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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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Etiology:
1) tumor diseases leading to the development of chronic adrenal insufficiency;
2) kidney and adrenal injuries;
3) congenital malformations of the adrenal glands;
4) hemorrhagic infarction of the adrenal glands on both sides;
5) acute pituitary insufficiency;
6) acute somatic and infectious diseases leading to adrenal insufficiency.
Clinical presentation. It occurs and develops within a few days.
The following clinical manifestations are characteristic:
gastrointestinal disorders — nausea, vomiting, abdominal pain, flatulence,
peritonism;
decreased appetite;
weight loss;
hypodynamics;
weakness;
depression;
pigmentation of the skin;
hemorrhagic gastritis, enteritis;
oliguria, anuria;
clonic seizures;
meningeal symptoms.
Deaths occur from dehydration, pulmonary edema, coma, cardiovascular disorders.
Catecholamine crisis.
Catecholamine crisis is a pathological condition accompanied by a massive
release of hormones (adrenaline, norepinephrine, dopamine) into the blood of the adrenal glands associated with pheochromocytoma, leading to cardiovascular complications: pulmonary edema, arterial hypertension, myocardial infarction, acute cerebrovascular accident and death.
Etiology. Pheochromocytoma develops in the adrenal glands on one or two
sides. The incidence of 3–11 cases per 10 000 population, i.e. per 1 000 patients with
arterial hypertension accounts for 1 patient with pheochromocytoma.
The provoking factors in the presence of pheochromocytoma itself are:
stressful situations;
fasting;
physical stress;
hypothermia;
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use of insulin, cardiac glycosides;
abuse of citrus, cheeses, chocolate, red wine, mustard;
operations;
injuries;
childbirth;
operations on the adrenal glands;
defects of preoperative preparation and postoperative management in opera-
tions for pheochromocytoma.
Clinical presentation, complications, special clinical manifestations of pheochromocytoma:
1) frequency varies from one attack for several months to 10–15 during the day;
2) development can be both with initially normal BP, and against the back-
ground of its previous persistent increase;
3) sudden onset, often after exposure to provoking factors;
4) pronounced increase in BP to 200–300/100 mmHg, mainly systolic;
5) accompanied by a triad of symptoms: headache, sweating, up to torrential
sweat, tachycardia;
6) nausea, vomiting, impaired vision, pale skin, feeling of fear, abdominal pain,
heart, blood: leukocytosis, lymphocytosis, eosinophilia, hyperglycemia, proteinuria;
7) duration from a few minutes to hours;
8) rapid reverse development;
9) polyuria occurs after the crisis.
Special clinical manifestations of pheochromocytoma. If the tumor is localized in the bladder wall, urination can cause attacks. They are often accompanied by
painless hematuria, palpitations, headache, nausea and increased BP.
In women, pheochromocytoma can manifest with hot flushes, in pregnant
women it sometimes mimics eclampsia, preeclampsia or rupture of the uterus.
Children with pheochromocytoma usually have arterial hypertension. Polyuria,
polydipsia and seizures are characteristic. Children have complications of pheochromocytoma: stunted growth, weight loss, vasomotor disorders, visual impairment,
sweating, nausea and vomiting.
Typical complications of pheochromocytoma are:
heart failure;
arrhythmias;
catecholamine shock;
cerebrovascular accident;
renal failure;
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hypertensive encephalopathy;
ischemic colitis;
an aortic dissecting aneurysm;
in pregnant women: fever, eclampsia, shock, death of the mother or fetus;
toxic catecholamine myocardiodystrophy.
Medical emergencies in mineral metabolism disorders hypocalcemic crisis.
Hypocalcemic crisis occurs when the blood calcium level decreases to
1.9–2.0 mmol/L, the ionized calcium level decreases below 1 mmol/L, and is manifested by titanic convulsive syndrome.
Etiology. The main causes of the development of the crisis are:
1) radioiodotherapy in the treatment of thyroid diseases;
2) parathyroid removal or damage in thyroid surgery and parathyroid removal;
3) hemochromatosis;
4) idiopathic hypoparathyroidism;
5) autoimmune destruction of the parathyroid glands;
6) violations of the action of parathormone;
7) vitamin D deficiency;
8) excessive secretion of calcitonin.
The clinical picture consists of characteristic symptoms:
numbness, tingling, burning, tension, stiffness in the muscles of the extre-
mities;
tetanic convulsive syndrome;
consciousness is preserved, but fainting is possible;
autonomic dysfunction syndrome: pallor, tachycardia, hypertension;
predominance of the tone of the parasympathetic system with vomiting, diar-
rhea, polyuria, bradycardia, arterial hypotension;
CNS lesion syndrome with cerebral disorders — stem and extrapyramidal
symptoms with the development of epilepsy attacks;
Visceropathy syndrome with the appearance of calcinates of internal organs,
the development of intracranial calcification in the basal ganglia, hypothalamus, cerebellum, the development of cataracts;
syndrome of skin damage and its derivatives: dryness, peeling, eczema, dex-
foliative dermatitis, areas of pigmentation and depigmentation (vitiligo), hair growth
disorder, gray hair, baldness, brittle nails.
Hypercalcemic crisis occurs with a sharp increase in the level of blood calcium, within 3.5–4.0 mmol/L, is characterized by neuromuscular disorders, increased
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blood clotting, the development of thrombosis and DIC syndrome leading to acute
cardiovascular pathology, arrhythmia and cardiac arrest. Deaths occur in 50–60 % of
patients.
The main causes of hypercalcemic crisis are:
parathyroid hyperplasia;
vitamin D poisoning;
malignant tumor with metastases to bone tissue.
The provoking factors are:
1) exacerbation of primary hyperparathyroidism in the absence of adequate
treatment;
2) dehydration in patients with primary hyperparathyroidism;
3) treatment with thiazide diuretics;
4) vitamin D hypervitaminosis;
5) consumption of large amounts of milk, high calcium dietary supplements,
soluble antacids, alkaline milk syndrome, or Burnett syndrome.
Clinic. The clinical picture consists of characteristic syndromes:
abdominal syndrome: acute epigastric pain, nausea, vomiting, gastric bleed-
ing, perforations of the stomach or duodenum, acute pancreatitis;
neuropsychiatric disorder: confusion, supor or hallucinations, somnalence,
coma;
dehydration syndrome: dry skin, mucous membranes, decreased skin turgor,
sharpening of facial features;
thermoregulation disorder: febrile body temperature;
acute cardiopulmonary failure syndrome: dyspnea, cyanosis, tachycardia, ar-
rhythmia, arterial hypotension;
renal syndrome: anuria, azotemia;
neuromuscular disorder syndrome: hypo- and areflexia, muscular hypo-
tension;
hypercoagulation syndrome: thromboembolism, DIC syndrome.
2.8. BONE SYSTEM EXAMINATION
Scoliosis.
Scoliosis is a curvature of the spinal column in a lateral projection (to the right
or left of the vertical axis). Most often, it is formed already in childhood (in infancy
and age from 3 to 5 years) or in the period from 18 to 25 years. The severity of scoliosis is determined by the angle of deviation of the spine. To measure it, X-rays are
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taken in standing and lying on the back. The severity of the manifestation of symptoms of the disease is directly related to the degree of scoliosis: the greater the curvature, the more noticeable the load on the internal organs and systems.
Four degrees of scoliosis are distinguished. Scoliosis of the first degree is ex-
pressed in a deviation from the norm up to 10°. In this case, there is a light slouching
and subtle asymmetry occur in the position of the shoulders and shoulder blades,
when inclined forward, one blade protrudes more noticeably than the other.
Scoliosis of the second degree is characterized by a deviation of the spine from
the axis up to 25°. The patient has asymmetry of the shoulders, shoulder blades, but-
tocks. When the body is tilted, vertebrae are unevenly distinguished, one shoulder
blade protrudes strongly, there are costal protrusions. A muscle roller is easily felt,
convex on the chest side, concave on the lower back side. Painful sensations are not
reflected, root neurological pain in the thoracic and lumbar spine periodically occurs.
Scoliosis of the third degree is distinguished by a curvature of the spine at
26–50°. The patient has a broken posture, the shoulders and pelvis are skewed, a rib
hump is formed, one leg may.
The fourth degree of scoliosis is the most severe, the scoliotic angle is 50° or
more. In the patient, the spine, chest and pelvis are deformed, the rib hump is formed
in front and behind. Due to compression, all internal organs and systems cease to
function normally, a person is haunted by constant pain and numerous pathological
manifestations on the part of the heart, lungs, gastrointestinal tract and urinary system, there are often pronounced neurological and endocrine disorders.
The causes of scoliosis are:
cerebral palsy;
congenital vertebral deformities;
rickets, polio;
vertebral injuries, including birth injuries;
injuries to the bones of the pelvis, legs;
diseases of muscles, connective tissues;
osteoporosis;
spinal tumors;
obesity.
Complications of scoliosis. In cervical scoliosis, the arteries of the spine are
compressed, which adversely affects the circulation of the brain. The patient suffers
from dizziness, headache, cognitive impairment.
Thoracic scoliosis is dangerous by squeezing the chest and abdomen, which
causes internal organs to suffer. Their improper functioning is fraught with numerous
malfunctions in the body.
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Lumbar scoliosis is characterized by deformation and displacement of the pelvic bones, which means imminent lumbar pain, problems with the kidneys, bladder
and intestines, sexual dysfunction.
Kyphosis.
Kyphosis is called the bend of the spine, turned back by the bulge, lordosis —
the bend of the spine by the bulge forward. When normal, these bends are physiological and help the spine cushion when walking, leaning, jumping, etc. However, often
under the influence of negative factors, natural curvatures of the spine acquire pathological features. Spine kyphosis is most often arcuate, but can also be angular, while
the vertebrae protrude not with an arc, but with an angle, with a spinous process
at the apex. Outwardly, pathology is manifested by the formation of a hump on
the back.
Thoracic kyphosis is the most common type of pathology. At the initial stage
(this form of curvature of the spine is called slouching), the condition does not cause
discomfort, it can be shown by an X-ray or detected by a doctor during a visual examination. When this type of kyphosis progresses, the patient forms a hump, ribs and
sternum shift, causing serious malfunctions of internal organs.
Cervical kyphosis, lumbar kyphosis, sacral kyphosis are very rare. They can
occur due to injuries, infectious diseases, or degenerative changes.
The causes of kyphosis are:
abnormalities of intrauterine development;
birth injuries;
injuries and spinal surgery;
weakness of the back muscles;
osteoporosis.
Lordoz.
Normally, the spine has a small bend forward in the lumbar region — physiological lordosis. Pathological lordosis is formed in the same area, only it is much
more pronounced. Lordosis of the lumbar region is characterized by “duck posture”:
the shoulders are lowered, the head is slightly inclined forward, the abdomen is protruded, the lower back is bent, the pelvis is displaced back, and the knees are apart.
The gait is heavy, which is explained by soreness and discomfort in the lower back
area. Lordosis of the spine has a negative impact on the work of the heart and lungs,
provokes respiratory and circulatory disorders.
The reasons for lordosis are:
abnormalities in the development of the spine;
spinal diseases, intervertebral hernias;
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spinal injuries, birth injuries;
hip diseases;
vertebral displacement (spondylolisthesis);
systematic posture disorders in the sitting/standing position;
low physical activity;
systemic diseases of the musculoskeletal system;
excess body weight;
rapid growth of the child.
Flat feet.
Flat feet are deformities of the foot. It comes in two types: transverse and lon-
gitudinal. In longitudinal flat feet, the inside of the foot begins to descend and even
touch the floor. Other people from the outside may notice this, i.e. it can be seen that
the foot is flattened. Not everyone can see the transverse flat feet. As a rule, it becomes noticeable only with secondary features when valgus deformation of the first
finger occurs. This is the so-called growing lump on the joint and the curvature of the
first finger (it begins to stick out to the side).
The longitudinal arch on the inside and the transverse arch form the arched
structure of the foot, which provides cushioning when running and walking. With the
help of such a structure, the foot moves smoothly: moves to the move, to a step, to
run, and at the same time the joints are not injured. Therefore, when flat feet are
formed, joint injuries can increase. The biomechanics of walking, the work of the
muscles of the lower leg and foot are impaired. Flat feet, which can be traced from
childhood, are usually congenital and can be transmitted from parents, grandparents.
For example, standing work can lead to flat feet in adulthood. Another reason is hormonal changes in women (flat feet, as a rule, are more common in them). This, firstly, is the stage of growing up, then pregnancy, childbirth. Some women become
pregnant and give birth several times in their lifetime. In this case, in particular, the
restructuring of connective tissue occurs. That is, the body prepares for childbirth,
then returns, say, to its previous state, and then again prepares for childbirth. The
connective tissue begins to change: it stretches, then becomes strong again.
Clinical signs of fracture and dislocation.
It is not always possible to reliably determine a fracture or dislocation, therefore, for confirmation, the doctor necessarily makes an X-ray examination of the affected part of the body or limb. However, there are absolute and relative symptoms of
fracture.
Absolute (i.e. those that obviously speak of a fracture):
the appearance is not characteristic, the position of the bone changes
visually;
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you can observe movement in places where there are no joints (pathological
mobility);
the presence of crepitation — crunch when pressing the zone where the frac-
ture is suspected;
open fracture (open wound, bone visible).
Relative symptoms:
pain occurs with movements or load of the limb;
the appearance of a hematoma or bruise at the site of the injured area.
In dislocations, there are also some symptoms indicating its presence:
1) pain prevents movement of the injured area;
2) when compared with a healthy joint, deformation is traced;
3) the appearance of edema;
4) dislocation of the leg, characteristic of visual contraction of the injured limb,
dislocation of the shoulder — a change in the pulse and numbness of the arm.
Causes of fractures and dislocations.
The main causes of fractures are:
age-related changes;
too high a load on the bone for which it is not ready;
injuries;
poor or inadequate nutrition;
immobile or sedentary lifestyle;
tumors;
bone and joint diseases;
degenerative changes in connective tissue;
power disturbance;
neurological disorders;
mental disorders;
general depletion of the organism.
Spinal injuries.
Spinal injuries are among the most severe disasters that can befall a completely
healthy person in the process of his life. They are one of the most severe injuries to
the musculoskeletal system. Injured with a spinal injury account for up to 17.7 % of
all inpatient trauma patients. According to different authors, in the occurrence of various spinal injuries, six main mechanisms of action of damaging violence should be
distinguished:
1) flexural;
2) flexor-rotational;
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3) extensible;
4) compression or vertical compression;
5) shear mechanism — shear damage;
6) mechanism of strain injury.
Each of these types of violence results in a specific form of spinal column
damage that can be categorized as stable or unstable.
Unstable damages include:
dislocation and subluxation of vertebrae;
fracture-dislocation of vertebrae;
traumatic spondylolisthesis;
shear or tensile damage.
Depending on whether the spinal cord is involved in the pathological process
or not, all spinal injuries are divided into uncomplicated and complicated.
Clinical manifestations. The patient complains of localized pain over the injured spinous process and stiff neck. During clinical examination, point soreness is
noted. X-rays show tear fractures.
Complications. Due to the substantial deformation of the spine, clearly visible
in lateral projection, bilateral dislocation causes a significant narrowing of the spinal
canal. Most injuries of this kind occur between S5, S6 and S7, where the spinal canal
is narrowest. The result of spinal cord compression is often quadriplegia. Urgent adjustment can have a good restorative effect. Due to the vastness of damage to the ligamentous apparatus, it is easier to correct the bilateral subluxation of the vertebra
than the unilateral one, and the instability of the spine in the first case is much more
pronounced. It is necessary to urgently correct and stabilize the damaged spine. The
displacement should be adjusted by drawing along the axis manually or by skeletal
stretching beyond the parietal tubercles, which is more effective and can lead to
a complete restoration of anatomical relationships. Surgery may also be required. The
frequency of chronic spinal instability without stabilization remains quite high.
Despite the interlocking dislocation, the injury is characterized by extreme instability due to significant damage to the ligament apparatus, which can lead to neurological disorders of the spinal cord, which means that it is preferable for such injured to offer surgical stabilization of the spinal fracture.
The diagnosis of closed spinal injuries represents the most difficult section of
emergency traumatology. Examination of any patient with suspected spinal injury
should be carried out in the supine position and include careful clarification of the
history and complaints, assessment of the mechanism of injury, clinical and radiation
(X-ray, computer, magnetic resonance) examinations.
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From objective clinical data, data from an external examination acquire particular value. We must not forget that they can be the most significant only if the patient
is undressed. During the initial examination, you should first of all pay attention to
the general condition of the victim, his position, the function of internal organs and
systems, local orthopedic and trauma status, the degree of neurological disorders. If
the victim's head and neck deformity resembles a true crank, a subluxation in the Atlanta-axial joint or a one-sided interlocking dislocation should be suspected.
The bilateral upper subluxation, or interlocking sliding dislocation, is characterized by a forward tilt of the head and disappearance of lordosis in the cervical
spine. In cases of overturning dislocations, kyphotic deformation is most pronounced.
Holding the head upright by the hands is characteristic of its instability of varying
degrees.
It is possible with a fracture of the anterior and posterior arcs of the atlant with
a divergence of fragments, traumatic spondylolistesis of the 2nd cervical vertebra,
due to a fracture of the roots of its arcs and a rupture of the intervertebral disc between the bodies of the 2nd and 3rd cervical vertebrae, with an isolated fracture of
the articular process of one of the cervical vertebrae with compression of the corresponding spine.
With a slight degree of instability, the patient can hold his head in a certain position independently without additional external support. With a severe degree, independent retention of the head is impossible, when the patient tries to accept the vertical position, its fall is noted (“symptom of guillotination”). The general condition and
severity of the victim is due to the possibility of damage to other segments of the
musculoskeletal system and internal organs (combined injury). With damage to the
four lower cervical segments of the spinal cord, short-term loss of consciousness can
be observed. Due to paresis or paralysis of the intercostal muscles, the respiratory
movements of the chest are sharply weakened, the inspiratory movements of the diaphragm are enhanced. The cough reflex is weakened or absent. Sputum flaking is difficult or impossible with abdominal muscle paralysis. Due to insufficient breathing,
death may occur in the coming hours and days. Its immediate cause is often rapidly
developing hypostatic or so-called paralytic pneumonia.
Damage to this part of the spinal cord is characterized by the presence of oneor bilateral Bernard — Gorner syndrome (narrowing of the pupil, eye gap and subsidence of the eyeball). Sometimes it can be observed with a severe injury of 1–4 thoracic vertebrae. Often, during examination, the forced position of the head and hands
is revealed, which, with certain clinical forms, damage is typical: leading the right
and left shoulder outward or bringing them to the head with simultaneous supination
of the forearm and flexion in the elbow joints in case of damage to the vertebra; mod-
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