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

–injuries;

–childbirth;

–surgeries on the adrenal glands;

–defects in preoperative preparation and postoperative management during operations for pheochromocytoma.

Clinical picture, complications, special clinical manifestations of pheochromocytoma:

1) frequency varies from one attack for several months to 10–15 during the day; 2) development can occur both with initially normal blood pressure and against

the background of its previous persistent increase;

3) sudden onset, often after exposure to provoking factors; pronounced increase in blood pressure 200–300/100 mmHg, mostly systolic;

4) accompanied by a triad of symptoms: headache, sweating, even heavy sweating, tachycardia;

5) nausea, vomiting, blurred vision, pale skin, feeling of fear, pain in the abdomen, heart, in the blood: leukocytosis, lymphocytosis, eosinophilia, hyperglycemia, proteinuria;

6) duration from several minutes to hours;

7) rapid reverse development;

8) after a crisis, polyuria occurs.

Special clinical manifestations of pheochromocytoma. If the tumor is located in the wall of the bladder, urination may cause attacks. They are often accompanied by painless hematuria, palpitations, headache, nausea and increased blood pressure.

In women, pheochromocytoma can manifest as hot flashes; in pregnant women, pheochromocytoma sometimes mimics eclampsia, preeclampsia, or uterine rupture.

Children with pheochromocytoma usually have arterial hypertension. Polyuria, polydipsia and convulsions are characteristic. Children experience complications of pheochromocytoma — growth retardation, weight loss, vasomotor disturbances, visual disturbances, sweating, nausea and vomiting.

Typical complications of pheochromocytoma are:

−heart failure;

−arrhythmias;

−catecholamine shock;

−cerebrovascular accident;

−renal failure;

−hypertensive encephalopathy;

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−ischemic colitis;

−dissecting aortic aneurysm;

−in pregnant women: fever, eclampsia, shock, death of mother or fetus;

−toxic catecholamine myocardial dystrophy.

Emergency conditions for disorders of mineral metabolism.

Hypocalcemic crisis occurs when the blood calcium level decreases to 1.9–2.0 mmol/L, the level of ionized calcium decreases to less than 1 mmol/L, manifested by titanic convulsive syndrome

Etiology. The main reasons for the development of the crisis are:

1)radioiodine therapy in the treatment of thyroid diseases;

2)removal or damage to the parathyroid glands during surgery on the thyroid gland and during removal of the parathyroid glands;

3)hemochromatosis;

4)idiopathic hypoparathyroidism;

5)autoimmune destruction of the parathyroid glands;

6)disturbances in the action of parathyroid hormone;

7)vitamin D deficiency;

8)excessive secretion of calcitonin.

The clinical picture consists of characteristic symptoms:

−numbness, tingling, burning, tension, stiffness in the muscles of the limbs;

−tetanic convulsive syndrome;

−consciousness is preserved, but fainting is possible;

−autonomic dysfunction syndrome — pallor, tachycardia, hypertension;

−predominance of the tone of the parasympathetic system with vomiting, diarrhea, polyuria, bradycardia, arterial hypotension;

−syndrome of central nervous system damage with brain disorders — brainstem and extrapyramidal symptoms with the development of epileptic attacks;

−visceropathy syndrome with the appearance of calcifications of internal organs, the development of intracranial calcification in the area of the basal ganglia, hypothalamus, cerebellum, and the development of cataracts;

−skin lesion syndrome and its derivatives — dryness, flaking, eczema, dexfoliative dermatitis, areas of pigmentation and depigmentation (vitiligo), impaired hair growth, gray hair, baldness, brittle nails.

A hypercalcemic crisis occurs with a sharp increase in blood calcium levels, in the range of 3.5–4.0 mmol/L, characterized by neuromuscular disorders, increased blood clotting, the development of thrombosis and disseminated intravascular coagulation syndrome, leading to acute cardiovascular pathology, to arrhythmias and cardiac arrest. Lethal outcomes occur in 50–60 % of patients.

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The main causes of hypercalcemic crisis are:

–hyperplasia of the parathyroid glands;

–vitamin D poisoning;

–malignant tumor with metastases to bone tissue.

Provoking factors are:

1) exacerbation of primary hyperparathyroidism in the absence of adequate

treatment;

2)dehydration in patients with primary hyperparathyroidism;

3)treatment with thiazide diuretics;

4)vitamin D hypervitaminosis;

5)consumption of large amounts of milk, high-calcium supplements, soluble antacids, alkaline milk syndrome or Burnett's syndrome.

Clinic. The clinical picture consists of characteristic syndromes:

– abdominal syndrome: acute pain in the epigastrium, nausea, vomiting, gastric bleeding, perforation of the stomach or duodenum, acute pancreatitis;

– syndrome of psychoneurological disorders: confusion, supor or hallucinations, somnolence, coma;

– dehydration syndrome: dry skin, mucous membranes, decreased skin turgor, sharpening of facial features;

– thermoregulation disorder syndrome: febrile body temperature;

– syndrome of acute cardiopulmonary failure: shortness of breath, cyanosis, tachycardia, arrhythmia, arterial hypotension;

– renal syndrome: anuria, azotemia;

– syndrome of neuromuscular disorders: hypoand areflexia, muscle hypotonia;

– hypercoagulation syndrome: thromboembolism, disseminated intravascular coagulation syndrome.

2.8.EXAMINATION OF THE CONDITION OF THE SKELETAL SYSTEM

Scoliosis.

Scoliosis is a curving deformation of the spinal column in the lateral projection (to the right or left of the vertical axis). Most often it is formed in childhood (in infancy and ages from 3 to 5 years) or in the period from 18 to 25 years. The severity of scoliosis is determined by the angle of deviation of the spine. To measure it, X-rays are taken in standing and supine positions. The severity of the symptoms of the disease is directly related to the degree of scoliosis: the more significant the curvature, the more noticeable the load on the internal organs and systems

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There are four degrees of scoliosis. First degree scoliosis is expressed as a deviation from the norm of up to 10°. In this case, a slight stoop and subtle asymmetry in the position of the shoulders and shoulder blades arise; when bending forward, one shoulder blade protrudes more noticeably than the other.

Scoliosis of the second degree is characterized by a deviation of the spine from the axis of up to 25°. The patient has asymmetry of the shoulders, shoulder blades, and buttocks. When the body is tilted, the vertebrae stand out unevenly, one shoulder blade protrudes strongly, and there are costal protrusions. The muscle roll is easily palpable, convex on the chest side, concave on the lumbar side. The painful sensations are not expressed; radicular neurological pain occurs periodically. in the thoracic and lumbar spine.

Scoliosis of the third degree is characterized by a curvature of the spine of 26–50°. The patient's posture is impaired, the shoulders and pelvis are distorted, a rib hump is formed, and one leg may appear shorter. Severe deformations of the chest and spinal column lead to compression of the internal organs. The condition is accompanied by pain, restrictions in movement, problems with digestion and other organs.

The fourth degree of scoliosis is the most severe, the scoliotic angle is 50° or more. The patient's spine, chest and pelvis are deformed, a rib hump is formed in front and behind. Due to compression, all internal organs and systems cease to function normally, a person is haunted by constant pain and numerous pathological manifestations of the heart, lungs, gastrointestinal tract and urinary system, and there are often severe neurological and endocrine disorders.

The causes of scoliosis are:

–cerebral palsy;

–congenital vertebral deformities;

–rickets, poliomyelitis;

–vertebral injuries, including birth injuries;

–injuries to the pelvic bones, legs;

–diseases of muscles, connective tissues;

–osteoporosis;

–spinal tumors;

–obesity.

Complications of scoliosis. With cervical scoliosis, compression of the arteries of the spine occurs, which adversely affects blood circulation in the brain. The patient suffers from dizziness, headaches, and cognitive impairment.

Thoracic scoliosis is dangerous because it compresses the chest and abdominal cavity, causing damage to internal organs. Their improper functioning is fraught with numerous malfunctions in the body.

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Lumbar scoliosis is characterized by deformation and displacement of the pelvic bones, which means inevitable lumbar pain, problems with the kidneys, bladder and intestines, and sexual dysfunction.

Kyphosis.

Kyphosis is a curve of the spine with its convexity facing backward, while lordosis is a curve of the spine with its convexity facing forward. In a normal position, these curves are physiological and help the spine to absorb shock when walking, bending, jumping, etc. However, often, under the influence of negative factors, the natural curvature of the spine acquires pathological features. Kyphosis of the spine is most often arched, but it can also be angular — in this case, the vertebrae do not protrude as an arch, but as an angle, with the spinous process at the apex. Externally, the pathology is manifested by the formation of a hump on the back.

Thoracic kyphosis is the most common type of pathology. At the initial stage (this form of spinal curvature is called stoop), the condition does not cause discomfort, and it can be shown by an X-ray or detected by a doctor during a visual examination. As this type of kyphosis progresses, the patient develops a hump, the ribs and sternum are displaced, causing serious disruptions in the functioning of the internal organs.

Cervical kyphosis, lumbar kyphosis, and sacral kyphosis are very rare. They can occur due to trauma, infectious diseases or degenerative changes.

The causes of kyphosis are:

–anomalies of intrauterine development;

–birth injuries;

–injuries and operations on the spine;

–weakness of the back muscles;

–osteoporosis.

Lordosis.

Normally, the spine has a slight forward bend in the lumbar region — physiological lordosis. Pathological lordosis forms in the same area, only it is much more pronounced. Lumbar lordosis is characterized by “duck posture”: the shoulders are lowered, the head is slightly tilted forward, the stomach is protruded, the lower back is arched, the pelvis is shifted back, and the knees are spread apart. The gait is heavy, which is explained by pain and discomfort in the lumbar region. Spinal lordosis has a negative impact on the functioning of the heart and lungs, causing breathing and circulatory disorders.

Causes of lordosis:

–developmental anomalies of the spine;

–diseases of the spine, intervertebral hernias;

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–spinal injuries, birth;

–diseases of the hip joints;

–displacement of the vertebrae (spondylolisthesis);

–systematic violations of posture in a sitting/standing position;

–low physical activity;

–systemic diseases of the musculoskeletal system;

–excess body weight;

–rapid growth of the child.

Flat feet.

Flat foot is a deformity of the foot. It comes in two types: transverse and longi-

tudinal. With longitudinal flatfoot, the inner part of the foot begins to descend and even touch the floor. Other people from the outside can notice this, i.e. it is clear that the foot is spread out. Not everyone can see transverse flatfoot. It, as a rule, becomes noticeable only with secondary signs when valgus deformity of the first finger occurs. This is the so-called growing bump on the joint and the curvature of the first finger (it begins to stick out to the side).

The longitudinal arch on the inside and the transverse arch form the arched structure of the foot, which provides shock absorption when running and walking. With the help of this structure, the foot moves smoothly: it switches to walking, stepping, running, and the joints are not injured. Therefore, when flat feet develop, joint trauma may increase. The biomechanics of walking and the work of the muscles of the lower leg and foot are disrupted. Flat feet, which can be traced from childhood, are usually congenital and can be transmitted from parents, grandparents. For example, standing work can lead to flat feet in adulthood. Another reason is hormonal changes in women (flat feet, as a rule, are more common among them). This is, firstly, the stage of growing up, then pregnancy, childbirth. Some women become pregnant and give birth several times during their lifetime. In this case, in particular, a restructuring of connective tissue occurs. That is, the body prepares for childbirth, then returns, so to speak, to its previous state, and then again prepares for childbirth. The connective tissue begins to change: it stretches, then becomes strong again.

Clinical signs of fracture and dislocation.

It is not always possible to reliably determine a fracture or dislocation, so to confirm, the doctor must do an X-ray examination of the affected part of the body or limb. However, there are absolute and relative symptoms of a fracture.

Absolute (i.e. those that obviously indicate a fracture):

–the appearance is not characteristic, the position of the bone visually changes;

–movement can be observed in places where there are no joints (pathological mobility);

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–the presence of crepitus — a crunching sound when pressing on the area where a fracture is suspected;

–open fracture (open wound, bone visible).

Relative symptoms:

1)pain occurs when moving or loading the limb;

2)the appearance of a hematoma or bruise at the site of the injured area.

With dislocations there are also some symptoms indicating its presence:

– pain that does not allow you to move the injured area;

– when compared with a healthy joint, deformation is visible;

– the appearance of edema;

– a dislocated leg is characterized by a visual contraction of the injured limb, a dislocated shoulder is characterized by a change in pulse and numbness of the arm.

Causes of fractures and dislocations.

The main causes of fractures are injuries and diseases:

1)age-related changes;

2)too high a load on the bone for which it is not ready;

3)injuries;

4)improper or insufficient nutrition;

5)motionless or sedentary lifestyle;

6)tumors;

7)diseases of bones and joints;

8)degenerative changes in connective tissue;

9)eating disorders;

10)neurological disorders;

11)mental disorders;

12)general exhaustion of the body.

Spinal injuries.

Spinal injuries are among the most severe disasters that can befall a completely

healthy person during his life. They are one of the most severe injuries to the musculoskeletal system. Injured with spinal trauma account for up to 17.7 % of all inpatient trauma patients. According to various authors, complicated spinal injuries

In the occurrence of various spinal injuries, six main mechanisms of action of damaging violence should be distinguished:

1)flexion;

2)flexion-rotation;

3)extensor;

4)compression or vertical compression;

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5)shearing mechanism — shear damage;

6)mechanism of injury from stretching.

Each of these types of abuse results in some form of spinal injury, each of which can be classified as stable or unstable.

Unstable injuries include:

–dislocations and subluxations of the vertebrae;

–fracture-dislocations of the vertebrae;

–traumatic spondylolisthesis;

–damage from shear or tension.

Depending on whether the spinal cord is involved in the pathological process or not, all spinal injuries are divided into uncomplicated and complicated.

Clinical manifestations. The patient complains of localized pain over the damaged spinous process and neck stiffness. On clinical examination, point tenderness is noted. X-rays show avulsion fractures.

Complications. Due to the significant deformation of the spine, clearly visible in the lateral projection, bilateral dislocation causes a significant narrowing of the spinal canal. Most injuries of this type occur between S5, S6 and S7 where the spinal canal is narrowest. The result of spinal cord compression is often quadriplegia. Emergency reduction can have a good restorative effect. Due to the extent of the damage to the ligamentous apparatus, it is easier to correct a bilateral vertebral subluxation than a unilateral one, and spinal instability in the first case is much more pronounced. Urgent reduction and stabilization of the damaged spine is necessary. The displacement should be corrected by manual traction along the axis, or with the help of skeletal traction on the parietal tuberosities, which is more effective and can lead to complete restoration of anatomical relationships. Surgery may also be required. The incidence of chronic spinal instability without stabilization remains quite high.

Despite the “interlocking” dislocation, the injury is characterized by extreme instability due to significant damage to the ligamentous apparatus, which can lead to neurological disorders of the spinal cord, which means that it is preferable to offer such injured surgical stabilization of the spinal fracture.

Diagnosis of closed spinal injuries is the most difficult section of emergency traumatology. Examination of any patient with suspected spinal injury should be carried out lying on his back and include a thorough examination of the medical history and complaints, assessment of the mechanism of injury, clinical and radiation (X-ray, computer, magnetic resonance) examinations. Among objective clinical data, external examination data are of particular value. We must not forget that they can be most significant only if the patient is undressed. During the initial examination, you

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should, first of all, pay attention to the general condition of the victim, his position, the function of internal organs and systems, local orthopedic and traumatological status, and the degree of neurological disorders. If the victim has a deformation of the head and neck that resembles true torticollis, subluxation in the atlantoaxial joint or unilateral concatenated dislocation should be suspected.

Bilateral upright subluxation or interlocking sliding dislocation is characterized by a forward tilt of the head and the disappearance of lordosis in the cervical spine. In cases of tipping dislocations, the kyphotic deformity is most pronounced. Holding the head with your hands in a vertical position is characteristic of its instability of varying degrees.

It is possible with a fracture of the anterior and posterior arches of the atlas with divergence of fragments, traumatic spondylolisthesis of the 2nd cervical vertebra, due to a fracture of the roots of its arches and rupture of the intervertebral disc between the bodies of the 2nd and 3rd cervical vertebrae, with an isolated fracture of the articular process of one of the cervical vertebrae with compression of the corresponding spine.

With a mild degree of instability, the patient can hold his head in a certain position independently without additional external support. In severe cases, it is impossible to independently hold the head; when the patient tries to take a vertical position, the head falls (“guillotining symptom”). The general condition and severity of the victim are determined by the possibility of damage to other segments of the musculoskeletal system and internal organs (combined injury). If the 4 lower cervical segments of the spinal cord are damaged, a short-term loss of consciousness may occur. Due to paresis or paralysis of the intercostal muscles, the respiratory movements of the chest are sharply weakened, and the inspiratory movements of the diaphragm are increased. The cough reflex is weakened or absent. Expectoration of sputum is difficult or impossible with paralysis of the abdominal muscles. Due to respiratory failure, death may occur in the coming hours and days. Its immediate cause is often rapidly developing hypostatic or so-called paralytic pneumonia.

Damage to this part of the spinal cord is characterized by the presence of unilateral or bilateral Bernard — Horner syndrome (constriction of the pupil, palpebral fissure and retraction of the eyeball). Sometimes it can be observed in cases of severe injury to the 1–4 thoracic vertebrae. Often, upon examination, a forced position of the head and arms is revealed, which in certain clinical forms of injury are typical: abduction of the right and left shoulders outward or bringing them to the head with simultaneous supination of the forearm and flexion at the elbow joints in case of vertebral damage; moderate abduction of the right and left shoulders, the forearms are bent at the elbow joints, are in a position on the chest, average between supination and

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pronation, the hands are in the middle position and the fingers are bent when the S7 vertebra is affected.

Free flexion and extension of the hand at the wrist joint indicates the integrity of the S7 vertebra. Preservation of movements in the fingers (function of the flexor and extensor muscles of the fingers) indicates the absence of damage to the S7 root.

When examining the thoracolumbar and lumbar regions, attention is paid to the presence or absence of kyphotic deformity. Its degree can be so little expressed that it is detected only by the experienced eye of a specialist.

In the lumbar region, it manifests itself as a smoothing of the physiological lordosis, against the background of which in people of asthenic physique the spinous process is visible in the form of a “button”. Often this protrusion of the spinous process of the damaged vertebra is determined only by palpation. In addition to deformation of the spine in the sagittal plane, there may also be a lateral curvature of the line of the spinous processes, indicating the presence of lateral compression of the vertebral body.

Palpation is of great importance. It reveals tension in the long muscles of the back, local pain, swelling along the line of the spinous processes, protrusion of the spinous process posteriorly in the form of “button” kyphosis, mobility in case of a fracture of the spinous process or the borderline sympathetic trunk, while tension of the anterior abdominal wall and a picture of a closed abdominal injury occur.

Percussion. Percussion of the spinous processes allows you to clarify palpation data. Significant pain caused by percussion along the line of the spinous processes, in the absence of pain during palpation, can confidently indicate damage to the vertebral body. Percussion for fractures complicated by damage to the spinal cord can lead to displacement of fragments and additional secondary damage to the spinal cord. In these cases, it is better to avoid percussion.

With uncomplicated spinal injuries, active movements in the limbs are preserved. If you ask the victim to raise his straight legs from a lying position, the patient may notice increased back pain. They will intensify more sharply when raising straight legs with simultaneous pressure on the spinous process of a broken or protruding overlying vertebra.

Other clinical symptoms may include reflex urinary retention, stool retention and intestinal paresis. Sometimes they persist for 1 week and require close attention from the attending physician. You must always remember the dangers of checking such symptoms as determining the range of motion in the spine, identifying Thompson's symptom (increased pain in the spine at the level of injury in a sitting position and a significant decrease in pain when unloading the spine with the victim's hands resting on the seat of a chair or couch).

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