Assessment of the severity of the condition of patients in the provision of emergency therapeutic and surgical medical care at the prehospital stage.

The sum of the points in three sections and its correspondence to the level of consciousness:

−clear consciousness — 15;

−stunning — 13–14;

−sopor — 9–12;

−coma — 4–8;

−brain death — 3.

Do not forget that the implementation of a motor reaction may be hampered by the presence of plegia or paresis on one or both sides. Consult a neuroresuscitator.

In the absence of speech, “verbal hash” or failure to follow instructions at a clearly sufficient level of wakefulness, you need to think about the presence of aphasic disorders and consult with a neurologist or neuroreanimatologist.

3.2. DIAGNOSIS OF ACUTE RESPIRATORY FAILURE

Acute respiratory (respiratory) failure (ARF = ODN (rus)) is a rapidly increasing (development time of several minutes/days) severe pathological condition of the patient, caused by the incompatibility of the external respiration system with the metabolic needs of the body to maintain normal partial tension of oxygen and carbon dioxide in the arterial blood, or it is achieved after due to increased work of the respiratory and circulatory systems, which leads to a decrease and subsequent depletion of the body's functional capabilities. Dyspnea is an early symptom of ARF, subjectively manifested by a feeling of lack of air or difficulty breathing. At the same time, the frequency, rhythm and depth of breathing change, accompanied by an increase in the work of the respiratory muscles.

Severity of ARF syndrome:

1. Ventilation ARF:

–normal: PaCO2 = 35–45 mmHg;

–grade I (moderate): PaCO2 < 50 mmHg;

–grade II (expressed): PaCO2 = 51–69 mmHg;

–grade III (heavy): PaCO2 > 70 mmHg;

–hypercapnic coma: PaCO2 = 90–140 mmHg.

2. Parenchymal ODN:

–normal: PaO2 = 80–100 mmHg (SpO2 ≥ 95 mmHg);

–grade I (moderate): PaO2 = 60–79 mmHg (SpO2 = 90–94 %);

–grade II (expressed): PaO2 = 40–59 mmHg (SpO2 = 76–89 %);

–grade III (severe): PaO2 < 40 mmHg (SpO2 ≤ 75 %);

–hypoxemic coma: PaO2 = 39–30 mmHg.

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Hemoglobin oxygen saturation of less than 90 % indicates ARF (category of evidence). Based on the level of decompensation of the respiratory and circulatory systems, consciousness, oxygen and carbon dioxide content in the blood, three stages of ARF are distinguished.

Stage I ARF. The patient is conscious, complains of a feeling of lack of air, is restless, and asthenic. The skin is pale, moist, slight acrocyanosis of visible mucous membranes. Heart rate up to 30 respiratory movements per minute, heart rate up to 110 bpm, BP is normal or slightly increased, PaO2 decreases to 70 mmHg, PaCO2 reduced due to compensatory shortness of breath.

Stage II ARF. The patient complains of severe suffocation, possible development of psychomotor agitation, impaired consciousness, delirium, and hallucinations. The skin is wet, cyanotic, often in combination with hyperemia. Heart rate 30–40 respiratory movements per minute, heart rate 120–140 bpm often arrhythmia, hypertension is recorded, PaO2 decreases to 60 mmHg, PaCO2 rises to 50 mmHg.

Stage III ARF. Consciousness is clouded or absent, convulsive syndrome may develop due to brain hypoxia, spotty cyanosis is observed, hypoxic pupillary dilation with lack of reaction to light. When the process progresses, tachypnea (BP > 40 respiratory movements per minute) becomes bradypnea (BP < 8 respiratory movements per minute). Hypotension, tachyarrhythmia are observed, PaO2 decreases to 50 mmHg and below, PaCO2 rises to 90 mmHg and above.

3.3. INJURY SEVERITY SCALE (ISS)

S.P. Baker et al in 1974 developed the ISS based on the Abbreviated injury scale (AIS) [5–7]. The AIS was created in 1969 (and refined in 1990) [2]. According to the abbreviated injury severity scale — AIS, currently adopted in most countries, those injuries that give a mortality rate of 25 % or more are considered critical. These include: intracranial hematomas with a volume of more than 80 cm3, bilateral large hemothorax, multiple liver ruptures with hemoperitoneum of more than 1 500 ml, multiple unstable pelvic fractures with ruptured joints and similar injuries in each of the 6 anatomical areas of the human body (head/neck and face, spine, chest, abdominal cavity, pelvic bones, limbs with skin and other soft tissues).

According to AIS, severe damage in each of these areas corresponds to a score of 5 points. Regarding the AIS scale, each injury is classified depending on the damage in any of the specified areas of the body, as well as by severity (1 — minor; 2 — moderate; 3 — significant, but not life-threatening; 4 — severe, life-threatening; 5 — critical, survival is doubtful; injuries with a score of 6 points are incompatible

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with life: aortic rupture). It is recommended to pay special attention to injured with ISS scores greater than 30 points, as having a severe injury with a risk to life.

When a victim with polytrauma is admitted to the hospital, the severity of the injury is first assessed on the AIS scale from 1 to 5 points in six anatomical areas (Table 4). Then the worst 3 indicators of the most severely damaged areas are selected from the 6 indicated (although there may be additional damage in 1–3 more areas of the body).

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3.4. POLYTRAUMA SEVERITY SCALE (PTS)

Employees of the Medical Graduate School in Hannover in 1983 proposed their Polytrauma severity scale, or Hannovischer Polytrauma schlüssel — PTS, in 1985 it was supplemented (Table 5) [1, 9] and use it in their practice.

Table 5

Hanover polytrauma severity scale (PTS)

3.5. MAINZ EMERGENCY EVALUATION SCORE

The Mainz emergency score is a dynamic system for assessing the effectiveness of prehospital emergency care in adult patients (Table 6). The scale is not in-

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tended for prognostic assessments, but is a good tool for assessing the effectiveness and quality of prehospital medical care.

Evaluated parameters:

1.Glasgow scale score.

2.Heart rate.

3.BH.

4.Heart rate.

5.Pain.

6.BP.

7.SpO2.

The MEES assessment is based on the following principles (Table 7).

Table 6

Mainz emergency assessment scale

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Note: * The original scale uses the term “absolute arrhythmia” and/or the abbreviation ABSARRH.

Table 7

Mainz emergency assessment scale

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MEES score is equal to the sum of the points for all 7 parameters. Interpretation: the minimum score on the scale is 7 points (the authors of the scale believe that the minimum score is 8 points); the maximum score on the scale is 28 points. The higher the score on the scale, the better the patient's condition.

It is recommended to evaluate the scale twice at the initial stage: first at the prehospital stage during the initial examination of the patient, and then in the emergency room or ICU. If the results of the second MEES assessment are ≥ 2 points compared to the initial assessment, then the patient's condition has improved. If the assessment results decrease by ≤ 2 points, then the patient's condition has worsened. If the scores fluctuate within the range of ±1, the patient's condition is considered unchanged. The MEES scale was subsequently modified. The essence of the modification was to combine the original MEES with capnometry. The new scale is called MEESc. It has more broad capabilities and is recommended for use both at the prehospital and hospital stages.

3.6. CINCINNATI PREHOSPITAL STROKE SCALE (CPSS)

The Cincinnati prehospital stroke scale (CPSS) is used as a prehospital stroke assessment. It is an abbreviated and simplified version of the NIH stroke scale.

The scale includes three items. It can be used by both physicians and emergency medical personnel to identify patients with stroke, and also serve as an assessment test for the selection of candidates for thrombolysis.

Detection of pathology on any of these points with high sensitivity (66 %) and specificity (87 %) indicates the presence of a stroke in the patient.

Prediction of the risk of cerebral stroke in patients with transient ischemic attacks. The ABCD Score is used to predict the risk of stroke during the first 7 days after a transient ischemic attack.

According to research results, when assessed on the ABCD scale from 0 to 4 points, the seven-day risk of developing a stroke is 0.4 %, 5 points — 2.1 %, 6 points — 31.4 %.

The ABCD score can be used in routine clinical practice to identify individuals at high risk who require urgent evaluation and treatment. Scales and tests for studying cognitive functions.

3.7. QSOFA SEPSIS CRITERIA

The following criteria for sepsis are distinguished:

–systemic blood pressure ≤ 100 mmHg;

–respiratory rate ≥ 22 per minute;

–any disturbance of consciousness (< 14 points on the Glasgow coma scale).

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If there are ≥ 2 points, as well as signs of infection, it is necessary to pay attention to this patient and assess the likelihood of sepsis using the expanded SOFA scale. This scale has a specificity of 96 % and a sensitivity of 30 % for determining organ dysfunction, and a specificity of 91 % and a sensitivity of 50 % for determining mortality. Compared to the criteria for systemic inflammatory response syndrome (SIRS), this scale has greater specificity, but less sensitivity.

After screening and if there is a qSOFA score of ≥ 2 or the suspicion of sepsis remains, an expanded SOFA score is assessed.

3.8. QSOFA CRITERIA FOR SEPTIC SHOCK

The following criteria of septic shock are distinguished:

− persistent hypotension requiring vasopressors to maintain a mean BP ≥ ≥ 65 mmHg;

− lactate > 2 mmol/L despite adequate infusion therapy.

If these criteria are met, the probability of in-hospital death exceeds 40 %.

The SOFA criteria include the definition of functions:

−breathing: PaO2/FiO2 ratio;

−coagulation: platelet count;

−liver: bilirubin level;

−cardiovascular system: level of blood pressure and inotropic support;

−CNS: determination of level according to the Glasgow coma scale;

−kidneys: creatinine level and urine output.

If there are ≥ 2 points on the expanded SOFA scale, sepsis is eligible.

After the diagnosis is made, initial intensive therapy is carried out, an important part of which is a massive infusion, then the mean arterial pressure (MAP) is determined, as well as the lactate level. Mean arterial pressure is determined by the formula: MAP – SBP – DBP + 1/3DBP, where SBP is systolic blood pressure, and DBP is diastolic blood pressure. If the use of vasopressors is necessary to maintain adequate mean arterial pressure (≥ 65 mmHg), as well as high lactate levels (> 2 mmol/L), a diagnosis of septic shock is made.

3.9. SIRS/SIRS SYSTEMIC INFLAMMATORY

RESPONSE SYNDROME SCALE

Body temperature: more than 38 °C or less than 36 °C.

Heart rate: more than 90 per minute.

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Tachypnea: develops either when the respiratory rate is more than 20 bpm, or when PaCO2 is less than 32 mmHg.

Leukocytes: more than 12 000 cells/mm3, or less than 4 000 cells/mm3, or more than 10 % immature forms of neutrophils.

Table 8

Assessment scale of the condition of patients and injured (E.P. Izmailov, I.G. Trukhanova (2019))

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Note: the estimated scores of the indicator are shown in parentheses.

The scale turned out to be useful not only in providing emergency care at the prehospital stage, but also in assessing the condition of patients and injured at the hospital stage (Table 8).

3.10. CLOCK DRAWING TEST

TO ASSESS THE PATIENT'S MENTAL STATE

The simplicity and high information content of this test, including for mild dementia, makes it one of the most commonly used tools for diagnosing the clinical syndrome. The test is carried out as follows. The patient is given a blank sheet of unlined paper and a pencil. Instructions are given: Please draw a round clock with numbers on the dial so that the clock hands show fifteen minutes to two. The patient must independently draw a circle, put all 12 numbers in the correct places and draw arrows pointing to the correct positions. Normally, this task never causes difficulties. If er-

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