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

–respiratory rate, severity of shortness of breath;

–excursion of the chest, work of auxiliary muscles during breathing;

–chest deformation;

–subcutaneous emphysema on the neck and chest;

–wounds on the neck and chest;

–floating rib fractures;

–damage, deformation of the neck, displacement of the trachea from the midline;

–whether the cough reflex is preserved;

–whether the cough is dry or productive;

–character of sputum;

–whether there is hemoptysis or pulmonary hemorrhage;

–is there any severity of shortness of breath?

–is there a wound on the chest or on the skin?

–is there subcutaneous emphysema on the chest or face?

–is there paradoxical breathing or pathological breathing?

c) blood circulation:

–pulse on the radial artery;

–pulse on the dorsal artery of the foot;

–in the absence of pulse in the limbs, heart contractions;

–pulse rate, arrhythmia, pulse deficit;

–arterial pressure;

–pathological murmurs in the projection of the heart;

–signs of shock, centralization of blood circulation;

–are there any wounds in the projection of blood vessels and heart;

–are there varicose veins in the lower extremities;

–signs of acute thrombophlebitis on the lower or upper extremities;

–signs of portal hypertension;

–splenomegaly;

–ascites;

–hepatomegaly.

Diagnosis of pathological symptoms, medical history or injury:

S: signs and symptoms. A: allergies.

M: medications.

P: past medical history. L: last meal.

E: events leading to current illness.

11

Inspection, palpation, percussion, and auscultation of all systems of the human body that are suspected of damage or pathological changes are carried out. When examining and examining a patient, you should follow the sequence of writing a medical history. That is, conduct an examination of the body's systems to assess the current condition and identify the affected systems. The patient's affected systems are then examined.

Instrumental and laboratory diagnostics carried out to identify:

–injuries;

–diseases;

–infections;

–other causes of illness / critical condition;

–diabetes mellitus.

Diagnostics includes studies:

1.Laboratory examination: blood sugar.

2.Electrocardiography (ECG).

3.Pulse oximetry.

4.Measuring body temperature.

5.Ultrasound of identified pathological formations, pleural cavities, abdominal cavity, heart, arteries and veins.

Patient routing

Patient routing depends on his condition, the nature of the disease or injury. If the patient shows signs of biological death, resuscitation measures are not carried out. If signs of clinical death are determined, the patient is given emergency cardiopulmonary resuscitation. When life-threatening disorders are determined in a patient, first aid and/or medical care is provided at the prehospital stage, followed by transportation to an on-duty hospital operating according to the profile of the diagnosed disease or injury.

If the patient’s condition is stable, but the diagnosis requires clarification or instrumental diagnosis, then the patient is taken to the emergency hospital according to the profile of the identified disease or injury. If the patient’s condition is stable and there is no concern about its deterioration during the initial examination, if the patient refuses hospitalization in a hospital, a decision is made on outpatient observation and treatment.

12

2. EXAMINATION OF THE PATIENT'S SYSTEMS

TO ASSESS THE GENERAL CONDITION OF THE PATIENT

AND MAKE A PRELIMINARY DIAGNOSIS

AT THE PREHOSPITAL STAGE

2.1. EXAMINATION OF PATIENT’S PHYSIQUE

AND ANTHROPOMETRIC PARAMETERS

The type of patient is of fundamental importance from the point of view of possible diseases and complaints of the patient.

Gigantism is a very large height, exceeding 213 cm, which occurs in individuals with excessive secretion of growth hormone (GH). Such disorders are characterized by elongation of the limbs, especially the lower ones, the head appears small, acromegaly.

Patients complain of headaches, general weakness, memory loss, changes in appearance, deterioration of vision, the voice changes, it becomes low, patients experience muscle wasting and atrophy, movement disorders, joint pain, which leads to injury.

The function of the thyroid gland, gonads, and adrenal glands is impaired, and diabetes mellitus may develop. Typical complaints are:

–headache;

–weakness;

–numbness in the hands;

–changes in the appearance and proportions of the body, the size of the hands, feet, ears, nose;

–dry mouth and thirst;

–joint pain;

–limitation and pain of movements;

–all women have irregular menstrual cycles;

–30 % of men develop sexual weakness.

Another extreme manifestation of height is a person's short stature.

Dwarfism is an abnormally low height of an adult: less than 147 cm, associated with a deficiency of the growth hormone somatotropin or a violation of its conformation (structure), which leads to disturbances in the formation of the skeleton (disproportionate dwarfism).

Types of dwarfism:

1. Pituitary associated with a large lack of growth hormone produced by the pituitary gland.

13

2.Thyroid associated with a deficiency of the main thyroid hormone, usually accompanied by dementia.

3.Cerebral — pathology of the neuroendocrine system.

4.Genetically determined — pathology combines diseases of cartilage, bone and other tissues of the body. Such diseases include achondroplasia, Shereshevsky — Turner syndrome, Robinov syndrome.

In this condition, characteristic disorders occur:

– violation of body proportions: compared to a child of similar height, the head is relatively larger than the body, and the arms are quite short;

– premature old age;

– facial wrinkles;

– poor growth of beard and hair in general on the face and body.

When examining a patient, you should pay attention to build and weight. This determines the prescription of medications for prehospital care, which are calculated per kilogram of body weight. A convenient WHO classification of obesity is based on the definition of body mass index (BMI) = body weight (kg) / body height (m) squared.

Obesity level:

1) normal weight — BMI < 25;

2) overweight — BMI = 25–29.9;

3) grade I obesity — BMI = 30–34.9; 4) grade II obesity — BMI = 35–39.9; 5) grade III obesity — BMI > 40.

Causes of obesity. In 90 % of cases, obesity occurs as a result of violations of diet and physical activity:

– long intervals between meals and excessive portions;

– overeating in the evening;

– eating before bed;

– large amounts of carbohydrates and fats (especially confectionery and animal origin) with a lack of fiber and dietary fiber;

– excessive intake of calories compared to their expenditure;

– lack of physical stimulation of muscle tissue to participate in fat processing;

– family predisposition.

However, in 50 % of cases, the development of obesity is caused by disturbances in the functioning of organs and systems:

a) endocrine diseases (disorders of the hypothalamic-pituitary system, thyroid gland, disruption of the endocrine function of the pancreas, adrenal glands);

14

b)the influence of hormonal drugs (COCs, steroids, insulin);

c)genetically determined lack of lipolysis enzymes (fat breakdown);

d)brain tumors.

Types of obesity by localization of deposits:

−ginoid (female, lower): the buttocks and thighs become fat first;

−android (male, upper): fat is deposited on the abdomen (in the omentum),

sides;

−mixed: the body gains weight evenly, including the limbs, neck, back.

Symptoms characteristic of obesity are:

a) enlargement of body parts, change in their ratio;

b) aesthetic defects: double chin, pseudogynecomastia, “apron” on the stomach; c) striae (stretch marks);

d) hernias.

Characteristic clinical manifestations of obesity are:

−shortness of breath, tachycardia;

−heartburn, esophageal reflux;

−snoring, sleep apnea;

−decreased in muscle mass;

−joint pain;

−episodic increase in pressure;

−menstrual cycle disorders, potency.

Over time, functional disorders turn into organic and systemic diseases.

Complications of obesity are:

1)respiratory and heart failure;

2)cardiac ischemia;

3)hypertension;

4)fatty liver, which can ultimately lead to cholelithiasis and cirrhosis;

5)pancreas, pancreatitis, diabetes;

6)erosion of the esophagus, gastritis, gastric and duodenal ulcers;

7)arthritis and arthrosis;

8)gout;

9)osteochondrosis with severe radicular pain.

There is a connection between obesity and a number of cancers: cancer of the colon, pancreas, prostate, ovaries and mammary glands. At the same time, a number of patients will also experience malnutrition resulting from various pathological processes or diseases.

15

To assess such conditions, it seems convenient to classify three degrees of malnutrition:

1.In case of grade I malnutrition, the body weight deficit relative to the age norm does not exceed 20 %. The child’s health and general condition are normal.

2.With grade II malnutrition, the loss of body weight is 25–30 %. The subcutaneous fat layer on the abdomen is significantly reduced, and its thinning is noticeable on the torso and limbs. The child is lethargic, stunted in growth and neuropsychic development.

3.With grade III malnutrition, body weight loss is more than 30 %.

There are obvious signs of exhaustion, the skin is pale gray, wrinkled, the subcutaneous fat layer is almost completely absent. An extreme manifestation of eating disorder in patients is cachexia. Cachexia occurs due to a severe decrease in the amount of food consumed and reactive weight loss. According to statistics, about 20 % of cancer patients die from this condition, and not from the tumor itself. In this condition, there is a significant decrease in BMI. Loss of body weight can reach more than 50 % of initial values within a short time and is fatal.

Losing body weight leads to characteristic symptoms:

–sleep disturbance;

–dehydration of the body;

–immune system disorder;

–muscle weakness;

–low blood pressure;

–mental disorders;

–low skin elasticity;

–brittle nails;

–hair loss;

–stomatitis.

Cachexia can be caused by the following diseases:

1)oncological diseases;

2)starvation, strong desire to lose weight with malnutrition;

3)endocrine disorders;

4)heart failure;

5)purulent processes in the body, intoxication;

6)metabolic disease;

7)prolonged psycho-emotional stress;

8)acute and chronic infections;

9)gastrointestinal diseases;

10)taking medications;

16

11)cerebral strokes;

12)conditions after surgical operations with digestive disorders;

13)mental disorders;

14)diseases and injuries leading to digestive and mental disorders.

In the medical classification, the following types of cachexia are distinguished:

–cancer;

–terminal;

–senile;

–cerebral;

–nutritional;

–cardiac;

–pituitary;

–kahechtinovaya;

–hypothalamic;

–anorexic.

2.2.EXAMINATION OF THE PATIENT’S SKIN

AND SUBCUTANEOUS TISSUE

When examining the skin, you should determine the presence of pathological changes on the skin or injuries — punctures, cuts, bites, gunshots, bruises, infected, postoperative wounds. Detection of wounds in patients is of fundamental importance for further diagnosis. Stab or cut wounds in the projection of the abdomen dictate the need for an emergency examination by a hospital surgeon to exclude penetrating wounds of the abdomen, in which there is damage not only to the full thickness of the skin, but also to the integrity of the parietal layer of the peritoneum. Diagnosis of such wounds requires primary surgical treatment and revision of the wound in an onduty surgical hospital. If a penetrating injury to the abdomen is confirmed, an emergency laparotomy is performed with inspection of the abdominal organs to diagnose injuries or emergency laparoscopy with examination of the abdominal organs.

The presence of bruised wounds on the abdomen without violating the integrity of the skin of the integument to its full depth is the reason for a diagnosis of closed abdominal injury and hospitalization in the on-duty surgical department. With this diagnosis, an emergency instrumental examination is indicated — ultrasound of the abdomen, CT scan of the abdomen, diagnostic laparoscopy, and, if necessary, placement of a groping catheter in the abdominal cavity according to the generally accept-

17

ed method. All these examination options are carried out in an on-duty surgical hospital.

The presence of puncture wounds in the projection of the abdomen always requires the diagnosis of penetrating abdominal wounds, even if these wounds are small and are not accompanied by clinical manifestations. All injured with stab, cut, gunshot, burn or other wounds should be examined by an on-duty surgeon or traumatologist, followed by primary surgical treatment of wounds, emergency tetanus prophylaxis, and if patients have bite wounds, anti-rabies vaccination.

Of particular danger are stab wounds in the projection of the heart; such patients must be taken to an emergency surgical hospital to exclude injury to the heart. In cases where, during the initial examination, patients are diagnosed with a wound on the chest from which air is released, patients should apply a hermetic bandage to the wound in order to convert an open pneumothorax into a closed one and take the patient to the on-duty surgical department.

If a patient with a chest injury or auscultation of the lungs cannot hear breathing on one side and the symptoms of acute respiratory failure increase, then before delivering the patient to the emergency surgical hospital, he needs to undergo a pleural puncture in the second intercostal space along the midclavicular line for health reasons to exclude tension pneumothorax.

The same actions should be carried out in patients with spontaneous pneumothorax, if breathing on the affected side is not heard and there are signs of tension pneumothorax.

It is important to note not only to examine all the patient’s wounds, but also to determine the nature of the wounds and the threat to the patient’s life. If there are wounds with ongoing bleeding, then at the prehospital stage the bleeding from the wound should be stopped and the patient should be taken to a surgical hospital. With continued bleeding from wounds on the limbs, in most cases, applying a pressure bandage to the wound is sufficient. Only in cases where it was not possible to stop the bleeding with such a bandage within 10–15 minutes, the patient is given an arterial tourniquet and taken to the emergency hospital. This tactic allows you to avoid pain in many patients and minimizes ischemic disorders and complications from the affected limb.

When examining wounds, it is advisable to determine not only the presence of the wound itself, but also the nature of the damage. Sometimes the patient has an open fracture of the bones on the limb and a wound above the fracture site. Such injuries require not only wound coverage and stopping bleeding from the wound, but also immobilization of the broken bones of the limb. If the victim has one wound, then, as a rule, it is an isolated injury.

18

However, in clinical practice there were situations when one wound hole led to combined thoraco-abdominal or thoraco-cardiac injuries, i.e. to combined injuries. If a patient has several wounds, a diagnosis of multiple injuries is made; if there are wounds caused by different types of energy, mechanical, radiation, thermal, chemical, then the patient is diagnosed with a combined injury.

When examining a patient, the color of the skin, mucous membranes and corneas of the eyes is of great importance. It is important to determine the clinical manifestations of the disease: types of scabies, paired locations of papules and vesicles, symptoms of skin lesions. Ardi's symptom (rashes and purulent crusts), Gorchakov's symptom (dotted bloody crusts on the elbows or in their circumference), triangle (vesicles, pustules, crusts above the gluteal fold). Pyoderma is the most common skin disease.

Pay attention to the manifestations of secondary pyoderma (eczema, atopic dermatitis, scabies), as well as the development of secondary pyoderma in patients receiving hormonal and cytostatic therapy, in HIV-infected patients.

Of great diagnostic importance is the presence or absence of a rash and its localization (psoriasis — extensor surfaces of the extremities; epidermophytosis — third and fourth interdigital folds of the feet and arch of the foot; lupus erythematosus — face), symmetry of the location of the rash (eczema, psoriasis, atopic dermatitis), unilaterality ( linear nevi), along the nerves (herpes zoster).

The rash may have a tendency to grow peripherally and merge (psoriasis, lichen planus), grouping, unusual color, shape.

Often, along with skin diseases, characteristic clinical symptoms are observed — anesthesia or hyposgesia (with leprosy), paresthesia (a feeling of anemia or crawling with Raynaud's disease), a feeling of skin tightening (with scleroderma, erythroderma).

During examination, it is important to identify patients with lichen. For lichen planus, a red-bluish color is characteristic, brick-red — for exudative erythema, yellowish — for tuberculous lupus.

A chronic inflammatory process (syphilis, psoriasis) is characterized by blurred boundaries, while an acute inflammatory process (acute eczema, erysipelas) has clear boundaries. As a rule, during inflammatory processes, lymphangitis and lymphadenitis of regional and distant levels occur; follicles are often involved in the inflammatory process. If it is difficult to diagnose, patients should consult a dermatologist who can determine the Auspitz phenomenon in lichen planus, conduct an iodine test, and visualize the skin in UV light.

Body temperature is the thermal state of the human body, which reflects the state of its health and thermoregulation.

19

A person’s body temperature changes within small limits during the day, remaining in the range of approximately 35.5 to 37.2 °C; body temperature below 35 °C indicates the presence of a disease.

Normal temperature — 36, 6 °С.

The subfebrile temperature — 37–37.9 °C. Moderate (febrile) temperature — 38–39 °С. High (pyretic) temperature — 39–41 °С.

Excessive (hyperpyretic) temperature — more than 41 °C.

The normal temperature depends on the location where it is measured.

Typical results for measuring the temperature of a healthy person are as follows:

–temperature in the anus (rectally), vagina or ear — 37.5 °C;

–temperature in the mouth (orally) — 37.0 °C;

–temperature in the armpit (axillary) — 36.6 °C.

Body temperature is controlled by thyroid hormones and the hypothalamus. The nerve cells of the hypothalamus directly respond to body temperature by increasing TSH, which regulates the activity of the thyroid gland, whose hormones (T3 and T4) are responsible for the intensity of metabolism. The hormone estradiol is involved to a lesser extent in temperature regulation; an increase in its level leads to a decrease in basal temperature. A decrease in body temperature by several degrees disrupts vital processes and can lead to cooling or overheating of the body and even to its death. The temperature rises as a result of stress, intense mental work, inflammatory diseases, thyroid diseases, infections, viral diseases.

Hyperthermia is overheating of the human body with an increase in body temperature, caused either by external factors that impede heat transfer to the external environment or by internal ones — as a protective-adaptive reaction of the body in response to the influence of pathogenic stimuli — bacterial allergens in infectious diseases, exposure to viruses or injuries in which the brain is affected and central thermoregulation is disrupted. With hyperthermia, in which there is an increase in internal body temperature above 43 °C, heat stroke and death occur.

Hypothermia is a general cooling of the body to a decrease in body temperature below normal, but within the limits of compensatory reactions of the body — not lower than 35 °C in humans.

According to the clinical course, they are distinguished:

–compensatory stage;

–adynamic stage;

–soporous stage;

–comatose stage.

20