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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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Body temperature is a complex indicator of the thermal state of the human
body, which reflects the state of his health, thermoregulation.
The body temperature of a person during the day varies within small limits,
remaining in the range of about 35.5 to 37.2 °C, the body temperature below 35 °C
indicates the presence of the disease.
Normal temperature — 36, 6 °С.
The subfebrile temperature — 37–37.9 °C.
Moderate (febrile) temperature — 38–39 °С.
High (pyretic) temperature — 39–41 °С.
Excessive (hyperpyretic) temperature — more than 41 °C.
The temperature norm depends on the place of its measurement.
Typical results of measuring the temperature of a healthy person:
temperature in the anus (rectal), vagina or ear — 37.5 °C;
mouth temperature (oral) — 37.0 °C;
axillary temperature (axillary) — 36.6 °C.
Body temperature is controlled by thyroid hormones and the hypothalamus.
Hypothalamic nerve cells respond directly to body temperature with an increase in
TSH (thyroid-stimulating hormone), which regulates the activity of the thyroid gland,
whose hormones (T3 and T4) are responsible for the intensity of metabolism. To
a lesser extent, the hormone estradiol is involved in temperature regulation, an increase in its level leads to a decrease in basal temperature. A decrease in body temperature by several degrees disrupts the processes of vital activity and can lead to
cooling or overheating of the body and even its death. The temperature rises as a result of stress, with intensive mental work, inflammatory diseases, thyroid diseases,
infection, viral diseases.
Hyperthermia — overheating of the human body with an increase in body
temperature, caused either by external factors that make it difficult to transfer heat to
the external environment, or internal as a protective and adaptive reaction of the body
in response to the effects of pathogenic stimuli — bacterial allergens in infectious
diseases, viruses or injuries, in which the brain is affected and central thermoregulation is disturbed. With hyperthermia, in which an increase in internal body temperature above 43 °C is observed, heat stroke occurs and human death occurs.
Hypothermia is the general cooling of the body, leading to a decrease in body
temperature below normal, but within the compensatory reactions of the body — not
lower than 35 °C in humans.
According to the clinical course, the following is distinguished:
compensatory stage;
adynamic stage;
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soporosis stage;
comatose stage.
In cases where a person is exposed to cold, their internal mechanisms may not
be able to replenish heat losses. A decrease in rectal temperature in humans to
33–32 °C and below causes drowsiness, darkening of consciousness; to 30 °C and be-
low — decrease in the main metabolism, hypotension, bradycardia, loss of consciousness; reduction to 25 °C and below is a vital hazard; up to 23–20 °C and below
irreversible, clinical death occurs; up to 17–18 °C — biological death.
Characteristics and types of temperature curves
Constant fever (febris continua): body temperature is usually high, within
39 °C, lasts for several days or weeks with fluctuations within 1 °C. Characteristic of
acute infectious diseases, pneumonia, typhus.
Debilitating or remitting fever (febris remittens) is characterized by significant
daily fluctuations in body temperature up to 2 °C or more. It is characteristic of diseases leading to purulent complications.
Intermittent fever (febris intermittens) is characterized by a sharp rise in body
temperature to 39–40 °C or more and a decline in a short time to normal and even
subnormal digits; after 1–2–3 days, the same rise and fall are repeated. Characteristic
of malaria.
Hectatic fever (febris hetica) is characterized by large daily fluctuations in
body temperature over 3 °C and its sharp fall to normal or subfebrile values. Charac-
teristic of sepsis, tuberculosis.
Return fever (febris recurrens): body temperature rises quickly to high numbers, stays at this level for several days, then decreases to normal, and after 4–5 days
it rises again to high values, and then remission occurs. Characteristic of return typhus, spirochetoses.
Wave fever (febris undulans) is characterized by wave-like temperature increases to febrile or subfebrile values in the evening, followed by decreases in the
morning for several days. Characteristic of brucellosis.
Febris in versa: morning fever is above evening fever. Characteristic of the
septic process, tuberculosis.
Irregular fever is most common and characteristic of inflammatory diseases.
The daily fluctuations in body temperature are diverse, the duration and their periods
are not determined. It is observed with rheumatism, pneumonia, dysentery, influenza.
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Three periods of fever are distinguished by temperature curves:
1) initial period (stadium incrementi): short — hours or long — several days;
2) stage of fever (fastigium or acme). It lasts from several hours to seve-
ral days;
3) stage of temperature reduction. A rapid drop in temperature is called a cri-
sis, a gradual decrease in lysis.
Edema — abnormal accumulation of fluid in certain tissues of the body as
a result of inflammation, systemic disorders or injuries. Fluid accumulation can occur
under the skin, usually in the lower extremities, on the face or in various cavities of
the body.
To diagnose edema, you need to press for a few seconds on the front surface of
the lower third of the lower leg. In the case of swelling, a hole remains at this site,
which does not disappear immediately.
The main factors of edema formation are a change in the biochemical composition of tissue fluid and blood plasma. Disturbances also occur against the background
of hormonal shifts and increased permeability of capillaries.
Lymphatic edema is associated with causes at the lymphatic system level. Pri-
mary — congenital malformations of the lymphatic system and secondary — acquired injuries associated with infection, operations, trauma affecting the lymphatic
vessels themselves are distinguished.
Dynamic edema occurs not as a result of damage to the lymphatic vessels
themselves, but as a result of other causes, as a rule, lesions of the veins, arteries with
blood clots, injuries, drugs, varicose or stagnated blood due to hypodynamics.
The main reasons for the development of edema:
kidney disease: glomerulonephritis, nephrotic syndrome, renal failure;
heart disease: heart failure;
vein lesions (varicose veins, inflammation, thrombosis);
liver disease: cirrhosis, blocked liver veins;
diseases of the endocrine system: hypothyroidism, diabetes mellitus;
severe cancer;
alimentary dystrophy;
pregnancy;
allergic reactions: insect bites, contact with an allergen.
Heart pathology is characterized by swelling on the legs. Edema develops
slowly over several weeks. The accumulation of edema depends on the degree of impaired blood circulation. First, edema occurs on the lower extremities, and then can
appear on the abdomen, lead to ascites, liver enlargement. With palpation of the skin,
a low temperature, dense swelling on the skin is determined.
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Pathology in the lungs leads to fluid accumulation in the pleural cavities on the
side of the lesion, respiratory failure and impaired gas exchange in the lungs develop.
Clinically, this is manifested by shortness of breath at rest, suffocation, a feeling of
tightness in the chest, cough with sputum secretion.
Kidney disease leads to swelling around the eyes and then on the legs. Damage
to tiny filtering blood vessels in the kidneys can lead to nephrotic syndrome. In nephrotic syndrome, electrolyte disorders occur and the level of albumin in the blood
decreases, which leads to the accumulation of fluid in the tissues and cavities of
the body.
With cirrhosis of the liver in the decompensation stage, porto-caval anastomoses open and fluid accumulates in the abdominal cavity. Often, this pathology is accompanied by dilation of the hemorrhoidal veins and veins of the esophagus, which
can be manifested by severe bleeding.
During the inflammatory process, a large amount of synovial fluid is secreted
in the joint area. It accumulates in the joint structures, often affected and infected
joint bags. Edema in venous insufficiency also appear more strongly in the evening,
cause a feeling of suddenly cramped shoes, the lower legs thicken visually, and often
asymmetrically. Swelling on the legs is accompanied by a feeling of heaviness, fatigue, pain in the legs. Vascular sprockets, reinforced vein pattern are noticeable on
the skin. In severe cases, swelling is kept constant, cramps in the calves of the legs
are possible, trophic changes develop: thinning of the skin, its persistent redness,
peeling, itching, poorly healing ulcers.
Allergic edema develops rapidly in a few minutes and is regional in nature.
They arise as a result of contact with an allergen, an insect bite. They develop most
often on the face, in the area of the eyes, eyelids, mucous membranes, lips, on the
hands, fingers, hands, in the area of the elbow and knee bends. Clinically allergic
swelling causes itching, rash, hoarseness of the voice, difficulty breathing. Quinke's
edema is associated with allergic factors or medication. The disease occurs sharply,
progresses rapidly and is manifested by angioedema of the skin and subcutaneous tissue, body systems and various organs. The development of laryngeal edema, which
can lead to asphyxia and death, is especially dangerous.
2.3. PERIPHERAL LYMPH NODE STUDY
Lymph nodes (nodi lymphatici) are a peripheral organ of the lymph system
that acts as a biological filter through which lymph flows from organs and parts of the
body. Several groups of lymph nodes, called regional, are distinguished in the human
body; there are also organ lymph nodes.
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Lymph nodes are rounded, oval, bean-shaped, less often ribbon-shaped formations with dimensions from 0.5 to 8 mm. The lymph node includes two main
zones. Closer to the capsule is a cortical substance in which there is a surface part and
a zone of deep crust. The inside of the lymph node is called the medulla. In the area
of the superficial cortex there are lymphatic follicles, it is in them that the proliferation and differentiation of B-lymphocytes occurs.
In the deep cortex zone, lymphocytes are densely located, it is in this zone that
T lymphocytes undergo antigen-dependent proliferation and differentiation. In the
brain, lymphoid tissue is represented by cerebral cords, in which B-lymphocytes are
differentiated into plasma cells that produce immunoglobulins — antibodies. Lymph
flows to the lymph nodes along the bringing lymph vessels, suitable for the node on
the convex side, and flows along the protruding lymph vessel extending from the
concave side of the node in the area of the gate.
Inside the node, the lymph slowly seeps through internal spaces called lymph
sinuses. The flowing lymph brings foreign antigens to the lymph node, which triggers
an immune response in the lymph nodes.
In cases where the sinuses are overflowing and inflammatory exudate accumulates in the filters of the lymph node, the lymph node increases and lymphadenitis occurs, which during infectious development turns into abscessing lymphadenitis,
which requires surgical treatment.
The lymph node is a barrier to the spread of both infection and cancer cells.
Lymphocytes mature in it — protective cells that are actively involved in the destruction of foreign substances and bacterial cells.
By the state of the lymph nodes, the state of the organs or systems of the body
can be judged.
There are the following groups of lymph nodes:
intrathoracic, mediastinal;
bronchopulmonary (hilar);
elbow (epitrochlear and brachial);
spleen;
paraaortic;
mesenteric;
iliac (general, internal and external);
inguinal (deep and superficial);
femoral;
popliteal.
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There are also lymph node enlargement syndromes associated with lipid accumulation:
1. Gaucher syndrome.
2. Nieman — Pick syndrome.
Lymph node changes in the following immunological diseases are especially
characteristic:
rheumatoid arthritis;
systemic lupus erythematosus;
dermatomyositis;
serum sickness;
reaction to medicinal products;
angioimmunoblastic lymphadenopathy;
bubonic plague.
Lymph node enlargement in infectious diseases has its features. Initially, the
lymph node enlarges, becomes painful, edematous, hyperemia attaches, and the surrounding fiber lymph node is involved, leading to a lymph node abscess and phlegmon. These processes develop especially quickly in patients with HIV infection, tuberculosis, and secondary immunodeficiency.
There are specific types of lymph node enlargement — cat scratch disease
caused by bartonella. In ARVI, lymph nodes in the neck can enlarge. Syphilis causes
an enlargement of the lymph nodes on the genitals in the form of a solid chancre. If
the enlarged lymph node does not contract within a few weeks, then brucellosis,
mononucleosis, listeriosis, HIV infection or tumor lesions should be thought of.
Tumor lesions of the lymph nodes can be a consequence of lymphogranulomatosis or lymphosarcoma, sometimes metastatic lesions. The lymph nodes in these
diseases increase to 3–4 cm, become dense, but remain painless.
2.4. STUDY OF PATIENT'S MOTOR ACTIVITY
Motor disorders occur in central and peripheral damage to the nervous system.
They are manifested by limiting the volume and strength of movements (paralysis),
disturbances in their pace, nature and coordination (ataxia), and the presence of involuntary violent movements (hyperkinesis). Movement disorders are divided by
specialists into akinetic-rigidic and hyperkinetic forms. At the first, patients have
muscle stiffness and inhibition of movements, and at hyperkinetic forms — unconscious movements. But in both cases, muscle strength is maintained. As a rule, motor
disorders develop due to impaired neurotransmitters in the basal nuclei.
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The pathogenesis may vary. Development factors are congenital and acquired
degenerative pathologies (develop with the use of medicines).
Causes of motor disorders:
rigidity. Indicates a violation of the function of the extrapyramidal system
and is due to damage to the basal nuclei (Parkinson's disease);
hypotension. Occurs in primary muscular diseases and cerebellar lesions
(Huntington's disease);
spasticity. Occurs when the CNS is affected (stroke);
paratonia. Characteristic of frontal lobe lesions.
Motor disorders:
1) paralysis — impaired motor function, which occurs due to the pathology of
innervation of the corresponding muscles and is characterized by the absence of arbitrary movements;
2) paresis — movement disorder, which is caused by the pathology of innerva-
tion of the corresponding muscles and is characterized by a decrease in the strength
and amplitude of arbitrary movements;
3) paraparesis — paralysis of both limbs;
4) monoplegia and monoparesis — paralysis of the muscles of one limb;
5) hemiplegia — paralysis and paresis of both limbs, sometimes the face;
6) tetraparesis — paralysis of all limbs of the body.
One of the most common forms of motor disorders is paralysis and paresis
(loss of movement due to impaired motor function of the nervous system).
The following types of paralysis are distinguished:
sluggish (the tone of the affected muscles has been lost);
spastic (muscle tone is increased);
peripheral;
central.
Classical pyramidal paralysis is characterized by an increase in muscle tone,
unevenness, resistance in various phases of passive movement.
The following types of disorders of the body muscles are diagnosed:
1) extrapyramidal rigidity — uniform diffuse increase in muscle tone, ex-
pressed in all phases of active and passive movements; caused by damage to the extrapyramidal system;
2) hypotension — decreased muscle tone, associated with damage to the pe-
ripheral motor neuron;
3) paratonia. It is impossible to completely relax the muscles. In mild cases,
rigidity is observed with rapid passive movement of the limb and normal tone with
slow movement;
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4) areflexia — the absence of one or more reflexes caused by a violation of the
integrity of the reflex arc;
5) hyperreflexion — an increase in segmental reflexes, occurs when the py-
ramidal pathways are affected;
6) pathological reflexes — the general name of reflexes found in an adult
when the pyramidal pathways are affected;
7) clonus — an increase in tendon reflexes, manifested by series of rapid
rhythmic contractions of a muscle or muscle group.
In extrapyramidal lesions, the following forms of disease occur:
trembling;
rigidna;
amiostatic;
mixed.
There are also several special forms of motor disorders:
1) bradykinesia — the inability to carry out the usual movements, a decrease
in the number of automatically performed movements (blinking, shaking hands when
walking). Characteristic of Parkinson's disease;
2) tremor — rhythmic fluctuations of the limb or torso relatively definitely
point. Tremors of the hands, feet, head, lower jaw are noted;
3) myoclonus — arrhythmic muscle strains and twitches. Occurs in patients af-
ter cardiac arrest, may be a symptom of drug encephalopathy;
4) leaflets — involuntary prolonged posture or static pathological postures
with forced flexion or extension in certain joints;
5) choreoathetosis: jointly flowing chorea — erratic, jerky movements and
athetosis — slow, involuntary convulsive movements. Chorea is characteristic of
Sydenham's disease and Huntington's disease, athetosis occurs in cerebral palsy;
6) tics — involuntary movements: blinking, sneezing or coughing; occur in
Tourette's disease.
Passive movement is a movement that is carried out with the help of “outside”.
In this case, pathological mobility may occur in the injured: the limb is mobile in the
place where there is a fracture or dislocation.
Injured with flotation fractures of the ribs have a paradoxical type of breathing.
Flotation (finished, leaf) fractures of the ribs — a group of fractures of the ribs, in
which a fragment of the ribs is formed that is not associated with the spine.
Thus, a pathologically mobile free fragment is formed in the chest — the rib
leaf (window). Violation of the frame of the chest leads to incomplete expansion of
the lung on the side of the injury. It is noteworthy that on inhalation due to the sink-
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ing of the floatation section, the intraluminal air pressure on the side of the damage is
higher, and on exhalation due to the swelling of the rib window is lower than in the
lung on the healthy side. In this regard, when breathing, there is a partial pumping of
air from the lung on the affected side to the lung on the healthy side, and when exhaling — vice versa.
Pendulum-shaped movement of air in the lungs leads to an increase in the
“dead” space, to an increase in hypoxia, mediastinal organs shift and cardiovascular
disorders increase.
When examining, attention is drawn to the lag of the damaged half of the chest
in the act of breathing, breast deformation, pathological mobility of the rib “window”,
and the greatest mobility is determined when there is a combination of floatation fractures of the ribs with fractures of the collarbone and sternum. Flotation of the costalsternal leaf with anterior bilateral fractures can be carried out in the anteroposterior
direction, along the horizontal axis of the sternum according to the type of swing and
along the longitudinal axis of the sternum. During palpation, tenderness in the area of
fractures is determined, as well as crepitation of fragments.
The clinical picture and severity of the state are determined by the position and
size of the edge “window”, as well as the amplitude of the vibrations. Flotation sections of ribs can be displaced by 4.0–4.7 cm, at that pathological mobility in lower
6–8 ribs is more than in upper 3–5 ribs. The larger and more mobile the sash, the
more severe the condition of the victim.
Active movement is a movement that is carried out “from the inside” of the
body, thanks to the interaction of the nervous system, musculature and skeleton.
Conducting a human examination in Romberg's pose. The patient in a standing position is offered to close his eyes, move his legs together, stretch his hands forward and to the sides, “melting” his fingers. Normally, a healthy person stands in
such a position straight, while in pathological cases he deviates to the side, staggers
or falls. Equilibrium changes are detected (shaking or even falling — Romberg's
symptom) when vision is turned off. In cases where the imbalance is not clearly detected (during medical diagnosis), it is proposed to complicate the pose, for example,
put the feet in one line — one ahead of the other. Romberg's symptom is detected
when the cerebellum is affected and its connections with other parts of the CNS, disorders of the vestibular analyzer function, violation of deep sensitivity due to spinal
cord damage.
When the cerebellum is affected, the patient deviates mainly towards the affected hemisphere. Shaking in the Romberg pose can be observed in the absence of
organic changes in the nervous system, in neuroses, intoxications. Romberg's pose is
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widely used to assess coordination abilities in drivers for study for alcohol intoxication, at the initial examination of patients with NSR doctors.
2.5. EXAMINATION OF NERVOUS SYSTEM CONDITION,
SKIN CONSCIOUSNESS AND SENSITIVITY
The assessment of neurological status is the leading means of neuromonitoring,
which allows, at the prehospital stage, an affordable way to assess the state of the
brain and nervous system.
General cerebral symptoms.
Norm: clear consciousness — the patient is contacted, fully oriented in his own
personality, time and place, adequate, fulfills all instructions.
Degrees of depression of consciousness (according to the classification of
A.N. Konovalov):
stunning (superficial, deep) — loss of attention, difficulty in concentration,
answers to questions after their repeated repetitions, rapid exhaustion during conversation, etc.;
sopor — eye opening during loud handling or braking, pain stimulation; lo-
calization of the source of inhibition (targeted motor response);
coma I — absence of eye opening in response to any stimuli; non-directional
motor reactions;
coma II — absence of eye opening and motor reactions in response to any
stimuli;
coma III — absence of eye opening and motor reactions in response to any
stimuli; muscle atony, areflexia, absence of meningeal syndrome, impaired respiratory and cardiovascular functions.
Orientation in a place, time, one's own personality. Availability of productive speech (verbal) contact.
General cerebral symptoms:
headache — localization, nature, frequency, concomitant symptoms, at what
time of day;
non-systemic dizziness — feeling of failure, quickness, instability;
systemic dizziness — apparent movements of surrounding objects or your
own body;
nausea, vomiting.
Meningeal symptoms:
stiffness of the posterior muscles of the neck;
Kernig's symptom;
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