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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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erate abduction of the right and left shoulders, forearms bent in the elbow joints, are
in a position on the chest, middle between supination and pronation, hands — in the
middle position, fingers are half-bent when the S7 vertebra is affected.
Free flexion and extension of the hand in the wrist joint indicates the integrity
of the S7 vertebra. The preservation of movements in the fingers (function of the
muscles of the flexors and extensors of the fingers) indicates the absence of damage
to the S7 root.
When examining the thoracic and lumbar regions, attention is paid to the presence or absence of kyphotic deformation. Its degree can be so little expressed that it
is captured only by the experienced eye of a specialist.
In the lumbar region, it manifests itself by smoothing physiological lordosis,
against the background of which in people of asthenic physique the spinous process is
visible in the form of a “button”. Often, this persistence of the spinous process of the
damaged vertebra is determined only palpatorally. In addition to deformation of the
spine in the sagittal plane, there may be a lateral curvature of the line of spinous processes indicating the presence of lateral compression of the vertebral body.
Palpation is given importance. It reveals tension of the long muscles of the
back, local tenderness, swelling along the line of the spinous processes, the persistence of the spinous process posteriorly in the form of a "button" kyphosis, mobility
at the fracture of the spinous process or the borderline sympathetic trunk, while the
tension of the anterior abdominal wall occurs and the picture of a closed abdominal
injury.
Percussion. The percussion of the spinous processes allows you to refine the
palpation data. Significant tenderness caused by percussion along the line of the spinous processes, in the absence of pain during palpation, can indicate damage to the
vertebral body with great confidence. Percussion in fractures complicated by spinal
cord damage can lead to dislocation of fragments and additional secondary spinal
cord damage. In these cases, it is better to abandon percussion.
With uncomplicated spinal injuries, active movements in the limbs are preserved. If you invite the victim to raise straight legs from the lying position, the patient may note an increase in back pain. They will intensify more sharply when raising straight legs with simultaneous pressure on the spinous process of a broken or
protruding overlying vertebra.
Of other clinical symptoms, reflex urinary retention, stool retention, and intestinal paresis may occur. Sometimes they persist for 1 week and require close attention
of the attending physician. It is necessary to always remember the danger of checking
symptoms such as determining the volume of movements in the spine, identifying
Thompson's symptom (increased spinal pain at the level of damage in the sitting posi-
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tion and a significant decrease in them when unloading the spine with the victim's
hands resting against the seat of a chair or couch).
The phenomenon of increased pain during load along the axis of the spine
should not be detected even in the lying position. Only easy swinging on the heels is
allowed. It is impossible to allow the patient to get up or sit down until the X-ray data
are obtained.
Impaired spinal cord function in fractures.
Impaired spinal cord function in spinal fractures depends on concussion, contusion, compression, swelling, partial or complete anatomical damage to the spinal
cord, damage to its roots. Compression of the spinal cord can be front, back and side.
In the front, it is most often caused by a hematoma, bone fragments of a broken or
dislocated posteriorly edge of the body of the underlying vertebra by fragments of
a torn intervertebral disc. Compression is much less common behind and is caused by
an arc of a dislocated vertebra or its fragments, a yellow ligament, and a hematoma.
Lateral compression occurs by the articular processes and the adjacent other structures of the spinal segment, depending on the mechanism of injury and the displacement of the broken vertebra or its fragments. In the first hours and days after the injury, it is difficult to resolve the issue of the cause of gross impairment of spinal cord
function, since the clinic in severe spinal shock (functional disorders) practically does
not differ from the clinic in complete anatomical damage.
The rapid increase in neurodystrophic processes, the appearance of pressure
sores and edema of soft tissues in the first day after injury indicate in favor of anatomical rupture. With complete ruptures of the spinal cord, its function is never restored. The violation of spinal cord function caused by compression by bone fragments occurs if the dislocation was corrected in a timely manner, the fracture, and, if
necessary, the fragments were removed. The clinic of spinal disorders associated with
concussion, contusion, compression of the spinal cord by supra — and sub-enveloped
hemorrhages, its edema, gradually regresses. Partial conduction of the spinal cord is
manifested by impaired sensitivity in the conductor type below the level of damage,
paresis, paralysis and pelvic organ function disorder.
Pelvic injuries.
Pelvic and pelvic injuries belong to the group of the most severe injuries of the
musculoskeletal system. With each decade they become difficult, the specific gravity
of open and combined injuries increases. According to statistics from the authors of
the second half of the XIX century, pelvic injuries were 0.3 to 1 % of all fractures.
According to modern authors, pelvic injuries range from 5 to 10 % in relation to the
total number of injuries, and in some regions up to 15 %
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Pelvic instability.
The nature and severity of the pelvic injury, in addition to the mechanism of
the injury, is assessed by the degree and nature of stability of the pelvic ring. Its stability should be understood as the ability of the bones of the pelvis and its compounds
to withstand ordinary physiological loads (body weight, running, jumping, walking,
physical work) without pain syndrome and pathological displacements. The latter are
diagnosed clinically and radiologically. The diagnostic stability criterion is considered to be an indicator of the amplitude of movement in the sacroiliac joints and pubic symphysis within 1–3 mm under the influence of physical violence that does not
cause their damage. The criterion for pelvic ring instability is the ligament of the sacroiliac junction, so pelvic instability depends more on damage to the ligaments and
bones of the posterior semicircle and less on the anterior semicircle.
There are rotary or horizontal and vertical instability. With rotational instability, horizontal rotational instability is distinguished with rotation of the corresponding
half of the pelvis outward by the type of “open book” or inside by the type of “closed
book” with upward displacement (vertical instability) or without upward displa-
cement.
Clinical diagnosis of pelvic injuries. To obtain an approximate idea of the
presence of pelvic damage, a history with clarification of the circumstances and
mechanism of injury, appearance, general condition and posture of the patient is of
great importance. Familiarity with the mechanism of injury is often crucial in the first
orientation. Inspection of the victim is carried out in order to diagnose damage. The
passive position of the patient, he is, as it were, chained to the bed, localization and
type of wound, increase in volume in the pelvis, violation of the axis of the limb
segment, unusual position of the leg in the external or internal rotation and, finally,
asymmetry of the pelvis are the main guidelines for examination.
An attempt at movement in the lower limb causes sharp pain in the pelvic ring.
Inspection of the pelvic region is advantageous both from the side and from the
front to compare both halves of the pelvis. Severe pelvic fractures with type shift
Malgen can always be suspected by the presence of pelvic asymmetry, the displacement of the navel from the midline, the reversal of one half of it and the external rotation of the leg of the same side.
With bilateral fractures of Malgen, a kind of “flattening” of the pelvis is
visible — a significant expansion of its diameter. Typical is the typical position of the
victim. When the symphysis ruptures, both legs are bent in the knee joints and are
given; the victim does not allow them to dilute due to the appearance of severe pain
in the projection of the pubic joint. With a fracture of both pubic and ischial bones, as
well as with vertical fractures of Malgen, the position of Volkovich, or “frog”, is
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characteristic (a symptom of Volkovich, 1928). In this position, the legs of the victim
are bent in the knee and hip joints and divorced. They resemble the shape of a rhombus or a preparation of “frog” paws. On the 2nd day, bruises may appear in the surrounding tissues, with a fracture localizing closer to the iliac bone — over the umbilical ligament, with a fracture of the descending branch of the pubic and ischial
bones — in the perineum.
In a tear fracture of the anterior upper axis of the iliac bone, the victim moves
his back forward, and not his face (a symptom of reverse, or Lozinsky, 1928), since
the sartorial muscle (m. sartonus) starts from the anterior superior spine of the ilium
and attaches to the anterior-copper-calf surface in the tuberositas tibia region. When
bending the thigh and lower leg when walking face forward, the muscle tightens,
causing a displacement of the fragment of the anterior superior spine of the iliac
bone, the patient sharply increases pain syndrome.
With a fracture of the horizontal branch of the pubic bone, the patient, being in
a horizontal position, cannot raise the corresponding leg in the extension position,
cannot “tear” the heel from the bed, but the passively raised limb holds independently
without assistance — a symptom of a “stuck” heel, or a symptom of Gorinevskaya.
Scallop muscle (m. pectineus) starts from the crest of the horizontal branch of
the pubic bone (rames superior et pecten ossis pubis) and, heading down and slightly
outward, attaches to the scalloped line (linea pectinea) of the thigh distal to the lesser
trochanter. The muscle flexes and brings the thigh, slightly rotating it outward. When
trying to raise the leg on the side of the damage to the pelvis, the muscles tighten, increasing the pain syndrome.
To diagnose pelvic fracture in the absence of traumatic shock, a number of
symptoms can be identified:
1) Verneil's symptom — increased pain with careful oncoming external com-
pression of the pelvis in the area of the wings of the iliac bones;
2) Larrey's symptom — increased pain in the area of pelvic damage during di-
lution or reversal of the wings of the iliac bones;
3) Sgaddart's symptom — the appearance or increase of pain in the sacroiliac
joint during the mixing and dilution of the iliac bones;
4) symptom of A.N. Karalin — appearance or increase of pain in internal hip
rotation.
Palpation. Local tenderness in the fracture area can be detected during palpation in the areas of the osteae or ridges of the iliac bones, pubic articulation, ischial
bones. When symphysis is broken, palpation determines diastasis and its value between the bones in the area of the pubic junction. In case of violation of the integrity
of the pelvic ring, the mobility of bone fragments occurs even with the slightest
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movements of the victim's legs, and non-cutting palpation during examination can
aggravate the patient's condition.
Symptom Mouse — shortening the distance from the xiphoid process or navel
to the anteroposterior spine of the iliac bone on the damaged side. With an isolated
fracture of the upper anterior spine of the iliac bone with a downward displacement
of the fragment, an apparent shortening can be detected.
Symptom Ru — shortening the distance from the upper anterior spine to the
pubic joint; indicates a fracture of the pubic bones with dislocation of fragments.
Bejul's symptom — shortening of the distance from the sternoclavicular joint
to the anteroposterior spine of the ilium on the damaged side.
Palpatory examination should be supplemented by careful rectal and vaginal
examination. In this case, a fracture of the coccyx, sacrum, pubic bones, the bottom
of the acetabulum and the head of the femur embedded in the pelvic cavity can be detected. If the rectum ruptures, the finger may fall into the wound, and the surgeon's
glove will contain blood. With vaginal examination, it is also possible to determine
the displaced fragments of the pubic, ischial bones, the bottom of the acetabulum and
the presence of damage to the vaginal mucosa. If vaginal or rectal damage is detected, an open communicating (penetrating) pelvic fracture should be diagnosed.
In an acetabulum fracture, A.P. Nadein in 1939 described the main
symptoms:
1) hip is in the position of reduction, easy flexion and external rotation;
2) significant limitation of movement and sharp soreness in passive and active
movements in the damaged joint;
3) tenderness along the obturator nerve and irradiation of pain to the knee joint;
4) restriction or complete impossibility of hip abduction;
5) the presence of a hematoma in the area of the greater trochanter, the umbili-
cal ligament and the Scarp triangle;
6) tenderness during lateral compression of the pelvis in the area of the large
trochanter, load along the thigh axis or on the large trochanter along the axis of the
neck on the side of damage to the acetabulum;
7) reducing the distance between symphysis and the large femoral trochanter
on the injury side;
8) relative shortening of the lower limb on the corresponding side;
9) the upper edge of the large spit is located above the Roser — Nelaton line;
10) subsidence in the greater trochanter area in central hip dislocation;
11) determination of femoral head protrusion in pelvic cavity at rectal and vag-
inal examination.
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The severity of damage and traumatic shock directly proportionally increases
with multiple, combined injury with damage to the pelvic organs, abdominal cavity
and chest, the size of blood loss. According to literary data, traumatic shock occurs in
40.2–93.1 %, and with polytrauma — in 60–100 % of injured. Stopped bleeding can
resume with the most insignificant movements of the patient: shifting, insufficiently
careful transportation of the victim from the scene or in a medical institution from
one structural unit (emergency room, operating room, intensive care unit) to others,
insufficiently careful research.
Hematoma in the retroperitoneal space can spread to the level of the kidneys
and diaphragm, and in front — to the level of the umbilical horizontal. Hematoma
through the obturator canal can spread to the lower third of the thigh down. In this
case, the intestines and kidneys are displaced inside and to the anterior abdominal
wall. It should be especially remembered that the severity of shock depends not so
much on the amount of lost blood as on the rate of bleeding, since with rapid massive
blood loss in the body they do not have time to react and develop compensatory
mechanisms (transition of interstitial fluid into the vascular channel, tachycardia,
spasm of peripheral vessels, centralization of blood circulation).
Traumatologists and surgeons with resuscitation anesthesiologists may not
have time to provide the necessary effective assistance. Injured by the time of admission to the medical institution lose from 2–3 to 3–4 liters of blood. With large hematoma sizes, blood from the retroperitoneal space can enter the free abdominal cavity
even with an intact peritoneum in a diapedetic way from a small amount to 2 liters.
A massive retroperitoneal hematoma with ongoing bleeding can be accompanied by a
rupture of the peritoneum and the penetration of whole blood into the abdominal
cavity. The literature suggests that bleeding in pelvic fractures can last from 2 to
5 days or more. One of the reasons for the severity of traumatic shock and aggravation of the general condition of the victim is damage to the bladder of the urethra, rectum and extremely rarely the vagina, uterus and appendages.
Damage to the urinary organs is diagnosed with fractures of the pelvic bones in
10–28 % of cases in adults and in 7–8 % in children. Most often, damage to the urinary organs occurs when the front is hit or compressed with scrolling. Any pelvic injury should therefore be considered as complicated until the absence of urinary tract
damage is proven or confirmed. The presence of blood in the urine is an important
diagnostic test, but not reliable for damage to the bladder or urethra. Blood can be observed with damage to the kidneys, ureters, thawing of the muscle layers of the pelvic
floor, hematoma of the bladder wall.
The subjective early sign of bladder damage is pain in the lower abdomen,
above the bony joint. In case of intraperitoneal rupture, the pain is taken to be spilled,
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intensified when strained in order to attempt spontaneous urination. Pains are irradiated into the navel area, the head of the penis, the rectum, sometimes into the thigh
area. Impaired urination manifests itself as a complete absence of urine discharge.
There is a gradual increasing tension of the anterior abdominal wall with symptoms
of irritation of the peritoneum, intestinal paresis.
Change of position the victim, leading to the movement of urine poured into
the abdominal cavity, causes an increase in abdominal pain and the patient's resistance to all movements (a positive symptom of “vanka-standing”).
Bladder catheterization is used for diagnosis. When the catheter is inserted,
a small amount of urine is released at once, but it is worth moving the catheter further
so that it gets through the bladder wound into the abdominal cavity, then up to 2 liters
of urine will be released, which confirms the intraperitoneal rupture of the bladder. In
doubtful cases, the bladder is emptied using a catheter, then 250–300 ml of furacilin
is introduced and the catheter is pressed. After a few minutes, the catheter is opened
and the contents are removed. If its contents significantly exceed the amount of furacilin injected, it can be assumed that fluid flows out of the abdominal cavity (Zeldo-
vich's symptom).
In the case of late diagnosis with intraperitoneal ruptures of the bladder, a clinic of purulent peritonitis develops. With extra-abdominal ruptures of the bladder, the
lateral, anterior, posterior walls that are not covered with the peritoneum are damaged, or a complete detachment of the bladder in the area of its neck occurs. The posterior wall of the bladder is most often damaged, where the lower cystic arteries and
veins pass. Patients complain of pain in the lower abdomen — above the pubis, frequent urge to urinate. It is possible in a weak stream, in small portions, urine is
stained with blood. With palpation — soreness over the pubis, sometimes there can
be tension of the anterior abdominal wall. Percutory — blunting extends to one or
both inguinal areas. It does not decrease during catheterization, and its boundaries do
not change when the victim turns. Palpation through the rectum reveals painful tissue
infiltration.
Later, swelling appears in the area of the pelvis, perineum, thigh with the formation of urinary fistulas, the development of pelvic phlegmon and osteomyelitis. In
the future, general intoxication increases, manifested in the form of dry tongue, skin,
tachycardia, BP fall and deterioration of general condition.
Urethral damage.
Urethral damage is characterized by urinary retention, blood excretion from the
urethra, perineal hematoma and complaints of patients about cutting pains in the perineum area, which increase during each attempt to urinate, blood excretion from the
urethra, urinary incisors, infertile urges to it, and delayed urinary discharge. With ure-
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thral damage, initial blood staining of urine is always noted. Its staining intensity will
vary. It will be more intense when the membranous part of the urethra breaks and less
pronounced when the prostatic part is damaged. The manifestation of perineal hematoma during the first 3 hours is characteristic of damage to the urethra, later it can be
with symphysis ruptures and fractures of the anterior half-ring of the pelvic bones.
The latter reduces the value of this symptom. Urine released from the damaged urethra impregnates the surrounding fiber and forms urinary weeds.
Rectal ruptures occur with fractures of the pelvic bones much less often. Distinguish between extraperitoneal and intraperitoneal injuries of the rectum. Extraperitoneal injuries are manifested by the development of severe pelvic phlegmon. Intraperitoneal ruptures are characterized by rapidly developing symptoms of peritonitis.
To exclude rectal pathology, rectal examination should be performed on all injured
with pelvic injury. Thus, with fractures of the pelvic bones, it is important to diagnose
not only the pelvic bones, but also the internal organs of the abdominal cavity and
pelvis, especially the rectum and bladder.
Head injuries.
Head injuries are some of the most severe injuries that injured can suffer from
accidents. Very often, they (especially injuries to the scalp) are accompanied by significant bleeding, which can threaten the life of the victim at the scene. If a person is
unconscious, then he should be given a stable lateral position, which reduces the likelihood of tongue sinking and minimizes the possibility of vomiting masses or blood
entering the respiratory tract. In the presence of a wound and bleeding, it is necessary
to perform direct pressure on the wound, if necessary, apply a bandage. If the victim
shows signs of violation of the integrity of the skull bones, it is required to cover the
wound edges with bandages and only after that apply a bandage.
When a foreign object is in the wound, you need to fix it by covering it with
napkins or bandages and apply a bandage. It is forbidden to remove a foreign object.
Bleeding with injuries to the scalp is usually very abundant and cannot stop on its
own. To stop bleeding from the scalp, it is necessary to perform direct pressure on the
wound and apply a pressing bandage. Head injuries are often accompanied by impaired brain function. Traumatic brain injury is characterized by pallor, general
weakness, drowsiness, headache, dizziness and loss of consciousness.
The victim may be conscious, but not remember the circumstances of the injury and the events preceding it. More severe brain damage is accompanied by prolonged loss of consciousness, paralysis of the limbs. Fractures of the bones of the
skull can be accompanied, in addition, by the following signs: the release of colorless
or bloody fluid from the ears, nose; bruising around the eyes. In the process of
providing first aid to the victim, he should conduct a physical and instrumental exam-
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ination, determine the nature of all injuries, provide emergency medical care at the
prehospital stage and deliver the patient to the duty specialized hospital.
Traumatic brain injury (TBI) — damage to the skull, brain, meninges, ves-
sels and/or craniocerebral nerves, accompanied by clinical symptoms and in most
cases morphological changes. The presence of a clear traumatic history is extremely
important.
Mild TBI (LTBI) is an acute impairment of brain function, which is the result
of traumatic effects, in which short-term loss of consciousness (up to 30 minutes)
and/or amnesia (up to 24 hours) can be noted. It includes two nosologies: a concussion and a mild brain contusion.
Concussion (SGM) is the mildest clinical form of diffuse transient brain damage. The disorders are based on metabolic, ionic, neurotransmitter disorders and neuroinflammation, characterized by the absence of visible changes on CT. LTBI dominates the structure of traumatic brain injuries — 60–95 % of all injured. The prevalence ratio of LCBI to severe is 22:1. The ratio of concussion and contusion of light
severity is approximately 4:1. Mortality in LCTI is low (0.04–0.29 %) and is almost
exclusively caused by intracranial hematomas. The causes of LTBI in the population
are both road accidents and domestic, criminal, sports and industrial injuries.
According to clinical forms, the following are distinguished:
1) concussion;
2) mild brain contusion;
3) moderate brain contusion;
4) severe brain contusion;
5) diffuse axonal injury;
6) compression of the brain;
7) head compression.
Following the course of traumatic brain disease, periods are distinguished:
– acute;
– intermediate;
– distant.
An acute period is a period of time from the moment of the damaging effect
of mechanical energy on the brain with a sudden disorder of its integrative-regulatory
and local functions to stabilization at one level or another of impaired general and
corporate functions or death of the victim. The time duration of the acute period is
from 2 to 10 weeks, depending on the clinical form of TBI. Approximate periods of
acute TBI in concussion — up to 2 weeks, mild brain contusion — up to 3 weeks,
medium-severe brain contusion — up to 4–5 weeks, severe brain contusion — up to
6–8 weeks, diffuse axonal damage — up to 8–10 weeks, brain compression —
3–10 weeks (depending on background).
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The interim period is the period of time from the stabilization of the corporate, cerebral, focal functions disturbed by the injury to their full or partial restoration
or sustainable compensation. The time duration of the intermediate period: with
LCTI — up to 2 months, with moderate TBI — up to 4 months, with severe TBI —
up to 6 months.
The long-term period is the period of clinical recovery, or the maximum
achievable rehabilitation of impaired functions, or the occurrence and/or progression
of new pathological conditions due to TBI. The time length of the distant period: with
clinical recovery — up to 2 years, with a complicated course is not limited. The duration of post-traumatic (or anterograde) amnesia is one of the prognostic characteristics of the course of concussion.
Studies show that the outcome of LCTI and the duration of temporary disability are more determined by the duration of post-traumatic amnesia compared to the
assessment of the level of consciousness by ShH. In the case of post-traumatic amnesia less than 24 hours, 100 % of patients have a good recovery (on the Glasgow outcome scale).
Physical examination. When examining the head, it is recommended to identify signs indicating the fact of an injury (bruises, abrasions, wounds) and a fracture of
the bones of the base of the skull with a brain contusion (bruising in the mastoid process, periorbital hematomas, fluid leakage from the external ear canal, nose, mouth).
In neurological status, fine-muscular nystagmus (40 %), non-tubular anisoreflexion of
tendon and skin reflexes (20 %), static ataxia (20 %), dynamic ataxia (10 %), increased tendon reflexes (20 %), mild sheath symptoms (10 %), disappearing in
90 % of patients during the first 4–5 days. There is no damage to the bones of the
skull. The general condition of the injured usually improves significantly during the
first, less often — the second week.
The regression periods of clinical symptoms in the vast majority of injured
with concussion are on average 4–5 days, and the periods of temporary disability
usually do not exceed two weeks. With prolonged preservation of symptoms and
complaints (more than 7 days), additional examination and clarification of the causes
are necessary. The regression time of neurological symptoms of mild brain contusion
with an untied history is usually 7–14 days, and temporary disability — up to 3 weeks.
To verify post-concussion syndrome according to the ICD-10 criteria, the diagnosis of this condition requires a condition that arose after a head injury with three
symptoms from the following group:
headache;
dizziness;
rapid fatigue;
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