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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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blueness of the skin is manifested, auscultatory — breathing on the side of the injury
is sharply weakened, percutory — sound with a box tint, subcutaneous emphysema is
determined with fractures of the ribs.
Characteristic symptoms are:
acute chest pain, worsening with inhalation;
shortness of breath;
lacrimation;
difficulty breathing;
rapid breathing;
attacks of dry cough;
palpitations;
feeling panicked;
pallor of the skin.
All patients with breast injury, rib fractures, pneumothorax or hemothorax after
providing emergency medical care at the prehospital stage should be taken to the duty
surgical department.
2.9. RESPIRATORY SYSTEM EXAMINATION
Shortness of breath (dyspnea) — a change in the frequency, rhythm and depth
of breathing, often accompanied by feelings of lack of air. In heart diseases, shortness
of breath appears during physical exertion, and then at rest, especially in a horizontal
position, forcing patients to sit (orthopnea). Attacks of severe shortness of breath
(more often night) in heart disease — the manifestation of cardiac asthma; shortness
of breath in these cases is inspiratory (breathing is difficult).
Expiratory shortness of breath (difficulty exhaling) occurs when the lumen of
the small bronchi and bronchioles is narrowed (with bronchial asthma) or when the
pulmonary tissue loses elasticity (for example, with chronic pulmonary emphysema).
Cerebral dyspnea occurs with direct irritation of the respiratory center (tumor,
hemorrhage). Shortness of breath can be caused by poisonous and narcotic gas poisoning, chladons, as well as disorders of the nervous system functions with severe
excitement, rage, hysteria, fright.
There are three types of shortness of breath:
1) inspiratory shortness of breath (difficult to inhale), more characteristic of
heart disease;
2) expiratory shortness of breath (difficult to exhale), most often occurs in
bronchial asthma and COPD;
3) mixed shortness of breath (difficulty in breathing and exhaling).
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Depending on the frequency of respiratory movements, three types of dyspnea are distinguished:
1) tachypnea — rapid superficial breathing (more than 20 respiratory move-
ments per minute). It is observed with anemia, fever, blood diseases. In hysteria,
NPD reaches 60–80 respiratory movements per minute, such breathing is called the
“breath of a driven beast”;
2) bradypnea — pathological reduction of breathing (12 or less respiratory
movements per minute). It occurs with lesions of the brain and its membranes, severe
and long hypoxia, acidosis, diabetes mellitus, diabetic coma;
3) apnea — lack of breathing, for example, in sleep, when immersed in cold
water, when the blood is impoverished with carbon dioxide, reflex when the carotid
sinus is irritated.
Depending on the factors leading to shortness of breath, it is divided into:
physiological — at increased physical stresses;
pathological — with painful lesions of some systems.
Cough is an innate unconditional reflex that acts as part of the body's immune
system. It is a forced exhalation through the mouth caused by contractions of the respiratory muscle due to irritation of receptors located along the entire respiratory tract
(in the nasal axils, pharynx, larynx, trachea, bronchi) and in the pleura.
The physiological role of coughing is the purification of the respiratory tract
from foreign substances and the prevention of mechanical obstacles that impair the
patency of the air. The cough center responsible for the cough reflex is controlled by
the cerebral cortex; accordingly, coughing can consciously be somewhat contained
and mimicked, as well as occur in non-respiratory pathologies. Cough is always
a symptom of a pathological condition, not an independent disease.
Cough is classified by nature (unproductive — dry, productive — wet), intensity (coughing, mild and severe), duration (episodic short-term or attack-like and
constant), flow (acute — up to 3 weeks, prolonged — more than 3 weeks, chronic —
3 months or more).
Chronic obstructive pulmonary disease (COPD) is a common, preventable,
and treatable chronic lung disease.
Chronic nonspecific lung diseases are etiologically and pathologically different diseases of the respiratory system, occurring with a constant productive cough
and dyspnea due to a predominant lesion of the bronchi or parenchyma.
By the nature and number of secretions, cough occurs:
– dry (non-productive);
– wet (productive).
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In the latter case, the nature, consistency and volume of sputum are assessed:
mucosa;
serous;
purulent;
bloody (hemoptysis);
viscous;
clots;
scarce;
“full mouth”.
Cough-causing diseases:
1) bronchial asthma, bronchiectatic disease, respiratory tumors, ascaridosis,
pulmonary hypertension, pulmonary bleeding in respiratory diseases or in respiratory
endometrial ectopia, acute and chronic rhinitis sinusitis, pharyngitis, laryngitis, tracheitis, bronchitis, pneumonia, pleurisy of non-infectious and infectious genesis,
pulmonary abscess, pulmonary edema, abnormalities (tracheoesophageal fistula, laryngeal cleft, glottal paralysis, tracheobronchomalacia, bronchopulmonary dysplasia,
dyskinesia, pneumoconiosis and other interstitial lung diseases);
2) heart asthma, heart failure, congenital heart disease, tumors of neighboring
organs that compress or germinate into the wall and lumen of the respiratory tract,
aspiration;
3) gastroesophageal reflux disease or vomiting, pathologies with impaired
swallowing, bleeding into the lumen of the respiratory tract in disorders of blood
coagulation and pathologies of blood vessels, hemosiderosis, cystic fibrosis, sarcoidosis.
Hemoptysis is a pathological condition in which no more than 50 ml of blood
with sputum is released during the day.
Pulmonary bleeding — secretion of more than 50 ml of blood with sputum
during the day.
Causes of pulmonary bleeding. Often the causes of pulmonary bleeding are
bronchial adenoma, malignant tumors of the lungs and bronchi, parasitic and fungal
lesions (ascaridosis, echinococcosis, schistosomatosis, actinomycosis of the lungs),
pneumoconioses (silicatosis, silicosis), tuberculosis, bronchiectatic disease, arteriovenous anamalia, pulmonary contusions, bronchial and tracheal injuries, lung, destructive pneumonia, abscess, operated lung.
Classification of pulmonary bleeding:
mild — 50–200 ml per day;
medium degree — 200–500 ml per day;
severe — over 500 ml per day.
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Pulmonary bleeding leads to bronchial obstruction, asphyxia, hemorrhagic
shock. Sometimes there is profuse bleeding of up to 2–3 liters of blood in a short
time, which is fatal.
The diagnosis of pulmonary bleeding is quite difficult, since it requires consideration of a large differential diagnostic series, which is usually carried out between
nasal bleeding, followed by sharpening of blood into the lower respiratory tract,
bleeding from the oral cavity, gastrointestinal bleeding, accompanied by aspiration of
blood into the respiratory tract. Therefore, before conducting in-depth, often invasive
studies, it is necessary to perform a thorough physical examination of the patient,
as well as a detailed history collection with a comprehensive assessment of laboratory data.
It is fundamentally important at the stage of examination of the patient to differentiate pulmonary bleeding and bleeding from the gastrointestinal tract. Bleeding
from the gastrointestinal tract is accompanied by the following clinical and historical
signs: history of peptic ulcer disease, vomiting of unchanged blood or coffee grounds,
black stool (melena). Sometimes massive bleeding of the gastrointestinal tract is accompanied by blood entering the tracheobronchial tree, which causes a picture of
pulmonary bleeding. With pulmonary bleeding, blood can enter the stomach and
cause “coffee grounds” to vomit.
Respiratory failure.
Respiratory failure (DN) — the inability of the respiratory system to ensure
the normal gas composition of arterial blood. The following definition is more applicable in practice: respiratory failure is a pathological syndrome in which the partial
stress of oxygen in arterial blood (PaO2) is less than 60 mmHg and/or partial stress of
carbon dioxide (PaCO2) is more than 45 mmHg. With DN, there is a limitation of the
ability of the lungs to ensure the normal gas composition of arterial blood, overvoltage of the compensatory capabilities of the respiratory system occurs.
Causes of occurrence:
acute and chronic diseases of the bronchopulmonary system;
CNS lesions;
anemia;
hypertension in the pulmonary circulation;
vascular pathology of the lungs and heart;
lung tumors.
The classic signs of respiratory failure are:
a) syndrome of weakness and fatigue of the respiratory muscles;
b) shortness of breath.
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Acute and chronic DN are distinguished by the rate of onset of the pathological
condition.
Acute DN develops within a short time, a few minutes or hours, and requires
urgent therapeutic interventions.
Symptomatology:
increasing shortness of breath;
impaired central regulation of breathing, participation in the breathing of on-
ly the muscles of the neck and movement of the larynx are observed;
feelings of anxiety and excitement, inappropriate behavior;
inhibition, gradual loss of consciousness;
seizures;
earthy skin tone.
In the initial stages, tachycardia is noted, the tendency to increase blood
pressure.
Chronic DN most often develops in chronic obstructive pulmonary diseases
(chronic obstructive bronchitis), obesity, lung resection, kyphoscoliosis. In all these
situations, the resulting hypoxia leads to an increase in the work of the respiratory
muscle, which for some time ensures the preservation of the gas composition of the
blood.
Symptomatology:
gradually developing shortness of breath;
shortness of breath with minor effort or even at rest;
drowsiness;
dilation of facial vessels;
limbs with a crimson-blue tint;
facial puffiness.
The main causes of DN are acute and chronic lung diseases leading to obstruc-
tive type hypoventilation.
Complications of respiratory failure. Respiratory failure is an urgent condi-
tion that threatens human health and life. In the absence of timely care, acute DN can
lead to the death of the patient.
The prolonged course and progression of chronic DN leads to the development
of right ventricular heart failure as a result of a deficiency in the supply of oxygen to
the heart muscle and its constant overloads.
Diagnosis. At the initial diagnostic stage, a history of life and concomitant diseases is carefully collected in order to identify possible causes of the development of
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DN. When examining the patient, attention is paid to the presence of changes in the
skin, the respiratory rate is calculated, and the following is carried out:
functional diagnosis of external respiration, which allows assessing the venti-
lation capacity of the lungs. In this case, the vital capacity of the lungs, the minute
volume of breathing, the speed of air movement along various parts of the respiratory
tract are measured;
laboratory analysis of the blood gas composition, which makes it possible to
determine the degree of saturation of arterial blood with oxygen and carbon dioxide;
X-ray of the chest organs in order to detect damage to the chest, lungs, ves-
sels, bronchi.
Among lung diseases, a separate group consists of diseases accompanied by
a violation of bronchial patency, the so-called bronchobstructive syndrome, what the
patient feels as a disorder, difficulty breathing. Among them, obstructive bronchitis,
bronchial asthma are the most common. Among the mechanisms of the formation of
respiratory disorders, bronchial spasm, swelling of the bronchial mucosa resulting
from the influence of an allergen or an inflammatory process, obturation of the bronchial sputum are distinguished.
In the formation of obstructive bronchitis, the leading cause is frequent colds
accompanied by cough. Sometimes the provoking factor is the pouring of acidic gastric contents into the esophagus with reflex formation of bronchomas spasm. An unfavorable background in this situation and a aggravating factor is prolonged smoking.
Bronchial asthma is characterized by infectious causes — frequent colds, al-
lergic causes, disharmonal option, when bronchial spasm may be based on long-term
decompensation monal background of the reproductive sphere or thyroid gland, psychogenic or neurogenic variant, when psychoemotional loads contribute to the development of difficulty breathing or even an unfolded attack of suffocation.
In the clinical course of chronic obstructive bronchitis and bronchial asthma,
three phases are distinguished. The exacerbation phase is characterized by vivid
manifestations of the disease that force the patient to see a doctor or cause NSR. In
the phase of remission after an acute attack and treatment for a long time, an exacerbation of the disease is not noted. In the intermediate phase — incomplete remission — there are clinical manifestations of the disease in a mild form, which the pa-
tient does not attach due importance and does not carry out adequate treatment. It is
during this period that an acute attack of the disease can develop again and the NSR
is called.
In the stratification of asthma by severity, there is a concept of a step corresponding to certain gradations of signs of the asthma symptom complex. There are
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four stages; if the patient does not take basic drugs, then each of these stages corresponds to one of four degrees of severity:
Stage 1. Intermittent asthma:
attacks of the disease occur rarely (less than once a week);
short exacerbations;
night attacks of the disease occur rarely (no more than twice a month);
OFV1 or PSV more than 80 % of the norm;
PSV spread is less than 20 %.
Stage 2. Mild persistent asthma:
symptoms of the disease occur more often 1 time a week, but less often 1
time a day;
exacerbations can disrupt the patient's sleep, depress physical activity;
night attacks of disease occur at least 2 times a month;
OFV1 or PSV more than 80 % of the norm;
PSV spread 20–30 %.
Stage 3. Moderate persistent asthma:
asthma attacks occur almost daily;
exacerbations disrupt the patient's sleep, reduce physical activity.
night attacks of the disease occur very often (more often 1 time a week);
OFV1 or PSV are reduced to 60 to 80 % of normal value;
PSV spread is more than 30 %.
Stage 4. Severe persistent asthma:
bouts of illness occur daily;
night asthma attacks are very common;
limiting physical activity;
OFV
1
or PSV is about 60 % of normal;
PSV spread is more than 30 %.
If the patient is on basic therapy, the severity of the disease is determined by
the stage and dosage of the basic drug (low, medium and high doses).
Community-acquired pneumonia is an acute infectious disease that occurred
in community-acquired conditions, accompanied by symptoms of lower respiratory
tract infection (fever, cough, sputum secretion, chest pain, shortness of breath) and
X-ray diagnostics of focal-infiltrative changes in the lungs.
Classification of pneumonia:
a) community-acquired pneumonia (acquired outside the medical institution),
synonyms: home (outpatient);
b) nosocomial pneumonia;
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c) in-hospital (acquired in a medical institution), synonyms: hospital;
d) aspiration pneumonia;
e) pneumonia in individuals with severe immune deficits (congenital immuno-
deficiency, HIV infection, iatrogenic immunosuppression) and clarification of the location and presence of complications.
Pneumonia severity criteria:
1. Mild course: non-reflected symptoms of intoxication, body temperature subfebrile, no DN and hemodynamic disorders, pulmonary infiltration within one segment, white blood cells 9.0–10.0 × 109/L, no concomitant diseases.
2. Mean course: moderate symptoms of intoxication, fever up to 38 °C, pul-
monary infiltrate within 1–2 segments, NPV up to 22 respiratory movements per minute, heart rate up to 100 bpm, no complications.
3. Severe course: severe condition of the patient, severe symptoms of intoxication, body temperature more than 38.0 °C, grade II–III DN, hemodynamic disorders
(BP — 10.7 mmol/L, DIC syndrome, sepsis, failure of other organs and systems, impaired consciousness, exacerbation of concomitant diseases).
Indications for hospitalization.
Physical examination data:
respiratory rate ≥ 30 respiratory movements per minute;
DBP ≤ 60 mmHg;
SBP < 90 mmHg;
HR ≥ 125 bpm;
body temperature < 35.0 or ≥ 40.0 °С;
impaired consciousness;
age over 60 years;
comorbidities (COPD, bronchiectasis, diabetes mellitus, chronic renal failure
(CRF), congestive heart failure, severe weight deficiency);
inefficiency of initial antibacterial therapy. Impossibility of adequate care
and compliance with all medical prescriptions at home.
Indications for ICU hospitalization:
tachypnea ≥ 30 per minute;
SBP < 90 mmHg;
bilateral or multi-salt pneumonic infiltration;
rapid progression of focal-infiltrative changes in the lungs;
septic shock;
the need to introduce vasopressors for more than 4 hours;
acute renal failure.
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2.10. CARDIOVASCULAR SYSTEM EXAMINATION
The study of the activity of the cardiovascular system occupies the main place
in the complex of human examinations, is carried out during physical education and
sports. The main indicators of the functional state of the cardiovascular system are
heart rate, BP, stroke and minute volumes, the amount of blood circulating and the
speed of blood flow. HR is one of the informative indicators of the effect of physical
activity on the human body. An important sign of assessment is BP. Its value depends
on the shock volume of the heart, i.e. the amount of blood thrown out in one contraction, as well as on the capacity of the vascular channel, the elasticity of the walls of
blood vessels, the viscosity of the blood, its amount and some other indicators.
There are maximum (systolic), minimum (diastolic) and pulse pressure. SBP
is the pressure that occurs in the arterial system at the time of left ventricular systole,
DBP is during the period of diastole, i.e. during the decline of the pulse wave. BP
pulse pressure is the difference between maximum and minimum pressures.
One of the indicators of the functional state of the cardiovascular system at relative rest is the Robinson index (IR):
IR = HRp × SBP / 100,
where HRp is HR at relative rest, bpm; SBP — systolic BP, mmHg. IR normally does
not exceed 85 conventional units. It is noted that the lower the IR, the higher the
maximum aerobic capabilities and, therefore, the level of somatic human health.
However, when examining the patient at the prehospital stage, along with the
assessment of pulse and BP, it is of great importance to check the microcirculation of
the vascular bed, which is determined by conducting a white spot test. In the area of
anatomical snuff box in the interval between the base of the 1st and 2nd fingers on
the back surface, finger pressure on the skin is performed until white spot appears.
Then they abruptly stop the pressure and look at how long the white spot will merge
with the color of the rest of the skin. With normal microcirculation of the vascular
system, this occurs in 2–3 seconds, if the time increases by 2–3 or more times, then
the microcirculation of the skin is impaired. In severe disorders, the white spot does
not disappear.
When palpating the pulse, it is important to determine its characteristics, deficiency and arrhythmia, and after measuring BP, record the ECG. Based on the patient's complaints, history of life and disease, objective examination and ECG data,
a preliminary diagnosis is made, emergency medical care is provided at the prehospital stage, and the patient is taken to the duty cardiological or therapeutic department.
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2.11. DIGESTIVE SYSTEM EXAMINATION
The digestive examination scheme includes the following actions:
1. Collection of complaints and medical history.
2. Visual examination of the patient with general therapy and abdomen.
3. Measurement of body temperature.
4. Heart rate measurement.
5. Measurement of BP on peripheral arteries.
6. Auscultation of the lungs.
7. Abdominal palpation.
8. Abdominal percussion and definition of “hepatic dullness“.
9. Checking the symptom of irritation of the Shchetkin — Blumberg peritoneum.
10. Auscultation of abdominal peristalsis.
11. Finger examination of the rectum.
12. ECG registration.
13. Decoding, description and interpretation of ECG data.
14. Determination of blood oxygen saturation on a pulse oximeter.
15. Assessment of the severity of the patient's condition.
Language diagnostics.
The method is based on a visual study of the body of the language, the various
zones of which are a projection of certain internal organs and systems. The pathological processes occurring in these organs are reflected in the state of these zones or the
entire tongue as a whole. We are talking about both changing the color of the language, and about its consistency, shape, degree of humidity, nature of plaque.
Geographic language (desquamative glossitis, exfoliative glossitis, benign
migratory glossitis) is a condition in which the nutrition of the tongue mucosa is disrupted, resulting in rejection of areas of the epithelium. It is based on inflammatory,
allergic processes and disorders in the work of the autonomic nervous system. The
tongue is covered with bright red spots surrounded by a white rim. Sometimes the patient is worried about burning, pinching, the tongue reacts to acute, hot, spicy, disorders of taste perception can be observed. Geographical language can occur against the
background of influenza, scarlet fever, typhoid fever, as well as gastritis (inflammation of the gastric mucosa), gastroduodenitis (inflammation of the gastric mucosa and
duodenum), peptic ulcer of the stomach and duodenum, syndrome of reduced absorption of nutrients in the intestine. In children, wet (exudative) diathesis and helminthiasis are often detected along with the geographical language.
The plaque on the tongue can be of different colors, consistencies, structures
and located in different zones. The color of plaque gives very important information
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