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1案例资料1.1简要案情及临床摘要2011年4月15日11时许,马某在与人发生纠纷的斗殴中被打伤,遂到某医院治疗。医院住院病历记录:头部外伤后意识障碍伴恶心、呕吐、小便失禁4h,中度昏迷,GCS为5分,左头顶部两处不规则创口,伴流血不止。CT检查示右额、颞、顶硬膜下血肿、小脑左叶脑内血肿;蛛网膜下腔出血、右额、颞骨多发骨折并气颅形成,右额、颞部皮下气肿。入院后手术记录:右额颞骨线状骨折,骨折线长约15cm,硬膜外大量暗红色血凝块,约100mL,清除血肿,见硬膜张力不高,呈蓝紫色,硬膜下少量血凝块伴血性液。入院经抢救
1 Case Information 1.1 Brief Case and Clinical Summary April 15, 2011 11 am, Ma Mou was injured in the fight with the people, then went to a hospital for treatment. Hospital inpatient records: head traumatic consciousness disturbance with nausea, vomiting, urinary incontinence 4h, moderate coma, GCS 5 points, the top of the left two irregular wounds, with more than bleeding. CT examination showed the right forehead, temporal, subdural hematoma, left cerebrum intracerebral hematoma; subarachnoid hemorrhage, right forehead, temporal bone fractures and gas cranial formation, right forehead, temporal subcutaneous emphysema. Surgical records after admission: Right frontal temporal bone linear fracture, fracture line length of about 15cm, a large number of epidural dark red blood clots, about 100mL, clear the hematoma, see the dural tension is not high, blue-purple, a small amount of subdural blood Clot with bloody fluid. Admission by the rescue