The three links theory" refers to the three key links in an emergency medical services system, viz. pre-hospital first-aid system, hospital emergency care system, and the ICU system. The construction of an emergency medical services system in China ought to be guided by the three links theory so as to set up a practical and highly efficient emergency medical services system, an instantly operating monitoring system, a smooth and real-time information system, a rational and long-lasting system of laws and contingency plans, and a system for cultivating universalists. The goal is to build an emergency green passage in the hospital.

The paper gives an account of the new ideas in trauma care and the transition of emergency care of trauma from the traditional model to the modern model,viz.the transition of emergency care of trauma by the emergency department from a paradigm of general practice to a paradigm of specialized care;the transition of trauma physicians training from a paradigm of general practitioners to a paradigm of specialists;and the transition of the flow of emergency care of trauma from a paradigm of "links" to a paradigm of "whole course".Based on the practice of the emergency department of the hospital the authors work with in setting up a quick clinical response mechanism of emergency care of trauma,a mechanism of priority to emergency care of trauma,a hospital-wide linking and coordinating mechanism of emergency care of trauma,a standardized management mechanism of wards for emergency care of trauma,and an operational mechanism of the team of emergency care of trauma,the paper discusses building an integrated model of emergency care of trauma on the basis of the "three links theory" by the emergency department.

Objective To detect the correlation of serum myoglobin (Mb) and creatine kinase (CK) levels in multiple trauma patients with outcome and renal failure and compare the prognostic value of the two predictors.Methods Forty-one patients with multiple trauma (ISS ≥ 16 points) were analyzed at days 1,3,7,and 14 posttrauma,for serum Mb and CK concentrations.Moreover,simplified acute physiology score Ⅱ (SAPS Ⅱ),injury severity score (ISS),as well as Glasgow coma score (GCS)at day 1 postrauma,final outcome,and presence or absence of renal failure were recorded.Correlation of serum Mb and CK with ISS,GCS,and SAPS Ⅱ was analyzed.Predictive values of Mb and CK for outcome and development of renal failure after multiple trauma were measured and compared at days 1,3,and 7 posttrauma,according to receiver operating characteristic (ROC) curve.Results Serum Mb concentration revealed a positive correlation with SAPS Ⅱ at each time point and with ISS at days 7 and 14,but a negative correlation with GCS at days 3,7,and 14.Similarly,serum CK concentration presented a positive correlation with SAPS Ⅱ at days 3,7,and 14 and with ISS at days 7 and 14,but a negative correlation with GCS at days 7 and 14.To predict outcome of the multiple trauma patients,area under the ROC curve for serum Mb at days 1,3,and 7 was 0.542,0.900,and 0.981 respectively and for serum CK was 0.232,0.771,and 0.968 respectively.To predict development of renal failure,area under the ROC curve for serum Mb at days 1,3,and 7 was 0.864,0.949,and 0.955 respectively and for serum CK was 0.480,0.889,and 0.939 respectively.Conclusions Serum Mb and CK are both predictive of outcome and development of renal failure following multiple trauma.Whereas in co；rast with CK,serum Mb appears to be a more sensitive marker.

ObjectiveTo detect the serum NT-proBNP level in patients with severe trauma 24 hours after injury in order to find the possible correlated factors for the evaluation of the clinical application.MethodsSixty patients with severe trauma admitted to the emergency ICU were enrolled. Serum NTproBNP level was detected 24 hours after injury for comparison between survivors and nonsurvivors. The validity of NT-proBNP for predicting outcome was analyzed by receiver operating characteristic ( ROC )curve. The factors with significant correlation between NT-proBNP level and the length of ICU stay as well as the duration of mechanical ventilation support were determined in those survivors with correlation and stepwise linear regression analysis. These factors included injury severity score (ISS), head abbreviated injury score (AIS), acute physiology and chronic health evaluation Ⅱ ( APACHE I ), Glasgow coma score (GCS), creatine kinase-MB (CK-MB), cardiac troponin-I (cTn-I) and central venous pressure. Results The median NT-proBNP levels were 762 pg/ml (IQR, 400-1131 pg/mL) in nonsurvivors versus 200 pg/ml (IQR, 80-383 pg/mL) in survivors (Z =-3. 972, P ＜0.01 ). The area under ROC curve of NTproBNP was not statistically different to that of ISS and that of APACHE Ⅱ. The best threshold value of NTproBN to predict the outcome was 384 pg/ml ( sensitivity 0. 846, specifity 0. 766). A positive correlation was found between NT-proBNP and the length of ICU stay ( r =0. 32, P ＜ 0. 05 ) as well as the duration of mechanical ventilation ( r =0. 37, P ＜ 0. 05 ) in survivors. Stepwise linear regression analysis indicated there were significant correlations between APACHE Ⅱ, CK-MB and NT-proBNP.ConclusionsSerum NT-proBNP level 24 hours after injury is correlated with the severity and outcome of patients with severe trauma. It may be used as a complementary biomarker for the rapid assessment of the severity of trauma.

Objective To investigate the dynamic change of serum myoglobin and assess its relation with injury severity in multiple trauma patients. Methods The concentration of serum myoglobin in 41 multiple trauma patients (ISS ≥16 points) was detected at days 1,3,7 and 14 after injury. In the meantime, injury severity score ( ISS), Glasgow coma score ( GCS), simplified acute physiology score Ⅱ( SAPS Ⅱ ), percentage of the injured muscle and soft tissue to entire body, shock on admission and ultimate outcomes were recorded at day 1 after injury. All patients were divided into ISS ≥25 group or ISS ＜ 25 group, survival group or death group based on the injury severity and ultimate outcomes. The dynamic changes of the serum myoglobin were observed and compared between the groups. The correlation of the serum myoglobin concentration with ISS, GCS, SAPS Ⅱ score, shock and the percentage of injured muscle and soft tissue was investigated. Results The serum myoglobin concentration in ISS ≥ 25group was decreased more slowly than that in the ISS ＜ 25 group, with higher concentration of the serum myoglobin concentration in the ISS ≥ 25 group than that in the ISS ＜ 25 group at all time points. The serum myoglobin concentration in the death group was increased first, then slowly declined and reached peak at day 3. While in survival group, the serum myoglobin concentration was continuously decreased, with lower serum myoglobin concentration than that in the death group at all time points. The serum myoglobin concentrations were positively correlated with the SAPS Ⅱ score at all time points, with ISS at days 7 and 14, with the percentage of the injured area at day 1 and with the shock at days 1 and 3, while the serum myoglobin concentration was negatively correlated with GCS at days 3,7 and 14. Conclusions The dynamic changes of the serum myoglobin concentration in multiple trauma patients may reflect the severity,trends and prognosis of the injury, and hence can be used as effective index for monitoring the disease.

Objective To detect the dynamic change of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in patients with major trauma and measure its relation to the outcome.Methods Sixty patients with major trauma were measured with serum NT-proBNP level at 1,3,and 7 days postinjury.According to the prognosis,the patients were allocated to survival group (n =47) and death group (n =13).Changes in NT-proBNP was detected and compared between the two groups.Correlation of NT-proBNP level with acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) and ISS was analyzed at each time point.Receiver operating characteristic curve (ROC) was developed to determine the prognostic value of NT-proBNP.Results Overall NT-proBNP level revealed no statistical difference at each time point and kept within normal reference range.NT-proBNP level in death group increased gradually,whereas in survival group the increase was followed by a reduction.Moreover,NT-proBNP level was higher in death group than in survival group at each time point.Area under the ROC of NT-proBNP had no statistical difference with that of APACHE Ⅱ and ISS at each time point.Conclusions Obviously high or continuously increased NT-proBNP level may indicate an unfavorable prognosis of major trauma patients.NT-proBNP can be used as a marker to dynamically predict prognosis of major trauma patients.

Based on the experience in providing emergency medical relief during the occurrence of the disastrous “Yunna” typhoon, the paper discusses the necessity of establishing a medical emergency relief system for regional disasters and ways of perfection. It is thus necessary to set up a multi level response mechanism for medical emergency relief; enhance the overall emergency response ability of the emergency medical service systems in case of disastrous events; work out the strategic layout of networks of medical emergency relief for regional disasters; optimize and rehearse in a planned way the crash programs for medical emergency relief for disasters; reinforce the role of the government in organizing and directing medical emergency relief for disasters; make overall arrangements of emergency relief manpower; and improve relief personnels personal sense and ability of self protection.

Objective To establish a model of multiple trauma combined with uncontrolled hemorrhagic shock so as to provide basis for basic study of multiple trauma.Methods Forty New Zealand male rabbits were equally and randomly divided into four groups,ie,sham group (Group A,with no bloodletting or resuscitation),uncontrolled group (Group B,with bloodletting alone),aggressive fluid resuscitation and limited fluid resuscitation groups (Groups C and D,with bloodletting,hemostasis and resuscitation).Fractures of the right hind limb in rabbits of each group were induced by free drop of a 3 kg hammer from a height of 45 cm.An estimated 30％ of total blood was withdrawn from the right common carotid artery in 20 minutes in bloodletting groups (Groups B,C and D).Successively,the uncontrolled bleeding was caused via acupuncture bloodletting from ileocecal artery branch at 30 minutes in bloodletting groups.Progressive and limited fluid resuscitation using lactated Ringer' s solution (LR) were performed for Groups C and D in the next one hour respectively.Blood transfusion was performed in Groups C and D after ligation of bleeding artery branch at 90 minutes.In addition,LR of three folds more than blood loss was administered in Group D.Survivorship of rabbits in each group was observed at 150 minutes to seven hours.Arterial blood sample was taken at each time point for blood gas analysis and coagulation test.Fracture type,fluid requirements,intra-abdominal blood loss,and rabbits' survival rate at seven hours were recorded.Results Closed comminuted tibiofibular fractures were founded in all groups.Bloodletting groups showed an obvious reduction of MAP,heart rate and pH value and significantly increased levels of K+,blood glucose and lactic acid at 30 minutes (P ＜0.01),whereas MAP and heart rate were returned to baseline level at 150 minutes.Progressive fluid resuscitation significantly increased the intra-abdominal blood loss and fluid requirements (P＜0.01),decreased erythrocrit (P ＜ 0.05),prolonged prothrombin time and activated partial thromboplastin time (P ＜0.05).Survival rate of rabbits was improved significantly by fluid resuscitation at 7 hours (P ＜ 0.01).Conclusion The model is of high stability and reproducibility and therefore is fit for study of multiple trauma combined with uncontrolled hemorrhagic shock.

Objective To evaluate the value and significance of bedside ultrasound in diagnosis of lung atelectasis/consolidation in multiple trauma patients with mechanical ventilation.Methods Bedside thoracic ultrasound and chest computed tomography(CT)were performed in 81 multiple trauma patients with mechanical ventilation admitted to the emergency intensive care unit(EICU).CT result was regarded as the "golden standard" to evaluate the value of ultrasound in diagnose lung atelectasis/consolidation.At the same time,the ultrasound was used to dynamically monitor the lung recruitment effect of the therapeutic measures.Results CT detected 154 regions of lung atelectasis/consolidation of 324 lung regions in 81 patients,while ultrasound detected 126 regions that were divided into 87 complete regions and 39 incomplete regions according to different sonogram in the breathing cycle.The sensitivity,specificity,positive predictive value,negative predictive value and accuracy of ultrasound were 81.8%,100%,100%,85.9% and 91.4% respectively.A concordance test showed a very high concordance between ultrasound and CT,with a Kappa coefficient of 0.825(P=0.031).Ultrasound found that 39 regions with incomplete lung atelectasis/consolidation were completely recruited and 62 out of 87 regions with complete lung atelectnsis/eonsolidatian gained visible recruitment within three days after different therapeutic measures,with total effective rate of 80.2%.Conclusion Bedside ultrasound can continuously monitor and guide the therapeutic measure to recruit the lung and is a convenient,safe,direct-viewing and accurate method for diagnosis of lung atelectasis/cansolidation in multiple trauma patients with mechanical ventilation.

AIM:To evaluate the relationship between RUNX3,cyclin E,P21,biological features and survival in gastric cancer patients.METHODS:RUNX3 was examined using immunohistochemical staining.Cyclin E and P21 were analyzed by flow cytometry.Survival was evaluated by Kaplan-Meier survival curves.RESULTS:The positive-expression rate of RUNX3,cyclin E and P21 in tumor tissue from 56 patients with gastric cancer were 44.6%,64.3% and 32.1%,respectively.RUNX3 expression was correlated with lymph node metastasis and distant metastasis(P0.05).Using Kaplan-Meier survival curves and the Log-rank test,there was correlation between RUNX3,cyclin E and survival(P0.05).CONCLUSION:RUNX3 may be related with tumorigenesis and tumor progression by affecting P21 expression.The detection of RUNX3 and cyclin E may be helpful in evaluating the clinicopathological parameters and prognosis in gastric carcinoma patients.