Добавил:
ivanov666
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Emergency medical care at the prehospital stage. Assessment of the severity of the condition of patients. Study aid
.pdf
71
irritability;
sleep disturbance;
difficulties in concentrating and solving mental problems;
memory impairment;
impaired resistance to stress, emotional strain and alcohol.
The delivery of rational intensive care should be based on monitoring of vital
signs. In patients with depression of waking by ShH up to 8 points or less, one should
strive for neuromonitoring, monitoring of blood circulation, breathing and oxygenation of arterial blood and the brain.
The increase of the inter-spinous gap is proportional to the degree of kyphotic
deformation and compression of the body of the broken vertebra, i.e. it is larger, the
more the degree of its wedge-shaped deformation is expressed. The enlargement and
palpation-determined subsidence of the inter-spinous gap is characteristic of the rupture of the supra-and inter-spinous ligaments. The protrusion of the spinous process
of the underlying vertebra and the subsidence of the overlying one suggests an interlocking dislocation or traumatic spondylolisthesis, and the protrusion with the presence of diastasis between the spinous processes is a tilting dislocation. Tenderness of
the posterior abdominal wall with deep palpation is possible in the presence of retroperitoneal hematoma, irritation or damage to the solar plexus.
Respiratory support. In the victim with waking disorders according to ShH up
to 10 points or less (sopor and coma), tracheal intubation should be performed, respiratory support should be carried out in order to prevent aspiration complications
and ensure normal oxygenation of arterial blood and elimination of hypercapnia
(standard). Tracheal intubation must be performed without extension of the cervical
spine: either nasotracheal or orotracheal with the spine axis preserved. If wakefulness
decreases to sopor and coma, auxiliary or controlled IVL is carried out with oxygenair mixture with oxygen content not less than 40–50 %. To prevent episodes of nonsynchronism by a respirator with respiratory attempts of the victim during mechanical
ventilation, causing a sharp increase in intrathoracic pressure and intracranial pressure, it is necessary to select ventilation modes or introduce short-acting muscle relaxants and sedatives. It is required to maintain PaCO2 within 36–40 mmHg and saturation of hemoglobin with oxygen in blood flowing from the brain of at least 60 %.
To prevent cerebral hypoxia, all manipulations associated with opening the contour
of the ventilator must be accompanied by pre- and postoxygenation with 100 % oxygen. During mechanical ventilation, hyperventilation and associated hypocapnia
should be prevented. Short-term hyperventilation can be used in the event of a sharp
deterioration in neurological status or for a longer time if intracranial hypertension
72
persists despite the use of sedation, muscle relaxation, removal of cerebrospinal fluid
from the ventricles of the brain and the use of hyperosmolar solutions.
Neurological examination. Neurological examination is the main diagnostic
technique for assessing the patient's condition and deciding on CT, magnetic resonance imaging (MRI), angiography, electroencephalography (EEG) and other diagnostic actions.
Purpose of neurological examination:
1) the wording of the patient's topical diagnosis;
2) assessment of the dynamics of focal and general cerebral symptoms;
3) selection of instrumental study methods (CT, MRI, EEG, angiography).
Frequency of examination depending on the severity of the patient's condition:
every 1–2 hours in patients with brain injuries of different genesis in the
acute phase of the disease;
1–2 times a day with stabilization of the patient's condition.
Clinical neurological examination plan.
Assessment of the patient's position in bed:
1) response to spoken speech;
2) response to pain irritations;
3) manifestations of hemispheric symptoms;
4) manifestations of diencephalic syndrome;
5) assessment of segmental symptoms (in detail for all levels of the trunk);
6) presence of dislocation and meningeal symptoms;
7) conclusion on examination with indication of the topical diagnosis, main
syndromes and dynamics compared to the previous examination.
Assessment of the patient's position in bed (in the form of a description):
active;
passive;
forced;
pathological postures.
Meningeal symptoms:
a) rigidity of the occipital muscles;
b) presence of Kernig symptoms.
Response to spoken speech:
no reaction;
individual sounds;
slurred speech;
73
monosyllabic responses;
clear articulation;
communicates, but the orientation (space, time, personal situation) is violated;
fully oriented.
Reaction to pain (most important in a patient in a coma):
1) differentiated;
2) undifferentiated;
3) by the type of positional-tonic reactions;
4) flexural: the level of damage above the average brain;
5) extensible: the level of damage is the middle brain and below the middle
brain.
Manifestations of hemispheric symptoms:
eye paresis to the side (the eye is directed to the focus);
hemiparesis on the opposite side;
seizure syndrome.
Manifestations of diencephalic syndrome:
vegetative-visceral disorders;
impaired gastrointestinal motility;
intestinal paresis;
tachycardia;
hyperhidrosis;
hypo-, hyperthermia;
water-electrolyte disorders (e.g. diabetes insipidus);
hormonal changes.
Brain stem assessment:
1) midbrain:
the size of the eye slits;
pupil size;
reaction to light;
position and movement of the eyeballs;
reflex gaze upwards;
oculocephalic reflex;
2) bridge:
width of the eye slits;
corneal reflexes;
pupil size;
74
mimic reaction;
position of the lower jaw;
reaction to corneal and facial irritation;
eye paresis (stem);
3) medulla oblongata:
the nature of breathing;
hemodynamic state;
bulbar syndrome;
persistence of parasympathetic innervation.
Dislocation syndrome.
Diencephalic stage:
drowsiness/agitation, narrowing of the pupil on the side of the focus;
pathological respiration (Cheyne — Stokes);
hyperthermia;
floating movements of the eyeballs;
decerebration reactions.
Midbrain stage:
in lateral dislocation;
anisocory on the hearth side;
hemiparesis on the opposite side;
at central dislocation;
bilateral miosis;
gaze-up paresis;
no oculocephalic reflex;
tachypnea;
decerebration reactions.
Lower hole stage:
tachypnea, apnea;
arterial hyper-, hypotension;
muscular atonia;
bilateral mydriasis.
Conclusion on neurological examination:
1) assessment of the level of wakefulness (clear — full orientation, somno-
lence, stunning, sopor, coma 1–3);
2) stem syndrome (lesion level);
3) reflex-motor sphere (presence of tetra-, hemiparesis, muscle tone, tendon re-
flexes);
75
4) presumptive topical diagnosis;
5) the presence of positive or negative dynamics compared to the previous ex-
amination;
6) features (e.g. sedative therapy).
In addition to the descriptive assessment, it is generally accepted to assess the
state of wakefulness according to ShH in points (used mainly in patients with TBI)
and compare with the scale of the level of depression of consciousness. After examining the patient with a head injury, he should be taken to the duty department of neurosurgery.
Fracture of the skull and bones of the facial skeleton.
In the overall structure of head injuries, the proportion of all skull bone fractures is from 2 to 20 %, while skull base bone fractures are rarer and statistically
4 % of the number of diagnosed severe TBIs. In 32–59 % of patients, the fracture line
changes from arch to base.
Fracture of the bones of the base of the skull is damage to the area of the
bones of the base of the skull due to TBI or iatrogenic interventions with the development of a symptom complex characterized by a violation of the anatomical integrity of the base of the skull and functional disorders. Fractures of the base of the skull
include fractures of the orbital surface of the frontal bone, the pyramid of the temporal bone, the articular process of the occipital bone or the scales of the occipital
bone with the transition to the large occipital opening, the lattice plate, the wedgeshaped bone.
A depressed skull fracture is a skull fracture in which bone fragments shift
more than the thickness of the adjacent bone, causing compression of the brain.
Classification by fracture type:
1. A closed skull fracture is characterized by the preservation of the integrity of
the soft tissues of the head or the presence of a soft tissue wound that does not affect
the aponeurosis of the skull.
2. An open skull fracture occurs in the presence of soft tissue damage to
the head.
3. A penetrating skull fracture occurs when the underlying dura is damaged.
The clinical picture in the presence of a skull fracture consists of a combina-
tion of three groups of symptom complexes:
– local changes in the cover of the head in the area of application of impact;
– cerebral symptoms of loss, irritation and dislocation due to the nature of con-
comitant brain injuries;
– general mathematical changes.
76
Clinical symptoms suggesting skull fracture pattern on external examination:
1) periorbital hematoma (symptom of “glasses”), which appeared 12–48 hours
after injury, is a sign of a fracture of the anterior cranial fossa;
2) hematoma in the mastoid process (Battle's symptom), lagophthalmos, facial
asymmetry indicate a fracture of the pyramid of the temporal bone and peripheral paresis of the facial nerve;
3) hemotympanum or rupture of the eardrum can accompany a fracture of the
base of the skull;
4) rhino- or otoliquorea — a sign of a fracture of the base of the skull (anterior
or middle cranial fossa, respectively) and penetrating TBI;
5) facial emphysema is a sign of a fracture of the bones of the facial part of the
skull and may indicate a combined craniofacial injury and a fracture of the bottom of
the anterior cranial fossa;
6) exophthalmos with conjunctival edema may indicate the occurrence of ca-
rotid-cavernous joint or the formation of a retrobulbar hematoma;
7) paresis or paralysis of cranial nerves;
8) bleeding from the nose or ears of varying intensity;
9) hearing impairment, nystagmus, vomiting;
10) quite rarely, a fracture can lead to visual impairment if broken bones pinch
the optic nerve.
Difficulties in recognizing early liquor arise in cases of combining it with
bleeding. To distinguish between bleeding from liquor and bleeding, a test is proposed to detect a light rim around a bloody spot on a gauze napkin, positive for liquor. It is recommended to assess the overall severity of the patient's condition based
on the examination and diagnosis of combined injuries, laboratory and instrumental
examination data.
Fractures of the bones of the facial skeleton — pathological conditions aris-
ing from a violation of the anatomical integrity of the bones of the facial skeleton of
the skull. All fractures of the facial skeleton can be divided into several groups de-
pending on the zone and the nature of the damage:
nose fracture;
fracture of the eye socket;
fracture of the zygomatic bone;
fracture of the upper jaw;
fracture of the lower jaw.
The most common cause of damage is traffic accidents, violent injury, falling
from a height. Emergency care is provided for maxillofacial injuries combined with
77
TBI and combined craniofacial injuries. Operations are carried out as a matter of urgency, in the initial delayed period.
The injured have deformation of the facial skeleton and violation of systemic
functions: chewing apparatus, temporomandibular joint, upper respiratory tract, organs of vision, neurological disorders and aesthetic defects. Such disorders require
surgical treatment in the department of neurosurgery, maxillofacial surgery in collaboration with oculists, otorhinolaryngologists and other specialists.
Chest injuries.
Chest injuries are injuries that include injuries to the ribs, sternum, and inter-
nal organs located in the chest cavity.
Classification. All chest injuries are divided into two groups: closed and open.
Closed injuries are the absence of a wound.
Chest wounds are subdivided into:
penetrating — with damage to the parietal pleura;
non-penetrating — without damage to the parietal pleura;
penetrating chest wounds;
stab-cut;
firearms;
fracture of the sternum;
rib fractures.
Isolated, multiple and combined chest injuries (wounds) stand out among combat chest injuries.
Isolated is an injury (wound) to the chest, in which there is one injury.
Multiple is called trauma (wound), in which there are several injuries within
the chest as an anatomical area of the body.
Simultaneous damage to the chest with other anatomical areas of the body
(head, neck, abdomen, pelvis, spine, limbs) is defined as a combined injury (wound)
to the chest.
Gunshot wounds to the chest are penetrating (with damage to the parietal pleura) and non-penetrating into the pleural cavity. By the nature of the wound canal, tangent, blind and through wounds differ. Gunshot wounds to the chest can be accompanied by damage to the bone frame of the chest (ribs, shoulder blades, clavicles, sternum), blood vessels of the chest wall (intercostal arteries, internal thoracic artery,
unpaired and semi-tubular veins), lung and large vessels of the mediastinum (aorta,
upper and lower hollow veins, shoulder trunk), internal organs.
Among injuries to internal organs, lung injuries prevail, wounds to the heart,
trachea and large bronchi, esophagus are much less common. Explosive chest injuries
78
are etiologically related to gunshot injury, but are similar in nature to mechanical injuries. Breast wounds can be accompanied by the development of their consequences,
i.e. pathological processes caused by a violation of the structure and function of organs and large breast vessels, of which life-threatening consequences are most dangerous (open and tense pneumothorax, cardiac tamponade, ongoing intrapleural
bleeding). All these wound characteristics should be taken into account when constructing the diagnosis.
Rib fractures.
Fractures can be isolated (1–2 ribs) and multiple (3 or more ribs); one-sided
and two-sided; with and without offset; complicated (with damage to the pleura, lung,
mediastinal organs) and uncomplicated.
Rib fractures — violations of the integrity of the bone or cartilaginous part of
one or more ribs. A fracture of one rib or fractures of a small number of ribs, not
accompanied by complications and other injuries, usually fuse on their own and do
not require significant interventions or immobilization. Rib fractures account for
5–15 % of all fractures. They arise as a result of blows, falls on protruding objects,
as well as without direct injury (chest compression), in various tumor, infectious, oncological diseases, osteoporosis.
Classification of flotation fractures of ribs:
anterior bilateral (anterior bilateral): rib fractures are located on both sides of
the sternum on the anterior surface of the chest; the anterior chest loses contact with
the spine;
anterolateral (anterolateral): each rib breaks in two (or more) places on one
side of the sternum along the anterior and lateral surface of the chest; the anterolateral
chest loses communication with the spine;
posterolateral (dorsolateral): each rib breaks in two (or more) places on one
side of the spine along the back and side of the chest; with the spine loses communication with the posterior lateral or posterior chest;
posterior bilateral (posterior bilateral): rib fractures are located on both sides
of the spine along the back surface of the chest.
Clinic. The clinical picture is characterized by complaints of severe pain in the
chest, worsening with deep breathing and coughing. On the affected side, breathing is
superficial. During examination, the chest lag in the act of breathing on the side of the
lesion, swelling, soreness, crepitation, deformation above the site of the rib fracture is
determined. With a deep breath, the victim notes an increase in pain over the fracture
site, the same happens when coughing. Pire's symptom (tenderness at inclinations in
a healthy direction) and the symptom of axial loads are detected: when the chest is
79
alternately compressed in sagittal and frontal planes, pain occurs in the area of bone
defect, and not in the place of compression.
For diagnostics, abdominal wall palpation, auscultation, BP measurement are
performed. If the lung is damaged by a broken rib, hemoptysis, subcutaneous emphysema, pneumo- or hemothorax may occur.
Complications:
1) damage to internal organs or vessels by an acute fragment of the lung rib
with the development of pneumo- or hemothorax, heart, liver, spleen, gastrointestinal
organs, intercostal vessels, kidneys, leading to bleeding;
2) flotation of the chest wall section;
3) pleuropulmonary shock;
4) subcutaneous emphysema;
5) infectious complications (pneumonia, purulent pleurisy).
Hemothorax — blood accumulation in the pleural cavity, is the result of
bleeding from the vessels of the lungs, intrathoracic branches of large vessels (aorta,
vena cava), vessels of the chest wall, mediastinum, heart, lung or diaphragm. With
a wound to the lung, hemopneumothorax occurs.
Classification:
small (up to 500 ml) — blood occupies only pleural sinuses;
medium (500 to 1 000 ml) — blood reaches the angle of the shoulder blade;
large, or total (more than 1 000 ml) — blood occupies almost the entire pleu-
ral cavity.
By the presence of ongoing bleeding:
withstopped bleeding into the pleural cavity;
withongoing intrapleural bleeding.
By complications:
clotted hemothorax;
infected hemothorax.
By localization of limited hemothorax:
apical (apical);
inter-salt;
supdiaphragmal;
paracostal;
paramediastinal.
The clinical picture depends on the intensity of bleeding and anemia. The skin
of such patients is pale, tachycardia is noted, BP lowering. With percussion of the affected half of the chest, the shortening of the percussion sound is determined; the up-
80
per boundary of the fluid, if there is no pneumothorax, forms the Damoiseau line.
With auscultation of the lungs, weakening of breathing or its absence is determined.
The boundaries of the heart are shifted in a healthy direction. The clarity of physical
signs of the presence of fluid depends on the size of hemothorax.
If the patient has a wound on the chest, a bandage is applied to it, in cases of air
discharge from the wound — a sealed bandage. If during examination on the chest
there is a sunken knife, spoke or other objects that caused a penetrating wound, then
these objects are not removed when providing medical care at the prehospital stage.
Pneumothorax — accumulation of air or gases in the pleural cavity. It can oc-
cur spontaneously in people without chronic lung disease (primary), as well as in
people with diseases or lung injury (secondary). Artificial pneumothorax — the introduction of air into the pleural cavity to create a collapse of the affected lung.
In relation to the environment, there are:
1) closed pneumothorax. In this form, a small amount of gas enters the pleural
cavity, which does not grow. There is no message with the external environment. It is
considered the lightest type of pneumothorax, since the air can potentially gradually
resolve itself from the pleural cavity, while the lung spreads;
2) open pneumothorax. With the pneumothorax open, the pleural cavity communicates with the external environment, so it creates a pressure equal to atmospheric. At the same time, the lung subsides, since the most important condition for spreading the lung is negative. This is the most dangerous type of pneumothorax, since irritation of the nerve endings of the pleura, leading to pleuropulmonary shock, as well
as displacement of the mediastinal organs, which disrupts their function, primarily
squeezing large vessels, is attached to turning off the lung from breathing. The collapsed lung is turned off from the breath, there is no gas exchange in it, the blood is
not enriched with oxygen. May be accompanied by hemothorax;
3) valve pneumothorax. This type of pneumothorax occurs in the case of the
formation of a valve structure that allows air to flow unilaterally, from the lung or
from the environment to the pleural cavity, and prevents it from leaving back. With
each respiratory movement, the pressure in the pleural cavity increases.
Pneumothorax can be according to the degree of pulmonary colabation:
small — up to 1/3 of the volume;
average — up to 1/2 of the volume;
larger — more than 1/2 of the volume;
total — completely colabated lung.
Clinical presentation. Complaints of sharp chest pain, shortness of breath,
breathing becomes superficial, frequent, the patient feels a feeling of lack of air. The
phenomena of acute respiratory and cardiovascular failure are increasing. Pallor or
Соседние файлы в предмете [НЕСОРТИРОВАННОЕ]