0.705). CONCLUSIONS:The prediction model based on age, triglyceride glucose, and procalcitonin is valuable for the prediction of AP-related AKI.
目的:探索一键卒中医嘱包在改进急性缺血性脑卒中静脉溶栓治疗中的价值。方法:选取上海交通大学医学院附属第一人民医院2021年1月至12月行静脉溶栓的急性缺血性脑卒中患者作为研究对象，分为启动一键医嘱包全流程改进的患者组（A组）和未启动一键医嘱包全流程改进的患者组（B组）。比较两组间的一般情况、发病后到院时间（onset to door time，ODT）、到院至CT检查时间（door to CT examination time，DCT）、到院至检验报告时间（door to laboratory time，DLT）、到院至溶栓时间（door to needle time，DNT）、美国国立卫生研究院卒中量表（national institute of health stroke scale，NIHSS）评分等资料。结果:A组29例和B组132例患者在年龄、性别、婚姻、血压、既往史、ODT等指标的差异均无统计学意义（ P>0.05）。而A组患者的DCT、DLT及DNT较B组均有显著缩短，差异有统计学意义（均 P<0.05）。A组45 min内DNT达标率较B组高（62.1% vs. 39.4%），差异有统计学意义（ P=0.026）。A组60 min内DNT达标率较B组高（82.8% vs. 69.7%），差异无统计学意义（ P=0.156）。 结论:一键包医嘱全流程可明显缩短急性缺血性脑卒中患者的DCT、DLT及DNT，有望成为临床中改善卒中患者预后的应用工具。
Objective:To optimize the dispatch of pre-hospital emergency resources and address the assessment challenge of ambulance demand, a pre-hospital emergency demand prediction model based on multi-model fusion was constructed.Methods:The retrospective study design method was adopted, and historical pre-hospital emergency dispatch records and corresponding weather data were extracted. Three types of primary learners were trained by 5-fold cross-validation, and the training results of the primary learners were fused by Stacking. The fusion results were input into the secondary learner as new features, and the final prediction results of ambulance demand were obtained by the secondary learner.Results:By comparison experiments, results showed that the multi-model fusion prediction model based on Stacking was superior to the single model in both mean absolute error and root mean square error, indicating that the model could predict ambulance demand more accurately.Conclusion:The pre-hospital emergency demand prediction model based on multi-model fusion could improve the accuracy and generalization ability of ambulance demand prediction by using historical emergency data and weather data, and provide strong support for the optimization of pre-hospital emergency resources.
创伤是全球45岁以下人群死亡的主要原因 [1]。据WHO报道，2018年有135万人死于道路交通伤害，创伤是5~29岁人群个体死亡的首要原因 [2]。预计到2030年，创伤将上升至全球第3位致残原因。致死性出血和失血性休克占创伤24 h内死亡的70%以上，不能及时有效的控制出血是可救治性创伤患者死亡的主要原因，是创伤急救面临的核心问题和主要挑战 [3,4]。创伤性活动性出血是指机体受创伤作用后，较大的血管破裂，血液不停地从损伤血管流出，若不及时采取止血措施，患者常因失血过多而危及生命 [5]。针对创伤活动性出血导致的失血性休克，高效出血控制、允许性低压复苏、延迟黄金救治时间窗等新的理念和技术的提出可有效的控制出血，降低患者的病死率 [6,7,8]。在临床工作中发现，医护人员对于创伤活动性出血患者的急救存在止血药物使用时间、止血带使用绑定部位、止血带加压压力及时间等疑惑，影响患者的紧急处理。本研究以澳大利亚Joanna Briggs Institute（JBI）循证卫生保健模式为理论框架，本院自2022年3月至9月在急诊抢救室开展基于证据的质量审查项目，旨在促进急诊成人创伤活动性出血患者止血措施最佳证据的转化，建立急诊成人创伤活动性出血患者止血标准，提高急诊医护人员对创伤活动性出血患者的评估和规范管理能力，提高止血效率及止血措施执行依从性，减少急诊停留时间，减低患者的病死率和致残率，改善患者的预后。
随着我国对核能的不断开发和探索，核技术在国民经济等各领域发挥了重要作用 [1,2]。另一方面，避免采取可能危及核设施安全运行和危及核物质安全的行动，是国家安全的底线。确保核与辐射安全，把核安全纳入国家安全整体工作当中，是党和国家对人民做出的庄严承诺，而核应急工作是确保核安全的重要保障 [3,4]。
目的:探讨低体温联合快速序贯器官衰竭评分（qSOFA），对严重创伤患者并发急性创伤性凝血病（acute traumatic coagulopathy, ATC）及其预后的预测价值。方法:采集2017年1月至2021年12月苏州大学附属第二医院创伤数据库中严重创伤患者的数据，使用回顾性队列研究方法，根据是否并发ATC分为ATC组和非ATC组，28 d预后分为生存组和死亡组，分别比较两组间临床特征的差异；采用二元Logistic回归分析差异有统计学意义的指标，来预测严重创伤患者并发ATC及28 d预后；绘制受试者工作特征曲线(ROC)分析RTS、ISS及TqSOFA（qSOFA评分+患者体温分值）评估创伤患者并发ATC和28 d死亡的效能；并比较TqSOFA对不同部位严重创伤患者ATC及预后评估的敏感度和特异度的差异。结果:严重创伤患者共509例，ATC发生率为12.0%，28 d病死率为23.4%。二元Logistic回归分析结果表明，并发ATC患者ISS、TqSOFA优势比分别为1.047和2.054；28 d死亡患者，其年龄、ISS、TqSOFA优势比分别为1.036、1.054、5.529。预测ATC的效能，RTS、ISS和TqSOFA的AUC值分别为0.729、0.683和0.743；预测28 d死亡的效能，RTS、ISS和TqSOFA评分的AUC值分别为0.742、0.762和0.784。TqSOFA对无TBI的严重创伤患者（NTBI）并发ATC及28 d生存的预测效能（AUC）分别是0.775和0.839；对伴有TBI的严重创伤患者（TBI+）预测效能0.765和0.786；对于单纯创伤性颅脑损伤患者（iTBI），其预测价值最低，分别是0.555和0.774。结论:低体温联合qSOFA评分可更好地预测严重创伤患者并发ATC及28d不良预后，提出了一种简单、快速且适合临床医师操作的评估工具，有助于对患者进行复温、早期输血等临床管理和转归预测，值得推广应用。
Objective:To retrospectively analyze the establishment and implementation effect of ECPR rapid response medical team in emergency department, and to explore a more efficient rescue mode.Methods:A total of 41 patients who started ECPR in the emergency room of a tertiary hospital in Beijing from November 2017 to September 2022 were selected as subjects. The 14 patients treated by the ECPR rapid response medical team in the emergency department were set as the experimental group, and the 27 patients treated by the ECPR team of the MDT mode led by the cardiac surgeon were set as the control group. The ECPR start-up time, pipeline pre-filling time, ECPR start-up to ECMO successful operation time, complication rate and treatment success rate were compared between the two groups.Results:There was no significant difference in the outcome between the two groups (all P>0.05), but the total time (min) of ECPR implementation by the rapid response medical team in the emergency department was shorter (20.86 ± 10.86 vs. 23.04 ± 11.40), the incidence of complications was lower, and the success rate of treatment was higher (28.57 % vs. 25.93 %). Conclusion:Establishing a mature ECPR rapid response team dominated by emergency medical care helps improve the rescue coordination and work efficiency, thereby providing the emergency protection and management of full -chain for the treatment of critical condition.
Objective:To investigate the clinical features and risk factors of infection in patients with heat stroke (HS).Methods:The patients with HS who were admitted to the emergency departments of seven hospitals, including West China Hospital of Sichuan University, the Second Affiliated Hospital of Chengdu Medical College and so on, between July 01, 2020 and September 30, 2022 were retrospectively analyzed. The basic characteristics and laboratory test results of the patients were collected. The patients were divided into infected group and non-infected group according to the etiological results, and the differences in clinical characteristics between the different groups were compared. Multivariate logistic regression was used to screen variables, and the predictive model was established and ROC curve was performed to compare the predictive efficiency with SOFA score.Results:During the study period, a total of 183 patients with HS were included, and 156 patients were finally included for analysis according to the inclusion and exclusion criteria. Among them, 58 cases (37.2%) were in the infected group. The mortality of infected group was significantly higher than that of non-infected group (41.4% vs. 25.5%, P < 0.05). Compared with the patients in non-infected group, the infected gourp serum procalcitonin, direct bilirubin, alanine transaminase (ALT), creatinine, lactate dehydrogenase (LDH), creatine kinase isoenzymes, myoglobin, activated partial thromboplastin time (APTT) and respiratory support ratio at admission were significantly higher and albumin level was lower in infected group (all P < 0.05). Multivariate logistic regression analysis showed that myoglobin, ALT, APTT and respiratory support required at admission were independent risk factors for HS co-infection. A prediction model was constructed based on these four indicators, and the area under ROC curve of the prediction model was 0.846, which was better than SOFA score (0.732, P < 0.05). Conclusions:The prognosis of patients with heat stroke complicated with infection were obviously poor. Myoglobin, ALT, APTT and need for respiratory support at admission are risk factors for HS complicated with infection. The prediction model based on these four indicators is better than SOFA score for the early identification of the HS patients with infection.
坏死性软组织感染(necrotizing soft tissue infections，NSTIs)是由病原微生物感染导致皮下组织、筋膜或（和）肌肉坏死的一类疾病。NSTIs起病急、病情进展快，致死致残率高。为了进一步规范NSTIs的临床诊疗，中国医师协会急诊医师分会、中华医学会急诊医学分会、中国急诊专科医联体、中国研究型医院学会休克与脓毒症专业委员会、中国医师协会急救复苏和灾难医学专业委员会和浙江省医学会灾难医学分会组织我国急诊医学科、感染科、烧伤/创伤外科、创面修复科等学科的专家组成编写委员会，结合国内外最新进展和临床诊疗经验，制定本共识。
Objective:Intravenous thrombolysis (IVT) in patients with acute ischemic stroke is strongly time-dependent.The purpose of this study was to investigate whether the transfer of ischemic stroke patients to hospital through emergency medical service (EMS) could shorten onset to needle time (ONT),onset to door time (ODT), door to imaging time(DIT), door to needle time(DNT) and improve the clinical outcomes of intravenous thrombolysis patients.Methods:We retrospectively collected the clinical and time data of acute ischemic stroke(AIS) patients who received IVT in the Affiliated Hospital of Qingdao University on Laoshan campus from September 2021 to August 2022 were retrospectively collected. Patients were divided into EMS group and Non-EMS group according to patients whether transferred by ambulance. The baseline characteristics, length of each period and differences in clinical outcome were compared. Good prognosis was defined as modified Rankin Scale score of 0-2 at 3-months.Results:A total of 175 patients aged (66.1 ±12.3) years were selected, including 63 females (36.0%) and 53 patients (30.3%) were transferred by EMS. Compared with the Non-EMS group, the patients in the EMS group were older, the baseline NIHSS score was higher, ODT and ONT were shorter (all P< 0.05), but there were no significant difference in DIT and DNT between the two groups. Binary Logistic regression model showed that after adjusting for age, sex, baseline NIHSS score, bridging therapy, history of atrial fibrillation, history of hypertension, the number of previous diseases and intracranial hemorrhage, EMS was independently associated with good prognosis of patients with acute ischemic stroke [odds ratio ( OR) 0.376, 95% confidence interval ( CI) 0.144~0.890, P=0.027). Conclusion:EMS could improve the clinical outcomes of acute stroke patients by shortening the ODT and ONT in patients with acute ischemic stroke.
Objective:To study the epidemiological data of 2601 in-hospital cardiac arrest (IHCA) patients in Renmin Hospital of Wuhan University from October 2019 to December 2021, describe the characteristics of IHCA, and discuss the early warning and prevention of IHCA.Methods:The patients were divided into cardiopulmonary resuscitation (CPR) group and DNAR group according to resuscitation implementation, and ROSC group and non- ROSC group according to resuscitation results. The characteristics of IHCA were retrospectively analyzed.Results:The male to female ratio of IHCA was 1.9, and the age was (67.05±16.23) years old. Acid-base imbalance/electrolyte disturbance, pulmonary infection, respiratory failure, and hypertension were the top four pre-cardiac arrest conditions, which occured in more than half of patients. The ROSC rate of all IHCA patients undergoing CPR was 24.3%, and the success rate of resuscitation in ICU patients was significantly higher than that in the general ward. The ROSC rate decreased significantly when IHCA occurred between 0 and 7 o 'clock.Conclusions:IHCA occurs mostly in elderly men. Early identification of risk factors before cardiac arrest is beneficial to early warning of cardiac arrest and improve the treatment rate of IHCA.
2012年荷兰Lambin首先提出"影像组学"的概念，是计算机深度分析结合大数据在临床中重要的应用研究，发展迅速。影像组学是对影像源文件经高通量提取深层次信息，分析图形纹理，量化处理，结合临床大数据分析，用于疾病预测与诊断治疗 [1]。目前影像组学广泛运用于肿瘤良恶性的诊断（如肺部、脑、前列腺）及预后判断 [2]。在非肿瘤性疾病领域的研究也日益增多，如阿尔兹海默病、肝硬化等疾病的鉴别诊断 [3]。在急重症领域的研究应用也越来越广泛，例如在急性心脑血管疾病关键问题的临床研究日渐成熟。本文将重点讨论影像组学在急重症非肿瘤性疾病的应用与进展，为后续影像组学在临床研究和应用提供更多的依据。
目的:了解河南省各级医院急诊科基本建设情况的现状。方法:对河南省18个地市的306家医疗机构的急诊科进行问卷调查，调查内容包括医院一般情况、人力资源情况、急诊科单元设置情况、业务技能开展情况以及急诊抢救室基本工作能力情况等五部分内容。结果:本研究共收到有效问卷229份，其中来自71家三级医院和158家二级医院。52家（73.24%）三级医院设置有EICU，床位中位数为12张，88家（55.70%）二级医院设有EICU，床位中位数为6张（ P < 0.01）。二级医院和三级医院急诊医生人数中位数分别为11人和22人（ P<0.01），男性医生的中位比例分别为58.58%和64.29%（ P<0.01）。只有19家（26.76%）三级医院急诊医生能独立完成气管镜检查，而独立完成ECMO操作的三级医院只有13家（18.31%）。尽管三级医院抢救室每年院前呼吸心脏骤停患者行心肺复苏术总例次数中位数为85例，高于二级医院的34例（ P<0.01），但是三级医院和二级医院的ROSC率无差异，中位数分别为14.2%和11.0%。 结论:河南省各级医院急诊科已初具规模，但整体的建设还需要进一步加强。
创伤是青壮年人群的首要死因，约30%~40%的创伤死亡因大量失血所致，失血也是严重创伤后"可预防性死亡"的主要原因。及时、快速控制出血，纠正失血性休克对严重创伤的救治至关重要，不仅可以有效减少严重创伤后继发性损伤所致的并发症，还可以大大降低"可预防性死亡" [1]的发生。中国医师协会急诊医师分会、中国人民解放军急救医学专业委员会、中国医师协会急诊医师分会急诊外科专业委员会针对创伤失血性休克紧急救治的关键问题，于2017年12月在国内首次推出了《创伤失血性休克中国急诊专家共识》 [2]，为中国急诊医生对此类患者进行诊疗工作提供了系统、全面的参考依据。随着时间的推移，在创伤失血性休克诊疗领域涌现了大量临床与基础研究，一些观念发生了变化。为此，编写组在第一版《共识》的基础上，以创伤救治流程的时间轴为主线，围绕创伤失血性休克诊疗关键问题，更新并依据最新临床证据总结推荐意见；通过全国急诊领域专家的共同讨论，以文献、数据的质量和每项推荐意见的收益与风险之间的平衡为基础进行了分级。临床证据的分级标准依据GRADE（grading of recommendations assessment, development and evaluation）评价系统制定，具体见表1。
水痘带状疱疹病毒（varicella-herpes zoster virus，VZV）属人类疱疹病毒a亚科，是水痘和带状疱疹病毒的病原体，既可感染免疫受损的成年人也可感染免疫正常的成年人 [1]。该病毒经呼吸道侵入人体后形成原发感染，临床表现为水痘。水痘好发于儿童，传染性强，常有皮肤水疱和发热症状。水痘痊愈后，病毒潜伏于脊髓后根神经节。当VZV的细胞介导免疫随着年龄的增长而减弱或在免疫受损状态时，VZV可以重新激活并引起临床表现为神经支配区的带状疱疹(继发感染)。在免疫受损个体或实体器官移植受者中，VZV可播散至全身，引起多器官组织病变，诱导肝炎、肺炎、脑炎甚至胰腺炎 [2]。内脏播散性VZV感染常危及生命，但因为内脏并发症往往先于皮肤爆发，故早期诊断具有挑战性。本例患者使用低剂量类固醇后罹患内脏播散性VZV感染，强调了早期诊断和及时治疗的重要性。
患者男性，35岁，主因"上腹部疼痛伴恶心呕吐4h"于2022-11-12 08:36至湖州市中心医院急诊科就诊。患者于4 h出现上腹部持续性剧烈绞痛症状，并伴有恶心、呕吐，呕吐物为胃液，有肛门停止排气排便。体格检查：血压190/100 mmHg（1 mmHg=0.133 kPa），心率159次/min，指氧饱和度98%，呼吸23次/min，肺部听诊呼吸音粗，啰音听诊不明显，心脏各瓣膜区杂音未及，腹部无压痛反跳痛。急诊内科医生开具血常规、超敏C反应蛋白、电解质、肝功能、肾功能、淀粉酶、凝血功能、D二聚体、肌钙蛋白I、肌红蛋白、肝胆胰腺B超检查。遗憾的是该患者未遵照医生的建议完善上述检查，并且未将上述情况告知医生，强烈要求医生予药物治疗改善腹痛、呕吐症状。所以医生开具了药物"甲氧氯普胺10 mg肌肉注射即用，间苯三酚注射液80 mg加入5%葡萄糖注射液250 mL静滴即用"。11:13患者家属再次来到急诊内科诊室并告知医生患者腹痛症状未缓解。医生此时发现该患者未完成此前开具的所有血化验及超声检查，立即陪同患者至急诊化验室抽取血化验标本。11:50该患者出现胸闷气促症状，随即送入抢救室。心电监护提示心动过速，心率162次/min，血压86/62 mmHg（1 mmHg=0.133 kPa），指氧饱和度92%，呼吸14次/min，立即查心电图，结果示：Ⅱ、Ⅲ、AVF、V 1~V 5 ST段广泛抬高。并加测床旁快速B型钠尿肽测定。12:10血化验结果全部取出，其异常的结果有：白细胞计数22.9×10 9/L,中性粒细胞计数百分率95.2 %，血红蛋白180.0 g/L，超敏C反应蛋白22.3 mg/L，肌酐209 μmol/L，镁1.80 mmol/L，D二聚体19.60 mg/L，BNP 1 256.1 pg/mL，肌钙蛋白I 11.43 pg/mL，肌红蛋白>1 200 ng/mL。12:15心电监护提示患者心率151次/min，血压86/62 mmHg，指氧饱和度92%，呼吸14次/min，同时查超声心动图，结果提示室间隔及室壁活动弥漫性减弱，心律失常，三尖瓣、二尖瓣、肺动脉瓣轻度反流，左室收缩功能不全。12:40患者突发肢体抽搐、双眼向上凝视、叹息样呼吸，心电监护示心律进行性下降至50次/min，查体颈动脉搏动未触及，意识丧失，立即行心肺复苏，呼吸球囊辅助通气，气管插管，机械辅助通气，并予药物"肾上腺素1 mg每3分钟静推（共20支）"。令人遗憾的是经过积极的抢救，该患者仍未恢复自主心率及呼吸，于14:00宣布死亡。
