Providing emergency assistance

The provision of emergency assistance in emergency situations at all stages raises a number of fundamental questions that require an urgent and correct solution. The doctor needs to navigate within the shortest possible time in the circumstances of the disease or trauma, carry out a post-prandic assessment of violations of vital systems and provide the necessary medical care. The effectiveness of the treatment is largely dependent on the completeness of the information that the doctor has. Diagnostic capabilities in the provision of emergency care are limited, which determines the direction of the doctor's actions to carry out the most urgent measures, postponing pathogenetic and etiotropic therapy for later.

In the basis of emergency care in critical and emergency conditions, emergency measures are taken to correct breathing and circulatory disorders. It is extremely important to distinguish between the main and secondary, to separate the means of etiological, pathogenetic and symptomatic therapy. It is necessary to observe a certain sequence of diagnostic and therapeutic measures. Immediate medical measures should go in parallel or even precede a detailed examination of the patient. It is extremely important to identify patients at high risk for developing respiratory and cardiac arrest. Identification should be based on an anamnesis, a thorough examination and examination of the patient. In approximately 80% of cases, clinical signs of deterioration develop rapidly in the first few hours before cardiac arrest. The most frequent clinical precursors are breathing disorders, tachycardia and a decrease in cardiac output.

Stages of emergency assistance

In the provision of emergency care, the following steps are usually identified:

The initial stage is the time from the moment of receiving the injury or the onset of the disease until the arrival of medical units (15-20 minutes). The lack of medical personnel and the inability of accident witnesses to provide competent first aid at this stage leads to horribly unjustified mortality from 45 to 96%. 2. Stage of professional medical care:

• pre-evacuation training (15-20 minutes) - includes the time required to assess the patient's condition and take measures to prepare him for transportation to the hospital;
• evacuation (8-15 minutes) - transportation of the patient to a hospital. Experience shows that at this stage there is a significant deterioration in the state of 55-75% of the victims. Mortality with polytrauma among them is 21-36%.

The concept of the "golden hour"

For patients in critical condition (especially with severe trauma), the time factor is of great importance. Therefore, the concept of a "golden hour" was introduced - the period from the moment of receiving the injury to rendering specialized assistance to the victim in the hospital. The help rendered during this period of time considerably increases the chances of the victim to survive. If the victim is delivered to the operating room within the first hour after the injury, the highest survival rate is achieved. Conversely, if circulatory disturbances in traumatic shock are eliminated more than sixty minutes after the injury, severe disorders on the part of vital body systems can become irreversible.

The concept of the "golden hour" is very conditional. Proceeding from the understanding of the pathogenesis of an emergency condition, a severe trauma with a shock can be affirmed: the faster the destructive process, triggered by tissue hypoxia, is stopped, the greater the chance of a favorable outcome.

Personal safety of medical personnel

Medical personnel in the provision of care may be at risk for their own health and life. Therefore, before you start to examine the patient, you need to make sure that there is no danger for the medical staff (active traffic, electricity, gas contamination, etc.). Precautions should be observed and the available protective devices used.

Medical workers should not enter the victim's area if this is dangerous and requires special training or equipment. Work in such conditions is the prerogative of rescue units trained and equipped appropriately (work "at altitude", in gassed or flame-affected rooms, etc.).

Medical personnel may be at risk if the patient is injured by toxic substances or contagious infections.

For example, if an accident occurs as a result of poisoning with strong gaseous substances (hydrogen cyanide or hydrogen sulfide gas), then any auxiliary ventilation should be carried out through a mask with a separate exhalation valve. These substances can lead to damage to the respiratory aid that is contained in the victim's lungs (with mouth-to-mouth dashes, airway or face mask).

Extremely toxic and dangerous are various corrosive chemicals (concentrated acids, alkalis, etc.), as well as organic phosphates and other substances that can easily be adsorbed through the skin or food tract.

During the resuscitation, Nesseria meningitidis was the most common microorganism that caused infection of the personnel. In the specialized literature, there are isolated reports of tuberculosis infection during resuscitation.

During medical events, you should beware of sharp objects. All cases of HIV transmission were the result of injuries to the skin of rescuers or accidental prick with a needle / medical instrument.

Transmission of cytomegalovirus, hepatitis B and C virus during cardiopulmonary resuscitation by literature sources was not noted.

Those who provide medical care must use protective glasses and gloves. To prevent the transmission of infections transmitted by airborne droplets, facial masks with a one-way valve or devices that seal the patient's airways (endotracheal tubes, laryngeal masks, etc.) should be used.

Syndromological approach

In the practice of emergency care in emergency conditions, it is first necessary to confine oneself to the establishment of the main syndrome prevalent in terms of severity (syndrome is a nonspecific clinical phenomenon, that is, one and the same set of pathological manifestations may be a consequence of different states of etiology). Given the specific features of emergency treatment (maximum efforts to provide emergency care with minimal information), the syndromological approach is fully justified. But completely adequate treatment can be carried out only with the establishment of a definitive diagnosis that takes into account the etiology, pathogenesis and pathomorphological substrate of the disease.

The setting of the final diagnosis is based on a comprehensive, comprehensive study of the main systems and organs (anamnestic data, the results of medical examination, data from instrumental and laboratory studies). The diagnostic process is built taking into account the urgency of medical measures, the prognosis of the disease for life, the dangers of medical measures in case of erroneous diagnosis and the time required to confirm the alleged cause of an emergency condition.

Inspection of the scene

Inspection of the patient's location in the unconscious state can help in establishing the cause of the development of his severe condition. Thus, the detection of the victim in the garage with the car with the engine running (or with the ignition on) is very likely to indicate carbon monoxide poisoning.

It is necessary to pay attention to unusual smells, the presence of packages and vials from drugs, household chemicals, medical certificates and documents available to the patient.

Certain information can give the patient's location. If he is on the floor, this indicates a rapid loss of consciousness. On the gradual development of the pathological process indicates the finding of the victim in bed.

Clinical examination

To rationally use the available opportunities in assessing the condition of the patient or patients it is customary to perform a primary and secondary examination. This division allows us to use a universal approach and make the right decision to choose the optimal further tactics for managing the patient.

[1], [2], [3]

Initial inspection

Primary examination of the victim (no more than 2 minutes) is performed to determine the cause that poses an immediate threat to life at the time of the examination: violation of airway patency, external bleeding, signs of clinical death.

During the initial examination, you should fix the victim's head with one hand (the patient may have damage to the cervical spine), slightly shake his shoulder and ask: "What happened?" Or "What's wrong?". Then the level of consciousness is estimated according to the following scheme.

Assessment of the level of consciousness

• The patient in consciousness - can name his name, location and day of the week.
• There is a reaction to speech - the patient understands speech, but is not able to correctly answer the three questions above.
• Pain response - reacts only to pain.
• The reaction is absent - it does not react to speech or pain.

Assessment of airway patency. It is necessary to be convinced of patency of respiratory ways or to reveal and eliminate available and potential disturbances of patency of respiratory ways

[4], [5], [6], [7]

Evaluation of breathing

It is checked whether the victim is breathing, whether breathing is adequate or not, whether there is a threat of a breathing disorder. It is necessary to identify and eliminate all existing or potential factors that can cause deterioration of the patient's condition.

[8], [9], [10], [11], [12]

Evaluation of blood circulation

Is the pulse determined, is there any evidence of severe internal or external bleeding, is the victim in shock, is the rate of capillary filling normal? It is necessary to identify and eliminate existing or potential threatening factors.

[13], [14]

Secondary inspection

Secondary examination of the patient is carried out after the elimination of an immediate threat to his life. This is a more detailed examination. During its conduct, it is necessary to assess the general condition of the victim, the level of consciousness, the degree of circulatory and breathing disorders. The patient should be examined, examined and felt "from head to toe." The medical examination should also include evaluation of general and focal neurological symptoms, as well as available methods of functional examination and laboratory diagnostics. It is necessary to establish a preliminary diagnosis or leading sign of damage.

Assessment of the general condition of the patient

In clinical practice, the most common are five degrees of severity of the general condition:

1. satisfactory - Clear consciousness, vital functions are not violated;
2. moderate - consciousness is clear or moderate stunning, vital functions are not significantly affected;
3. severe - deep stunning or sopor, expressed disturbances from the respiratory or cardiovascular system;
4. extremely severe - a coma of the I-II degree, pronounced violations of respiration and circulation;
5. terminal condition - a coma of the third degree with gross violations of vital functions.

[15], [16]

Collection of anamnesis and clarification of the circumstances of the development of an emergency condition

In an environment where immediate action is necessary, there is almost no time to collect an anamnesis. Nevertheless, after the therapy starts to give positive results, you still need to get the necessary information.

The collection of an anamnesis and clarification of the circumstances of the development of an emergency condition should be made as soon as possible. To obtain the most complete information, you should use a targeted survey scheme.

[17]

Algorithm for clarifying the circumstances of the development of an emergency

1. Who! Personality sick (name, sex, age, occupation).
2. Where? The place of the disease (at home, on the street, at work, in a public place, at a party, etc.).
3. When? Time of appearance of the first signs of the disease (time from the onset of the disease).
4. What happened? A brief description of the existing disorders (paralysis, convulsions, loss of consciousness, vomiting, fever, changes in heart rate, breathing, swallowing, etc.).
5. Because of what, after what? Circumstances, usual and unusual situations immediately preceding the disease (alcohol abuse, trauma, bodily harm, severe mental turmoil, hospital stay, diseases, homes, overheating, animal bites, vaccinations, etc.).
6. What happened before? Changes in the state from the moment of the disease to the examination (a brief description of the speed of development and the sequence of the development of violations - a sudden or gradual onset, an increase or decrease in the severity of the existing disorders).
7. Medical measures, which were carried out from the moment of the disease to the examination (transfer of accepted medications, applied therapeutic measures and the degree of their effectiveness).
8. Chronic diseases in the anamnesis (diabetes, mental illnesses, diseases of the cardiovascular system, etc.).
9. The presence in the past of similar conditions (the time of onset, signs and symptoms of the disease, their duration, whether inpatient care was required than it ended).

If the patient's condition allows (or after stabilization as a result of the treatment), it is necessary to collect information about him in the most detailed manner. The collection is made by interviewing relatives, relatives and other persons who were with the patient and carefully examining the place or place where the patient is, as well as by searching and studying medical documents and items to find out the cause of the emergence of an emergency condition (medicines, food and so on .P.).

[18], [19], [20], [21], [22]

Determining the state of consciousness

Determination of the state of consciousness allows you to assess the degree of danger of the existing lesion for the life of the patient, allows you to determine the scope and direction of the necessary studies, choose the type of emergency care (neurosurgical intervention or intensive care). The pre-hospital stage usually uses the Glasgow Coma Scale Scale, which allows you to assess the degree of impairment in adults and children over 4 years of age. The evaluation is carried out using three tests evaluating the opening reaction of the eyes, speech and motor reactions. The minimum number of points (three) means brain death. The maximum (fifteen) indicates a clear consciousness.

[23], [24], [25], [26], [27]

Skin covers

The color and temperature of the skin of the limbs give an idea of the patient's condition. Warm to the touch pink skin and pink nails indicate sufficient peripheral blood flow and are considered a positive prognostic sign. Cold pale skin with pale nails indicates centralization of blood circulation. The "marbling" of the skin, cyanosis of the nails, which color when pressed easily becomes white and does not recover for a long time, indicates the transition from spasm of peripheral vessels to their paresis.

The presence of hypovolemia is indicated by a decreased turgor (elasticity) of the skin. Turgor is determined by taking the skin into the fold with two fingers. Normally, the skin fold after the removal of the fingers quickly disappears. With reduced skin turgor, she remains in the unfavorable state for a long time - a symptom of a "skin fold".

The degree of dehydration can be determined by intradermal injection into the forearm area of 0.25 ml of physiological saline. Normally, the resorption of the papule occurs after 45-60 minutes. With an easy degree of dehydration, the resorption time is 30-40 minutes, with an average degree of 15-20 minutes, with a heavy degree of 5-15 minutes.

With some pathological conditions, edema of the lower extremities, abdomen, lower back, face and other parts of the body appear, which speaks of hypervolemia. The contours of the swollen parts of the body are smoothened, after pressing a finger on the skin, a fossa disappears after 1-2 minutes.

Body temperature

By measuring the central and peripheral temperature of the body, it is possible to judge with sufficient accuracy the hemoperfusion of the peripheral parts of the extremities. This indicator serves as the integration temperature characteristic of microcirculation and is called the "rectal-skin temperature gradient". The indicator is simple for determining and represents the difference between the temperature in the lumen of the rectum (at a depth of 8-10 cm) and the skin temperature at the rear of the foot at the base of the 1st finger.

The plantar surface of the first finger of the left foot is the standard place of skin temperature control, here it is normally 32-34 ° C.

The rectal-skin temperature gradient is sufficiently reliable and informative for assessing the severity of the shock state of the victim. Normally, it is 3-5 ° C. Increasing it more than 6-7 ° C indicates a shock.

The rectal-skin temperature gradient allows an objective assessment of the state of microcirculation under various conditions of the body (hypotension, normo- and hypertension). An increase of more than 16 ° C indicates a probability of a lethal outcome in 89% of cases.

Observation of the dynamics of the rectal-cutaneous temperature gradient makes it possible to monitor the effectiveness of antishock therapy and makes it possible to predict the outcome of the shock wave.

As an addition, a comparison of the temperature in the external auditory canal / temperature in the oral cavity and underarm temperature can be used. If the latter is lower than the first by more than 1 ° C, perfusion of the peripheral tissues is probably reduced.

[28], [29],

Evaluation of the circulatory system

The initial evaluation of the circulatory system is carried out on the basis of the analysis of pulse characteristics, arterial and central venous pressure, the state of the myocardium - with the help of electrocardiography or electrocardiography.

Heart rate. Normally, the heart rate is about 60-80 beats per minute. Its deviation to one side or the other in patients in critical condition should be considered as an unfavorable sign.

A significant decrease or increase in the heart rate may cause a drop in cardiac output to a level of hemodynamic instability. Tachycardia (more than 90-100 beats per minute) leads to an increase in the work of the heart and increase its oxygen demand.

With sinus rhythm, the maximum tolerable heart rate (that is, maintaining adequate blood circulation) can be calculated by the formula:

Heart rate max = 220 - age.

Exceeding this frequency can cause a decrease in cardiac output and myocardial perfusion, even in healthy people. In the case of coronary insufficiency and other pathological conditions, cardiac output may decrease with a more moderate tachycardia.

It should be borne in mind that sinus tachycardia with hypovolemia is an adequate physiological response. Therefore, hypotension in this condition should be accompanied by compensatory tachycardia.

The development of bradycardia (less than 50 beats per minute) can lead to circulatory hypoxia, as well as a critical decrease in coronary blood flow and the development of myocardial ischemia.

The main causes of severe bradycardia in emergency medicine are hypoxemia, increased vagal tone and cardiac conduction blockade of a high degree.

Normally, a healthy heart adapts to physiological or pathological heart rate depression through the Starling mechanism. A well-trained athlete can have a heart rate of less than 40 beats per minute at rest without any negative consequences. In patients with compromised contractility or myocardial dilatability, a bradycardia of less than 60 contractions per minute can be accompanied by a significant decrease in cardiac output and systemic blood pressure.

With disturbances of the rhythm, pulse waves can follow through unequal intervals of time, the pulse becomes arrhythmic (extrasystole, atrial fibrillation, etc.). The number of heartbeats and pulse waves may not coincide. The difference between them is called a pulse deficit. The presence of disturbances of the heart rhythm can significantly worsen the patient's condition and is subject to corrective therapy.

The measurement of blood pressure provides valuable information about the state of hemodynamics in general. The easiest way to measure blood pressure is the palpation of the pulse on the radial artery using a cuff of a sphygmomanometer. The method is convenient in emergency situations, but not very accurate in the case of low pressure or with the presence of vasoconstriction. In addition, in this way, only systolic blood pressure can be determined.

More accurate, but requiring more time and use of the phonendoscope is the measurement by auscultation of Korotkov's tones over the arteries in the ulnar fossa.

At present, the indirect measurement of blood pressure with the use of automated oscillometry is gaining increasing popularity.

The accuracy of the various electronic devices for non-invasive blood pressure measurement, currently available, is not better, and sometimes even worse than when using standard methods. Most models are not accurate at a systolic pressure below 60 mm Hg. Art. In addition, there is an underestimation of high blood pressure. Determination of pressure may not be possible during arrhythmia episodes, in addition, oscilloscopes are not able to detect abrupt jumps in blood pressure.

In patients with shock, invasive methods of measuring blood pressure are preferred, but at present they are of little use at the prehospital stage (although technically these methods do not represent great difficulties).

Systolic blood pressure within 80-90 mm Hg. Art. Indicates a dangerous, but compatible with the maintenance of basic vital functions deterioration. The systolic pressure is below 80 mm Hg. Art. Testifies to the development of a life-threatening condition requiring urgent urgent measures. Diastolic pressure over 80 mm Hg. Art. Indicates a rise in vascular tone, and pulse pressure (the difference between systolic and diastolic pressure in the norm of 25-40 mm Hg) is less than 20 mm Hg. Art. - the reduction of stroke volume of the heart.

The magnitude of arterial pressure indirectly characterizes the cerebral and coronary blood flow. Autoregulation of cerebral blood flow maintains the consistency of cerebral blood flow with changes in mean arterial pressure from 60 to 160 mm Hg. Art. Due to the regulation of the diameter of the supply arteries.

When the autoregulation boundaries are reached, the relationship between mean arterial pressure and volumetric blood flow assumes a linear nature. With systolic blood pressure below 60 mm Hg. Art. The reflation of cerebral vessels is violated, as a result of which the volume of cerebral blood flow begins to passively follow the level of arterial pressure (hypotension decreases dramatically the perfusion of the brain). But it should be remembered that arterial pressure does not reflect the state of organ and tissue blood flow in other parts of the body (except the brain and heart).

Relative stability of arterial pressure in a patient with shock does not always indicate the preservation of a normal physiological optimum of the organism, since its invariance can be achieved by several mechanisms.

Arterial pressure depends on cardiac output and overall vascular resistance. The ratio between the level of systolic and diastolic blood pressure can be considered as the ratio between the impact volume and the minute volume of blood circulation on one side and the resistance (tone) of peripheral vessels, on the other. The maximum pressure reflects mainly the volume of blood discharged into the vascular bed at the time of the systole of the heart, since it is determined mainly by the minute volume of the circulation and the stroke volume. Arterial pressure can change as a result of changes in the vascular tone of peripheral vessels. The increase in vascular resistance with an unchanged minute volume of blood circulation leads to a predominant increase in diastolic pressure with a decrease in pulse pressure.

Mean arterial pressure (SBP) is normally 60-100 mm Hg. Art. In clinical practice, the mean arterial pressure is calculated by the formulas:

SBP = AD diast + (AD system-AD dist) / 3 or SBP = (BP system + 2A diast) / 3.

Normally, the average arterial pressure lying on the back of the patient is the same in all large arterial vessels. Usually, there is a small pressure gradient between the aorta and the radial vessels. The considerable influence on the supply of blood to the tissues of the organism is exerted by the resistance of the vascular bed.

Mean arterial pressure of 60 mm Hg. Art. Can cause abundant blood flow through the significantly widened vascular bed, while the mean arterial pressure is 100 mm Hg. May be inadequate during malignant hypertension.

Errors in measuring blood pressure. The pressure determined by sphygmomanometry is characterized by inaccuracy when the width of the cuff is less than 2/3 of the circumference of the arm. The measurement can show an overestimated blood pressure in the case of using an overly narrow cuff, as well as in the presence of severe arteriosclerosis, which prevents the compression of the brachial artery by pressure. In many patients with hypotension and low cardiac output, the points of muffling and disappearance of tones during the determination of diastolic pressure are poorly discernible. During the shock, all Korotkov's tones can be lost. In this situation, Doppler ultrasound cardiography helps detect systolic pressures below the threshold of audibility.

The state of central hemodynamics can be quickly estimated from the ratio of heart rate and systolic pressure. To determine the severity of the condition and the need for emergency measures, the following nomogram is convenient.

Normally, the systolic pressure exceeds twice the pulse rate (120 mm Hg and 60 beats per minute, respectively). When these indicators are equalized (tachycardia to 100 per minute and a systolic pressure drop to 100 mm Hg), then we can talk about the development of a threatening state. A further decrease in systolic blood pressure (80 mm Hg and below) on the background of tachycardia or bradycardia indicates the development of a shock state. Central venous pressure is a valuable, but very approximate indicator for assessing the state of central hemodynamics. It is a gradient between intrapleural pressure and right atrial pressure. The measurement of central venous pressure allows an indirect assessment of venous return and the state of contractility of the right ventricle of the myocardium.

Central venous pressure is determined using a catheter inserted into the superior vena cava through a subclavian or jugular vein. A device for measuring the central venous pressure of Valhchan is connected to the catheter. The zero mark of his scale is set at the level of the middle axillary line. Central venous pressure characterizes venous return, mainly depending on the volume of circulating blood, and the ability of the myocardium to cope with this return.

Normally, the central venous pressure is 60-120 mm of water. Art. Its decrease is less than 20 mm of water. Art. Is a sign of hypovolemia, while an increase of more than 140 mm of water. Art. Is caused by oppression of pumping function of the myocardium, hypervolemia, increased venous tone or obstruction of blood flow (cardiac tamponade, pulmonary embolism, etc.). That is, hypovolemic and distributive shocks cause a decrease in central pressure, and cardiogenic and obturation - an increase.

Increase in central venous pressure in excess of 180 mm of water. Art. Indicates the decompensation of cardiac activity and the need to stop or limit the volume of infusion therapy.

With central venous pressure within 120-180 mm water. Art. You can use a trial jet infusion of 200-300 ml of fluid into a vein. If there is no additional recovery or it is eliminated within 15-20 minutes, the infusion can be continued, reducing the infusion rate and controlling the venous pressure. The level of central venous pressure is below 40-50 mm of water. Art. Should be regarded as evidence of hypovolemia requiring compensation.

This sample serves as a key test for determining hemodynamic reserves. Improving cardiac output and normalizing systemic blood pressure without developing symptoms of excessive cardiac filling pressure makes it possible to adjust the ongoing infusion and drug therapy.

The rate of refilling the capillaries. Assessing the state of the blood circulation, it is useful to check the filling of the pulse and the speed of refilling the capillaries of the nail bed (spot symptom). The duration of filling the capillaries of the nail bed after the pressure is normal is no more than 1 -2 seconds, with shock exceeding 2 seconds. This test is extremely simple, but not very popular in clinical practice, since it is difficult to accurately determine the moment and time of disappearance of a pale spot on the skin after pressing.

[30], [31],

Evaluation of the respiratory system

In assessing the respiratory system, first of all, it is necessary to take into account factors such as frequency, depth, the nature of breathing, the adequacy of chest movements, the coloration of the skin and mucous membranes. A thorough examination of the neck, chest and abdomen is required to differentiate the paradoxical movement. Auscultation of pulmonary fields should be performed to determine the adequacy of air intake, and also to detect bronchial obstruction or pneumothorax.

The normal frequency of respiratory movements is 12-18 per minute. An increase in the frequency of respiratory movements in excess of 20-22 per 1 minute leads to a decrease in the effectiveness of the respiratory function, as the proportion of the dead volume in the minute ventilation of the lungs increases and the work of the respiratory musculature increases. Rare breathing (less than 8-10 per 1 minute) is associated with a risk of hypoventilation.

It is extremely important to assess the degree of patency of the upper respiratory tract in patients at risk of developing their obstruction. With partial obstruction of the upper respiratory tract, the patient is conscious, excited, complains of shortness of breath, coughing, noisy breathing.

Inspiratory stridor is caused by obstruction at the level of the larynx or lower. The presence of expiratory rales testifies to obstruction of the lower respiratory tract (collapse and obstruction during inspiration).

With complete obstruction of the upper respiratory tract, breathing is not heard and there is no movement of air from the oral cavity.

Bulling sounds during breathing indicate the presence of fluid or semi-liquid foreign bodies in the respiratory tract (blood, stomach contents, etc.). Snoring sounds occur with a partial occlusion of the pharynx with tongue or soft tissue. With laryngeal spasm or obstruction, sounds resemble "crow-crowds."

With various pathological conditions, there may be irregularities in rhythm, frequency and depth of breathing. Cheyne-Stokes breathing is characterized by series of gradually increasing depths of inspiration alternating with periods of shallow breathing or short-term stops of breathing. A disorderly, irregular pattern of deep and shallow breathing can be observed with a distinct difficulty of exhalation-Biot's breathing. In patients with impaired consciousness, in extremely severe condition, against the background of acidosis Kussmaul's breathing often develops - pathological breathing, characterized by uniform rare respiratory cycles, deep noisy inspiration and exhaled exhalation. With some diseases develops wheezing (sudden, irregularly appearing convulsive contractions of the diaphragm and respiratory muscles) or breathing in group breaths (alternating group breaths with gradually extending respiratory pauses).

There is also an atonal breath arising during the process of dying after a terminal pause. It is characterized by the appearance of a short series of breaths (or one superficial inspiration) and indicates the onset of agony.

The necessary information can be given by the definition of the type of breathing disorder. So, with intensified excursions of the musculature of the abdomen with simultaneous switching off of the chest muscles (abdominal type) from the act of breathing, in some cases it is possible to assume damage to the cervical spinal cord. Asymmetry of chest movements indicates the presence of pneumothorax, hemothorax, unilateral damage to the diaphragmatic or vagus nerve.

When assessing the state of the respiratory system, it is necessary to take into account such clinical symptoms as cyanosis, sweating, tachycardia, arterial hypertension

[32], [33], [34], [35]

Instrumental methods of examination

If 10 years ago we had to state that, unfortunately, the doctor at the stage of rendering first aid is practically deprived of the possibilities of instrumental examination of patients, at present the situation has radically changed. A large number of portable devices that allow using qualitative or quantitative methods to provide full information about the status of patients in real time and on the scene have been created and introduced into clinical practice.

Electrocardiography

Electrocardiography is a method of graphical recording of electrical phenomena that occur in the heart when the membrane potentials change.

On the electrocardiogram, positive teeth P, RwT, negative Q and S spines are normally recorded. Sometimes a non-permanent U wave is observed.

The tooth P on the electrocardiogram reflects the excitation of the atria. His ascending knee is due mainly to the excitation of the right atrium, which results from the excitation of the left atrium. Normally, the amplitude of the P wave does not exceed -2 mm, the duration is 0.08-0.1 seconds.

Behind the tooth P follows the interval PQ (from the tooth P to the beginning of Q or R). It corresponds to the time of the pulse from the sinus node to the ventricles. Its duration is 0.12-0.20 seconds.

When the ventricles are excited on an electrocardiogram, the QRS complex is recorded. Its duration is 0.06-0.1 seconds.

The tooth Q reflects the excitation of the interventricular septum. It is not always recorded, but if it is present, the amplitude of the Q wave should not exceed 1/4 of the amplitude of the R wave in this lead.

The tooth R is the highest tooth of the ventricular complex (5-15 mm). It corresponds to the almost complete spread of the pulse along the ventricles.

Sine S is recorded with complete excitation of the ventricles. As a rule, a small amplitude (2.5-6 mm) may not be completely expressed.

After the QRS complex, a straight line is recorded - the ST interval (corresponds to the phase of complete depolarization, when there is no potential difference). The duration of the ST interval varies widely depending on the frequent heartbeats. Its displacement should not exceed more than 1 mm from the isoelectric line.

Tine T corresponds to the phase of repolarization of the ventricular myocardium. In norm it is asymmetric, has an ascending knee, a rounded apex and a steeper downward knee. Its amplitude is 2.5-6 mm. The duration is 0.12-0.16 seconds.

The QT interval is called an electric systole. It reflects the time of excitation and recovery of the ventricular myocardium. The duration of QT varies greatly depending on the heart rate.

In urgent and terminal states, II standard leads are usually used for evaluation, which allows better differentiation of a number of quantitative indicators (for example, differentiation of small-scale ventricular fibrillation from asystole).

The second standard lead is used to determine cardiac arrhythmias, V5 leads to ischemia identification. The sensitivity of the method in identification is 75%, and in combination with the data of the II lead increases to 80%.

Electrocardiographic changes in various pathological conditions will be described in the relevant sections.

In the practice of emergency care, cardiomonitors, devices permanently fixing an electrocardiogram curve on the monitor display, are widely used. Their use makes it possible to quickly determine cardiac rhythm disturbances, myocardial ischemia (ST segment depression), acute electrolyte disorders (especially changes in K +).

In some cardiomonitors, a computer analysis of the electrocardiogram, in particular the ST segment, is possible, which allows early detection of myocardial ischemia.

[36], [37], [38], [39], [40]

Pulse Oximetry

Pulse oximetry is an informative non-invasive method for the continuous assessment of arterial blood hemoglobin saturation with oxygen (SpO2) and peripheral blood flow. The method is based on measuring the absorption of light in the area of the body (earlobe, finger) at the height of the pulse wave, which makes it possible to obtain saturation values close to the arterial (along with the plethysmogram and heart rate values).

The hemoglobin (Hb), bound to oxygen (HbO2) and not bound to oxygen, differently absorb light of different wavelengths. Oxygenated hemoglobin absorbs more infrared light. Deoxygenated hemoglobin absorbs more red light. Pulse oximeter on one side of the sensor has two LEDs, emitting red and infrared light. On the other side of the sensor is a photodetector, which determines the intensity of the light flux incident on it. By the difference between the amount of light absorbed during systole and diastole, the device determines the amount of arterial ripple.

Saturation is calculated as the ratio of the amount of HNO2 to the total amount of hemoglobin, expressed in percent. Saturation correlates with the partial oxygen tension in the blood (the rate of PaO2 = 80-100 mm Hg). At PaO2 80-100 mm Hg. Art. SpO2 is in the range of 95-100%, with 60 mm Hg. Art. SpO2 is about 90%, and at 40 mm Hg. SpO2 is about 75%.

In comparison with invasive methods of determining blood oxygenation (SaO2), pulse oximetry makes it possible to quickly obtain information, allows to estimate the level of organ blood flow and the adequacy of oxygen delivery to tissues. Pulse oximetry data, showing an oxygen hemoglobin saturation of less than 85% with an oxygen concentration in the respirable mixture above 60%, indicate the need for a patient to be transferred to an artificial lung ventilation.

Currently, there is a wide range of portable, network-operated and battery-operated pulse oximeters that can be used at the scene, at home or while transporting patients in an ambulance. Their use can significantly improve the diagnosis of respiratory disorders, timely establish the danger of development of hypoxia and take measures to eliminate it.

Sometimes pulse oximetry does not accurately reflect lung function and the level of PaO2. This is often observed when:

• wrong position of the sensor;
• bright external light;
• movements of the patient;
• reduction of perfusion of peripheral tissues (shock, hypothermia, hypovolemia);
• anemia (at hemoglobin values below 5 g / l, 100% saturation of blood can be noted even with a lack of oxygen);
• carbon monoxide poisoning (high concentrations of carboxyhemoglobin can give a saturation value of about 100%);
• violation of the heart rate (changes the perception of the pulse oximeter pulse signal);
• presence of dyes, including nail polish (can provoke an understated value of saturation). Despite these limitations, pulse oximetry has now become a generally accepted monitoring standard.

Capnometry and Capnography

Capnometry refers to the measurement and digital display of the concentration or partial pressure of carbon dioxide in the inhaled and exhaled gas during the patient's breathing cycle. Capnography is understood as the graphical representation of these indicators in the form of a curve.

Methods for estimating the carbon dioxide content are of high value, since they allow us to judge the adequacy of ventilation and gas exchange in the patient's body. Normally, the level of pCO2 in the exhaled air is 40 mm Hg. Ie, approximately equal to alveolar pCO2 and 1-2 mm Hg. Art. Lower than in the arterial blood. There is always an arterial-alveolar gradient of the partial stress of CO2.

Usually in a healthy person this gradient is 1-3 mm Hg. Art. The difference is due to the uneven distribution of ventilation and perfusion in the lung, as well as shunting the blood. If there is a pathology of the lungs, then the gradient can reach significant values.

The apparatus consists of a gas sampling system for analysis and the analyzer itself.

For the analysis of a gas mixture, infrared spectrophotometry or mass spectrometry methods are usually used. The change in the partial pressure of carbon dioxide in the patient's airways during inspiration and expiration is graphically represented by a characteristic curve.

The segment of the curve AB reflects the arrival of dead air deprived of CO2 into the analyzer (Figure 2.5). Starting from point B, the curve goes up, that

Is due to the intake of a mixture containing CO2 in increasing concentrations. Therefore, the section of the sun is depicted in the form of a steeply rising curve. At the very end of exhalation, the speed of the air stream decreases, and the concentration of CO2 approaches the value called the concentration of CO2 at the end of the exhalation - EtCO2 (section CD). The highest concentration of CO2 is observed at point D, where it closely approaches the concentration in the alveoli and can be used to estimate pCO2. The segment DE reflects the decrease in concentration in the analyzed gas, the conditioned arrival with the onset of inspiration in the respiratory tract of a mixture with a low content of CO2.

Capnography to some extent reflects the adequacy of ventilation, gas exchange, CO2 production and the state of cardiac output. Capnography is successfully used to monitor the adequacy of ventilation. Thus, with a random intubation of the esophagus, unintentional extubation of the patient or obstruction of the endotracheal tube, there is a marked decrease in the level of pCO2 in the exhaled air. A sudden decrease in pCO2 in the exhaled air is most often due to hypoventilation, airway obstruction, or an increase in dead space. The growth of pCO2 in the exhaled air is most often due to changes in pulmonary blood flow and hypermetabolic states.

According to the recommendations of ERC and AHA 2010, continuous capnography is the most reliable method of confirming and monitoring the position of the endotracheal tube. There are other ways to confirm the position of the endotracheal tube, but they are less reliable than continuous capnography.

During transport or movement of patients, there is an increased risk of displacement of the endotracheal tube, so the rescuers should constantly monitor the level of ventilation of the lungs according to the capnogram to confirm the position of the endotracheal tube.

When measuring the CO2 content on expiration, it is meant that blood passes through the lungs, and therefore the capnogram can also act as a physiological indicator of the effectiveness of compression compressions and the restoration of spontaneous circulation. Inefficient compression compressions (due to the characteristics of the patient or the actions of the caregiver) cause low values of PetCO2. Reduction of cardiac output or repeated cardiac arrest in patients with restored spontaneous circulation also leads to a decrease in PetC02. And, on the contrary, the restoration of spontaneous circulation can cause a sharp increase in PetCO2

[41], [42], [43]

Determination of troponin and cardiomarkers

The rapid diagnosis of myocardial infarction is easily accomplished at the prehospital stage with the help of various qualitative test systems for the determination of "Troponin I". The result is determined 15 minutes after the application of blood to the test strip. At present, rapid test systems for the diagnosis of myocardial infarction have been developed, based on the qualitative immunochromatographic detection of several markers (myoglobin, SK-MB, Troponin I).

Quantitative determination of the concentration of cardiomarkers is possible with the help of immunochemical express-analyzers. This portable portable device (weight 650 g, dimensions: 27.5 x 10.2 x 55 cm), the principle of which is based on the use of highly specific immunochemical reactions. The accuracy of the studies is highly comparable with laboratory immunochemical methods of analysis. The parameters determined are troponin T (measuring range 0.03-2.0 ng / ml), SK-MB (measuring range 1.0-10 ng / ml), myoglobin (measuring range 30-700 ng / ml), J- dimer (measuring range 100-4000 ng / ml), natriuretic hormone (NT-proBNP) (measuring range 60-3000 pg / ml). The time for obtaining the result is from 8 to 12 minutes from the time of blood sampling.

[44], [45], [46], [47], [48], [49], [50], [51], [52]

Measurement of glucose

Standards for emergency care in patients with impaired consciousness require the measurement of blood glucose. This study is carried out using a portable glucometer. To use the meter, you need a handle for piercing the skin, sterile lancets and special test strips, substance

Which reacts with blood. Evaluation of the level of glucose concentration depends on the type of device. The principle of photometric models is based on the staining of the indicator area due to the reaction of blood and the active substance. The color saturation is analyzed with the built-in spectrophotometer. Electrochemical instruments, on the other hand, measure the strength of the electric current that appears as a result of the chemical reaction of glucose and the enzyme substance of the test strip. Devices of this type are characterized by ease of use, obtaining a fast (from 7 seconds) measurement result. For diagnosis, a small amount of blood is required (from 0.3 μl).

Measurement of gas composition of blood and electrolytes

A rapid study of the gas composition of blood and electrolytes (including at the hospital stage) became possible with the creation of portable analyzers. These are mobile and precise instruments with easy control that can be used anywhere and anytime (Figure 2.9). The speed of measurement of indicators varies from 180 to 270 seconds. The devices have built-in memory that stores the analysis results, identification number, date and time of analysis. Instruments of this type are capable of measuring pH (ion concentration - H + activity), partial pressure of CO2 (pCO2), partial pressure of O2 (pO2), concentration of sodium ions (Na +), potassium (K +), calcium (Ca2 +), blood urea nitrogen , glucose and hematocrit. The calculated parameters are the concentration of bicarbonate (HCO3), total CO2, excess (or deficiency) of bases (BE), hemoglobin concentration, saturation (saturation) of O2, O2 corrected (O2ST), the sum of bases of all buffer systems of blood (BB), standard excess of bases (SBE), standard bicarbonate (SBC), arterial alveolar gradient O2, respiratory index (RI), standardized calcium (cСа).

Normally, the body maintains a constant balance between acids and bases. PH is the value equal to the negative decimal logarithm of the concentration of hydrogen ions. The pH value of arterial blood is 7.36-7.44. With acidosis, it decreases (pH <7.36), with alkalosis increases (pH> 7.44). The pH reflects the ratio of CO2, the content of which is regulated by the lungs, and the HCO3 bicarbonate ion, the exchange of which occurs in the kidneys. Carbon dioxide dissolves to form carbonic acid H2CO3, the main acidic component of the internal environment of the body. Its concentration can not be measured directly, so the acid component is expressed through the carbon dioxide content. Normally, the ratio of CO2 / HCO3 is 1/20. If the balance is disturbed and the acid content increases, then acidosis develops, if the base of RaCO2: the partial voltage of carbon dioxide in the arterial blood. This is the respiratory component of the regulation of the acid-base state. It depends on the frequency and depth of breathing (or adequacy of ventilation). Hypercapnia (PaCO2> 45 mmHg) develops as a result of alveolar hypoventilation and respiratory acidosis. Hyperventilation leads to hypocapnia - a decrease in the partial pressure of CO2 below 35 mmHg and respiratory alkalosis. In case of CBS disturbances, respiratory compensation is turned on very quickly, therefore it is extremely important to check the values of HCO2 and pH to find out whether the changes in PaCO2 are primary or they are compensatory changes.

PaO2: partial oxygen tension in the arterial blood. This value does not play a primary role in the regulation of CBS, if it is within the norm (not less than 80 mmHg).

SpO2: saturation of arterial blood hemoglobin with oxygen.

BE (ABE): deficiency or excess of bases. In general, it reflects the number of blood buffers. An abnormally high value is characteristic for alkalosis, low values are for acidosis. Normal value: + 2.3.

HCO-: bicarbonate of plasma. The main renal component of CBS regulation. The normal value is 24 meq / l. Reduction of bicarbonate is a sign of acidosis, increase - alkalosis.

Monitoring and evaluation of the effectiveness of the therapy

In addition to the initial evaluation of the patient's condition, dynamic observation is necessary during the treatment, especially during transportation. The adequacy of the therapy should be assessed in a comprehensive manner, according to several criteria, and in stages, depending on the stage of intensive care.

Control of vital body functions in time is an integral technology in the practice of emergency medicine. In critical states, the change in these functions occurs so quickly that it is very difficult to follow all the changes. Emerging violations are multifunctional, occur simultaneously and in different directions. And a doctor for managing and replacing disturbed functions needs objective and maximum information about the functioning of vital systems in real time. Therefore, in the clinical practice of emergency medicine, it is mandatory to introduce standards for monitoring vital functions - dynamic monitoring of functional correction and management of vital functions in patients and those who are in critical condition.

Monitoring is not only important, but also fundamentally indispensable complex of actions, without which the effective management of patients in critical conditions is impossible. At the initial stage of care, there is no possibility of conducting most diagnostic activities and modern monitoring of vital functions. Therefore, the evaluation of such easily interpreted indicators as the level of consciousness, pulse, arterial and central venous pressure, diuresis, is the first step to assess the adequacy of the intensive therapy being conducted. These indicators allow to judge adequately the adequacy of the therapy during the first hours of development of an emergency condition.

So, for example, the adequacy of infusion therapy can be judged by the magnitude of diuresis. Adequate urine production is most likely to suggest the adequacy of perfusion of other vital organs. Achieving diuresis within 0.5-1 ml / kg / h indicates adequate renal perfusion.

Oligouric is a decrease in the rate of diuresis less than 0.5 ml / kg / h. Urine excretion of less than 50 ml / h indicates a reduced perfusion of tissues and organs, less than 30 ml / h - indicates the need for urgent recovery of peripheral blood flow.

With anuria, the volume of diuresis per day is less than 100 ml.

In the case of a patient developing cerebral insufficiency, dynamic monitoring of the level of consciousness, the appearance of cerebral symptoms, dislocation syndrome, etc. Is of great importance.