2014年 · 第94卷第15期

As a vigorous discipline, critical care medicine in China has been enriched and developed rapidly in recent years, and has gradually played a more and more powerful role in public health emergencies in China. After the earthquake and other disasters, the first-class experts in critical care medicine in China led a large number of young and middle-aged key medical staff to rush to the disaster area at the first time. In the ruins, wilderness, field hospitals and grass-roots hospitals, they are like a special force to treat the seriously injured in disasters, saving a large number of wounded people who are hovering on the verge of life and death, and greatly reducing the disability rate of the wounded. As the rescue witnesses of public health emergencies such as SARS, Wenchuan earthquake and Xiamen BRT fire, we discuss the task, role and direction of intensive care medicine in the rescue of public health emergencies in earthquake based on our own experience and relevant literature in recent years.

China is a highly earthquake-prone area, with 7% of the land area bearing 33% of the strong earthquakes in the world^[1]。 From the Wenchuan earthquake to the Lushan earthquake, tens of thousands of people have died and hundreds of billions of property have been lost. The sudden earthquake disaster has brought us trauma and great pain, and it also warns medical staff to constantly learn experience and lessons from the disaster, especially for critical care doctors, they should constantly improve the early scientific treatment and management strategies of severe earthquake wounded, so as to learn from the past and respond calmly after similar disasters in the future, strive to minimize the casualties caused by earthquakes and effectively reduce the disability rate.

Since 2008, several strong earthquakes of high magnitude have occurred in western China such as Wenchuan in Sichuan, Yushu in Qinghai, Yiliang in Yunnan, and Lushan in Sichuan, causing huge loss of life and property. Treatment of serious earthquake injured is one of the most core tasks in earthquake relief. From Wenchuan earthquake to Yushu earthquake to Lushan earthquake, although the geographical environment, magnitude and traffic recovery of earthquakes are different, there have been many improvements and progress in the concept and practice of medical rescue for seriously injured earthquakes. Comprehensively sorting out the changes in the treatment concept, the optimization of the process and the analysis of the results in the critical treatment of the wounded in these major earthquakes, and constantly summing up the experiences and lessons will surely provide valuable guidance for improving the critical treatment actions in response to sudden disasters in the future.

Hypertension is one of the major public health problems faced worldwide, causing more than 13% of the total deaths every year^[1]。 Many guidelines and intervention programs for the prevention and treatment of hypertension have been developed and implemented at home and abroad, but more than two-thirds of hypertensive people have not been effectively controlled^[2]。 Direct medical expenses caused by hypertension amounted to $175 billion in 2005, accounting for about 7.2% of China's total health expenditure^[3]。 Evidence shows that aggressive treatment and effective control of hypertension can avoid a large amount of associated health resource consumption^[4]。 Therefore, hypertension is not just a simple personal disease and medical problem, but also a serious public health problem and social problem. We should learn from the advanced experience of developed countries, make use of limited resources to do a good job in the prevention and treatment of hypertension, and carry out comprehensive prevention and treatment strategies in communities, mainly health education and health management.

A 61-year-old male suffered from uninduced upper abdominal discomfort accompanied by intermittent dull pain for 3 months. He was admitted to Subei People's Hospital of Jiangsu Province for treatment on February 26, 2013. Splenectomy and appendectomy were performed more than 20 years ago. A 6 cm long surgical scar was seen in the middle abdomen and a 5 cm long surgical scar was seen in the right lower abdomen. No obvious abnormalities were found in relevant laboratory tests and electrocardiogram. Ultrasound examination revealed a hypoechoic mass at the base of the stomach, originating in the muscular layer (Figure 1)。 Energy spectrum CT enhanced scan of the whole abdomen showed a massive soft tissue density shadow on the posterior wall of the stomach base, with a size of 26 mm ×19 mm, with clear boundary and clear envelope. The enhanced scan showed obvious uniform enhancement, no obvious enlarged lymph node shadow in the liver-stomach space and retroperitoneum, and no obvious signs of invasion in adjacent tissues and organs. It is considered that the stomach base occupies space, and stromal tumor may be (Figure 2、Figure 3、Figure 4、Figure 5)。 The energy spectrum curve showed that the normal stomach wall curve intersected with the mass curve, suggesting that the mass and the stomach wall may have different sources. Electronic gastroscopy was performed and fundus stromal tumor (muscle layer) was considered (Figure 4)。 After completing the relevant examinations, gastroscopy + laparoscopic intestinal adhesiolysis + proximal gastrectomy were performed. Laparoscopic exploration of the abdominal cavity showed that the tumor was located at the posterior wall of the gastric fundus at the entrance of the cardia, protruding out of the cavity, with a size of 3.0 cm ×2.0 cm, and extensive adhesion of the transverse colon and omentum to the abdominal wall, and the abdominal cavity adhered to the gastric fundus, so laparoscopic separation and exposure were difficult. Switched to open surgery after communicating with family members. After laparotomy, a 3 cm ×3 cm mass was palpable at the posterior wall of the gastric fundus at the entrance of the cardia. It was adhered to the top of the left diaphragm in the middle of the mass, with poor mobility and no special remaining. Intraoperatively, "gastric stromal cell tumor" was diagnosed and "proximal gastrectomy" was decided. The postoperative pathology showed that the envelope composed of fibrous tissue was seen outside the serous layer of the stomach wall, and the hyperplasia of red pulp and white pulp tissue of the spleen was seen inside it, which was considered as the spleen tissue at the fundus of the stomach (Figure 5)。

A 23-year-old female was admitted to the Department of Vascular Surgery of Peking Union Medical College Hospital for "intermittent low back pain with elevated blood pressure for 4 months and aggravated for 1 week". Past physical fitness. Physical examination: blood pressure 138/100 mmHg (1 mmHg =0.133 kPa), soft abdomen, no pulsatile mass palpable, good pulsation of bilateral, radial and dorsal pedis arteries, and no vascular murmur in bilateral renal areas. Liver and kidney function: glutamate aminotransferase 16 U/L, urea nitrogen 9.91 mmol/L, creatinine 83 μ mol/L. Erythrocyte sedimentation rate: 6 mm/h. C-reactive protein: 0.91 mg/L. Functional imaging of renal blood flow: Glomerular filtration rate (GFR) =8.31 ml/min in the right kidney and 19.39 ml/min in the left kidney. The results of rheumatism immunoassay were all negative. Computed tomography angiography (CTA) showed that the abdominal aorta showed tumor-like dilatation at the initial level of both renal arteries, with a size of about 4.5 cm ×3.5 cm. The opening segments of the celiac trunk and superior mesenteric artery were not shown, and the distal end was supplied with blood through the thickened Riolan artery arch. The initial portion of the opening of both renal arteries was severe stenosis (Figure 1)。 Admission diagnosis: Takayasu arteritis (thoracic-abdominal aortic type), pseudoaneurysm of the abdominal aorta, severe stenosis of both renal arteries, occlusion of the celiac trunk, occlusion of the superior mesenteric artery. Abdominal aorta-right renal artery autologous great saphenous vein bypass and Riolan artery arch-left renal artery bypass were performed under general anesthesia on day 17 after admission (Figure 2), endovascular repair of pseudoaneurysm of the abdominal aorta. The operation went smoothly, and low molecular weight heparin anticoagulation and aspirin antiplatelet therapy were given postoperatively. The patient recovered well after surgery and was followed up for 12 months without any discomfort and peripheral blood pressure returned to normal. The CTA at 3 and 9 months after operation showed that the abdominal aortic stent was in good position, the pseudoaneurysm disappeared, the lumen of the graft vessel was unobstructed, and no stenosis was found in each anastomosis (Figure 3)。