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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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sopor — 9–12;
coma — 4–8;
brain death — 3.
Do not forget that the implementation of a motor reaction can be prevented by
the presence of plegia or paresis on one or two sides. It is necessary to consult with
a neurorealist.
In the absence of speech, “verbal okroshka” or failure to comply with instructions with a clearly sufficient level of wakefulness, you need to consult with a neuropathologist or neuroresimatologist.
3.2. DIAGNOSIS OF ACUTE RESPIRATORY FAILURE (ARF)
Acute respiratory (respiratory) failure (ARF = ODN (rus)) is a rapidly increasing (development time — several minutes/days) serious pathological condition
of the patient, due to the inconsistency of the external breathing system with the metabolic needs of the body to maintain normal partial tension of oxygen and carbon dioxide in the arterial blood or achieved due to increased work of the respiratory and
circulatory systems, which leads to a decrease and subsequent depletion of the body's
functional capabilities. Shortness of breath is an early symptom of ARF, subjectively
manifested by a feeling of lack of air or difficulty breathing. In this case, the frequency, rhythm and depth of breathing, accompanied by an increase in the work of respiratory muscles, change.
Severity of ARF syndrome:
1. Ventilation ARF:
– limit: PaCO2 = 35–45 mmHg;
– grade I (moderate): PaCO2 < 50 mmHg;
– grade II (expressed): PaCO2 = 51–69 mmHg;
– grade III (heavy): PaCO2 > 70 mmHg;
– hypercapnic coma: PaCO2 = 90–140 mmHg.
2. Parenchymal ODN:
– limit: PaO2 = 80–100 mmHg (SpO2 ≥ 95 mmHg);
– grade I (moderate): PaO2 = 60–79 mmHg (SpO2 = 90–94 %);
– grade II (expressed): PaO2 = 40–59 mmHg (SpO2 = 76–89 %);
– grade III (severe): PaO2 < 40 mmHg (SpO2 ≤ 75 %);
– hypoxemic coma: PaO2 = 39–30 mmHg.
A haemoglobin oxygen saturation of less than 90 % indicates an ODN (category of evidence). According to the level of decompensation of respiratory and circula-
112
tory systems, consciousness, oxygen and carbon dioxide content in the blood, three
stages of ODN are distinguished.
Stage I ODN. The patient is conscious, complains about the feeling of lack of
air, worried, asthenic. The skin is pale, moist, a small acrocyanosis of visible mucous
membranes. Heart rate up to 30 respiratory movements per minute, heart rate up to
110 bpm, BP is normal or slightly increased, PaO2 decreases to 70 mmHg, PaCO2 reduced due to compensatory shortness of breath.
Stage II ODN. The patient complains of pronounced suffocation, the development of psychomotor arousal, violation of consciousness, delirium, hallucinations
is possible. The skin is wet, cyanotic, often in combination with hyperemia. Heart
rate 30–40 respiratory movements per minute, heart rate 120–140 bpm often arrhythmia, hypertension is recorded, PaO2 decreases to 60 mmHg, PaCO2 rises to
50 mmHg.
Stage III ODN. Consciousness is darkened or absent, the development of convulsive syndrome due to brain hypoxia is possible, there is spotted cyanosis, hypoxic
dilation of the pupil with no reaction to light. When the process progresses, tachypnea
(BP > 40 respiratory movements per minute) becomes bradypnea (BP < 8 respiratory
movements per minute). Hypotension, tachyarrhythmia are observed, PaO2 decreases
to 50 mmHg and below, PaCO2 rises to 90 mmHg and above.
3.3. DAMAGE SEVERITY SCALE (ISS)
S.P. Baker et al. in 1974 developed ISS based on the abbreviated damage scale,
or Abbreviated injury scale — AIS [5–7]. The AIS scale was created in 1969 and
modified in 1990 [2]. According to the reduced damage severity scale — AIS, currently adopted in most countries, those injuries that give a mortality rate of 25 % or
more are considered critical. These include intracranial hematomas with a volume of
more than 80 cm3, bilateral large hemothorax, multiple liver tears with hemoperitoneum more than 1 500 ml, multiple unstable pelvic fractures with broken connections
and similar injuries in each of the six anatomical regions of the human body
(head/neck and face, spine, chest, abdomen, pelvic bones, limbs with skin and other
soft tissues).
For AIS, severe damage in each of these areas corresponds to a score of
5 points. Relative to the AIS scale, each injury is classified according to damage in
any of the specified areas of the body, as well as by severity (1 — minor; 2 — average; 3 — significant, but not life-threatening; 4 — pronounced, with a threat to life;
5 — critical, survival doubtful; damage with a score of 6 points is incompatible with
life, always fatal).
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It is recommended to pay special attention to injured with ISS scores greater
than 30 points as having a severe injury with a risk to life.
When a patient with polytrauma is admitted to the hospital, the severity of the
injury is initially assessed on the AIS scale from 1 to 5 points in six anatomical areas
(Table 4). Then, the three worst values of the most severely damaged areas are selected from the six indicated (although there may be additionally several injuries in
another 1–3 areas of the body).
Table 4
ISS damage severity scale
Type of damage
Points AIS
Points ISS
Traumatic brain injury
Multiple one- and bilateral facial fractures skeleton
3
9
Concussion
1
1
Brain contusion
3
9
Severe brain contusion
4
16
Intracranial hematoma
5
25
Spinal fractures
Uncomplicated, single
2
4
Multiple 3 9
Complicated (except upper cervical)
4
16
Complicated upper cervical with severe impairment vital functions
5
25
Breast injury
Clavicle fracture
2
4
Fracture of the sternum
2
4
Scapular fracture
2
4
Rib fracture (NMT 3)
2
2
Breast injury
Multiple rib fractures
3
9
Lung contusion
3
9
Rupture of the lung
3
9
Rupture of the lung with a tense pneumohemothorax
3
9
Bruising of the heart
4
16
Through wound to the heart
5
25
Rupture of the trachea or major bronchi
5
25
Aortic rupture
6
75
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3.4. HANOVER POLYTRAUMA SEVERITY SCALE (PTS)
Employees of the Medical Higher School in Hannover in 1983 proposed their
own Polytrauma severity scale, or Hannovischer polytrauma schlüssel — PTS, in
1985 it was supplemented (Table 5) [1, 9] and used in practice.
Table 5
Hanover polytrauma severity scale (PTS)
PTS (skull)
PTS (chest)
Traumatic brain injury mild — 4
Traumatic brain injury medium degree — 8
Traumatic brain injury severe — 12
Fracture of the bones of the central part
persons — 2
Severe fracture of the bones of the central parts
of the face — 4
Fracture of the sternum, 1–3 ribs — 2
Rib fractures on one side — 5
Bilateral rib fracture — 10
Hemopneumothorax — 2
Lung contusion — 7
Bilateral lung injury — 9
Unstable chest — 3
Aortic rupture — 7
PTS (abdomen)
PTS (pelvis)
Splenic rupture — 9
Rupture of spleen and liver — 18
Multiple liver ruptures, intestines, mesentery,
kidneys — 18
Pancreatic rupture — 9
Simple pelvic fracture — 3
Combined pelvic fracture — 9
Pelvis and genitourinary system — 12
Vertebral fracture — 3
Horizontal vertebral fracture — 3
Pelvic soft tissue reproduction — 15
PTS (limbs)
“Central” fracture-dislocation in the hip
joint — 12
Simple hip fracture (transverse, oblique) — 8
Split hip fracture — 12
Fracture of the lower leg — 4
Knee ligament rupture — 2
Patellar fracture — 2
Fracture of the forearm, in the elbow, ankle
joints — 2
Shoulder fracture — 4
Ulnar vascular injury and knee joints — 8
Vascular injury distal to the ulnar and knee
joints — 4
Hip, shoulder amputation — 12
Amputation of the forearm, lower leg — 8
Severe open fracture — 4
Large contusion/soft tissue reproduction — 2
3.5. MAINZ EMERGENCY ASSESSMENT SCALE
The Mainz emergency assessment scale (H.J. Hennes et al., 1992) is a dynamic
system for evaluating the effectiveness of emergency care at the prehospital stage in
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adult patients (Table 6). The scale is not intended for prognostic assessments, but is
a good tool for assessing the effectiveness and quality of prehospital care.
Parameters evaluated:
1) Glasgow scale score;
2) HR;
3) PR;
4) heart rate;
5) pain;
6) BP;
7) SpO2.
The MEES assessment is based on the following principles (Table 7).
Table 6
Mainz emergency assessment scale
Parameter
Values
Points
Glasgow scale score
15
4
12–14
3
8–11
2
≤ 7
1
HR, bpm
≤ 39
1
40–49
2
50–59
3
60–100
4
101–130
3
131–160
2
≥ 161
1
BD, respiratory movements
per minute
≤ 4
1
5–7
2
8–11
3
12–18
4
19–24
3
25–30
2
≥ 31
1
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Parameter
Values
Points
Heart rhythm
Sinus rhythm.
4
Supraventricular extrasystole.
Isolated ventricular
extrasystoles
3
Multiple ventricular
extrasystoles.
Atrial fibrillation*
2
Ventricular tachycardia.
Ventricular fibrillation.
Asystolia
1
Pain
No
4
Moderate
3
Strong
2
Intolerable
1
BP, mmHg
≤ 79/59
1
80/60–99/69
2
100/70–119/79
3
120/80–140/90
4
141/91–159/94
3
160/95–229/119
2
≥ 230/120
1
SpO2, %
96–100
4
91–95
3
86–90
2
≤ 85
1
Note: * The original scale uses the term “absolute arrhythmia” and/or the abbreviation
ABSARRH.
Table 7
Mainz emergency assessment scale
Parameter deviation level
Points
Physiological value, normal
4
Moderate deviation
3
Significant deviation
2
Life-threatening deviation
1
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The MEES score is equal to the sum of the points for all 7 parameters. Interpretation: the minimum score on the scale is 7 points (the authors of the scale believe
that the minimum score is 8 points); the maximum score on the scale is 28 points.
The higher the scale score, the better the patient's condition.
It is recommended to perform the scale at the initial stage twice: first at the
prehospital stage at the initial examination of the patient, and then at the receiving
rest or ICU. If the results of the second MEES assessment are greater by 2 or more
points compared to the initial assessment, then the patient's condition improves (Table 7). If the assessment results decrease by 2 or more points, then the patient's condi-
tion worsened. If the scores fluctuate within the ±1 range, then the patient's condition
is considered unchanged.
Subsequently, the MEES scale was modified. The essence of the modification
was to combine the original MEES with capnometry. The new scale was called
MEESc. It has broader capabilities and is recommended for use at both the prehospi-
tal and hospital stages.
3.6. CINCINNATI STROKE PREHOSPITAL SCORE SCALE (CPSS)
The Cincinnati prehospital stroke scale (CPSS) is used as a pre-hospital stroke
assessment. She is an abbreviated and simplified version of the NIH stroke scale.
The scale includes three points. It can be used by both doctors and paramedical
staff of the ambulance service to identify stroke patients, as well as serve as an evaluation test of the choice of candidates for thrombolysis.
Detection of pathology according to any of these items with a high sensitivity
of 66 % and specificity of 87 % indicates the presence of a stroke in a patient.
Predicting the risk of cerebral stroke in patients with transient ischemic attacks. The ABCD Score is used to predict stroke risk within the first 7 days after
transient ischemic attack.
According to the results of studies, when assessed on the ABCD scale from 0
to 4 points, the seven-day risk of stroke is 0.4 %, 5 points — 2.1 %, 6 points — 31.4 %.
The ABCD scale can be used in routine clinical practice to identify individuals
at high risk and in need of emergency screening and treatment.
3.7. CCBO/SIRS SYSTEMIC INFLAMMATORY
RESPONSE SYNDROME SCALE
In clinical practice, the differential diagnosis of inflammatory response, sys-
temic inflammatory response, sepsis and septic shock has great difficulties. Such di-
118
agnosis is important for proper treatment at the prehospital stage according to clinical
protocols.
The CCBO/SIRS scale of systemic inflammatory response syndrome includes
the following clinical features:
1) body temperature: more than 38 or less than 36 °С;
2) HR: more than 90 bpm;
3) tachypnea: develops either with NPV more than 20 respiratory movements
per minute, or with PaCO2 less than 32 mmHg;
4) white blood cells: more than 12 000 cells/mm3, less than 4 000 cells/mm3,
or more than 10 % of immature forms of neutrophils.
Note: at the pre-hospital stage, without laboratory diagnostics, it is impossible
to determine the number of white blood cells, so a preliminary diagnosis can be made
according to three clinical signs.
3.8. QSOFA SEPSIS CRITERIA
The following criteria for sepsis are distinguished:
systemic BP ≤ 100 mmHg;
BD ≥ 22 respiratory movements per minute;
any impairment of consciousness (< 14 points according to ShH).
If there are 2 or more points, as well as signs of infection, it is necessary to pay
attention to this patient and assess the likelihood of sepsis on the expanded SOFA
scale. This scale for organ dysfunction has a specificity of 96 % and a sensitivity of
30 %, and for mortality, a specificity of 91 % and a sensitivity of 50 %. Compared to
the criteria for systemic inflammatory response syndrome (CCBO/SIRS), this scale
has greater specificity, but less sensitivity.
After screening and with 2 or more qSOFA scores or remaining suspected of
sepsis, an expanded SOFA score is performed.
3.9. QSOFA SEPTIC SHOCK CRITERIA
The following criteria of septic shock are distinguished:
persistent hypotension requiring vasopressors to maintain a mean BP ≥
≥ 65 mmHg;
lactate > 2 mmol/L despite adequate infusion therapy.
With these criteria, the probability of in-hospital death exceeds 40 %.
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The SOFA criteria include the definition of functions:
breathing: PaO2/FiO2 ratio;
coagulation: platelet count;
liver: bilirubin level;
cardiovascular system: blood pressure and inotropic support;
CNS: ShH level determination;
kidneys: creatinine and diuresis.
If there are 2 or more points on the expanded SOFA scale, sepsis is eligible.
After the diagnosis, initial intensive therapy is carried out, an important part of
which is the implementation of massive infusion, then the average BP is determined,
as well as the level of lactate. The mean BP is according to the formula: mean BP –
– SBP – DBP + 1/3DBP, where SBP is systolic BP and DBP is diastolic BP. If vaso-
pressors are required to maintain adequate mean BP (≥ 65 mmHg), as well as with
a high level of lactate (> 2 mmol/L), a diagnosis of “septic shock” is made.
3.10. ASSESSMENT SCALE OF THE CONDITION OF SICK AND INJURED
At the prehospital stage, an objective assessment of the patient's condition is
of great importance, based on specific indicators of clinical signs and their deviations
in points (Table 8). E.P. Izmailov, I.G. Trukhanova (2019) meets these requirements.
Table 8
Assessment scale of the condition of patients and injured
(E.P. Izmailov, I.G. Trukhanova (2019))
State
Indicators
Points
Consciousness
(on scale
Glasgow)
Frequency
pulse
Arterial
pressure
Test
fillings
capillaries
Frequency
breath
and pulse
oximetry
Satisfactory
Norm
(1 point)
Norm
(1 point)
More
100 mmHg
(1 point)
Normal, 3 s
(1 point)
Normal, up
to 20 per
minute.
PO2 more
than 94 %
(1 point)
Up
to 5
120
State
Indicators
Points
Consciousness
(on scale
Glasgow)
Frequency
pulse
Arterial
pressure
Test
fillings
capillaries
Frequency
breath
and pulse
oximetry
Moderate
Norm
(1 point)
Raised
by 20 %,
100 per minute
(2 points)
20 % reduction
from baseline, not
less than
90 mmHg
(2 points)
Slowmotion,
4–7 s
(2 points)
Increased by
20 % per
minute,
more than
21–29, per
minute, grade I ODN,
PO2 up to
90 %
(2 points)
Up
to 10
Heavy
Sopor
(3 points)
Raised
30 %,
100–120
per minute
(3 points)
30 % reduction
from baseline,
not lower
than
80 mmHg
(3 points)
8–14 s
(3 points)
Learned on
30 % per
minute,
30–35 per
minute, grade II ODN,
PO2 up to
80 %
(3 points)
Up
to 15
Critical
Coma moderate
(3 points)
or deep
(4 points)
Increased by
40 %, more
than 120 per
minute, determined
on large arteries, arrhythmia
(4 points)
40 % reduction
from baseline, not
lower than
70 mmHg
(4 points)
Very slowmotion,
more than
15 s
(4 points)
Learned on
40 % per
minute,
36–45 per
minute, grade III ODN,
PO2 less than
70 %
(4 points)
Up
to 20
Agonal
Coma terminal
(5 points)
Increased by
50 %, more
than 150 per
minute, determined on
large vessels, arrhythmia,
bradycardia
(5 points)
Reduction
of more
than 50 %
from baseline, below
70 mmHg
(5 points)
No padding
(5 points),
preagonal
or agonal
state
Coma,
pathological
breathing
(Cheyne —
Stokes, Biota), PO2 less
than 50 %
(5 points)
Over
20
Note: the estimated scores of the indicator are shown in parentheses.
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