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

ensure normal oxygenation of arterial blood and eliminate hypercapnia (standard). Tracheal intubation must be performed without extension of the cervical spine: either nasotracheally or orotracheally while maintaining the spinal axis. When wakefulness decreases to stupor and coma, auxiliary or controlled artificial pulmonary ventilation (ALV) is performed with an oxygen-air mixture with an oxygen content of at least 40–50 %. To prevent episodes of non-synchronization of the respirator with the respiratory attempts of the victim during mechanical ventilation, causing a sharp increase in intrathoracic pressure and ICP, it is necessary to select ventilation modes or administer short-acting muscle relaxants and sedatives. It is necessary to maintain PaCO2 within 36–40 mmHg and saturation of hemoglobin with oxygen in the blood flowing from the brain is at least 60 %. To prevent cerebral hypoxia, all manipulations associated with opening the ventilator circuit must be accompanied by preand post-oxygenation with 100 % oxygen. When performing mechanical ventilation, hyperventilation and associated hypocapnia should be prevented.

Short-term hyperventilation can be used in case of a sharp deterioration in neurological status or for a longer time if intracranial hypertension persists despite the use of sedation, muscle relaxation, removal of cerebrospinal fluid from the ventricles of the brain and the use of hyperosmolar solutions.

Neurological examination. Neurological examination is the main diagnostic technique for assessing the patient’s condition and making a decision on performing CT, MRI, angiography, EEG and other diagnostic actions.

The purpose of a neurological examination:

1.Formulation of a topical diagnosis for the patient.

2.Assessment of the dynamics of focal and general cerebral symptoms.

3.Selection of instrumental research methods (CT, MRI, EEG, angiograp-

hy, etc.).

The frequency of examination depends on the severity of the patient’s condi-

tion:

– every 1–2 hours in patients with brain damage of various origins in the acute phase of the disease;

– 1–2 times a day when the patient’s condition is stabilized.

Clinical neurological examination plan.

Assessing the patient's position in bed:

1.Reaction to addressed speech.

2.Reaction to painful stimuli.

3.Manifestations of hemispheric symptoms.

4.Manifestations of diencephalic syndrome.

5.Assessment of segmental trunk symptoms (in detail at all levels of the trunk).

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6.Presence of dislocation and meningeal symptoms.

7.Conclusion of the examination indicating the topical diagnosis, main syndromes and dynamics in comparison with the previous examination.

Assessment of the patient's position in bed (in the form of a description):

– active;

– passive;

– forced;

– pathological postures.

Meningeal symptoms:

а) stiff neck;

b) presence of Kernig's symptoms.

Reaction to addressed speech:

– no reaction;

– individual sounds;

– slurred speech;

– one-word answers;

– clear articulation;

– communicates, but orientation is disturbed (space, time, personal situation);

– fully oriented.

Reaction to pain (most important in a patient in a coma):

1.Differentiated.

2.Undifferentiated.

3.According to the type of posture-tonic reactions.

4.Flexor — level of damage above the midbrain.

5.Extensor — level of damage: midbrain and below midbrain.

Manifestations of hemispheric symptoms:

– paresis of gaze to the side (gaze is directed towards the lesion);

– hemiparesis on the opposite side;

– convulsive syndrome.

Manifestations of diencephalic syndrome:

– autonomic-visceral disorders;

– dysfunction of gastrointestinal motility;

– intestinal paresis;

– tachycardia;

– hyperhidrosis;

– hypo-, hyperthermia;

– water-electrolyte;

– disorders (e.g., diabetes insipidus);

– hormonal changes.

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Assessment of the brain stem:

1. Midbrain:

–the size of the palpebral fissures is assessed;

–pupil size;

–reaction to light;

–position and movement of the eyeballs;

–reflexive gaze upward;

–oculocephalic reflex.

2. Bridge:

–the width of the palpebral fissures is assessed;

–corneal reflexes;

–pupil size;

–mimic reaction;

–position of the lower jaw;

–reaction to irritation of the corneas and face;

–gaze paresis (stem).

3. Medulla:

–the breathing pattern is assessed;

–hemodynamic status;

–bulbar syndrome;

–preservation of parasympathetic innervation.

Dislocation syndrome.

Diencephalic stage:

–drowsiness/excitement, constriction of the pupil on the side of the lesion;

–pathological breathing (Cheyne — Stokes);

–hyperthermia;

–floating movements of the eyeballs;

–decerebration reactions.

Midbrain stage:

–with lateral dislocation;

–anisocoria on the side of the lesion;

–hemiparesis on the opposite side;

–with central dislocation;

–bilateral miosis;

–paresis of upward gaze;

–there is no oculocephalic reflex;

–tachypnea;

–decerebration reactions.

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Stage of the lower parts of the trunk:

–tachypnea, apnea;

–arterial hyper-, hypotension;

–muscle atony;

–bilateral mydriasis.

Conclusion on neurological examination:

1.Assessment of the level of wakefulness (clear — full orientation, somnolence, stupor, stupor, coma 1–3).

2.Stem syndrome (level of damage).

3.Reflex-motor sphere (presence of tetra-, hemiparesis, muscle tone, tendon reflexes).

4.Presumable topical diagnosis.

5.The presence of positive or negative dynamics compared to the previous examination.

6.Features (e.g., sedation).

In addition to the descriptive assessment, it is generally accepted to assess the state of the level of wakefulness using the Glasgow coma scale in points (used mainly in patients with TBI) and compare it with the scale of the level of depression of consciousness. After examining a patient with a head injury, he should be taken to the neurosurgery department on duty.

Fracture of the skull and facial bones.

In the general structure of head injuries, the share of all fractures of the skull bones ranges from 2 to 20 %, while at the same time, fractures of the bones of the base of the skull are a more rare injury and statistically account for 4 % of the number of diagnosed severe traumatic brain injuries. In 32–59 % of patients, the fracture line passes from the arch to the base.

A fracture of the bones of the base of the skull is damage to a section of the bones of the base of the skull caused by traumatic brain injury or iatrogenic interventions with the development of a symptom complex characterized by a violation of the anatomical integrity of the base of the skull and functional disorders. Fractures of the base of the skull include fractures of the orbital surface of the frontal bone, the pyramid of the temporal bone, the articular process of the occipital bone or the squama of the occipital bone with transition to the foramen magnum, the cribriform plate, and the sphenoid bone.

A depressed skull fracture is a skull fracture in which bone fragments are displaced by more than the thickness of the adjacent bone, causing compression of the brain.

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Classification by type of fracture:

1.A closed skull fracture is characterized by the preservation of the integrity of the soft tissues of the head or the presence of a soft tissue wound that does not affect the cranial aponeurosis.

2.An open skull fracture occurs in the presence of damage to the soft tissues of the head.

3.A penetrating skull fracture occurs when the underlying dura mater is damaged.

The clinical picture in the presence of a skull fracture consists of combinations of three groups of symptom complexes:

– local changes in the scalp in the area of impact application;

– cerebral symptoms of prolapse, irritation and dislocation, due to the nature of concomitant brain damage;

– general somatic changes.

Clinical symptoms that suggest the nature of the skull fracture during external examination:

1) periorbital hematoma (symptom of “glasses”), which appears 12–48 hours after injury, is a sign of a fracture of the anterior cranial fossa;

2) hematoma in the mastoid area (Battle’s symptom), lagophthalmos, facial asymmetry indicate a fracture of the temporal bone pyramid and peripheral paresis of the facial nerve;

3) hemotympanum or rupture of the eardrum may accompany a fracture of the base of the skull;

4) rhinoor otoliquorhea — a sign of a fracture of the base of the skull (anterior middle cranial fossa, respectively) and penetrating TBI;

5) facial emphysema is a sign of a fracture of the facial bones of the skull and may indicate a combined craniofacial injury and a fracture of the bottom of the anterior cranial fossa;

6) exophthalmos with conjunctival edema may indicate the occurrence of a ca- rotid-cavernous anastomosis or the formation of a retrobulbar hematoma;

7) paresis or paralysis of cranial nerves;

8) bleeding from the nose or ears of varying intensity; 9) hearing impairment, nystagmus, vomiting;

10) quite rarely, a fracture can lead to visual impairment if the broken bones pinch the optic nerve.

Difficulties in recognizing early liquorrhea arise when it is combined with bleeding. To differentiate between bleeding from liquorrhea and bleeding, a test was proposed to identify a light rim around a bloody spot on a gauze pad — positive for

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liquorrhea. It is recommended to assess the general severity of the patient’s condition based on examination and diagnosis of associated injuries, laboratory and instrumental examination data.

Fractures of the bones of the facial skeleton are pathological conditions that arise as a result of a violation of the anatomical integrity of the bones of the facial skeleton of the skull. All fractures of the facial skeleton can be divided into several groups, depending on the area and nature of the damage:

–nose fracture;

–orbital fracture;

–fracture of the zygomatic bone;

–fracture of the upper jaw;

–fracture of the lower jaw.

The most common causes of injury are road traffic accidents, violent trauma, and falls from a height.

We provide emergency care for maxillofacial injuries combined with traumatic brain injury and combined craniofacial injuries. Operations are performed urgently, in the primary delayed period. Injured experience deformation of the facial skeleton and disruption of systemic functions: the masticatory apparatus, the temporomandibular joint, the upper respiratory tract, the organs of vision, neurological disorders and aesthetic defects. Such disorders require surgical treatment in the department of neurosurgery, maxillofacial surgery in collaboration with ophthalmologists, otolaryngologists and other specialists.

Chest injuries.

Chest injuries are injuries that include injuries to the ribs, sternum, and internal organs located in the chest cavity.

Classification. All chest injuries are divided into two groups: closed and open. Closed injuries are the absence of a wound.

Chest wounds are divided into:

–penetrating — with damage to the parietal pleura;

–non-penetrating — without damaging the parietal pleura;

–penetrating chest wounds;

–stabbed;

–firearms;

–fracture of the sternum;

–rib fractures.

Among combat chest injuries, isolated, multiple and combined chest injuries (wounds) are distinguished.

Isolated is a chest injury (wound) in which there is one injury.

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Multiple is a trauma (wound) in which there are several injuries within the chest as an anatomical area of the body.

Simultaneous injury to the chest with other anatomical areas of the body (head, neck, abdomen, pelvis, spine, limbs) is defined as a combined injury (wound) of the chest.

Gunshot wounds of the chest can be penetrating (if the parietal pleura is damaged) or non-penetrating into the pleural cavity. According to the nature of the wound channel, tangential, blind and through wounds are distinguished. Gunshot wounds to the chest may be accompanied by damage to the bone frame of the chest (ribs, shoulder blades, collarbones, sternum), blood vessels of the chest wall (intercostal arteries, internal mammary artery, azygos and semi-gypsy veins), lung and large vessels of the mediastinum (aorta, superior and inferior vena cava, brachiocephalic trunk), internal organs.

Among injuries to internal organs, injuries to the lungs predominate; injuries to the heart, trachea and large bronchi, and esophagus are much less common. Explosive chest injuries are related to gunshot trauma in etiology, but the nature of the damage is similar to mechanical injuries. Injuries to the chest may be accompanied by the development of their consequences, i.e. pathological processes caused by disruption of the structure and function of organs and large vessels of the chest, of which the most dangerous are the life-threatening consequences of injury (open and tension pneumothorax, cardiac tamponade, ongoing intrapleural bleeding). All these characteristics of the wound must be taken into account when making a diagnosis.

Rib fractures.

Rib fractures are the most common complication of closed chest trauma. Fractures can be isolated (1–2 ribs) or multiple (3 or more ribs); unilateral and bilateral; with and without displacement; complicated (with damage to the pleura, lung, mediastinal organs) and uncomplicated.

Rib fractures are violations of the integrity of the bone or cartilaginous part of one or more. A single rib fracture or fractures of a small number of ribs that are not accompanied by complications or other injuries usually heal on their own and do not require significant intervention or immobilization. Rib fractures account for 5–15 % of all fractures. Rib fractures occur as a result of impacts, falls on protruding objects, as well as without direct trauma (compression of the chest). They can occur in various tumor, infectious diseases, cancer, osteoporosis.

Classification of floating rib fractures:

1. Anterior bilateral (anterior bilateral): rib fractures are localized on both sides of the sternum on the anterior surface of the chest; The anterior part of the chest loses its connection with the spine.

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2.Anterolateral (anterolateral): each rib is broken in two (or more) places on one side of the sternum along the front and side of the chest; The anterolateral part of the chest loses its connection with the spine.

3.Posterolateral (dorsolateral): each rib is broken in two (or more) places on one side of the spine along the back and side of the chest; The posterolateral or posterior part of the chest loses its connection with the spine.

4.Posterior bilateral (posterior bilateral): rib fractures are located on either side of the spine along the back of the chest.

Clinic. The clinical picture is typical. Complaints of severe chest pain, aggravated by deep breathing and coughing. On the affected side, breathing is shallow. Upon examination, a lag of the chest in the act of breathing on the affected side, swelling, pain, crepitus, and deformation over the site of the rib fracture are determined. When taking a deep breath, the victim notices increased pain over the fracture site, and this also happens when coughing. Pire's symptom (pain when bending to the healthy side) and the symptom of axial loads are detected — when the chest is alternately compressed in the sagittal and frontal planes, pain occurs in the area of the bone defect, and not at the site of compression.

For diagnosis, palpation of the abdominal wall, auscultation, and measurement of blood pressure are performed. If the lung is damaged by a broken rib, hemoptysis, subcutaneous emphysema, pneumoor hemothorax may occur.

Complications:

– damage to internal organs or blood vessels by a sharp fragment of a lung rib with the development of pneumoor hemothorax, heart, liver, spleen, gastrointestinal tract organs, intercostal vessels, kidneys, leading to bleeding;

– flotation of a section of the chest wall;

– pleuropulmonary shock;

– subcutaneous emphysema;

– infectious complications (pneumonia, purulent pleurisy).

Hemothorax — accumulation of blood in the pleural cavity is a consequence of bleeding from the vessels of the lungs, intrathoracic branches of large vessels (aorta, vena cava), vessels of the chest wall, mediastinum, heart, lung or diaphragm. When the lung is injured, hemopneumothorax occurs.

Classification:

– small (up to 500 ml) — blood occupies only the pleural sinuses;

– medium (from 500 to 1 000 ml) — blood reaches the angle of the scapula;

– large, or total (more than 1 000 ml) — blood occupies almost the entire pleural cavity.

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Based on ongoing bleeding:

–with stopped bleeding into the pleural cavity;

–with ongoing intrapleural bleeding.

For complications:

–clotted hemothorax;

–infected hemothorax.

By localization of limited hemothorax:

–apical (apical);

–interlobar;

–supradiaphragmatic;

–paracostal;

–paramediastinal.

The clinical picture depends on the intensity of bleeding and anemia. The skin of such patients is pale, tachycardia and low blood pressure are noted. When percussing the affected half of the chest, a shortening of the percussion sound is determined; the upper boundary of the liquid, if there is no pneumothorax, forms the Damoiseau line. Auscultation of the lungs reveals weakening or absence of breathing. The boundaries of the heart are shifted to the healthy side. The clarity of the physical signs of the presence of fluid depends on the size of the hemothorax.

If the patient has a wound on the chest, a bandage is applied to the wound; in cases where air is released from the wound, an airtight bandage is applied. If, during examination, there is an embedded knife, knitting needle or other objects on the chest that caused a penetrating wound, then these objects are not removed when providing medical care at the prehospital stage.

Pneumothorax is the accumulation of air or gases in the pleural cavity. It can occur spontaneously in people without chronic lung disease (primary), as well as in people with lung disease or injury (secondary). Artificial pneumothorax is the introduction of air into the pleural cavity to create collapse of the affected lung.

Based on their relationship with the environment, there are:

1.Closed pneumothorax. With this type, a small amount of gas enters the pleural cavity, which does not increase. There is no communication with the external environment. It is considered the easiest type of pneumothorax, since air can potentially gradually dissolve from the pleural cavity on its own, while the lung expands.

2.Open pneumothorax. With an open pneumothorax, the pleural cavity communicates with the external environment, so a pressure equal to atmospheric pressure is created in it. In this case, the lung collapses, since the most important condition for

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the expansion of the lung is a negative increase. This is the most dangerous type of pneumothorax, since the exclusion of the lung from breathing is accompanied by irritation of the nerve endings of the pleura, leading to pleuropulmonary shock, as well as displacement of the mediastinal organs, which disrupts their function, primarily squeezing large vessels. The collapsed lung is switched off from breathing, gas exchange does not occur in it, and the blood is not enriched with oxygen. May be accompanied by hemothorax.

3. Valvular pneumothorax. This type of pneumothorax occurs when a valve structure is formed that allows air to pass in one direction, from the lung or from the environment into the pleural cavity, and prevents it from exiting back. Moreover, with each respiratory movement, the pressure in the pleural cavity.

Pneumothorax can be classified according to the degree of collapse of the lung:

–small — up to 1/3 of the volume;

–medium — up to 1/2 volume;

–large — more than 1/2 volume;

–total — completely collapsed lung.

Clinical picture. Complaints of sharp pain in the chest, shortness of breath, breathing becomes shallow and frequent, the patient feels a feeling of lack of air. The phenomena of acute respiratory and cardiovascular failure are increasing. Pallor or cyanosis of the skin appears, auscultation of breathing on the side of the injury is sharply weakened, percussion — a sound with a boxy tint, and with rib fractures, subcutaneous emphysema is determined.

Characteristic symptoms are:

–acute pain in the chest, intensifying when inhaling;

–shortness of breath;

–lacrimation;

–labored breathing;

–rapid breathing;

–attacks of dry cough;

–cardiopalmus;

–feeling of panic fear;

–pallor of the skin.

All patients with chest trauma, rib fractures, pneumothorax or hemothorax should be taken to the emergency surgical department after emergency medical care at the prehospital stage.

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