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Файл:Emergency medical care at the prehospital stage. Assessment of the severity of the condition of patients. Study aid
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not only about the products used with coloring properties, but also about the state of
the gastrointestinal tract, teeth, infectious processes in the body. The consistency of
plaque on the tongue and its structure vary depending on the disease: it can be curd,
dense, mucous, dry or viscous. Plaque can cover the entire area of the tongue, be located at its root, on the back surface or in the middle of it.
Possible causes of plaque on the tongue. The appearance of plaque on the
tongue can have many reasons: smoking, infectious diseases, pathologies of the gastrointestinal and respiratory systems, worm invasions, 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 plaque, which disappears on day 5–6, and the
back of the tongue becomes intensely red (“crimson tongue”), enlarged mushroom
papillae stand out on it.
With diphtheria in the area of the throat, on the palate arms, root and back of
the tongue, dirty white films are observed, when removed, the bleeding surface is exposed. Dysentery is characterized by the appearance of thick white-brown plaque in
the language.
Candidiasis (thrush), caused by the development of yeast flora, is accompanied
by the formation of merging plaques on the tongue, tightly adjacent to the back of the
tongue and covered with curd milk-white plaque.
The state of dehydration of the body is accompanied by the formation of
a dark, sometimes almost black (as with cholera) plaque, which is difficult to remove
from the tongue. A characteristic plaque occurs with Vincent's stomatitis (fusospirochetosis), it has a grayish green color and a fetid putrid smell, after its removal
a loose, bleeding ulcer remains. With leptotrichosis, a dense, difficult to remove whitish-gray plaque is formed on the tongue; in some places, areas of the loosened and
easily bleeding mucous membrane are exposed under it.
Diseases of the gastrointestinal tract.
Gastritis, gastric ulcer, enterocolitis lead to a significant increase in plaque on
the tongue, it is located mainly in its posterior parts, and may cover the entire back. In
diseases of the stomach and food tract, plaque on the tongue is greyish-white. With
stomach ulcer, whitish plaque on the tongue, regardless of its abundance, is easily
removed. In this case, a feeling of burning and soreness can occur. On the lateral surfaces of the tongue, due to its swelling, there may be tooth prints. If the plaque is too
strong, it can be accompanied by a decrease in taste sensitivity. The color and consistency of plaque may vary depending on the intensity and severity of the manifestations of the disease. In liver and biliary pathologies, plaque can acquire various
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shades of yellow (dirty yellow, brown). Parasitic diseases, blockage of the bile ducts
and congestion of bile can lead to the appearance of yellow plaque.
Pancreatitis is characterized by a yellow-white plaque on the tongue, which is
difficult to brush. Filamentous papillae on the tongue are enlarged, it is possible that
foci of desquamation (desquamation) of the epithelium appear on the back of the
tongue.
Diabetes mellitus develops increased dry mouth. Insufficient saliva excretion
leads to the formation of abundant dental deposits and white plaque. In addition, candidiasis develops in the oral cavity, which aggravates the severity of plaque.
Geographic language may be due to neurotrophic disorders and GI diseases.
Dyspepsia is the sensation of pain or discomfort in the upper abdomen; often it
is relapsing. Dyspepsia is described as impaired digestion in the stomach, excessive
gas formation, feeling of early saturation, sucking or burning pain.
When digestion is impaired, symptoms appear that are united by a common
name — “gastric dyspepsia”, clinical manifestations arise:
dysphagia;
nausea and vomiting attacks;
burping;
stomach pain;
heartburn;
rumbling in the abdomen;
bloating;
constipation, diarrhea.
Dyspepsia of the stomach and intestines causes pain in the epigastric region.
They can be either quite intense or in the form of slight discomfort. There is a feeling
of rapid saturation and overcrowding, and as a result, nausea, burping, heartburn. Another alarming sign is the loss of appetite, and quickly and sharply. After that, a person begins to lose weight for no reason. Intestinal dyspepsia is accompanied by rumbling in the abdomen, flatulence, diarrhea or constipation.
Violation of the process of digesting food in the intestines can indicate pathologies such as dysbiosis, diverticulitis, enzymopathy, enteritis, colitis, tumors in the
intestines, irritable bowel syndrome, pancreatic diseases, metabolic pathologies. Also,
intestinal dyspepsia may indicate that an infection develops in it (dysentery, cholera,
intestinal tuberculosis, salmonellosis, etc.).
Two main groups of dyspeptic disorders are distinguished — functional dys-
pepsia and organic. In the first case, only violations of the organ's activity are found,
i.e. functional lesions, and in the second they are exclusively organic in nature.
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Several forms are distinguished depending on the causes that cause the development of the syndrome:
1) simple dyspepsia. It is also called alimental, caused by food problems. This
dyspepsia, in turn, is fatty (soap), fermenting and putrid. Putrid develops if the food is
dominated by protein products or stale meat is used. Fermentation arises from excessive consumption of carbohydrates (bread, cabbage, legumes, sugar) and drinks that
cause fermentation (beer and kvass). Fatty dyspepsia develops with an immoderate
consumption of fatty foods, especially pork and lamb;
2) dyspepsia associated with a deficiency of released enzymes for digesting
food in the intestine and stomach. In turn, it is gastrogenic (lack of enzymes in the
stomach), pancreatogenic (deficiency of pancreatic substances), enterogenic (lack of
intestinal juices), hepatogenic (insufficient bile release from the liver);
3) dyspepsia, which is associated with intestinal food absorption problems in
malabsorption syndrome. As a result, the nutritional components do not flow from
the intestine into the blood;
4) dyspepsia, which is associated with intestinal infections. Such conditions
can be caused by dysentery or salmonellosis;
5) intoxication dyspepsia. It manifests itself due to poisoning in various diseas-
es, including influenza, surgical pathologies in acute form, as well as when using
poisons.
Assessment of nausea and vomiting in adults.
Nausea and vomiting are extremely common symptoms that can be caused by
various diseases and pathological conditions. Their manifestation can be acute or
chronic, and severity — from moderate to a condition that worsens the quality of life
or threatens life.
There are two mechanisms for developing nausea and vomiting:
1. Neurological:
stimulation of the posterior field, sensitive to the action of harmful chemicals
(for example, poisons, chemotherapeutic drugs, digoxin), provokes further stimulation of the vagus nucleus, which causes nausea and coordinates the emetic reflex;
CNS diseases, such as infections or brain tumors, stimulate CNS structures
and can cause nausea and vomiting due to effects on the vagus nerve.
2. Peripheral:
diseases and disorders occurring in peripheral organ systems, for example,
such as the gastrointestinal tract, stimulate vagus or afferent nerves of the spinal cord
in contact with vagus sensitive (single bundle) and efferent motor nuclei. Eventually,
through efferent pathways, the cortical centers, which are responsible for the onset of
nausea, are stimulated;
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tumors, infections and medical drugs in case of their effect on peripheral or-
gan systems can cause local dysfunction of the latter, which is manifested by a feeling of nausea, which then causes vomiting.
Belching is a reflex contraction of the muscles of the diaphragm, abdominal
press and stomach walls, in which air and gases escape from the stomach through the
mouth.
Dysbiosis — the occurrence of an imbalance of microflora. The ratio of normal
and opportunistic pathogens is disturbed. This phenomenon can occur in the intestines (most often) and reproductive organs. Dysbiosis is characterized by the occurrence of burping with air with a bitter or rotten taste.
A hernia of the esophagus (diaphragmatic hernia, hernia of the esophageal orifice of the diaphragm) is a common chronic recurrent pathology in which the initial
abdominal part of the digestive tube moves to the supradiaphragmal zone through the
esophageal orifice of the diaphragm.
Gastroenterocolitis (food toxicoinfection) is a disease in which an inflammatory process occurs in several parts of the gastrointestinal tract — the mucous membranes of the stomach, small and large intestines, and digestive function is impaired.
With gastroenterocolitis, burping occurs with food or with a rotten taste, gastritis with
increased acidity is characterized by an increase in the production of hydrochloric
acid, which contributes to the dissolution of food. As a result, mucosal walls become
inflamed and erosion forms. Burping in gastritis with increased acidity has an
acidic taste.
Biliary pancreatitis is a chronic disease of the pancreas of an inflammatory
nature resulting from pathologies of the liver and biliary ducts. It is often combined
with other diseases of the digestive system. Biliary pancreatitis is characterized by
burping with a bitter taste and a characteristic smell of bile.
Stone-free cholecystitis is an inflammation of the gallbladder in which bile
nodules do not form. The motor function of the organ is impaired, bile congestion occurs. This disease is several times more likely to occur in women. Stone-free cholecystitis is characterized by burping with air and a bitter taste.
Oesophageal cardia achalasia is characterized by burping with a rotten taste.
Heartburn — a feeling of discomfort or burning behind the sternum, spread-
ing upward from the epigastric (substrate) area, sometimes giving to the neck area.
Heartburn is caused by the contents of the stomach with high acidity entering the
esophagus.
Heartburn is most closely correlated with gastroesophageal reflux disease
(GERD). Moreover, if heartburn is the main or only symptom, then in 75 % of pa-
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tients the cause of heartburn is GERD. Heartburn often causes inflammation of the
esophageal mucosa — esophagitis. If GERD is observed, then such a disease is called
“reflux esophagitis”. Heartburn can also signal peptic esophageal ulcer, esophageal
strictures, Barrett's esophagus, and esophageal adenocarcinoma. The cause of heartburn can also be disorders of the motility of the esophagus, stomach and duodenum.
Vomiting is a complex reflex act in which an involuntary ejection of the contents of the gastrointestinal tract occurs. Frequent vomiting is always a symptom of
the disease and requires timely medical care due to the risk of severe complications:
dehydration, heart rhythm disturbances due to loss of electrolytes (salts) with emetic
masses, thrombosis, acute renal injury.
Esophageal vomiting is rare and mainly in children with pathologies of esophageal development. In addition, it can occur as a result of ingestion of a foreign body
or large pieces of food, as well as in the case of scar constriction of the esophagus after a burn or injury. Emetic masses appear after each meal. In adulthood, esophageal
vomiting can be seen in esophageal tumors. In cirrhosis of the liver, varicose veins
occur on the esophageal mucosa, which often burst and produce severe esophageal
bleeding. Emetic masses of esophageal origin have unpleasant odors, contain impurities of mucus and blood.
Stomach vomiting is the result of irritation of the stomach mucosa with bacterial toxins when poisoned with food or various chemicals.
If vomiting is a symptom of stomach ulcer, then its contents have an acidic
taste and smell, the patient has belching, heartburn, nausea, pain syndrome.
With bleeding from the stomach, vomiting of the “coffee grounds” often occurs, and with bleeding from the esophagus — vomiting of unchanged blood. Acute
bleeding occurs with stomach ulcer, disintegrating stomach tumor, esophageal varicose veins in cirrhosis.
Intestinal vomiting or vomiting by feces is characteristic of intestinal obstruction, such patients need emergency surgery. If frequent vomiting (up to 10 times
a day or more) is combined with a pronounced headache, increased muscle tone, photophobia, hypersensitivity to sounds and high fever, then it can be a symptom of meningitis.
The central type of vomiting is characteristic of hypertensive crisis (sudden increase in BP), brain tumors, lesions of the labyrinth apparatus of the inner ear, seasickness. Vomiting, which has become a consequence of TBI, is also central in nature, accompanied by loss of consciousness, dizziness, headache. It occurs suddenly,
happens up to 10–15 times a day, usually without nausea. With fever during colds,
reflex vomiting is possible, especially in young children.
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Many intestinal infections are manifested by frequent vomiting and diarrhea,
while rising temperatures are not required. In children under 3 years of age, rotavirus
infection in 80 % of cases is accompanied by vomiting.
Some chronic diseases, such as chronic kidney disease, decompensated diabetes mellitus (poorly controlled, with very high blood glucose values and the appearance of glucose in the urine), can cause frequent vomiting (up to 5–6 times a day). In
these diseases, significant metabolic disorders occur and the deceleration of the elimination of toxic metabolic products from the body. In some women, repeated vomiting is possible during menstruation (2–3 times a day). It occurs reflexively in response to painful contractions of the muscles of the uterus. Vomiting of pregnant
women (toxicosis) occurs, as a rule, in the first trimester. In some women, it happens
once in the morning, while others suffer from vomiting and nausea throughout
the day.
Abdominal pain.
It is generally accepted that the cause of abdominal pain is most often spasm of
the smooth muscle organ (spastic) or inflammation. Spastic pain (colic) develops
acutely, suddenly, can be short or long depending on the source and cause of the pain.
Examples of spastic pain: intestinal, renal, biliary colic.
The pain as a result of inflammation increases gradually, to a certain point it
can be tolerated. For example, it is for this reason that patients with acute appendicitis
often late seek medical help, already at the stage of phlegmonotic or gangrenous appendicitis.
The nature of the pain is of diagnostic importance. In order to correctly diagnose, the doctor asks questions about the nature of the pain that the patient is experiencing. The patient needs to describe the nature and location of the pain as accurately
as possible. Usually, the doctor asks the patient to lie on his back in order to relax the
abdominal muscles, press movements gently feel the abdomen with the fingertips,
without sharp movements, determines the place in which pressure causes the most
pain. It establishes the nature of pain: dull, aching, sharp, cutting, bursting, irradiation
of pain, intensification when coughing or walking, the appearance of pain — suddenly or after eating, exercise, defecation.
Localization of pain. There is no absolute link between pain location and the
damaged organ. Pain near the navel, moving to the right lower abdomen, is most often a symptom of appendicitis, and pain from inflammation of the pancreas can begin
“under the spoon”, and then become zoster. Pain at the top of the abdomen on the
right may indicate a disease of the liver, gallbladder, biliary tract, duodenum. Pain at
the top of the abdomen on the left can be a symptom of gastritis, stomach ulcers, hernia of the esophageal orifice of the diaphragm. Emergency medical care is required
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for sharp, rapidly increasing pain in the right hypochondrium, suprachral area with
irradiation to the right shoulder, collarbone, shoulder blade, iliac area, lower back
(symptoms of biliary colic), as well as if the pain is sharp, occurs suddenly and is accompanied by fever, nausea, vomiting (symptoms of intestinal puncture, peritonitis),
increasing pain is noted, pain below abdomen on the right (symptom of acute appendicitis). Dagger intense pain in the epigastric region occurs with a perforated stomach
ulcer.
Pain at the bottom of the abdomen on the right can be a symptom of appendicitis, mainly in the left or right half of the abdomen — diseases of the colon (colitis,
acute intestinal obstruction, diverticulitis, Crohn's disease, ulcerative colitis), above
the pubic — diseases of the genitals, bladder.
Abdominal pain in women.
The most common occurrence in women is both menstrual pain caused by contraction of the uterine muscles and pain resulting from gynecological diseases and inflammatory events in sexually transmitted infections. Pain can be felt at the bottom of
the abdomen above the pubis, in the groin areas to the left/right. Ectopic pregnancy
should be excluded if the next menstruation is delayed if severe pain occurs in the
lower abdomen on the right or left, not accompanied by vomiting and fever.
Before contacting a doctor, three main rules should be observed: hunger, cold
and peace. In no case should you warm your stomach. If pain is a symptom of an inflammatory process, its development can accelerate. Do not (however, this is not
mandatory) take painkillers and antispasmodics before going to the doctor, these
drugs smooth the clinical picture and make diagnosis difficult.
When assessing abdominal pain, the following clarifications are relevant:
the pain appeared suddenly, severe and lasts more than 3 hours;
pain appeared as a result of an abdominal injury — a strong blow to the ab-
domen or fall;
there was acute cutting pain, stabbing pain, which shifts to the right hypo-
chondrium;
zoster pain occurred;
pain is accompanied by fever, darkening of urine, nausea or vomiting;
pain is accompanied by the release of blood from the rectum or vomiting
with blood;
pain is accompanied by blood discharge from the vagina;
pain is accompanied by dizziness, increased heart rate, general severe weak-
ness, pallor and sweating of the skin;
any abdominal pain during pregnancy.
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Diagnosis of esophageal damage is based on the collection of history and
characteristic symptoms, fits into the following scheme:
1. Collection of complaints and medical history, attention to dysphagia,
hoarseness of the voice.
2. Visual examination of the patient is general therapy.
3. Visual examination of the face, neck and chest for subcutaneous emp-
hysema.
4. Visual examination and abdomen.
5. Measurement of body temperature.
6. Heart rate measurement.
7. Measurement of BP on peripheral arteries.
8. Auscultation of the lungs and determination of weakened breathing and
wheezing.
9. Percussion of pleural cavities on the back side and definition of “blunting”.
10. Abdominal palpation.
11. Abdominal percussion and definition of “hepatic dullness”.
12. Checking the symptom of irritation of the Shchetkin — Blumberg peritoneum.
13. Auscultation of abdominal peristalsis.
14. Please drink a sip of chilled water and note the nature of the pain behind
the sternum when swallowing.
15. Determination of blood oxygen saturation on a pulse oximeter.
Peritonitis is an inflammation of the parietal and visceral leaves of the peritoneum, which is accompanied by a severe general condition of the body. Peritonitis
occurs as a result of exposure to infectious or chemical stimuli due to the ingress of
gastric contents (containing hydrochloric acid), bile, urine, blood into the free abdominal cavity.
The most common cause of bacterial peritonitis is perforation of the hollow organ of the gastrointestinal tract, as a result of which gastric or intestinal contents and
microflora enter the abdominal cavity, i.e. bacteria that live in the lumen of the stomach/intestine.
Perforation of a hollow organ can occur due to:
rupture of the appendix (complication of acute appendicitis);
perforation of a stomach or duodenum ulcer;
ulceration of lymphoid plaque in typhoid fever;
damage to the intestinal wall by a foreign body;
perforations of the intestinal diverticulum;
necrosis of the intestine during hernia;
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intestinal overextension in intestinal obstruction;
perforations of malignant tumor and other causes.
In addition, peritonitis can appear due to suppuration of excess free fluid in the
abdominal cavity, formed as a result of propotis-due to increased venous pressure
(ascites), inflammation of the abdominal organs (for example, in intestinal obstruction, gynecological diseases), intraperitoneal bleeding.
Classification of peritonite by Yu.M. Lopukhin and V.S. Savelyev:
1) by clinical course:
– acute;
– chronic;
2) by the nature of the infection:
– primary (hematogenic or lymphogenic infection);
– secondary (infection due to injuries and surgical diseases of the abdominal
cavity): infectious-inflammatory, perforated, traumatic, postoperative;
– tertiary (in weakened patients who have undergone severe operations, inju-
ries, with a pronounced depletion of anti-infectious protection mechanisms);
3) by microbiological features:
– microbial (bacterial);
– aseptic;
4) special forms of peritonitis: carcinomatous, parasitic, rheumatoid, granu-
lomatous;
5) by the nature of the exudate:
– serous;
– fibrinous;
– purulent;
– hemorrhagic;
6) by the nature of the peritoneal lesion:
a) by delimitation: delimited — infiltrate, non-delimited — does not have clear
boundaries and tendencies for delimitation;
b) by prevalence:
– local (delimited and non-delimited) — occupies only one anatomical sections
of the abdominal cavity;
– common — occupies 2–5 anatomical sections of the abdominal cavity;
– total (total) — total peritoneal lesion — 6 or more parts of the abdominal
cavity.
Objective determination of the severity of the condition of the patient with
peritonitis and the probable prognosis of the disease is significant in the identification
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of patients, it is necessary, given in more active treatment. One of the most common
methods of objective assessment of the severity of the condition in peritonitis is the
Mannheim peritonitis index (Table 1).
Table 1
Mannheim Peritonitis Score Scale
Parameter
Size
Points
Age, in years
> 50
5
≤ 50
0
Floor
women's
5
men's
0
Organ failure (see below)
is available
7
is absent
0
Malignancy
is available
4
is absent
0
Duration of peritonitis before surgery is more than 24 hours
is available
4
is absent
0
Primary focus
in the colon
4
not in the colon
0
Common peritonitis
is available
6
is absent
0
Exudate
transparent
0
viscous (purulent)
6
fecal
12
Table 2
Indicators of organ failure for Mannheim peritonite index
Organ failure
Indicators
Kidneys
creatinine level ≥ 177 mcmol/L
urea ≥ 1 mol/L
oligurium < 20 ml/h
Lungs
PaO2 < 50 mmHg
PaCO2 > 50 mmHg
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