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

It is not necessary to detect the phenomenon of increased pain when loading along the axis of the spine, even in a lying position. Only light tapping on the heels is acceptable. The patient should not be allowed to stand up or sit down until X-ray data are obtained.

Spinal cord dysfunction due to fractures.

Spinal cord dysfunction in spinal fractures depends on concussion, bruise, compression, swelling, partial or complete anatomical damage to the spinal cord, and damage to its roots. Compression of the spinal cord can be from the front, back and side. In the front, it is most often caused by a hematoma, bone fragments of a broken or, in case of dislocation by the posterior-superior edge of the body of the underlying vertebra, fragments of a ruptured intervertebral disc. Posterior compression is much less common and is caused by the arch of a dislocated vertebra or its fragments, the yellow ligament, and hematoma. Lateral compression — by the articular processes and other structures of the vertebral segment adjacent to them, depending on the mechanism of injury and displacement of the broken vertebra or its fragments.

In the first hours and days after the injury, it is difficult to resolve the issue of the cause — gross dysfunction of the spinal cord, since the clinic for severe spinal shock (functional impairment) is practically no different from the clinic — complete anatomical damage.

The rapid increase in neurodystrophic processes, the appearance of bedsores and swelling of soft tissues in the first day after injury indicate an anatomical rupture. With complete ruptures of the spinal cord, its function is never restored. Disorders of spinal cord function caused by compression by bone fragments resolve if the dislocation or fracture is corrected in a timely manner and, if necessary, the fragments are removed. The clinical picture of spinal disorders associated with concussion, bruise, compression of the spinal cord, supraand intrathecal hemorrhages, and its edema gradually regresses. Partial disruption of the conductivity of the spinal cord is manifested by a disturbance of conduction-type sensitivity below the level of damage, paresis, paralysis and dysfunction of the pelvic organs.

Pelvic injuries.

Injuries to the pelvis and pelvic organs are among the most severe injuries of the musculoskeletal system. With every decade they become heavier, the proportion of open and combined injuries increases. According to statistical data from authors of the second half of the 19th century, pelvic injuries ranged from 0.3 to 1 % of all fractures. According to modern authors, pelvic injuries range from 5 to 10 % of the total number of injuries, and in some regions up to 15 %.

Pelvic instability.

The nature and severity of pelvic trauma, in addition to the mechanism of injury, is assessed by the degree and nature of stability of the pelvic ring. Stability should

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be understood as the ability of the pelvic bones and its joints to withstand normal physiological loads (body weight, running, jumping, walking, physical work) without pain and pathological displacements. The latter are diagnosed clinically and radiologically. A diagnostic criterion for stability is considered to be an indicator of the amplitude of movement in the sacroiliac joints and pubic symphysis within 1–3 mm when exposed to physical violence that does not cause damage to them. The criteria for instability of the pelvic ring are the ligamentous apparatus of the sacroiliac joint, so instability of the pelvis depends to a greater extent on damage to the ligaments and bones of the posterior semi-ring and, to a lesser extent, to the anterior semi-ring.

A distinction is made between rotational or horizontal and vertical instability. In case of rotational instability, horizontal rotational instability is distinguished with outward rotation of the corresponding half of the pelvis like an “open book” or inward — a “closed book” with upward displacement (vertical instability) or without upward displacement.

Clinical diagnosis of pelvic injuries. To obtain an approximate idea of the presence of pelvic injury, anamnesis is of great importance, clarifying the circumstances and mechanism of injury, the type, general condition and posture of the patient. Familiarity with the mechanism of injury is often critical during the first orientation.

An examination of the victim is carried out in order to diagnose injuries: the passive position of the patient, he is as if chained to the bed, the location and type of wound, an increase in volume in the pelvic area, a violation of the axis of the limb segment, an unusual position of the leg in external or internal rotation and, finally, asymmetry of the pelvis — here are the main guidelines for inspection. An attempt to move the lower limb causes sharp pain in the pelvic ring.

It is advisable to examine the pelvic area both from the side and from the front to compare both halves of the pelvis. Severe pelvic fractures with displacement of the Malgenya type can always be suspected by the presence of asymmetry of the pelvis, displacement of the navel from the midline, by the “rotation of one half of it and external rotation of the leg of the same side .

With bilateral Malgenya fractures, a peculiar “flatness” of the pelvis is visible — a significant expansion of its diameter. The typical position of the victim is typical. When the symphysis is torn, both legs are bent at the knee joints and adducted; the victim does not allow them to be separated due to the appearance of severe pain in the projection of the symphysis pubis. With a fracture of both pubic and ischial bones, as well as with vertical Malgenya fractures, the Volkovich or “frog” position is characteristic (Volkovich’s symptom, 1928). In this position, the victim’s legs are bent at the knee and hip joints and apart. They resemble the shape of a diamond

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or a preparation of “frog” legs. On the 2nd day, bruising may appear in the surrounding tissues; for a fracture localized closer to the ilium — above the Pupart ligament, for a fracture of the descending branch of the pubic and ischial bones — in the perineal area.

In case of an avulsion fracture of the anterior superior iliac spine, the victim moves backwards and not facing forward (backward symptom or Lozinsky, 1928), since the sartorius muscle (m. sartonus) starts from the anterior superior iliac spine and is attached to the anteromedial surface of the leg in the area of tuberositas tibia. When flexing the hip in the lower leg, when walking face forward, the muscle tenses, causing displacement of a fragment of the anterior superior iliac spine, and the patient's pain sharply increases.

In case of a fracture of the horizontal branch of the pubic bone, the patient, being in a horizontal position, cannot raise the corresponding leg in the extension position, cannot “tear off” the heel from the bed, but passively holds the raised limb independently without assistance — a symptom of a “stuck” heel or a Gorinevskaya’s symptom.

Secondly, the pectineus muscle (m. pectineus) starts from the crest of the horizontal branch of the pubis (rames superior et pecten ossis pubis) and, going down and slightly outward, is attached to the pectineal line (linea pectinea) of the thigh distal to the lesser trochanter. The muscle flexes and adducts the thigh, slightly rotating it outward. When trying to lift the leg on the side of the pelvic injury, the muscles tense, increasing the pain syndrome.

To diagnose a pelvic fracture in the absence of traumatic shock, a number of symptoms can be identified:

1.Verneuil's symptom — increased pain with careful counter external compression of the pelvis in the area of the wings of the iliac bones.

2.Larrey's symptom — increased pain in the area of pelvic injury when the wings of the iliac bones are spread or turned.

3.Sgaddart's symptom — the appearance or intensification of pain in the sacroiliac joint when the iliac bones are brought together and spread apart;

4.Symptom of A.N. Karalin — the appearance or intensification of pain during internal rotation of the hip.

Palpation. Local pain in the area of the fracture can be detected by palpation in the area of the spines or crests of the iliac bones, the area of the pubic symphysis, and the ischia. When the symphysis is ruptured, the diastasis and its size between the bones in the area of the pubic symphysis are determined by palpation. If the integrity of the pelvic ring is violated, mobility of bone fragments occurs even with the slight-

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est movements of the victim’s legs, rather than rough palpation during examination, which can aggravate the patient’s condition.

Mouse's symptom is a shortening of the distance from the xiphoid process or navel to the anterior superior iliac spine on the damaged side. In an isolated fracture of the superior anterior iliac spine with downward displacement of the fragment, an apparent shortening may be detected.

Symptom Roux — shortening the distance from the upper anterior spine to the pubic joint indicates a fracture of the pubic bones with displacement of fragments;

Bejul's symptom is a shortening of the distance from the sternoclavicular joint to the anterosuperior iliac spine on the injured side.

Palpation examination should be complemented by careful rectal and vaginal examination. In this case, a fracture of the coccyx, sacrum, pubic bones, bottom of the acetabulum and the head of the femur embedded in the pelvic cavity can be detected. If the rectum is ruptured, the finger may fall into the wound, and blood may appear on the surgeon's glove. During a vaginal examination, it is also possible to determine displaced fragments of the pubic, ischial bones, the floor of the acetabulum and the presence of damage to the vaginal mucosa. If damage to the vagina or rectum is detected, an open communicating (penetrating) pelvic fracture should be diagnosed.

For a fracture of the acetabulum, A.P. Nadein described the main symptoms in 1939:

1)the hip is in a position of adduction, slight flexion and external rotation;

2)significant limitation of movements and severe pain during passive and active movements in the damaged joint);

3)pain along the obturator nerve and pain radiating to the knee joint;

4)limitation or complete impossibility of hip abduction;

5)the presence of a hematoma in the area of the greater trochanter, Poupart's ligament and Scarp's triangle;

6)pain with lateral compression of the pelvis in the area of the greater trochanter, load along the axis of the femur or on the greater trochanter along the axis of the neck on the side of the damage to the acetabulum;

7)decreasing the distance between the symphysis and the greater trochanter of the femur on the side of the injury;

8)relative shortening of the lower limb on the corresponding side;

9)the upper edge of the greater trochanter is located above the Roser — Nela-

ton line;

10)retraction in the greater trochanter with central hip dislocation;

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11) determination of protrusion of the femoral head in the cavity of the small pelvis during rectal and vaginal examination.

The severity of injury and traumatic shock increases in direct proportion to multiple, combined trauma with damage to the pelvic organs, abdominal cavity and chest, and the amount of blood loss. Traumatic shock, according to literature data, occurs in 40.2–93.1 %, and with polytrauma — in 60–100 % of injured. Bleeding that has already stopped can resume with the slightest movements of the patient: shifting, insufficiently careful transportation of the victim from the scene of the accident or in a medical institution from one structural unit (emergency room, operating room, intensive care unit) to others, insufficiently careful examination.

A hematoma in the retroperitoneal space can extend to the level of the kidneys and diaphragm, and in front to the level of the umbilical horizontal. The hematoma through the obturator canal can spread down to the lower third of the thigh. In this case, the intestines and kidneys shift inward and toward the anterior abdominal wall. It should be especially remembered that the severity of shock depends not so much on the volume of lost blood, but on the rate of bleeding, since with rapid massive blood loss in the body, compensatory mechanisms do not have time to react and develop (transition of interstitial fluid into the vascular bed, tachycardia, spasm of peripheral vessels, centralization of blood circulation).

Traumatologists and surgeons with resuscitators and anesthesiologists may not have time to provide the necessary effective assistance.

By the time they are admitted to a medical facility, injured lose from 2–3 to 3–4 liters of blood. If the hematoma is large, blood from the retroperitoneal space can enter the free abdominal cavity, even with intact peritoneum, through the diapedetic route from a small amount to 2 liters. A massive retroperitoneal hematoma with ongoing bleeding may be accompanied by rupture of the peritoneum and penetration of whole blood into the abdominal cavity. Literature data suggests that bleeding from pelvic fractures can last from 2 to 5 days or more.

One of the reasons for the severity of traumatic shock and the worsening of the general condition of the victim is damage to the bladder, urethra, rectum and, very rarely, the vagina, uterus and appendages.

Damage to the urinary organs is diagnosed with fractures of the pelvic bones in 10–28 % of cases in adults and in 7–8 % in children. Most often, damage to the urinary organs occurs from a frontal impact or compression with twisting. Therefore, any pelvic injury should be considered complicated until the absence of urinary tract injury is proven or confirmed. The presence of blood in the urine is an important diagnostic test but is not reliable for bladder or urethral injury. Blood can be observed when the kidneys, ureters are damaged, when the muscle layers of the pelvic floor are crushed, or when there is a hematoma of the bladder wall.

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A subjective early sign of bladder damage is pain in the lower abdomen, above the symphysis pubis. With an intraperitoneal rupture, the pain becomes diffuse and intensifies when straining to attempt spontaneous urination. The pain radiates to the navel, glans penis, rectum, and sometimes to the thigh area. Urinary dysfunction manifests itself as a complete lack of urine output. There is a gradual increasing tension in the anterior abdominal wall with symptoms of peritoneal irritation and intestinal paresis. A change in the position of the victim, leading to the movement of urine poured into the abdominal cavity, causes increased pain in the abdomen and the patient’s resistance to all movements (a positive symptom of “stand up”).

Bladder catheterization is used for diagnosis. When the catheter is inserted, a small amount of urine is immediately released, but as soon as the catheter is advanced further so that it enters through the wound of the bladder into the abdominal cavity, up to 2 liters of urine are released, which confirms intraperitoneal rupture of the bladder. In doubtful cases, the bladder is emptied using a catheter, then 250–300 ml of furatsilin are injected and the catheter is clamped. After a few minutes, the catheter is opened and the contents are drained. If its contents significantly exceed the amount of administered furatsilin, it can be assumed that fluid is leaking from the abdominal cavity (Zeldovich's symptom).

In the case of late diagnosis with intraperitoneal ruptures of the bladder, a clinical picture of purulent peritonitis develops. With extraperitoneal ruptures of the bladder, the lateral, anterior, and posterior walls not covered by the peritoneum are damaged, or the bladder is completely torn off in the area of its neck. The most commonly damaged wall is the posterior wall of the bladder, where the inferior vesical arteries and veins pass. Patients complain of pain in the lower abdomen — above the pubis, frequent urge to urinate. It is possible in a weak stream, in small portions, the urine is colored with blood. On palpation there is pain above the pubis, sometimes there may be tension in the anterior abdominal wall. Percussion — dullness extends to one or both groin areas. It does not decrease during catheterization and its boundaries do not change when the victim is turned. Palpation through the rectum reveals painful tissue infiltration.

Later, leaks appear in the tissues of the pelvis, perineum, and thigh with the formation of urinary fistulas, the development of pelvic phlegmon and osteomyelitis. Subsequently, general intoxication increases, manifested in the form of dry tongue, dry skin, tachycardia, a drop in blood pressure and a deterioration in general condition.

Damage to the urethra.

Damage to the urethra is characterized by urinary retention, bleeding from the urethra, perineal hematoma and patient complaints of cutting pain in the perineal ar-

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ea, intensifying with each attempt to urinate, bleeding from the urethra, pain during urination, fruitless urge to urinate, and delayed urination. When the urethra is damaged, there is always an initial staining of urine with blood. The intensity of its color will vary. It will be more intense if the membranous part of the urethra is ruptured and less pronounced if the prostatic part is damaged. The manifestation of a perineal hematoma during the first 3 hours is typical for damage to the urethra, later it can occur with ruptures of the symphysis and fractures of the anterior semi-ring of the pelvic bones. The latter reduces the value of this symptom. Urine released from the damaged urethra permeates the surrounding tissue and forms urinary streaks.

Rectal ruptures occur with fractures of the pelvic bones much less frequently. There are extraand intraperitoneal injuries to the rectum. Extraperitoneal damage is manifested by the development of severe phlegmon of the pelvic tissue. Intraperitoneal ruptures are characterized by rapidly developing symptoms of peritonitis. To exclude pathology from the rectum, all patients with pelvic trauma should undergo a rectal digital examination. Thus, in case of fractures of the pelvic bones, it is important to diagnose not only the pelvic bones, but also the internal organs of the abdominal cavity and pelvis, especially the rectum and bladder.

Head injuries.

Head injuries are among the most severe injuries that injured can suffer as a result of accidents. Very often they (especially injuries to the scalp) are accompanied by significant bleeding, which can threaten the life of the victim at the scene. If a person is unconscious, he should be placed in a stable lateral position, which reduces the likelihood of tongue retraction and minimizes the possibility of vomit or blood entering the respiratory tract. If there is a wound and bleeding, apply direct pressure to the wound and, if necessary, apply a bandage. If the victim shows signs of a violation of the integrity of the skull bones, it is necessary to cover the edges of the wound with bandages and only then apply a bandage.

If there is a foreign object in the wound, you need to fix it, cover it with napkins or bandages, and apply a bandage. It is prohibited to remove a foreign object. Bleeding from injuries to the scalp is usually very profuse and cannot stop on its own. To stop bleeding from the scalp, apply direct pressure to the wound and apply a pressure bandage. Head injuries are often accompanied by impaired brain function. Traumatic brain injury is characterized by pallor, general weakness, drowsiness, headache, dizziness and loss of consciousness.

The victim may be conscious, but does not remember the circumstances of the injury and the events preceding it. More severe brain damage is accompanied by prolonged loss of consciousness and paralysis of the limbs. Fractures of the skull bones may also be accompanied by the following symptoms: discharge of colorless or

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bloody fluid from the ears and nose; bruising around the eyes. In the process of providing first aid to the victim, he should conduct a physical and instrumental examination, determine the nature of all injuries, provide emergency medical care at the prehospital stage and transport the patient to an on-duty specialized hospital.

Head injuries are often accompanied by impaired brain function. Traumatic brain injury is characterized by pallor, general weakness, drowsiness, headache, dizziness and loss of consciousness. The victim may be conscious, but does not remember the circumstances of the injury and the events preceding it. More severe brain damage is accompanied by prolonged loss of consciousness and paralysis of the limbs.

Fractures of the skull bones may also be accompanied by the following symptoms: discharge of colorless or bloody fluid from the ears and nose; bruising around the eyes.

Traumatic brain injury (TBI) is damage to the skull, brain, meninges, blood vessels and/or cranial nerves, accompanied by clinical symptoms and, in most cases, morphological changes. A clear traumatic history is extremely important.

Mild TBI (MTBI) is an acute impairment of brain function resulting from traumatic exposure, which may result in short-term loss of consciousness (up to 30 minutes) and/or amnesia (up to 24 hours). It includes two nosologies: concussion and mild brain contusion.

Concussion (CBM) is the mildest clinical form of diffuse transient brain damage. The disorders are based on metabolic, ionic, neurotransmitter disorders and neuroinflammation, characterized by the absence of visible changes on computed tomography (CT). Mild traumatic brain injury (MTBI) dominates in the structure of traumatic brain injuries — 60–95 % of all injured. The prevalence ratio of MTBI relative to severe is 22:1. The ratio of concussion to mild bruise is approximately 4:1. Mortality from MTBI is low (0.04–0.29 %) and is almost exclusively caused by intracranial hematomas.

The causes of MTBI in the population include both road traffic accidents and domestic, criminal, sports and industrial injuries.

According to clinical forms:

1)concussion;

2)mild brain contusion;

3)moderate brain contusion;

4)severe brain contusion;

5)diffuse axonal damage;

6)brain compression;

7)head compression.

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According to the course of traumatic brain disease (L.B. Likhterman et al., 2012):

1)acute;

2)intermediate;

3)long-term.

The acute period is the period of time from the moment of the damaging effect of mechanical energy on the brain with a sudden disorder of its integrativeregulatory and local functions until the stabilization at one level or another of impaired cerebral and general body functions, or the death of the victim. The duration of the acute period is from 2 to 10 weeks, depending on the clinical form of TBI. Approximate duration of the acute period of TBI for concussion — up to 2 weeks; mild brain contusion — up to 3 weeks; moderate brain contusion — up to 4–5 weeks; severe brain contusion — up to 6–8 weeks; diffuse axonal damage — up to 8–10 weeks, compression of the brain — from 3 to 10 weeks (depending on the background).

The intermediate period is the period of time from the stabilization of general body, cerebral, and focal functions disturbed by trauma to their complete or partial restoration or stable compensation. The duration of the intermediate period: for mild TBI — up to 2 months, for moderate TBI — up to 4 months, for severe TBI — up to 6 months.

The long-term period is a period of clinical recovery, or the maximum achievable rehabilitation of impaired functions, or the emergence and/or progression of new pathological conditions caused by a TBI. Assessment of the condition of patients and injured at the prehospital stage. Temporal length of the long-term period: with clinical recovery — up to 2 years, with a complicated course — not limited. The duration of post-traumatic (or anterograde) amnesia is one of the prognostic characteristics of the course of a concussion.

Studies show that the outcome of MTBI and the duration of temporary disability are determined to a greater extent by the duration of post-traumatic amnesia compared to the assessment of the level of consciousness using the GCS. In case of posttraumatic amnesia for less than 24 hours, good recovery (according to the Glasgow Outcome Scale) is observed in 100 % of patients.

Physical examination. When examining the head, it is recommended to identify signs indicating the fact of trauma (bruises, abrasions, wounds) and fractures of the bones of the base of the skull due to brain contusion (bruising in the mastoid area, periorbital hematomas, leakage of fluid from the external auditory canals, nose, mouth). In the neurological status, small-scale nystagmus (40 %), mild anisoreflexia of tendon and skin reflexes (20 %), static ataxia (20 %), dynamic ataxia (10 %), increased ten-

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don reflexes (20 %), mild meningeal symptoms (10 %), disappearing in 90 % of patients during the first 4–5 days. There are no injuries to the skull bones. The general condition of the injured usually improves significantly during the first, less often — the second week.

The time for regression of clinical symptoms in the vast majority of injured with BMS is on average 4–5 days, and the period of temporary disability usually does not exceed two weeks. If symptoms and complaints persist for a long time (more than 7 days), additional examination and identification of the causes are necessary. The time for regression of neurological symptoms of a mild brain contusion with an uncomplicated history is usually 7–14 days, and temporary disability — up to 3 weeks.

To verify post-concussion syndrome according to ICD-10 criteria, the diagnosis of this condition requires a condition arising after a head injury with the presence of three symptoms from the following group:

–headache;

–dizziness;

–fast fatiguability;

–irritability;

–sleep disturbance;

–difficulties in concentrating and solving mental problems;

–memory impairment;

–impaired resistance to stress, emotional stress and alcohol.

Rational intensive care should be based on monitoring vital functions. In injured with depression of wakefulness according to the GCS of 8 points or less, one should strive to implement neuromonitoring, monitoring of blood circulation, respiration and oxygenation of arterial blood and brain. The increase in the interspinous space is proportional to the degree of kyphotic deformation and compression of the body of a broken vertebra, i.e. the greater the degree of wedge-shaped deformation, the greater it is. An increase and retraction of the interspinous space determined by palpation is characteristic of a rupture of the supraspinous and interspinous ligaments. The protrusion of the spinous process of the underlying vertebra and the retraction of the overlying one suggests an entangled dislocation or traumatic spondylolisthesis, and a protrusion with the presence of diastasis between the spinous processes suggests a tipping dislocation. Pain in the posterior abdominal wall upon deep palpation is possible in the presence of a retroperitoneal hematoma, irritation or damage to the solar plexus.

Respiratory support. In a victim with impaired wakefulness according to GCS of 10 points or less (stupor and coma), tracheal intubation should be performed, respiratory support should be provided in order to prevent aspiration complications and

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