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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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1. SEVERITY ASSESSMENT STEPS FOR SICK AND INJURED
Assessment of the severity of the condition of patients and injured is applied
for any patient and injured in the provision of first aid or medical care at the prehospital level.
General assessment of the condition
of patients and injured
It is carried out at the first examination of the patient by a rescuer, paramedic
or doctor in order to identify violations that threaten his life in a person for effective
medical measures and timely delivery to the hospital on duty.
It is made in the position of the patient sitting or lying down depending on the
general condition.
The evaluation sequence is based on the principles of “Safar alphabet”:
A — Airways — airway patency.
B — Breathing — breathing.
C — Circulation — blood circulation.
D — Disability — capacity (neurological status).
E — Exposure — appearance (temperature, skin, mucous membranes, presence
of injuries, etc.).
The assessment method is visual (exclusively by examining the patient).
It is carried out according to the rule of examination of three main systems of
the body:
a) appearance:
assessment of consciousness;
skin coloration;
lesions on the skin;
skeletal bone deformation and pathological mobility;
laxity or tension of muscles, convulsions;
active or passive limb movements;
standing and walking stability;
disturbance of skin sensitivity, pain sensitivity;
disturbances of the senses — hearing, vision, taste, smell;
skin temperature or rectal temperature;
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b) breathing:
whether there is breathing;
whether the airways are passable;
respiratory rate, dyspnea;
excursion of the chest, the work of auxiliary muscles during breathing;
chest deformity;
subcutaneous emphysema on the neck and chest;
wounds to the neck and chest;
flotation fractures of ribs;
injuries, neck deformation, displacement of the trachea from the midline;
whether the cough reflex is preserved;
whether the cough is dry or productive;
the nature of sputum;
whether there is hemoptysis or pulmonary bleeding;
whether there is a degree of breathlessness;
whether there is a wound on the chest or on the skin;
whether there is subcutaneous emphysema on the chest or on the face;
whether there is paradoxical or pathological respiration;
c) blood circulation:
pulse on the radial artery;
pulse on the back artery of the foot;
in the absence of a pulse on the extremities — cardiac contractions;
pulse rate, arrhythmia, pulse deficiency;
BP;
pathological noises in the projection of the heart;
signs of shock, centralization of blood circulation;
whether there are wounds in the projection of blood vessels and the heart;
whether there is varicose veins on the lower extremities;
signs of acute thrombophlebitis in the lower or upper extremities;
signs of portal hypertension;
splenomegaly;
ascites;
hepatomegaly.
Diagnosis of pathological symptoms, medical history, or injury:
S: signs and symptoms.
A: allergies.
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M: medications.
P: past medical history.
L: last meal.
E: events leading to current illness.
Examination, palpation, percussion, auscultation of all suspected damage or
pathological changes of the human body systems are carried out. When examining
and examining the patient, the sequence of writing the medical history should be followed, i.e. an examination of the body systems to assess the present condition and
identify the affected systems, then examine the affected systems of the patient.
Instrumental and laboratory diagnostics are carried out to identify:
injuries;
diseases;
infections;
other causes of disease / critical condition;
diabetes mellitus.
Diagnosis includes the following studies:
1. Laboratory examination: blood sugar.
2. Electrocardiography (ECG).
3. Pulse oximetry.
4. Measurement of body temperature.
5. Ultrasound examination of the detected pathological lesions, pleural cavities,
abdominal cavity, heart, arteries and veins.
Patient routing
The patient's routing depends on their condition, the nature of the disease or injury. If the patient has signs of biological death, resuscitation measures are not carried
out. If signs of clinical death are determined, cardiopulmonary resuscitation is performed on an emergency basis. When determining life-threatening disorders in a patient, first and/or medical care is provided at the prehospital stage with subsequent
transportation to an on-duty hospital operating according to the profile of the diagnosed disease or injury.
If the patient's condition is stable, but the diagnosis requires clarification or instrumental diagnosis, then the patient is taken to the duty hospital according to the
profile of the detected disease or damage. If the patient's condition is stable and there
is no fear for his deterioration during the initial examination, if he refuses hospitalization in the hospital, a decision is made on outpatient observation and treatment.
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2. PATIENT SYSTEM STUDIES TO ASSESS
THE GENERAL CONDITION OF THE PATIENT
AND PRELIMINARY DIAGNOSIS IN THE PREHOSPITAL PHASE
2.1. GENERAL PATIENT STUDY IN TERMS OF HIS PHYSIQUE
AND ANTHROPOMETRIC PARAMETERS
The type of patient is of fundamental importance in terms of possible diseases
and complaints.
Gigantism is a very large growth exceeding 213 cm, occurring in persons with
excessive secretion of “growth hormone” (somatotropic hormone). In such disorders,
elongation of the limbs, especially the lower ones, is characteristic, while the head
seems small, acromegaly.
Patients complain of headache, general weakness, memory decline, change in
appearance, vision deterioration, voice changes, it becomes low, hypotrophy and atrophy of muscles, movement disorders, joint pain that lead to injuries occur.
The function of the thyroid gland, genital glands, adrenal glands is impaired,
the development of diabetes mellitus is possible.
Typical are complaints about:
headache;
weakness;
numbness in the hands;
change in the appearance and proportions of the body, the size of the hands,
feet, auricles, nose;
dry mouth and thirst;
joint pain;
limitation and soreness of movements.
All women have impaired menstrual cycles, 30 % of men develop sexual
weakness. Another extreme manifestation of growth is the small growth of a person.
Dwarfism is an abnormally low growth of an adult, less than 147 cm. It is associated with a lack of “growth hormone” (somatotropin) or a violation of its conformation (structure), which lead to disorders of the formation of the skeleton (disproportionate nanism).
Types of dwarfism:
1) pituitary associated with a large deficiency of growth hormone produced by
the pituitary gland;
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2) thyroid associated with a lack of the main thyroid hormone is usually ac-
companied by dementia;
3) cerebral — pathology of the neuroendocrine system;
4) genetically determined — pathology combines diseases of the cartilage,
bone and other tissues of the body. Such diseases include achondroplasia, Shereshevsky — Turner syndrome, Robinov syndrome.
With this condition, characteristic disorders arise:
violation of body proportions: compared to a child of similar height, the head
is relatively larger than the body, and the hands are quite short;
premature old age;
facial wrinkle;
weak beard growth and generally facial and body hair.
When examining the patient, attention should be paid to the build and weight.
The prescription of drugs to provide assistance at the prehospital stage, which are
calculated per kilogram of body weight, depends on this. The WHO classification of
obesity based on the definition of body mass index (BMI) = body weight (kg) / body
height (m) squared.
Degree of obesity:
1) normal weight — BMI < 25;
2) overweight — BMI = 25–29.9;
3) grade I obesity — BMI = 30–34.9;
4) grade II obesity — BMI = 35–39.9;
5) grade III obesity — BMI > 40.
Causes of obesity. In 90 % of cases, obesity occurs as a result of disorders of
the diet and motor activity:
long intervals between meals and excessive portions;
binge eating in the evening;
food before bed;
a large amount of carbohydrates and fats (especially confectionery and ani-
mal) with a lack of fiber and dietary fiber;
excess calorie production compared to calorie consumption;
lack of physical stimulation of muscle tissue to participate in fat processing;
familial predisposition.
However, in 50 % of cases, the development of obesity is due to disorders in
the work of organs and systems:
a) endocrine diseases (disorders of the hypothalamic-hypo-physical system,
thyroid gland, impaired endocrine function of the pancreas, adrenal glands);
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b) the influence of hormonal drugs (combined oral contraceptives, steroids,
insulin);
c) genetically determined lack of lipolysis enzymes (breakdown of fats);
d) brain tumors.
Types of obesity by sediment location:
ginoid (female, lower): the buttocks and thighs are full first of all;
android (male, upper): fat is deposited on the abdomen (in the omentum),
sides;
mixed: the body fills evenly, including limbs, neck, back.
For obesity, the following symptoms are characteristic:
a) increase of body parts, change of their ratio;
b) aesthetic defects: second chin, pseudogynecomastia, “traitor” on the ab-
domen;
c) strii (stretch marks);
d) hernia.
Characteristic clinical manifestations of obesity are:
shortness of breath, tachycardia;
heartburn, esophageal reflux;
snoring, nocturnal apnea;
decreased muscle mass;
joint pain;
episodic increase in pressure;
menstrual disorders, potency.
Over time, functional disorders turn into organic and systemic diseases.
Complications of obesity are:
1) respiratory and heart failure;
2) coronary heart disease;
3) hypertension;
4) fatty liver dystrophy, which can ultimately lead to gallstone disease, cir-
rhosis;
5) adipose dystrophy of the pancreas, pancreatitis, diabetes;
6) esophageal erosion, gastritis, gastric and duodenal ulcers;
7) arthritis and arthrosis;
8) gout;
9) osteochondrosis with pronounced root pain.
The association of obesity with a number of oncological diseases is traced:
cancer of the large intestine, pancreas, prostate, ovaries and mammary glands. At the
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same time, in a number of patients, hypotrophy will also be determined, arising from
various pathological processes or diseases.
To assess such states, it is convenient to classify three degrees of hypotrophy:
1) in case of grade I hypotrophy, body weight deficit relative to age norm does
not exceed 20 %. The child's well-being and general condition are normal;
2) in case of grade II hypotrophy, weight loss is 25–30 %. The subcutaneous
fat layer on the abdomen is significantly reduced, its thinning on the trunk and extremities is noticeable. The child was lying, lagging behind in growth and neuropsychiatric development;
3) in case of grade III hypotrophy, body weight loss is more than 30 %.
Obvious signs of exhaustion: pale gray skin, wrinkled, almost completely absent subcutaneous fat layer. The extreme manifestation of eating disorder in patients
is cachexia. Cachexia occurs due to a strong decrease in the amount of food consumed and reactive loss of body weight. According to statistics, about 20 % of cancer
patients die from this condition, and not from the tumor itself. With this condition,
there is a significant decrease in BMI. Weight loss can reach more than 50 % of baseline values within a short time and is fatal.
Weight loss leads to the following characteristic symptoms:
sleep disturbance;
dehydration of the body;
impaired immune system;
muscle weakness;
low BP;
mental disorders;
low skin elasticity;
brittle nails;
hair loss;
stomatitis.
Cachexia can cause:
1) oncological diseases;
2) fasting, a strong desire to lose weight with malnutrition;
3) endocrine disorders;
4) heart failure;
5) purulent processes in the body, intoxication;
6) metabolic disorders;
7) prolonged psycho-emotional tension;
8) acute and chronic infections;
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9) GI diseases;
10) taking medicinal products;
11) brain strokes;
12) conditions after undergoing surgical operations with impaired digestion;
13) mental disorders;
14) diseases and injuries leading to disorders of digestion and consciousness.
In the medical classification, the following types of cachexia are distinguished:
cancerous;
terminal;
senyl;
cerebral;
alimental;
cardiac;
pituitary;
hypothalamic;
anorexic.
2.2. EXAMINATION OF SKIN
AND SUBCUTANEOUS TISSUE OF THE PATIENT
When examining the skin, it is necessary to determine the presence of pathological changes on the skin or injuries — punctured, cut, bitten, gunshot, bruised, infected, postoperative wounds. The detection of wounds in patients is of fundamental
importance for further diagnosis.
Punctured or cut wounds in the projection of the abdomen dictate the need for
an emergency examination of the surgeon of the hospital to exclude penetrating
wounds to the abdomen, in which there is damage not only to the skin for the entire
thickness, but also to the integrity of the parietal sheet of the peritoneum. Diagnosis
of such wounds requires primary surgical processing and wound revision in the conditions of an on-duty surgical hospital. When confirming a penetrating wound of the
abdomen, an emergency laparotomy is performed with a revision of the abdominal
organs to diagnose injuries or an emergency laparoscopy with an examination of the
abdominal organs.
The presence of bruised wounds on the abdomen without violating the integrity
of the skin to the full depth is the reason for the diagnosis of “closed abdominal injury” and hospitalization to the duty surgical department. With such a diagnosis, an
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emergency instrumental examination is shown — ultrasound of the abdomen, computed tomography (CT) of the abdomen, diagnostic laparoscopy, and, if necessary,
placing a scalding catheter into the abdominal cavity according to a generally accepted method. All these options for examination are carried out in the conditions of the
duty surgical hospital.
The presence of puncture wounds in the projection of the abdomen always requires the diagnosis of penetrating abdominal wounds, even if they are small and not
accompanied by clinical manifestations. All injured with puncture, cut, gunshot, burn
or other wounds should be examined by a duty surgeon or traumatologist with subsequent primary surgical treatment of wounds, emergency prevention of tetanus, and, if
patients have bitten wounds, anti-viral vaccination.
Stab wounds in the projection of the heart pose a particular danger; such patients must be taken to the duty surgical hospital to exclude a wound to the heart. In
cases of detection of a wound on the chest from which air is released in patients during the initial examination, a sealed bandage should be applied to the wound in order
to transfer the open pneumothorax to the closed one and deliver the patient to the duty surgical department.
If the patient with a breast injury or with auscultation of the lungs does not listen to breathing on one side and the symptoms of acute respiratory failure increase,
then before delivering the patient to the duty surgical hospital, he must carry out
a pleural puncture in the second intercostal space along the mid-cutaneous line according to vital indications to exclude a tense pneumothorax.
The same actions should be carried out in patients with spontaneous pneumothorax, if breathing on the side of the lesion is not heard and there are signs of tense
pneumothorax. It is important not only to examine all the wounds in the patient, but
also to determine the nature of the wounds and the threat to the patient's life. If there
are wounds with ongoing bleeding, then at the prehospital stage, bleeding from the
wound should be stopped and the patient should be taken to a surgical hospital. With
ongoing bleeding from wounds on the extremity, in most cases, the application of a
pressure bandage on the wound is sufficient. Only in cases when it was not possible
to stop the bleeding with such a bandage for 10–15 minutes, patients are applied an
arterial tourniquet and taken to the duty hospital. This tactic avoids many patients
with ischemic disorders and complications from the affected limb.
When examining wounds, it is advisable to determine not only the fact of the
presence of the wound itself, but also the nature of the injury. Sometimes the patient
has an open fracture of the bones on the limb and a wound above the fracture site.
Such injuries require not only wound coverage and stopping bleeding from the
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wound, but also immobilizing the broken bones of the limb. If the victim has one
wound, then, as a rule, this is isolated damage.
However, in clinical practice, there have been situations where a single wound
opening has resulted in combined thoracic-abdominal or thoracocardial injuries, i.e.
combined injuries. If the patient has several wounds, a diagnosis of multiple injuries
is made; if there are wounds arising from different types of energy: mechanical, radiation, thermal, chemical, then patients are diagnosed with a combined lesion.
When examining the patient, the color of the skin, mucous membranes and
cornea of the eyes is of great importance. It is important to determine the clinical
manifestations of the disease: varieties of scabies, paired location of papules and vesicles, symptoms of skin lesions. Ardi's symptom (rashes and purulent crusts),
Gorchakov's symptom (spot bloody crusts on the elbows or in their circumference),
triangle (vesicles, pustules, crusts above the gluteal fold), pyoderma are the most
common skin diseases.
Attention should be paid to the manifestations of secondary pyoderma (eczema, atopic dermatitis, scabies), as well as the development of secondary pyoderma in
patients receiving hormonal and cytostatic therapy in HIV-infected people.
Of great diagnostic importance is the presence or absence of a rash and its
localization (psoriasis — extensor surfaces of the extremities; epidermophyty —
the third and fourth interdigital folds of the feet and arch of the foot; lupus erythematosus — face), symmetrical location of the rash (eczema, psoriasis, atopic dermatitis),
unilaterality (linear nevi), location along the nerves (shingles).
The rash may have a tendency to peripheral growth and fusion (psoriasis,
lichen planus), to grouping, unusual color, shape.
Often, along with skin diseases, characteristic clinical symptoms are noted: anesthesia or hyposthesia (with leprosy), paresthesia (feeling anemia or crawling
goosebumps in Raynaud's disease), feeling tightened skin (with scleroderma,
erythrodermia).
When examining, it is important to identify patients with lichen. Red-blue color is characteristic of red flat lichen, brick-red for exudative erythema, yellowish for
tuberculous lupus. A chronic inflammatory process (syphilis, psoriasis) is characterized by non-sharp boundaries, with an acute inflammatory process (acute eczema, erysipelas) — clear boundaries. As a rule, in inflammatory processes, lymphangoitis
and lymphadenitis of the regional and distant link occur, often follicles are involved
in the inflammatory process. With difficulties in diagnosing patients, you should consult a dermatologist who can determine the phenomenon of Auspitz in scaly lichen,
conduct a test with iodine, and visualize the skin in UV light.
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