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

In cases where a person is exposed to cold, his internal mechanisms may not be able to replenish heat loss. A decrease in rectal temperature in a person to 33–32 °C and below causes drowsiness, confusion; up to 30 °C and below causes a decrease in basal metabolism, hypotension, bradycardia, loss of consciousness; up to 25 °C and below represents threat to life; up to 23–20 °C and below — irreversible, clinical death occurs; up to 17–18 °C — biological death.

Characteristics and types of temperature curves

Constant fever (febris continua): body temperature is usually high, within 39 °C, lasting for several days or weeks with fluctuations within 1 °C. Characteristic of acute infectious diseases, pneumonia, typhus.

Remitting fever (febris remittens) is characterized by significant daily fluctuations in body temperature of up to 2 °C or more. Characteristic of diseases leading to purulent complications.

Intermittent fever (febris intermittens) characterized by a sharp rise in body temperature to 39–40 °C or more and decline in a short time to normal and even subnormal numbers; after 1–2–3 days the same rise and fall are repeated. Characteristic of malaria.

Hectic fever (febris hectica) is characterized by large daily fluctuations in body temperature over 3 °C and a sharp drop to normal or subfebrile values. Characteristic of sepsis and tuberculosis.

Recurrent fever (febris recurrens): body temperature rises quickly to high values, remains at this level for several days, then decreases to normal, and after 4–5 days rises again to high values, and then remission occurs. Characteristic of relapsing fever, spirochetosis.

Undulating fever (febris undulans) is characterized by wave-like increases in temperature to febrile or subfebrile values in the evening, followed by decreases in the morning for several days. Characteristic of brucellosis.

Perverted fever (febris in versa). Morning temperatures are higher than evening temperatures. Characteristic of the septic process, tuberculosis.

Irregular fever is most common and is characteristic of inflammatory diseases. Daily fluctuations in body temperature are varied; their duration and periods are not determined. It is observed in rheumatism, pneumonia, dysentery, and influenza.

Based on temperature curves, three periods of fever are distinguished:

1. The initial period (stadium incrementi), can be short — hours, or long — several days.

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2.The height of the fever (fastigium or acme). Lasts from several hours to several days.

3.Temperature reduction stage. A rapid drop in temperature is called a crisis; a gradual decrease is called lysis.

Edema is an abnormal accumulation of fluid in certain tissues of the body as a result of inflammation, systemic disorders, or injury. Fluid accumulation can occur under the skin — usually in the lower extremities, on the face or in various body cavities.

To diagnose edema, you need to press for a few seconds on the front surface of the lower leg in the lower third. In case of edema, a hole remains in this place, which does not disappear immediately.

The main factors in the formation of edema are changes in the biochemical composition of tissue fluid and blood plasma. Disturbances also occur against the background of hormonal changes and increased capillary permeability.

Lymphatic edema associated with causes at the level of the lymphatic system. There are primary — congenital malformations of the lymphatic system and secondary — acquired damage associated with infection, surgery, trauma, affecting the lymphatic vessels themselves.

Dynamic edema arising not as a result of damage to the lymphatic vessels themselves, but as a result of other reasons, usually veins, arteries, as a result of their damage by blood clots, injuries, medications, varicose veins or stagnation of blood in them due to physical inactivity.

The main reasons for the development of edema are:

– kidney diseases: glomerulonephritis, nephrotic syndrome, renal failure;

– heart diseases: heart failure;

– vein lesions (varicose veins, inflammation, thrombosis);

– liver diseases: cirrhosis of the liver, blockage of the hepatic veins;

– diseases of the endocrine system: hypothyroidism, diabetes;

– severe oncological diseases;

– nutritional dystrophy;

– pregnancy;

– allergic reactions: insect bites, contact with an allergen.

Heart pathology is characterized by swelling in the legs. Swelling develops slowly over several weeks. The accumulation of edema depends on the degree of circulatory impairment. Initially, swelling occurs in the lower extremities, and then can be detected in the abdomen, leading to ascites and enlarged liver. Upon palpation of the skin, a low temperature is determined, swelling on the skin is dense.

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Pathology in the lungs leads to the accumulation of fluid in the pleural cavities on the affected side, respiratory failure and impaired gas exchange in the lungs develop. Clinically, this is manifested by shortness of breath at rest, suffocation, a feeling of tightness in the chest, cough with sputum production.

Kidney disease leads to swelling around the eyes and then in the legs. Damage to the tiny filtering blood vessels in the kidneys can lead to nephrotic syndrome. With nephrotic syndrome, electrolyte disturbances occur and the level of albumin in the blood decreases, which leads to the accumulation of fluid in the tissues and cavities of the body.

With liver cirrhosis in the decompensation stage, porto-caval anastomoses open and fluid accumulates in the abdominal cavity. Often this pathology is accompanied by dilation of hemorrhoidal veins and esophageal veins, which can manifest as severe bleeding.

During the inflammatory process in the joint area, a large amount of synovial fluid is released. It accumulates in the joint structures, often affecting the joint capsules and becoming infected. Swelling due to venous insufficiency also becomes more pronounced in the evening, causing the sensation of suddenly tight shoes, and the shins become visually thicker, often not symmetrically. Swelling in the legs is accompanied by a feeling of heaviness, fatigue, and pain in the legs. Spider veins and an enhanced pattern of veins are noticeable on the skin. In severe cases, swelling persists constantly, cramps in the calves are possible, trophic changes develop — thinning of the skin, persistent redness, peeling, itching, and poorly healing ulcers.

Allergic edema develops quickly within a few minutes and is regional in nature. They arise as a result of contact with an allergen or an insect bite. They develop most often on the face, in the area of the eyes, eyelids, mucous membranes, lips, on the arms, fingers, hands, in the elbow and knee bends. Clinically, allergic edema is caused by itching, rash, hoarseness, and difficulty breathing. Quincke's edema is associated with allergic factors or medications. The disease occurs acutely, progresses rapidly and is manifested by angioedema of the skin and subcutaneous tissue, body systems and various organs. Particularly dangerous is the development of laryngeal edema, which can lead to asphyxia and death.

2.3. EXAMINATION OF PERIPHERAL LYMPH NODES

Lymph nodes (nodi lymphatici) are a peripheral organ of the lymphatic system that perform the function of a biological filter through which lymph flows from organs and parts of the body. In the human body there are several groups of lymph nodes, called regional, and there are also organ lymph nodes.

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Lymph nodes are round, oval, bean-shaped, and less often ribbon-shaped formations ranging in size from 0.5 to 8 mm. The lymph node includes two main zones. Closer to the capsule is the cortex, which has a superficial part and a zone of deep cortex. The inside of the lymph node is called the medulla. Lymphatic follicles are located in the area of the superficial cortex; it is in them that proliferation and differentiation of B-lymphocytes occur.

In the zone of the deep cortex, lymphocytes are densely located; it is in this zone that T-lymphocytes undergo antigen-dependent proliferation and differentiation. In the medulla, lymphoid tissue is represented by medullary cords, in which B-lymphocytes differentiate into plasma cells that produce immunoglobulin antibodies. Lymph flows to lymph nodes along the afferent lymphatic vessels, approaching the node from the convex side, and flows through the efferent lymphatic vessel, extending from the concave side of the node in the hilum area.

Within the node, lymph slowly leaks through internal spaces called lymphatic sinuses. Flowing lymph brings foreign antigens to the lymph node, which causes an immune response in the lymph nodes.

In cases where the sinuses become overcrowded and inflammatory exudate accumulates in the filters of the lymph node, the lymph node enlarges and lymphadenitis occurs, which, with infectious development, turns into abscessing lymphadenitis, requiring surgical treatment.

The lymph node is a barrier to the spread of both infection and cancer cells. Lymphocytes mature in it — protective cells that actively participate in the destruction of foreign substances and bacterial cells.

The condition of the lymph nodes can be used to judge the condition of the organs or systems of the body.

There are the following groups of lymph nodes:

–intrathoracic, mediastinal;

–bronchopulmonary (hilar);

–elbows (epitrochlear and brachial);

–spleen;

–paraaortic;

–mesenteric;

–iliac (general, internal and external);

–inguinal (deep and superficial);

–femoral;

–popliteal.

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There are also syndromes of enlarged lymph nodes associated with lipid accumulation:

1.Gaucher syndrome.

2.Niemann — Pick syndrome.

Changes in the lymph nodes are especially characteristic in the following immunological diseases:

–rheumatoid arthritis;

–systemic lupus erythematosus;

–dermatomyositis;

–serum sickness;

–reaction to drugs;

–angioimmunoblastic lymphadenopathy;

–bubonic plague.

Enlarged lymph nodes in infectious diseases have their own characteristics. Initially, the lymph node enlarges, becomes painful, swollen, hyperemia occurs and the tissue surrounding the lymph node is involved, which leads to abscess of the lymph node and phlegmon. These processes develop especially quickly in patients with HIV infection, tuberculosis, and secondary immunodeficiency.

There are specific types of lymph node enlargement — cat scratch disease caused by Bartonella.

With acute respiratory viral infections (ARVI), the lymph nodes in the neck may become enlarged. With syphilis, the lymph nodes on the genitals become enlarged in the form of chancre. If an enlarged lymph node does not shrink within several weeks, then one should think about brucellosis, mononucleosis, listeriosis, HIV infection, or tumor lesions.

Tumor damage to the lymph nodes can be a consequence of lymphogranulomatosis or lymphosarcoma, sometimes a consequence of metastatic lesions. Lymph nodes in these diseases increase to 3–4 cm, become dense, but remain painless.

2.4. EXAMINATION OF THE PATIENT’S MOTOR ACTIVITY

Motor disorders occur with central and peripheral damage to the nervous system. They are manifested by a limitation in the volume and strength of movements (paralysis), disturbances in their tempo, character and coordination (ataxia), as well as the presence of involuntary violent movements (hyperkinesis). Experts divide movement disorders into akinetic-rigid and hyperkinetic forms. With the former, patients experience muscle stiffness and retardation of movements, and with hyperkinetic forms, unconscious movements are observed. But in both cases, muscle strength

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is maintained. As a rule, movement disorders develop due to disruption of the functioning of neurotransmitters in the basal ganglia.

Pathogenesis may be different. Development factors are congenital and acquired degenerative pathologies (they develop with the use of medications).

Causes of movement disorders:

−rigidity. It indicates a dysfunction of the extrapyramidal system and is caused by damage to the basal ganglia (Parkinson's disease);

−hypotension. Occurs in primary muscular diseases and lesions of the cerebellum (Huntington's disease);

−spasticity. Damage to the central nervous system (stroke);

−paratonia. Characteristic of lesions of the frontal lobe.

Movement disorders:

1)paralysis — impaired motor function, which occurs due to pathology of the innervation of the corresponding muscles and is characterized by the absence of voluntary movements;

2)paresis — a movement disorder that is caused by pathology of the innervation of the corresponding muscles and is characterized by a decrease in the strength and amplitude of voluntary movements;

3)paraparesis — paralysis of both limbs;

4)monoplegia and monoparesis — paralysis of the muscles of one limb;

5)hemiplegia — paralysis and paresis of both limbs, sometimes the face;

6)tetraparesis — paralysis of all limbs of the body.

One of the most common forms of movement disorders is paralysis and paresis (loss of movement due to impaired motor function of the nervous system).

The following types of paralysis are distinguished:

–flaccid (lost tone of the affected muscles);

–spastic (muscle tone is increased);

–peripheral;

–central.

Classic pyramidal palsy is characterized by increased muscle tone and irregularity and resistance during various phases of passive movement.

The following types of disorders of the body muscles are diagnosed:

1)extrapyramidal rigidity — a uniform diffuse increase in muscle tone, expressed in all phases of active and passive movements, is caused by damage to the extrapyramidal system;

2)hypotension — decreased muscle tone; associated with peripheral motor neuron damage;

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3)paratonia. It is impossible to completely relax the muscles. In mild cases, rigidity is observed with rapid passive movement of the limb and normal tone with slow movement;

4)areflexia — the absence of one or more reflexes caused by a violation of the integrity of the reflex arc;

5)hyperreflexion — an increase in segmental reflexes, occurs when the pyramidal pathways are affected;

6)pathological reflexes — the general name of reflexes found in an adult when the pyramidal pathways are affected;

7)clonus — an increase in tendon reflexes, manifested by series of rapid rhythmic contractions of a muscle or muscle group.

With extrapyramidal lesions, the following forms of diseases occur:

– trembling;

– rigid;

– amyostatic;

– mixed.

There are also several specific forms of movement disorders:

1)bradykinesia — the inability to carry out habitual movements, reduction in the number of automatically performed movements (blinking, swaying arms when walking). Characteristic of Parkinson's disease;

2)tremor — rhythmic oscillations of a limb or torso relative to a specific point. Tremors of the hands, feet, head, and lower jaw are noted;

3)myoclonus — arrhythmic muscle tension and twitching. Occurs in patients after cardiac arrest; it may be a symptom of drug-induced encephalopathy;

4)leaflets — involuntary prolonged posture or static pathological postures with forced flexion or extension in certain joints;

5)choreoathetosis: co-occurring chorea — erratic, jerky movements and athetosis — slow, involuntary convulsive movements. Chorea is characteristic of Sydenham's disease and Huntington's disease, athetosis occurs with cerebral palsy;

6)tics — involuntary movements: blinking, sneezing or coughing; occur with Tourette's disease.

Passive movement is movement that is carried out using the “outside”. Injured may experience pathological mobility — the limb is mobile in the place where there is a fracture or dislocation.

In injured with floating rib fractures, a paradoxical type of breathing is observed. Floating (fenestrated, leaflet) rib fractures are a group of rib fractures in which a fragment of the ribs is formed that is not connected to the spine.

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Thus, a pathologically mobile free fragment is formed in the chest — the costal valve (window). Violation of the chest frame leads to incomplete expansion of the lung on the side of the injury. It is noteworthy that on inspiration, due to the retraction of the floating area, the intrapulmonary air pressure on the damaged side is higher, and on exhalation, due to the bulging of the costal window, it is lower than in the lung on the healthy side. In this regard, when breathing, partial pumping of air occurs from the lung on the affected side to the lung on the healthy side, and when exhaling, vice versa.

The pendulum-like movement of air in the lungs leads to an increase in “dead” space, to an increase in hypoxia, the mediastinal organs shift, and cardiovascular disorders increase.

Upon examination, attention is drawn to the lag of the damaged half of the chest in the act of breathing, deformation of the chest, pathological mobility of the costal “window”, and the greatest mobility is determined when there is a combination of floating fractures of the ribs with fractures of the clavicle and sternum. Flotation of the costosternal valve in case of anterior bilateral fractures can be carried out in the anteroposterior direction, along the horizontal axis of the sternum like a swing and along the longitudinal axis of the sternum. Palpation reveals pain in the area of the fractures, as well as crepitus of the fragments.

The clinical picture and severity of the condition is determined by the position and size of the rib “window”, as well as the amplitude of oscillations; the floating areas of the ribs can shift by 4.0–4.7 cm, while the pathological mobility of the lower 6–8 ribs is greater, the upper 3–5 ribs, the larger and more mobile the valve, the more severe the victim’s condition.

Active movement is movement that occurs “from within” the body, thanks to the interaction of the nervous system, muscles and skeleton.

Conducting an examination of a person in the Romberg’s position. The patient, in a standing position, is asked to close his eyes, move his legs together, stretch his arms forward and to the sides, “spreading” his fingers. Normally, a healthy person stands straight in this position, but in pathological cases he deviates to the side, staggers or falls. Detects changes in balance (staggering or even falling — “Romberg’s symptom”) when vision is turned off. In cases where imbalance is not clearly identified (during medical diagnosis), it is suggested to complicate the pose, for example, placing the feet in one line — one in front of the other. Romberg's symptom is detected with damage to the cerebellum and its connections with other parts of the central nervous system, disorders of the function of the vestibular analyzer, and impairment of deep sensitivity due to damage to the spinal cord.

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When the cerebellum is damaged, the patient deviates mainly towards the affected hemisphere. Staggering in the Romberg’s position can also be observed in the absence of organic changes in the nervous system, with neuroses, and with intoxication. The Romberg’s position is widely used to assess the coordination abilities of drivers for testing for alcohol intoxication, during the initial examination of patients by EMS doctors.

2.5. EXAMINATION OF THE STATE OF THE NERVOUS SYSTEM,

CONSCIOUSNESS AND SENSITIVITY

Assessment of neurological status is the leading means of neuromonitoring, which allows an accessible way to assess the condition of the brain and nervous system at the prehospital stage.

General cerebral symptoms.

Norm: consciousness is clear — the patient is communicative, fully oriented in his own personality, time and place, adequate, follows all instructions.

Degree of depression of consciousness (according to the classification of A.N. Konovalov):

–stupor (superficial, deep) — loss of attention, difficulty concentrating, answering questions after repeated repetitions, rapid exhaustion during a conversation, etc.;

–sopor — opening of the eyes during loud handling or braking, painful stimulation; localization of the source of inhibition (targeted motor reaction);

–coma I — absence of eye opening in response to any stimuli; non-targeted motor reactions;

–coma II — absence of eye opening and motor reactions in response to any

stimuli;

–coma III — absence of eye opening and motor reactions in response to any stimuli; muscle atony, areflexia, absence of meningeal syndrome, dysfunction of the respiratory and cardiovascular systems.

Orientation in place, time, self. Availability of productive speech (verbal) contact.

General cerebral symptoms:

−headache — localization, nature, frequency, concomitant symptoms, at what time of day;

−non-systemic dizziness — feeling of failure, unsteadiness, instability;

−systemic dizziness — apparent movements of surrounding objects or one's own body;

−nausea, vomiting.

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Meningeal symptoms:

−stiffness in the back muscles of the neck;

−Kernig's symptom;

−Brudzinski's symptom (upper, middle, lower);

−zygomatic ankylosing spondylitis symptom;

−Mondonesi's symptom;

−photophobia, phonophobia;

−headache;

−hyperesthesia of the skin and mucous membranes.

Focal symptoms.

Cranial nerves.

I pair (n. olfactorius). The sense of smell is not impaired; hyposmia, anosmia

(right, left); dysosmia, hyperosmia; olfactory hallucinations — yes, no.

II pair (n. opticus). Visual acuity is not impaired; amblyopia (decreased visual acuity), amaurosis (blindness); fields of vision are not impaired; scotoma (loss of a portion of the visual field); hemianopsia: homonymous (right, left), heteronymous (bitemporal, binasal); visual hallucinations — yes, no.

III (n. oculomotorius), IV (n. trochlearis), VI (n. abducens). Voluntary eye movements — in full, strabismus (strabismus): convergent, divergent, vertical.

Pupils OD > < = OS, deformed; pupil width: corresponds to illumination, miosis (narrow), mydriasis (wide).

Photoreactions are direct, friendly: preserved, reduced, absent (right, left). Gaze paresis, tonic abduction of the eyes: to the right, to the left.

V (n. trigeminus). Sensitivity on the face — preserved, reduced: neural type (I, II, III branches); segmental type (inner, middle, outer brackets); conductor type (right, left).

The strength of the masticatory muscles is preserved; reduced (right, left). Corneal reflexes — preserved, reduced, absent (right, left).

Mandibular reflex — unchanged, increased.

VII (n. facialis). Mimic muscles. The face is symmetrical, paresis of facial muscles: central — the nasolabial fold is smoothed, peripheral — the inability to raise the eyebrow, close the eye, the nasolabial fold is smoothed (right, left).

Taste disturbance on the anterior 2/3 of the tongue (right, left).

Lacrimation (lacrimation), dry sclera; hyperacusis (increased sound perception).

VIII (n. vestibulocohlearis). Hearing is preserved, reduced, absent (right, left).

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