(I) On-site resuscitation 1. Initial examination (1) Head injuries If there are scalp hematomas, lacerations and wounds with or without active hemorrhage, cerebrospinal fluid leakage and spillage of brain tissue, immediately and temporarily bandage the wounds and apply compression to stop bleeding. (2) Respiratory status Check for cyanosis, shortness of breath, signs of hypoxia and temporary respiratory arrest and asphyxia. (3) Pulse and blood pressure Check for rapid pulse, hypotension, and signs of shock. (4) Whether there are injuries in other parts of the body, especially serious combined injuries affecting the life of the patient. Initial treatment focuses on respiratory and circulatory resuscitation and support. Immediate correction of post-injury apnea and hypotension is crucial. If there is a slight delay in diagnosis and treatment and the time is lost, ischemic and hypoxic damage has occurred in the brain, which is likely to lead to irreversible or permanent damage, thus leading to a poor prognosis or even early death. First aid focuses on the following points. (1) For patients with the above mentioned critical signs, the patient should be quickly sent to the nearest hospital with emergency conditions. (2) For those who are not breathing well and have difficulty in breathing, untie the collar, lift up the lower jaw, adjust the head position to tilt back or turn sideways, and keep the airway open; if necessary, place an oropharyngeal ventilation tube or endotracheal intubation in the place, and connect a simple respirator for assisted respiration. If the patient’s skull base is severely fractured, maxillofacial fracture, oral hemorrhage source injected into the trachea, the patient’s teeth are closed, or there is restlessness, there is a risk of asphyxiation, then immediately selected for tracheotomy, in order to maintain breathing patency. (3) If hemothorax and pneumothorax cause lung compression and shortness of breath, immediately perform closed chest drainage. For those with weak pulse and low blood pressure, take the lying low position and inject cardiotonic agent to make the blood pressure rise to normal. If possible, set up infusion channel as soon as possible to replenish fluids. (4) First-aid setup includes first-aiders and necessary equipment and medicines. ①There are first-aid trained personnel to participate in the scene rescue. ② equipped with first aid box: inside the mouthpiece, tongue forceps, oropharyngeal catheter, endotracheal intubation complete set of supplies, oxygen bags or small oxygen cylinders, simple artificial respiration and ephedrine, epinephrine, Lobelin and other first aid medicines. (iii) The emergency vehicle should be equipped with power supply, suction device, infusion equipment, wound dressing kit and hemostatic instrument kit. (ii) Initial diagnosis and treatment. The patient is sent from the scene of injury or transferred from the first aid station or health center. 1. Initial examination and record the following (1) Time of injury, cause and course of injury. (2) Head injury, including the condition of the five senses, pupil size and light reaction. (3) Respiration, pulse, blood pressure. (4) Maxillofacial and neck injuries. (5) Brief peripheral and neurologic examination. (6) State of consciousness and degree of coma, and make a preliminary GCS score. (7) Any concomitant injuries to other extracranial areas, especially neck injuries (including rupture of large blood vessels in the neck, tracheal injuries, and cervical vertebral fracture), injuries to thoracic and abdominal organs, and fractures of the spine, pelvis, and femur, and injuries to the bladder and urethra. These serious injuries often cause shock and should not be missed. (8) urinary and fecal conditions, whether urinary incontinence. 2, the necessary auxiliary examination of the vital signs are stable, according to the hospital conditions. (1) Cranial X-ray film, can be more comprehensive display skull fracture. (2) CT cranial scan focuses on cerebral contusion, intracranial hematoma, subarachnoid hemorrhage, open wound tract, skull fracture status and whether the midline structure is displaced and whether the ring pool is narrowed. (3) In the absence of CT, cranial ultrasonography can be performed to find out whether there is any displacement of the midline wave of the brain and indirectly diagnose intracranial hematoma. 3.Emergency treatment of critical situations (1)For active bleeding from wounds on the head and other parts of the body, stop bleeding immediately. (2) For those who are not breathing well, treatment is as follows. (1) Keep the head on one side and tilt it back, suction off the bloody secretion and vomit in the oropharynx and trachea to prevent aspiration and asphyxiation. ② Place the oropharyngeal ventilation tube or pull the tongue out and high-flow oxygen. ③ For those with respiratory distress, endotracheal intubation or tracheotomy should be performed as soon as possible, and mechanical ventilation should be used to assist respiration and prevent early hypoxemia and cerebral hypoxia. ④Ventilator-assisted respiration: adjust respiratory parameters to keep PaCO2 at 30-35mmHg (4-5kPa); PaO2 greater than 75mmHg (10kPa); oxygen saturation should be more than 95%. (5) For those whose spontaneous respiration has stopped, if the heartbeat exists and the blood pressure is still normal, artificial respiration should be performed to maintain a good artificial respiration state and create conditions for emergency treatment, such as craniotomy to remove hematoma. (3) For those who have circulatory disorders, hypotension and shock, circulatory resuscitation should be carried out rapidly. According to the cause of shock, make the following emergency treatment. ① Rapid intravenous infusion, available balanced saline, glucose solution, saline, blood substitutes and blood, replenish blood volume. ② require blood pressure to normal levels, adult systolic blood pressure stabilized at 120mmHg (16kPa) or so, do not fall below 90mmHg (12kPa), keep the average arterial pressure at 80mmHg (10kPa) or more, in order to maintain effective cerebral perfusion pressure. 4.Preliminary diagnosis (1)The type of craniocerebral injury (closed or open brain injury) and degree (mild, moderate, severe, extra severe) should include: ① scalp injury; ② cranial bone injury; ③ brain injury; ④ intracranial hemorrhage; ⑤ others.Glasgow Coma Scale (GCS) is a recognized method to assess the degree of the condition. (2) Comorbid injuries and the presence of shock. (3) Confirmation of any indication for emergency surgery, including both craniocerebral injuries and combined injuries. 5.Treatment decision (1)Firstly, make sure whether there is any indication of emergency surgery for craniocerebral injury, the following cases need surgery. ① Acute intracranial hematoma has caused brain tissue compression, slow pulse, decreased respiration, blood pressure tends to increase, and the injury is progressively aggravated. ② coma deepens progressively, one side or successive bilateral pupil dilation, and brain tissue compression vital signs changes. (iii) Open craniocerebral injury, especially those with more than one bleeding inside and outside the injury tract, bulging brain tissue, and large amount of cerebrospinal fluid leakage. (2) Emergency surgery and indications for combined injuries ① Neck injury: neck arterial and venous injury, tracheal rupture and bleeding may be injected into the trachea and asphyxia occurs, bleeding should be stopped and repaired immediately. ② chest injury: tension pneumothorax or hemopneumothorax, as soon as possible for closed chest drainage. As a last resort, open the chest to explore the treatment. ③ Abdominal visceral injuries: the patient is in shock, it is necessary to replenish blood volume, correct the shock at the same time, quickly do a caesarean section to find out the condition of organ injuries and carry out appropriate surgical treatment to stop bleeding. Any surgery should be explained to the family, accompanying personnel or the person in charge of the unit to explain the injury and the need for surgical treatment, please confirm and need to sign the consent form for surgery and anesthesia before surgery. Without consent and confirmation and signature, no surgical treatment can be performed. (3) About referral ① Patients with heavy craniocerebral injuries who have developed signs of brain hernia should be treated locally. Craniotomy in l ~ 2 hours, remove hematoma, such as time permitting, it is advisable to fight for higher hospitals to quickly send people to cooperate in the rescue, so as to avoid the deterioration of injuries in transit difficult to deal with. ② If the local blood transfusion, drugs, surgery to ensure conditions, it is advisable to transfer as soon as possible. ③Transfer means of transportation: according to the local conditions of choice of stretcher, ambulance, general cars, trains, boats, helicopters, airliners, on the way to protect the patient, to avoid falling out of bed to aggravate the brain injury. Comatose patients should take the side lying position, which is good for protecting the respiratory patency and preventing asphyxiation caused by vomiting and misdirection. On the way of transfer, medical personnel should accompany the patient, closely observe the change of condition, keep the airway open, and make feasible treatments, such as fluid infusion, dehydration treatment, oxygen absorption and so on. ⑤ The following cases are not suitable for transfer, and should be treated locally: ① the patient is in shock; ② respiratory failure; ③ advanced cerebral herniation, bilateral pupil dilatation, no light reaction. (iii) Sedation There is a great deal of variation in whether to apply sedative and muscle relaxant medications to patients with severe craniocerebral injuries, and there is evidence to suggest that sedation and pharmacologic relaxation have an impact on the initial assessment and management of neurotrauma patients. Unfortunately, no one has studied the impact on the prognosis of patients with severe craniocerebral injury. Therefore, the application of sedation and the choice of medication is left to the operator to decide on a case-by-case basis. (iv) Neuromuscular blockade There are only a few studies on the prognostic impact of neuromuscular blockade in severe craniocerebral injuries.Hsiang et al. in the Trauma Coma Library, studied the prognostic impact of the prophylactic use of neuromuscular blockade (pharmacological paralysis was applied to the patient early on and continued for 12 hrs but not for the purpose of controlling high cranial pressure) in 514 patients with heavy cranial injuries. They concluded that the use of neuromuscular blockade is associated with prolonged intensive care, increased incidence of pneumonia, and increased tendency to toxemia, and that these will have a negative impact on the patient’s prognosis. Therefore, it is recommended that neuromuscular blockade be used when there are special indications (e.g., high cranial pressure and patient transfer), but not routinely used for heavy craniocerebral injury. (v) Blood pressure and oxygen metabolism Hypotension and hypoxia in the early post-injury period significantly increase mortality in severe craniocerebral injury. Their actual physiologic values are not adequately defined in the literature. However, there is sufficient Class II evidence that early hypotension (defined as simple systolic blood pressure below 90 mmHg) and hypoxia (defined as dyspnea or cyanosis with PaO2 below 60 mmHg) are associated with increased mortality. Considering the effect of early management, there is ample support in the evidence of prospective randomized controlled studies that intensive blood pressure resuscitation improves the prognosis of severe craniocerebral injury. Relevant single-center prospective randomized controlled trials have shown that delayed resuscitation improves prognosis more than immediate resuscitation for open trunk injuries. Notably, patients with craniocerebral injuries were excluded from this trial. Therefore, the concept of delayed resuscitation cannot be applied to craniocerebral injuries. (vi) Mannitol There are several uncontrolled studies and prospective double-blind controlled studies that support the use of mannitol to reduce intracranial hypertension. (vii) Hyperventilation Hyperventilation decreases ICP by causing cerebral vasoconstriction and further decreases cerebral blood flow (CBF). Studies over the past 20 years have clearly demonstrated that CBF falls to less than 1/2 of normal on the day of injury and that the use of hyperventilation poses a risk of cerebral ischemia. These findings are confirmed by arteriovenous oxygen content differences and jugular venous oxygen saturation measurements.