Добавил:
ivanov666
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Emergency medical care at the prehospital stage. Assessment of the severity of the condition of patients. Study aid
.pdf
101
Organ failure
Indicators
Shock (Shoemaker criteria)
hypodynamic
hyper dynamic
Intestinal obstruction
paresis ≥ 24 hours
complete mechanical obstruction
The Mannheim peritonite index consists of eight risk factors, which are evaluated in points from 0 to 12, while the index values can range from 0 to 47 points.
A value above 26 points predicts the probability of death with a high sensitivity of
84 %, specificity of 79 % and accuracy of 81 % (Table 2).
The diagnosis of acute peritonitis has a characteristic clinical picture, fits into the following scheme:
1. Collection of complaints and medical history.
2. Visual examination of the patient with general therapy and abdomen.
3. Measurement of body temperature.
4. Heart rate measurement.
5. Measurement of BP on peripheral arteries.
6. Auscultation of the lungs.
7. Abdominal palpation.
8. Abdominal percussion and definition of “hepatic dullness”.
9. Checking the symptom of irritation of the Shchetkin — Blumberg peritoneum.
10. Auscultation of abdominal peristalsis.
11. Finger examination of the rectum.
12. ECG registration.
13. Determination of blood oxygen saturation on a pulse oximeter.
14. Assessment of the severity of the patient's condition.
All patients diagnosed with acute peritonitis after providing medical care at the
prehospital stage should be taken to the duty surgical hospital.
Acute intestinal obstruction is a disease characterized by a violation of the
passage of intestinal contents through the gastrointestinal tract, in which acute stool
and gas retention occurs.
Classification of acute intestinal obstruction:
1. Dynamic obstruction:
spastic;
paralytic.
2. Mechanical obstruction:
strangulation (swirl, nodulation, infringement);
obturative (intraintestinal form, extraintestinal form);
mixed (invagination, adhesive obstruction).
102
Diagnosis of pathology at the prehospital stage fits into the following
scheme:
1. Collection of complaints and medical history. Paying attention to the swol-
len stomach vomiting, stool and gas retention.
2. Visual examination of the patient with general therapy and abdomen. Paying
attention to the presence of hernial bulges, abdominal asymmetry, visible peristalsis.
3. Measurement of body temperature.
4. Heart rate measurement.
5. Measurement of BP on peripheral arteries.
6. Auscultation of the lungs.
7. Abdominal palpation, paying attention to the presence of a bloated loop of
the intestine in the abdomen, above which high tympanitis is detected — a symptom
of Valya.
8. Checking Sklyarov's symptom is the noise of the shoulder with a slight con-
cussion of the abdomen (succussia).
9. Checking the symptom of irritation of Shchetkin — Blumberg bryushchina.
10. Checking for Mondor symptom — increased or no peristaltic noise in dif-
ferent parts of the abdomen.
11. Checking the symptom of Spasokukotsky — Wilms — the noise of a fall-
ing drop.
12. Finger examination of the rectum, checking the symptom of Grekov — the
atony of the anal pulp and the bloated empty ampoule of the rectum.
13. Determination of blood oxygen saturation on a pulse oximeter.
14. Assessment of the severity of the patient's condition.
All patients with acute intestinal obstruction after providing them with emergency medical care at the prehospital stage should be taken to the duty surgical
hospital.
Acute pancreatitis.
Acute pancreatitis is initially an aseptic inflammation of the pancreas, which
is based on necrobiosis (edematous pancreatitis) and necrosis of the gland itself and
surrounding tissues, followed by the addition of endogenous infection and accompanied by systemic disorders.
This disease has a stage course of the process, during which there is a regular
and sequential change in the phases of inflammation with the occurrence of pathomorphological changes specific for each stage. Edema and necrobiosis underlie
edematous pancreatitis, while for destructive pancreatitis the pathomorphological basis is necrosis.
103
The classification of acute pancreatitis is based on the Atlanta-92 classification, proposed in 2011, modified by the Russian Society of Surgeons (2014):
1. Mild acute pancreatitis, which is characterized by swelling of pancreatic tissue and has a completely reversible character (abortive course). Multiple organ failure for this form does not develop.
2. Moderate acute pancreatitis, characterized by the presence of one of the local manifestations of the disease: parapancreatic infiltrate, pseudocyst, delimited uninfected and/or infected (abscess) fluid accumulation with the development of common manifestations of multiple organ failure (up to 48 hours).
3. Severe acute pancreatitis, characterized by the presence of non-delimited infected (purulent-necrotic) pancreatitis and/or the development of multiple organ failure (more than 48 hours).
Pancreatic necrosis (destructive pancreatitis):
– hemorrhagic;
– fatty;
– mixed.
By prevalence, small-focal, large-lobed and total pancreatitis are distinguished.
Purulent pancreonecrosis causes:
1) uninfected and infected sequesters;
2) gland abscess;
3) purulent parapancreatitis;
4) retroperitoneal fiber phlegmon.
Complications of purulent pancreatitis:
fistulas of the pancreas and hollow organs;
arrosion of large vessels;
gland sequestration;
false purulent cysts;
sepsis.
According to the prevalence of the necrotic process in the pancreas, the fol-
lowing are distinguished:
1. Interstitial pancreatic edema (multiple microscopic necrosis not visualized
by ultrasound and CT).
2. Small-focal pancreatic necrosis (pancreatic lesion volume according to ultrasound and CT less than 30 %).
3. Large-frequency pancreatic necrosis (pancreatic lesion volume according to
ultrasound and CT from 30 to 50 %).
4. Subtotal pancreonecrosis (pancreatic lesion volume according to ultrasound
and CT more than 50–75 %).
104
5. Total pancreonecrosis (pancreatic lesion volume according to ultrasound and
CT more than 75 %; prevalence of the process beyond the pancreas).
All patients diagnosed with acute pancreatitis should be delivered to the duty
surgical department after providing medical care at the prehospital stage.
Diagnosis of acute pancreatitis at the prehospital stage fits into the following
scheme:
1. Collecting complaints and history of the disease, paying attention to Mon-
dor's symptom — epigastric pain, vomiting, flatulence.
2. Visual examination of the patient with general therapy and abdomen.
3. Paying attention to the presence of cyanosis spots on the lateral areas of the
abdomen is a Gray — Turner symptom, on the jaundice of the sclera and skin.
4. Measurement of body temperature.
5. Heart rate measurement.
6. Measurement of BP on peripheral arteries.
7. Auscultation of the lungs.
8. Auscultation of abdominal peristalsis.
9. Abdominal palpation.
10. Mayo — Robson symptom test — soreness in palpation of the left costo-
vertebral angle.
11. Checking Kerte's symptom — transverse painful resistance of the anterior
abdominal wall in the projection of the pancreas.
12. Checking the symptom of Voskresensky — the absence of pulsation of the
abdominal aorta.
13. Definition of a painful infiltrate in the epigastric region.
14. Checking the symptom of irritation of the Shchetkin — Blumberg peri-
toneum.
15. ECG registration.
16. Decoding, description and interpretation of ECG data.
17. Blood glucose testing using an analyzer.
18. Determination of blood oxygen saturation on a pulse oximeter.
19. Assessment of the severity of the patient's condition.
Acute appendicitis — acute inflammation of the worm-like process.
Clinical manifestations of acute appendicitis increase gradually over several
hours and in most patients begin with dyspepsia and the symptom of Kocher
(or Kocher — Volkovich), when pain occurs in the epigastric region, and then after
2–3 hours move to the right iliac region. A somewhat less common pain sensation
appears immediately in the right iliac region. Pains are constant, their intensity is
usually moderate. As the disease progresses, the pain increases somewhat, although it
105
can also subside due to the death of the nervous apparatus of the worm-like process in
gangrenous inflammation. Pains increase when walking, coughing, changing the position of the body in bed. Irradiation with a typical form of acute appendicitis is not
observed and is characteristic only of atypical forms. The onset of nausea and vomiting before the onset of pain is not typical for acute appendicitis. Body temperature
rarely rises above 37–37.4 °C (subfebrile fever).
Appendicitis classification:
acute uncomplicated appendicitis: catarrhal (simple, superficial) and destruc-
tive (phlegmonotic, gangrenous);
acute complicated appendicitis: perforation of the process, appendicular infil-
trate, abscesses (pelvic, subdiaphragmatic, intercingular), peritonitis, retroperitoneal
reflux, sepsis, pileflebitis;
chronic appendicitis (primary chronic, permanent, recurrent).
Diagnosis of acute appendicitis fits into the following scheme:
1. Collection of complaints and medical history. Paying attention to the Ko-
cher — Volkovich symptom is the movement of pain from the epigastric to the right
iliac region of the abdomen.
2. Visual examination of the patient with general therapy and abdomen.
3. Measurement of body temperature.
4. Heart rate measurement.
5. Measurement of BP on peripheral arteries.
6. Auscultation of the lungs.
7. Auscultation of abdominal peristalsis.
8. Abdominal palpation.
9. Rovzing symptom check — increased pain in the right iliac region when the
left iliac region is shaken.
10. Checking Voskresensky's symptom, “shirts” — increased soreness with
sliding movements over the right iliac region.
11. Checking Sitkovsky's symptom — the appearance of pulling pains in the
right iliac region when the patient turns on his left side.
12. Checking the symptom of Obraztsov — an increase in pain in the right iliac
region when raising the straight right leg in the lying position by 40°, without extending the knee.
13. Checking the symptom of irritation of the Shchetkin — Blumberg peri-
toneum.
14. Finger examination of the rectum, determination of soreness and overhang
of the anterior wall of the rectum.
15. Assessment of the severity of the patient's condition.
106
All patients with suspected acute appendicitis should be taken to the duty surgical hospital.
Acute cholecystitis.
Acute cholecystitis is an acute inflammation of the gallbladder.
Acute calculous cholecystitis is inflammation caused by obturation of the
cystic duct by a stone, leading to stagnation, infection of bile, hypertension in the
gallbladder, destruction of its wall, and peritonitis.
Clinical manifestations. The disease usually begins with an attack of pain in
the right subcostal region. Pain irradiates upward into the right shoulder and shoulder
blade, the right supraclavicular region. It is accompanied by nausea and repeated
vomiting. Characteristic signs are the appearance of a feeling of bitterness in the
mouth and the presence of bile impurity in vomiting masses.
In the initial stage of the disease, the pain is blunt, as the process progresses,
it becomes more intense. At the same time, an increase in body temperature up to
38 ° C is noted, sometimes chills occur. It is mandatory to collect an epidemiological
history — contact with hepatitis A.
Diagnosis of acute cholecystitis at the prehospital stage fits into the following
scheme:
1. Collection of complaints and medical history. Attention to cholecystocoro-
nary Botkin syndrome.
2. Visual examination of the patient with general therapy and abdomen.
3. Paying attention to the presence of jaundice sclera and skin.
4. Measurement of body temperature.
5. Heart rate measurement.
6. Measurement of BP on peripheral arteries.
7. Auscultation of the lungs.
8. Auscultation of abdominal peristalsis.
9. Palpation of the abdomen, paying attention to the enlargement of the
gallbladder in the right hypochondrium.
10. Abdominal percussion and definition of “hepatic dullness”.
11. Checking the frenicus symptom (Mussy — Georgievsky symptom) — ten-
derness when the finger presses the right supraclavicular fossa between the legs of the
nodding muscle.
12. Checking for Ortner's symptom — soreness when shaking the right cos-
tal arch.
13. Checking for Ker's symptom — tenderness when palpating the gall bladder
point when inhaling.
14. Checking the symptom of irritation of the Shchetkin — Blumberg peri-
toneum.
107
15. Checking for Murphy's symptom is involuntary breath retention when the
gall bladder point is palpated.
16. ECG registration.
17. Decoding, description and interpretation of ECG data.
18. Blood glucose testing using an analyzer.
19. Determination of blood oxygen saturation on a pulse oximeter.
20. Assessment of the severity of the patient's condition.
2.12. URINARY SYSTEM ORGANS EXAMINATION
The diagnosis of emergency states of the urinary system has its own characteristics, but fits into the scheme of specific states. Thus, in patients with acute urine
retention and patients with renal colic the working diagnostic scheme contains the
following stages:
1. Collection of complaints and medical history, attention to dysuric disorders,
pain in the scrotum and in the lumbar region.
2. Visual examination of the patient with general therapy and abdomen, paying
attention to swelling on the face, increasing the size of the scrotum.
3. Measurement of body temperature.
4. Heart rate measurement.
5. Measurement of BP on peripheral arteries.
6. Auscultation of the lungs.
7. Auscultation of abdominal peristalsis.
8. Abdominal palpation.
9. Checking Pasternatsky's symptom — the appearance of tenderness when the
lumbar region oscillates in the projection of the kidneys.
10. Visual inspection of the head of the penis.
11. Palpation of the testicles and appendages of the testicles through the
scrotum.
12. Finger examination of the rectum and prostate.
13. Visual examination of urine in the container.
14. Assessment of the severity of the patient's condition.
In patients with nonspecific hematuria, the scheme has its own characterristics:
1. Collection of complaints and history of the disease, attention to dysuric dis-
orders, pain in the scrotum and in the lumbar region, symptoms of poisoning with
poisons, mushrooms.
108
2. Visual examination of the patient is general therapy, paying attention to
swelling on the face, legs, bruising, wounds, rashes on the skin, enlargement of
lymph nodes.
3. Measurement of body temperature.
4. Heart rate measurement.
5. Pulse palpation on the peripheral arteries of the lower and upper extremities.
6. Measurement of BP on peripheral arteries.
7. Auscultation of the lungs.
8. Auscultation of abdominal peristalsis.
9. Abdominal palpation.
10. Checking Pasternatsky's symptom — the appearance of tenderness when
the lumbar region oscillates in the projection of the kidneys.
11. Palpation of the testicles and appendages of the testicles through the
scrotum.
12. Finger examination of the rectum and prostate.
13. Visual examination of urine in the container.
14. Assessment of the severity of the patient's condition.
In patients with oliguria or anuria, it is advisable to adhere to the following
scheme:
1. Collection of complaints and history of the disease, attention to dysuric dis-
orders, pain in the scrotum and in the lumbar region, symptoms of poisoning with
poisons, mushrooms.
2. Visual examination of the patient is general therapy, paying attention to
swelling on the face, legs, bruising, wounds, rashes on the skin, enlargement of
lymph nodes.
3. Measurement of body temperature.
4. Heart rate measurement.
5. Pulse palpation on the peripheral arteries of the lower and upper extremities.
6. Measurement of BP on peripheral arteries.
7. Measurement of BD.
8. Auscultation of the lungs.
9. Auscultation of abdominal peristalsis.
10. Abdominal palpation.
11. Checking Pasternatsky's symptom — the appearance of tenderness when
the lumbar region oscillates in the projection of the kidneys.
12. Palpation of the testicles and appendages of the testicles through the
scrotum.
13. Finger examination of the rectum and prostate.
109
14. Visual examination of urine in the container.
15. ECG registration.
16. ECG decoding, description and interpretation.
17. Detection of ketone bodies in urine using a test strip.
18. Assessment of the severity of the patient's condition.
Diagnosis of acute prostatitis, orchitis, epididymitis is carried out according
to the following scheme:
1. Collection of complaints and medical history, attention to dysuric disorders,
pain in the scrotum and in the lumbar region.
2. Visual examination of the patient with general therapy and abdomen, paying
attention to swelling on the face, increasing the size of the scrotum.
3. Measurement of body temperature.
4. Heart rate measurement.
5. Measurement of BP on peripheral arteries.
6. Auscultation of the lungs.
7. Auscultation of abdominal peristalsis.
8. Abdominal palpation.
9. Checking Pasternatsky's symptom — the appearance of tenderness when the
lumbar region oscillates in the projection of the kidneys.
10. Visual inspection of the head of the penis.
11. Palpation of the testicles and appendages of the testicles through the
scrotum.
12. Finger examination of the rectum and prostate.
13. Visual examination of urine in the container.
14. Urine blood test.
15. Assessment of the severity of the patient's condition.
All patients with acute urological diseases after providing medical care at the
prehospital stage are taken to the duty urological hospital.
110
3. GENERAL HEALTH SCALES FOR SICK AND INJURED
3.1. GLASGOW SCALE
To determine the criterion for the initial assessment of the condition of patients
with severe head and brain injury, the Glasgow coma depth scale (GCS) was developed in 1974. It assesses clinical signs of impaired consciousness taking into account
eye opening, speech and motor response (Table 3). Summation of the scores on the
three parameters gives the final measure of the patient's condition. The maximum
(favorable) possible indicator is 15, the minimum (unfavorable) — 3. In the medical
history, along with the final general indicator, it is recommended to provide data of
individual parameters (for example, E2V3M5 = GCS10). The GCS scale is widely
used around the world, since the procedure it provides for examining the victim is
simple and gives reliable results. A thorough examination of the patient should be
performed prior to intubation and/or administration of sedatives and painkillers.
Table 3
Glasgow coma depth scale (GCS)
Patient examination
Points
Clinical signs
Eye opening
1
2
3
4
Patient does not open eyes
Patient opens eyes until pain occurs
Patient opens eyes by speech command
Eyes open spontaneously
Verbal response
1
2
3
4
5
No speech response
The patient makes incomprehensible sounds
Inadequate responses
Speech confused
Speech meaningful
Motor response
1
2
3
4
5
6
No motor response
Extension to the onset of pain
Flexion to the onset of pain
Patient avoids movement due to pains
Localized pain
Patient performs physician commands
The sum of the points in three sections and its correspondence to the level of
consciousness:
clear consciousness — 15;
stunning — 13–14;
Соседние файлы в предмете [НЕСОРТИРОВАННОЕ]