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

2.9. EXAMINATION OF THE RESPIRATORY SYSTEM

Shortness of breath (dyspnea) — a change in the frequency, rhythm and depth of breathing, often accompanied by a feeling of lack of air. In heart disease, shortness of breath appears during physical exertion, and then at rest, especially in a horizontal position, forcing patients to sit (orthopnea). Attacks of severe shortness of breath (usually at night) with heart disease are a manifestation of cardiac asthma; shortness of breath in these cases is inspiratory (difficulty breathing).

Expiratory shortness of breath (difficulty in exhaling) occurs when the lumen of the small bronchi and bronchioles narrows (with bronchial asthma) or with a loss of elasticity of the lung tissue (for example, with chronic emphysema).

Cerebral dyspnea occurs with direct irritation of the respiratory center (tumor, hemorrhage). Shortness of breath can be caused by poisoning with poisonous and narcotic gases, freons, as well as dysfunction of the nervous system due to severe excitement, rage, hysteria, and fear.

There are three types:

1)inspiratory dyspnea (difficulty breathing), more typical for heart disease;

2)expiratory shortness of breath (difficulty exhaling), most often occurs with bronchial asthma and COPD;

3)mixed shortness of breath (when both inhalation and exhalation are difficult).

Depending on the respiratory rate (RR), three types of dyspnea are distin-

guished:

1.Tachypnea — rapid shallow breathing (over 20 BP per minute). Observed in anemia, fever, blood diseases. With hysteria, the respiratory rate reaches 60–80 per minute, such breathing is called “the breathing of a cornered animal.”

2.Bradypnea is a pathological decrease in breathing (12 or less respiratory movements per minute). Occurs with brain damage and its membranes, severe and prolonged hypoxia, with acidosis, with sugar diabetes, diabetic coma.

3.Apnea — absence of breathing, for example, during sleep, when immersed in cold water, when the blood is depleted of carbon dioxide, reflexively when the carotid sinus is irritated.

Depending on the factors that led to the occurrence of shortness of breath, it is divided into:

– physiological — appears with increased physical stress;

– pathological — with painful lesions of certain systems.

Cough is an innate protective unconditioned reflex that acts as part of the body's immune system. It is a forced exhalation through the mouth, caused by contractions of the respiratory muscles due to irritation of receptors located along the en-

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tire respiratory tract (in the nose, paranasal sinuses, pharynx, larynx, trachea, bronchi) and in the pleura.

The physiological role of cough is to cleanse the respiratory tract of foreign substances and prevent mechanical obstacles that disrupt the patency of the airways. The cough center, responsible for the cough reflex, is controlled by the cerebral cortex; Accordingly, a cough can be deliberately restrained and imitated to some extent, and also occur in pathologies not related to the respiratory system. Cough is always a symptom of a pathological condition, and not an independent disease.

Cough is classified by nature (non-productive — dry, and productive — wet), intensity (coughing, light and strong), duration (episodic short-term or paroxysmal and constant), course (acute — up to 3 weeks, prolonged — more than 3 weeks and chronic — 3 months or more).

Chronic obstructive pulmonary disease (COPD) is a common, preventable, and treatable chronic lung disease.

Chronic nonspecific lung diseases (CNLD) are diseases of the respiratory system that are different in etiology and pathomorphology, occurring with constant productive cough and dyspnea due to predominant damage to the bronchi or parenchyma.

According to the nature and amount of discharge when coughing:

–dry (unproductive);

–wet (productive).

In the latter case, the nature, consistency and volume of sputum are assessed:

–mucous membrane;

–serous;

–purulent;

–bloody (hemoptysis);

–viscous;

–clots;

–scanty;

–“mouth full”.

Diseases that cause cough:

1) bronchial asthma, bronchiectasis, tumors of the respiratory system, ascariasis, pulmonary hypertension, pulmonary hemorrhage in diseases of the respiratory system or endometrial ectopia in the respiratory system, acute and chronic rhinitis, sinusitis, pharyngitis, laryngitis, tracheitis, bronchitis, pneumonia, pleurisy of noninfectious and infectious genesis, lung abscess, pulmonary edema, developmental anomalies (tracheoesophageal fistula, laryngeal cleft, vocal cord paralysis, tracheo-

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bronchomalacia, bronchopulmonary dysplasia, dyskinesia, pneumoconiosis and other interstitial lung diseases);

2)cardiac asthma, heart failure, congenital heart defects, tumors of neighboring organs compressing or growing into the wall and lumen of the airways, aspiration;

3)for gastroesophageal reflux disease or vomiting, pathology with impaired swallowing, bleeding into the lumen of the respiratory tract due to blood clotting disorders and pathologies of blood vessels, hemosiderosis, cystic fibrosis, sarcoidosis.

Hemoptysis is a pathological condition in which no more than 50 ml of blood with sputum is released during the day.

Pulmonary hemorrhage is the release of more than 50 ml of blood with sputum during the day.

Causes of pulmonary hemorrhage. Often the causes of pulmonary hemorrhage are bronchial adenoma, malignant tumors of the lungs and bronchi, parasitic and fungal infections (ascariasis, echinococcosis, schistosomatosis, pulmonary actinomycosis), pneumoconiosis (silicatosis, silicosis), tuberculosis, bronchiectasis, arteriovenous anomalies, pulmonary contusions, trauma bronchi and trachea, lungs, destructive pneumonia, abscess, operated lung.

Classification of pulmonary hemorrhage:

– mild degree — 50–200 ml per day;

– moderate — 200–500 ml per day;

– severe — over 500 ml per day.

Pulmonary hemorrhage leads to bronchial obstruction, asphyxia, and hemorrhagic shock. Sometimes profuse bleeding occurs, up to 2–3 liters of blood in a short time, which leads to death.

Diagnosis of pulmonary hemorrhage is quite complex, as it requires consideration of a large differential diagnostic series, which is usually carried out between nosebleeds, followed by blood flow into the lower respiratory tract, bleeding from the oral cavity, gastrointestinal bleeding, accompanied by aspiration of blood into the respiratory tract. Therefore, before conducting in-depth, often invasive studies, it is necessary to perform a thorough physical examination of the patient, as well as a detailed history taking, with a comprehensive assessment of laboratory data.

It is fundamentally important at the stage of examining the patient to differentiate pulmonary bleeding and bleeding from the gastrointestinal tract. Bleeding from the gastrointestinal tract is accompanied by the following clinical and anamnestic signs: a history of peptic ulcer disease, vomiting of unchanged blood or “coffee grounds”, black stools (melena). Sometimes massive gastrointestinal bleeding is accompanied by blood entering the tracheobronchial tree, which causes a picture of pulmonary hemorrhage.

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With pulmonary hemorrhage, blood can enter the stomach and cause vomiting of coffee grounds.

Respiratory failure.

Respiratory failure (RF) is the inability of the respiratory system to provide a normal gas composition of arterial blood. The following definition is more applicable in practice: DN is a pathological syndrome in which the partial tension of oxygen in arterial blood (PaO2) is less than 60 mmHg and/or the partial tension of carbon dioxide (PaCO2) is more than 45 mmHg. With DN, the ability of the lungs to provide a normal gas composition of arterial blood is limited, and the compensatory capabilities of the external respiration system are overstrained.

Causes:

–acute and chronic diseases of the bronchopulmonary system;

–CNS lesions;

–anemia (anemia);

–hypertension in the pulmonary circulation;

–vascular pathology of the lungs and heart;

–lung tumors.

Classic signs of respiratory failure are:

a)syndrome of weakness and fatigue of the respiratory muscles;

b)shortness of breath.

According to the rate of onset of the pathological condition, acute and chronic DN are distinguished.

Acute respiratory failure develops within a short time, within a few minutes or hours, and requires urgent therapeutic measures.

Symptoms:

–increasing shortness of breath;

–violation of the central regulation of breathing, only the participation of the neck muscles and movement of the larynx in breathing is observed;

–feeling of anxiety and agitation, inappropriate behavior;

–lethargy, gradual loss of consciousness;

–convulsions;

–earthy skin tone.

In the initial stages, tachycardia and a tendency to increase blood pressure are noted.

Chronic respiratory failure most often develops with chronic obstructive pulmonary diseases (chronic obstructive bronchitis), obesity, pulmonary resection, and kyphoscoliosis. In all of these situations, the resulting hypoxia leads to an increase in

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the work of the respiratory muscles, which for some time ensures the preservation of the blood gas composition.

Symptoms:

–gradually developing shortness of breath;

–shortness of breath even with little effort or even at rest;

–drowsiness;

–dilation of facial skin vessels is noted;

–limbs with a purplish-bluish tint;

–puffiness of the face appears.

The main causes of respiratory failure are acute and chronic lung diseases, leading to obstructive hypoventilation.

Complications of respiratory failure. Respiratory failure is an emergency condition that threatens human health and life. If timely assistance is not provided, acute respiratory failure can lead to the death of the patient.

Long-term course and progression of chronic respiratory failure leads to the development of right ventricular heart failure as a result of a lack of oxygen supply to the heart muscle and its constant overload.

Diagnostics. At the initial diagnostic stage, a medical history and concomitant diseases are carefully collected in order to identify possible causes of respiratory failure. When examining the patient, attention is paid to the presence of changes in the skin, the respiratory rate is calculated:

–functional diagnostics of external respiration, allowing to assess the ventilation capacity of the lungs. In this case, the vital capacity of the lungs, minute volume of respiration, and the speed of air movement through various parts of the respiratory tract are measured;

–laboratory analysis of blood gas composition, allowing to determine the degree of saturation of arterial blood with oxygen and carbon dioxide;

–X-ray of the chest organs to identify damage to the chest, lungs, blood vessels, bronchi.

Among lung diseases, a separate group consists of diseases accompanied by a violation of bronchial obstruction, the so-called broncho-obstructive syndrome, which the patient feels as a violation of breathing, difficulty breathing. Among them, the most common are obstructive bronchitis and bronchial asthma. Among the mechanisms for the formation of breathing disorders are: bronchospasm, swelling of the bronchial mucosa resulting from exposure to an allergen or inflammatory process, obstruction of the bronchus with sputum.

The leading cause in the formation of obstructive bronchitis is frequent colds accompanied by cough. Sometimes the provoking factor is the reflux of acidic gastric

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contents into the esophagus with the reflex formation of bronchial spasm. An unfavorable background in this situation and an aggravating factor is long-term smoking.

Bronchial asthma is characterized by infectious causes — frequent colds, as well as allergic causes, or a disharmonic variant, when bronchospasm may be based on long-term decompensation of the hormonal background of the reproductive sphere or thyroid gland, less often — a psychogenic or neurogenic variant, when psychoemotional stress contributes to the development of difficult breathing or even a fullblown attack of suffocation.

The clinical course of chronic obstructive bronchitis and bronchial asthma is divided into three phases. The exacerbation phase, characterized by vivid manifestations of the disease, which force the patient to consult a doctor or call an ambulance. The remission phase, in which, after suffering an acute attack and treatment for a long time, no exacerbation of the disease is observed. During the intermediate phase — incomplete remission, clinical manifestations of the disease occur in a mild form, to which the patient does not attach due importance and does not carry out adequate treatment. It is during this period that an acute attack of the disease and an emergency call may again develop.

In the stratification of asthma by severity, there is the concept of a stage corresponding to certain gradations of symptoms of the asthma symptom complex.

There are four stages; if the patient does not take basic medications, then each of these stages corresponds to one of four degrees of severity:

Stage 1. Intermittent asthma:

–attacks of the disease occur rarely (less than once a week);

–short exacerbations;

–night attacks of the disease occur rarely (no more than twice a month);

–FEV1 or PEF more than 80 % of normal;

–PSV spread is less than 20 %.

Stage 2. Mild persistent asthma:

–symptoms of the disease occur more often than once a week, but less than once a day;

–exacerbations can disturb the patient's sleep and inhibit physical activity;

–night attacks of illness occur at least 2 times a month;

–FEV1 or PEF more than 80 % of normal;

–the spread of PSV is 20–30 %.

Stage 3. Moderate persistent asthma:

–asthma attacks occur almost daily;

–exacerbations disturb the patient's sleep and reduce physical activity;

–night attacks of the disease occur very often (more than once a week);

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–FEV1 or PEF decreases to 60 to 80 % of normal;

–PSV spread more than 30 %.

Stage 4. Severe persistent asthma:

–attacks of the disease occur daily;

–asthma attacks at night are very common;

–limiting physical activity;

–FEV1 or PEF is about 60 % of normal;

–PSV spread is more than 30 %.

If the patient is on basic therapy, the severity of the disease is determined by the stage and dosage of the basic drug (low, medium and high doses)

Community-acquired pneumonia is an acute infectious disease that arose in a community setting, accompanied by symptoms of lower respiratory tract infection (fever, cough, sputum production, chest pain, shortness of breath) and X-ray diagnosis of focal infiltrative changes in the lungs.

Classification of pneumonia:

a)community-acquired pneumonia (acquired outside a medical institution, synonyms: home (outpatient);

b)nosocomial pneumonia;

c)nosocomial (acquired) in a medical institution, synonyms: hospital;

d)aspiration pneumonia;

e)pneumonia in persons with severe immune deficiencies (congenital immunodeficiency, HIV infection, iatrogenic immunosuppression) and clarification of the location and presence of complications.

Criteria for the severity of pneumonia:

1. Mild course: unexpressed symptoms of intoxication, subfebrile body temperature, no respiratory failure and hemodynamic disturbances, pulmonary infiltration within 1 segment, leukocytes 9.0–10.0 × 109/L, no concomitant diseases.

2. Moderate severity: moderate symptoms of intoxication, increased body temperature up to 38 °C, pulmonary infiltrate within 1–2 segments, respiratory rate up to 22 per minute, heart rate up to 100 beats per minute, no complications.

3. Severe course of pneumonia: serious condition of the patient, severe symptoms of intoxication, body temperature more than 38.0 °C, respiratory failure stage II–III, hemodynamic disorders (BP — 10.7 mmol/L, disseminated intravascular coagulation syndrome, sepsis, failure of other organs and systems, disorders consciousness, exacerbation of concomitant diseases).

Indications for hospitalization.

Physical examination data:

– respiratory rate ≥ 30 per minute;

– diastolic blood pressure ≤ 60 mmHg;

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–systolic blood pressure < 90 mmHg;

–heart rate ≥ 125 per minute;

–body temperature < 35.0 or ≥ 40.0 °C;

–disturbance of consciousness;

–age over 60 years;

–presence of concomitant diseases (COPD, bronchiectasis, diabetes mellitus, chronic renal failure, congestive heart failure, severe body weight deficiency);

–ineffectiveness of initial antibiotic therapy. Inability to provide adequate care and follow all medical prescriptions at home.

Indications for admission to the ICU:

–tachypnea ≥ 30 per minute;

–systolic blood pressure < 90 mmHg;

–bilateral or multilobar pneumonic infiltration;

–rapid progression of focal infiltrative changes in the lungs;

–septic shock;

–need for vasopressors > 4 hours;

–acute renal failure.

2.10. EXAMINATION OF THE STATE OF THE CARDIOVASCULAR SYSTEM

The study of the activity of the cardiovascular system occupies the main place in the complex of human examinations carried out during physical education and sports. The main indicators of the functional state of the cardiovascular system are heart rate (HR), blood pressure, stroke and minute volumes, amount of circulating blood and blood flow speed. Heart rate (HR) is one of the informative indicators of the impact of physical activity on the human body. An important assessment feature is blood pressure (BP). Its value depends on the stroke volume of the heart, i.e. the amount of blood ejected in one contraction, as well as on the capacity of the vascular bed, the elasticity of the walls of blood vessels, the viscosity of blood, its quantity and some other indicators.

There are maximum (systolic), minimum (diastolic) and pulse pressure. Systolic blood pressure (SBP) is the pressure that occurs in the arterial system at the time of left ventricular systole, diastolic blood pressure (DBP) is during diastole, i.e. during the decline of the pulse wave. Pulse pressure blood pressure (APP) is the difference between the values of maximum and minimum pressure.

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One of the indicators of the functional state of the cardiovascular system in a state of relative rest is the Robinson Index (RI):

RI = HRSp × SBP / 100,

where HRSp is heart rate in a state of relative rest, bpm; SBP — systolic blood pressure, mmHg. The Robinson index normally does not exceed 85 conventional units. It is noted that the lower the RI, the higher the maximum aerobic capacity and, consequently, the level of human somatic health.

However, when examining a patient at the prehospital stage, along with assessing the pulse and blood pressure, checking the microcirculation of the vascular bed, which is determined by examining the “White Spot” test, is of great importance. In the area of the anatomical snuffbox, in the interval between the base of the 1st and 2nd fingers on the dorsal surface, finger pressure is applied to the skin until a white spot appears. Then they abruptly stop the pressure and see how long it takes for the white spot to merge with the color of the rest of the skin. Normally, with normal microcirculation of the vascular system, this occurs in 2–3 seconds; if the time increases by 2–3 or more times, then the microcirculation of the skin is impaired. With severe disorders, the white spot does not disappear.

When palpating the pulse, it is important to determine its characteristics, deficiency and arrhythmia, and after measuring BP, record an ECG. Based on the patient’s complaints, medical history and illness, objective examination and ECG data, a preliminary diagnosis is made, emergency medical care is provided at the prehospital stage, and the patient is taken to the on-duty cardiology or therapeutic department.

2.11. EXAMINATION OF THE STATE OF THE DIGESTIVE SYSTEM

Visual examination of the patient for general medical purposes and the abdomen:

1.Body temperature measurement.

2.Heart rate measurement.

3.Blood pressure measurement in peripheral arteries.

4.Auscultation of the lungs.

5.Palpation of the abdomen.

6.Percussion of the abdomen and determination of “liver dullness”.

7.Checking the Shchetkin — Blumberg symptom of peritoneal irritation.

8.Auscultation of abdominal peristalsis.

9.Digital examination of the rectum.

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10.Electrocardiogram registration.

11.Decoding, description and interpretation of electrocardiographic data.

12.Determining blood oxygen saturation using a pulse oximeter.

13.Assess the severity of the patient's condition.

Diagnosis by language.

The method is based on a visual examination of the body of the tongue, the various zones of which are the projection of certain internal organs and systems. The pathological processes occurring in these organs affect the state of these zones or the entire tongue as a whole. We are talking about a change in the color of the tongue, as well as its consistency, shape, degree of humidity, and the nature of the coating.

Geographic tongue (desquamative glossitis, exfoliative glossitis, benign migratory glossitis) is a condition in which the nutrition of the mucous membrane of the tongue is disrupted, resulting in rejection of areas of the epithelium. It is based on inflammatory, allergic processes and disturbances in the functioning of the autonomic nervous system. The tongue is covered with bright red spots surrounded by a white rim. Sometimes the patient is bothered by burning, tingling, the tongue reacts to sharp, hot, spicy foods, and taste disturbances may occur. Geographic tongue can occur against the background of influenza, scarlet fever, typhoid fever, as well as gastritis (inflammation of the gastric mucosa), gastroduodenitis (inflammation of the stomach and duodenal mucosa), peptic ulcer of the stomach and duodenum, and syndrome of reduced absorption of nutrients in the intestine. In children, weeping (exudative) diathesis and helminthiases are often detected along with geographic tongue.

Plaque on the tongue can be of different colors, consistency, structure and located in different areas. The color of plaque provides very important information not only about the products consumed with coloring properties, but also about the state of the gastrointestinal tract, teeth, and infectious processes in the body. The consistency of plaque on the tongue and its structure varies depending on the disease — it can be curdled, dense, mucous, dry or viscous. The plaque can cover the entire area of the tongue, located at its root, on the back surface or in its middle part.

Possible causes of plaque on the tongue. The appearance of plaque on the tongue can have many causes: smoking, infectious diseases, pathologies of the gastrointestinal tract and respiratory system, helminthic infestations, and oncological processes.

Infectious diseases.

With scarlet fever, in the first days of the disease, the tongue is covered with a thick, dense gray-white or yellow-white coating, which disappears on the 5–6th day, and the back of the tongue becomes intensely red (“crimson tongue”), enlarged mush- room-shaped papillae stand out on it.

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