肝衰竭时因乳酸代谢障碍使机体乳酸水平升高,近年来研究血乳酸对肝衰竭的预后具有较高的预测价值.结合近年来的研究发现,介绍LiFe评分预测模型,就血乳酸水平在肝衰竭患者中临床应用的国内外进展进行综述.认为高乳酸水平是肝衰竭患者不良预后的独立危险因素,提出乳酸可作为评估肝衰竭严重程度及预后的重要指标,并能进一步优化相关肝病预后评分系统.

按全链条干预观点分析各时段的伤病死亡与救治潜力,以急救时效学观点建立数学计算模型公式,代入课题组既往对现场、院前"120"、急诊和重症医学科的抢救成功率等结果,计算出实际、理想的结果.按照国家对意外事故的经济损失补偿为基础,引入经济学研究,模拟白金十分钟时效应急的经济学分析模型,计算白金十分钟理论进行院外自救互救因素的影响,可以推广到其他疾病的经济学研究,对促进社会和国家在应急救援的判断和决策、急救培训和相关设施投入方面有现实的指导意义.

总结白金十分钟时效性自救互救的学术专业理论,阐明急救时效学、急救时效经济学、急救的时效性与时效值、时效学研究方法等概念,通过对流行病学数据的分析提出重特大自然灾害的自救互救的应对策略,重新认识白金十分钟全国自救互救志愿公益服务联盟的时效应急成果对国家应急救援的指导意义,规范白金十分钟自救互救理论与实践的培训和操作流程,提出链式流程的医学救援方案,开展白金十分钟围心跳骤停心理学研究,加快和推进国家时效应急领域的科学研究,为构建和实践新时代中国特色应急救援理论奠定基础.

Objective To study the success of “public cardiopulmonary resuscitation(CPR)”,and put forward the “platinum ten minutes plan of public CPR”.Methods In the past 10 years from the major security,public places,competition venues and condition that the author execute task out of hospital,16 successful cases of CPRwere analyzed using the information collected,the occurrence time,sex,age,place of occurrence,breathing and heartbeat stop,the first aid status,the beginning time of the rescue,the rescue,the time of the connection,the result,etc.Results 16 cases,(13 vs 3 were male vs female),7 cases were middle and young,6 cases of children,2 cases of old people,8 case of international sports competition and garden ,2 case of swimming pool,villa 6,cases of other public places.Accidental causes:drowning and suffocation in 6 cases,4 cases of sports,accident in 3 cases,2 cases of electric shock,1 cases of trauma.The first reaction was:7 witnesses (1 of the family),6 medical personnel,3 ambulance.Rescue response time:From the discovery of the situation,the judge after the chest compression began to (54.36 ± 45.46 )s(immediately press 30 seconds)seconds.Rescue methods:15 cases with CPR,1 cases with back running CPR ,and 3 cases with AED.And the professional connection time is 7.13 ±2.66 mins .These are completed in 8-10 within minutes.In addition to 5 cases of late complications of death.The other did not leave a clear brain damage.Conclusion In the field of CPR the golden 4 mins concept needs to be improved;public CPR of “platinum ten minutes plan”is:immediately began,the rapid convergence,that is within 1 minutes to start the chest press,follow-up (AED)or professional rescue within 7 minutes;we want more accurate and more scientific dissemination of first aid theory and philosophy.

Objective To observe the clinical feasibility of disposable ejection-type intraosseous infusion device in cardiopulmonary resuscitation (CPR). Methods In the process of clinical rescue of patients with heart and lung resuscitation, 8 bone marrow puncture points were selected from four locations including the upper end of the tibia, the distal radius, the humerus head and sternum. The ejection-type intraosseous infusion device was used together with conventional venous infusion and the relating indicators were observed and analyzed. Results Clinical observation was performed in 38 patients (35 in ICU and 3 in orthopedics department), including 24 males and 12 females at age range of 17-78 years. Rescue was failed in 9 patients. Restoration of spontaneous circulation (ROSC) was succeeded in 29 patients including 8 patients with ROSC maintenance within 4 hours and 21 patients with ROSC over 4 hours. Infusion speed free from pressure in upper end of the tibia, the distal radius, the humerus head and sternum was 16.5 mL/min, 7.2 mL/min, 15.0 mL/min and 23.8 mL/min respectively. The infusion speed under pressure could reach 50 mL/min or higher. Time for successful insertion was 15-120 seconds. The operation could be completed within 15-20 seconds for the skilled person and within 60-120 seconds for the unskilled persons. The needle could be retained for 4-6 hours, and no fracture was observed. The intraosseous infusion included plasma, plasma substitutes, normal saline or Ringer′s solution. The success rate of disposable ejection-type intraosseous infusion device was 100% (38/38). Conclusion Bone marrow infusion with aid of disposable ejection-type intraosseous infusion device can be used not only in pre-hospital, but also in hospitals or even in ICU, where a fast and reliable fluid resuscitation is required in order to achieve the best effect of resuscitation within platinum 10 . Key words: Bone marrow infusion; Intraosseous infusion device; Emergency timeliness; Platinum 10 minutes

目的：探讨弹射式一次性骨髓腔输液器在临床的应用价值。方法在多家军地医院对输液时建立静脉通道失败、批量伤病员需紧迫建立输液通道、需建立心肺复苏输液通路的患者，使用自主研发的弹射式一次性骨髓腔输液器进行输液，选择内踝胫骨下端、胫骨上端、骼前上棘、髂后上棘、桡骨远端、肱骨头、胸骨7个部位13个骨髓穿刺点，观察并统计相关临床指标。结果47例患者共进行52例次骨髓腔输液，男性31例，女性16例；年龄23～75岁；其中重症医学科39例次（先后2个部位行骨髓腔输液者5例）。急诊科9例次，其他科室3例次，长途转运1例次；心肺复苏28例次，休克复苏18例次，术后大出血抢救5例次，肿瘤1例次；输入液体有血浆、血浆代用品、生理盐水或林格液；内踝胫骨下端、胫骨上端、骼前上棘、桡骨远端、肱骨头、胸骨部位的重力输液速度分别为30.0、15.4、21.2、7.2、15.0、23.8 mL/min；加压输液速度可以达到50.0 mL/min或更高；操作成功时间15～120 s，保留时间20 min～2.5 d。拔针后进行局部观察，仅2例出现液肿，均未发生骨折。47例次完成操作，成功率为90.3%，其中于髂后上棘处取骨髓标本2例；不成功原因中操作不当4例，器械故障1例。结论骨髓腔输液不仅在院前、院内，即使是重症监护病房（ICU），也可以发挥其快速、可靠、便捷的输液优势，在“白金10 min”内取得最佳的复苏效果。

OBJECTIVE:To investigate the diagnosis and effectiveness of limited operative treatment for multisegmental lumbar disease.METHODS:Between February 2008 and February 2011, 47 patients with multi-segmental lumbar disease were treated, including 27 males and 20 females with an average age of 60.3 years (range, 38-82 years) and a median disease duration of 21 months (range, 6 months to 7 years). Based on preoperative clinical manifestation and imaging examination results, the possibility of preliminary responsible segment was identified as two levels in 31 cases (L4,5 and L5, S1 in 22 cases, L3,4 and L4,5 in 6 cases, L2,3 and L3,4 in 3 cases) and three levels in 16 cases (L3,4, L4,5, and L5, S1 in 9 cases, L1,2, L4,5, and L4, S1 in 4 cases, L2,3, L4,5, and L5, S1 in 3 cases). Selective nerve root block (SNRB) was used in all cases to identify the responsible segment. Based on the results, the patients were treated by limited operative treatment. The operation time, intraoperative blood loss, postoperative drainage volume, postoperative ambulation time, and complications were recorded. The clinical outcome was evaluated according to the visual analogue scale (VAS) scores for back and leg pain, Japanese Orthopaedic Association (JOA) scores, and Oswestry disability index (ODI). The position of internal fixators and interbody fusion were observed through lumbar anteroposterior and lateral X-ray films.RESULTS:The responsible segment was identified as single level in 33 cases (L4,5 in 18 cases, L5, S1 in 11 cases, and L3,4 in 4 cases) and two levels in 10 cases (L4,5 and L5, S1 in 6 cases, L3,4 and L4,5 in 3 cases, L2,3 and L4,5 in 1 case) by SNRB. After SNRB, 4 cases did not receive surgical treatment because of a low relief rate of less than 30%. The operations were performed successfully in all 43 patients. The mean operation time was 101.9 minutes; the mean intraoperative blood loss was 164.5 mL; the mean postoperative drainage volume was 238.9 mL; and the mean postoperative ambulation time was 38.2 hours. There was no complication of nerve injury or incision infection. All 43 patients were followed up 12-36 months (mean, 19.3 months). The VAS scores, JOA scores, and ODI after operation were significantly improved when compared with preoperative ones (P < 0.05). The postoperative JOA recovery rates were 62.2% +/- 12.6%, 63.4% +/- 12.4%, and 68.6% +/- 14.6% at 3, 6 months, and last follow-up respectively, showing no significant difference (F = 2.841, P = 0.062). The postoperative X-ray films showed that the internal fixators were in good position without loosening or fracture, and the interbody fusion was good.CONCLUSION:After identifying the responsible segment by SNRB in the diagnosis, limited operative treatment is safe and reliable in the treatment of multi-segmental lumbar disease. It can relieve compression effectively, decrease the range of operation, maintain the spinal stabilization, and has a good effectiveness.

Objective To analyze and explore the surgical treatment methods and clinical outcomes of comminuted fractures of the patella. Methods The data of 18 patients with comminuted fractures of the patella who were treated in our department from February 2007 to March 2012 were retrospectively analyzed. Among them, there were 13 males and 5 females, whose average age was 41 years old ( range;20-61 years ). According to the classification of comminuted fractures of the patella made by Pengjian Wang and so on, 11 patients were at III A, 6 patients at III B and 1 patient at III C. All patients underwent open reduction and internal fixation with tension band, multiple K-wire and annular steel-wire. The X-rays of the patients were reviewed in the clinic monthly after the operation, and rehabilitation exercises were introduced to them. The treatment outcomes were measured by the operation time, flatness of the patellar articular surfaces, start time after the operation, loss of reduction during the follow-up postoperatively, surgical incision healing time, bone fracture healing time, function of the knee joints and so on. Results All the 18 patients were followed up for an average period of 16 months ( range;6-24 months ). The average operation time was 120 min ( range;100-150 min ). The intraoperative fluoroscopy and postoperative X-rays showed the flatness of the patellar articular surfaces was satisfactory. Gradual functional exercises were started 3 days postoperatively. Sutures were removed 12-14 days postoperatively, with no surgical site infection or poor healing. The X-rays showed no loss of reduction during the follow-up postoperatively. Bone healing of the fractures was obtained in all the 18 patients after an average period of 9 weeks ( range; 6-11 weeks ). According to Yupu Lu’s standard of knee joint function evaluation, there were 10 excellent cases, 6 good and 2 fair, and the excellence and good rate was 88.9%. Conclusions Tension band can maintain the stabilization of the fractures, so as to improve the early postoperative activities. Multiple K-wire can prop annular steel-wire and tension band up. Annular steel-wire can ensure good reduction and prevent its loss. Internal fixation with tension band, multiple K-wire and annular steel-wire is an effective treatment method for comminuted fractures of the patella, with the advantages of simple operation, reliable fixation, early functional exercises and exact effects.

目的 探讨皮肤病专科医院意外急症事件的防范措施与对策.方法 制定防范措施方案,皮肤病专科医院3年内皮肤科诊治过程中发生意外事件112例,87例为自感不适,缓解时间<10 min并继续专科诊治,抢救25例(住院和门诊就诊患者男17例,女8例,年龄15～75岁).对在不同科室突发病情变化时的抢救、转运过程进行分析.结果 意外医疗事件112例,在就诊过程或住院期间突发病情变化并抢救25例.抢救成功率100%(25/25).其中住院患者处置完毕时间在50～60 min,门诊患者处置完毕时间<20 min.没有出现转运途中死亡,随访28 d均无转运者死亡.无纠纷事件发生.结论 专科医院建立院内诊疗过程意外医疗事件的防范方案可以防范死亡,避免医疗纠纷.

Objective To investigate the effects of long-term oral administration of warfarin on cardiac valvular calcification. Methods Thirty-four patients who received oral administration of warfarin for over one year,and 18 disease condition-matched controls were selected. Echocardiography was performed to detect the valvular calcification. Some calcium metablic factors 〔calcium,phosphate,parathyroid hormone (PTH),alkaline phosphatase (AKP)〕,inflammation indicators 〔including high-sensitive C reactive protein (HsCRP),low density lipid cholesterol (LDL-C)〕,and calcification related matrix proteins 〔matrix Gla protein (MGP),osteopontin (OPN),Fetuin-A〕 were analyzed. The incidence of osteoporosis was recorded. Results The incidence of valvular calcification was 14.7% in warfarin group,and 11.1% in control group,with no significant difference between two groups. Serum MGP concentration was significantly lower in warfarin group 〔(3.7±1.9) nmol/L〕 than in control group 〔(11.0±4.3) nmol/L〕. OPN concentration was significantly higher in warfarin group 〔(154±56 ) μg/L〕 than in control group 〔(86±35) μg/L〕. Fetuin-A level was not different between the two groups. AKP level was significantly higher in warfarin group 〔(79±10) U/L〕 than in control group 〔(65±8) U/L〕. There was no difference in serum calcium,phosphate,PTH between the two groups. The patients suffering from osteoporosis accounted for 52.9% in warfarin group,higher than that in control group (38.9%). Conclusion Long-term oral administration of warfarin does not add the risk of valvular calcification,but increases the incidence of osteoporosis,which is not obviously associated with arterial inflammation,but might be associated with changes of MGP level.

Objective Investigate about the management of lower limb ulcer complicated with diabetes.Methods Review the 12 cases with lower limb ulcer complicated with diabetes who were treated in the emergency department of our hospital last year.All the cases had the blood sugar controlled by insuline,infection treated by antibiotic,blood circulation improved by the traditional chinese medicine injection,and local wound surface managed with the traditional chinese medicine slurry.Meanwhile the patients get learned some knowledge about diabetes.Results All the cases healed.Among them,1 case had the toe amputated,one had the skin grafted,and all others get wound healed.There were no ulcer recur in follow-up period of 1~3 years.Conclusion The patients with lower limb ulcer complicated with diabetes could get healed depending on combined therapy.Self-management of diabetes patients has much more importance.

干休所已逐渐成为现代生活的基本结构,完善干休所医疗保障体制、提高干休所抢救脱险率将成为应对意外医疗事件的工作目标.根据临床工作经验,认为需要加强和完善以下方面的工作.

Objective Analyzing the reason of the local tissue necrosis after being bited by poisonous snake.Methods To review the Clinical records of 106 cases in recent tow years in our hospital.Results The incidence rate approach to 15%,and the cause is very complex.The therapy;include local blockade,sectioning for expelling of toxin,bundle up the bited limbs,should be fit.Unsuitable therapy is harmful.Conclusion Analysis to the reason of the tissue necrosis after being bited by poisonous snake is helpful.Correct treatment could decrease the incidence rate.

Objective To analyze the epidemiological feature of the poisonous snake bite around Beijing area. Method In our hospital,270 cases were treated in recent two years. 106 cases had relatively complete records and were reviewed. Result There were more snake bite cases in northern mountain area of Beijing and about Beijing. Most of the snakes involved in this study were Agkistrodon halys. Snake bite occurred mainly in May to September and the patients were mostly 40～59 years old. 5 critical patients of snake bite accounted for 1.9% (5/270). Conclusion According to the above-mentioned epidemiological characteristics,one or more snakebite remedy centres are necessary for the prevention and cure of snake bite at local region.

To set up the community emergency management servers system to improve survival of the sudden death.Compare international emergency management servers system situation with china ,analysis the effect factors on the community management servers system and the time effective of emergency platinum ten minutes (EPTM).Build up 4 ties fist aid (the family ,unite, building ,community )and improve the community clinic department ( promote the ability of rescuer, license certification ,telephone net ,enough equipment ) to fulfill the “emergency platinum ten mins(EPTM)” first aid socially.