Broad concept: refers to the facts witnessed by the sick or injured, including medical personnel, members of the Red Cross,
Drivers, police and other on-site personnel give them necessary first aid to maintain basic vital signs and relieve pain.
Narrow concept: refers to the activities that professional emergency institutions are equipped with professional medical personnel, communication and emergency equipment to carry out on-site treatment and on-the-way monitoring before patients arrive at the hospital. Closely related to emergency medicine. According to the definition of emergency medicine by American College of Emergency Physicians (ACEP), emergency medicine is a major whose main task is to evaluate, handle, treat and prevent unpredictable diseases and injuries. The clinical work of emergency medicine includes the initial evaluation, treatment and disposal of anyone, any symptom, any event and the emergency that patients think at any time, or someone treats them. Emergency medicine provides effective clinical and management services for out-of-hospital emergency system. Let's talk about the identification of pre-hospital critical diseases in combination with the "clinical model of emergency medicine".
First, the clinical model of emergency medicine
"Clinical model of emergency medicine" refers to the analysis of clinical practice of emergency medicine by SAEM (Society for Academic Emergency Medicine) in the United States, so as to formulate the core content of emergency medicine and list common symptoms, signs and diseases. Including the emergency contents of all clinical departments, such as internal medicine, surgery, gynecology, pediatrics, eyes, ears, oral cavity and so on. 78 symptoms, 665 diseases, 66 technical operations and management rules and regulations of more than 40 departments are listed.
The "model" mainly includes three contents: ① evaluating the severity of the patient's illness; ② What must be done to provide emergency medical services; ② List common symptoms, signs and disease manifestations. Concentrate on these three contents to compile this "model" and make it clear that emergency medicine is different from other majors. "Mode" represents the main information and technology necessary for clinical work of emergency medicine, and has been widely verified by emergency doctors.
The "model" especially emphasizes the characteristics of emergency medicine. Emergency patients often come to the clinic with the main symptoms, and the diagnosis is unknown. Therefore, the diagnosis and treatment of patients by emergency doctors begins with the diagnosis and differential diagnosis of symptoms. In the whole process of contact with patients, the judgment and understanding of patients' clinical manifestations are the characteristics and cornerstones of emergency clinical practice, thus guiding the selection of diagnostic examination items and treatment measures.
Evaluating the severity of patients is one of the three main contents in the "model". The "model" divides various symptoms and diseases into three levels: critical, severe and mild. List some symptoms and explain them.
The first group of symptoms belong to critical diseases: asphyxia, shock, coma and cyanosis;
The second group of symptoms are critical or severe: dehydration, hypotension, multiple trauma, hemiplegia or paraplegia, wheezing, peritonitis, dyspnea, shortness of breath, hemoptysis, laryngeal sound;
The third group of symptoms are critical, severe or mild: fever, change of consciousness, headache, chest pain, back pain, abdominal pain, syncope, systemic bleeding, rectal bleeding, bloody stool, vaginal bleeding, erythema and poisoning. In this group of symptoms, it is the key to distinguish between fatal symptoms and mild symptoms.
Two, the four boundaries in clinical work
There are many things in clinical work, but the earliest reaction to contact patients should be to draw four boundaries, namely, death or immortality; Fatal and non-fatal; Organic and functional; Infectious and non-infectious
1, dying indication This is the most critical patient in the emergency department. Oxygen should be given immediately after the initial diagnosis, and the rescue measures of opening veins should respond quickly. The indication of judging dying is that blood pressure cannot be measured or can only be heard somewhere, such as 60/60/0 mmHg; ; The pulse disappears or is extremely weak; Breathing slowly and irregularly, double inhalation, long inhalation, sighing; Pupils respond to light by enlarging, centering and disappearing. On the other hand, if the vital signs are normal, there is generally no sudden death, such as catastrophic death, which is also sudden death and unpredictable.
2. Fatal indications: such as shock, rapid coma, multiple injuries, dyspnea, falling to the ground, malignant arrhythmia, etc.
3, organic and functional: such as headache, long course of disease, headache nature, intensity, frequency unchanged for many years, generally functional headache; If the headache is short and severe, it may be an organic headache, especially coughing and sneezing.
4. Infectious and non-infectious: Through the example of SARS for two years, we should get a profound lesson: infectious diseases should be included in our basic diagnostic thinking, and sometimes they should be listed as the first disease to be excluded.
Third, key indications
[Consciousness disorder and mental symptoms]
There are many kinds of consciousness disorders, including drowsiness, lethargy, coma and mental disorders. Serious disturbance of consciousness can generally realize that the condition is critical, while mild disturbance of consciousness and mental symptoms are often not well understood. But once there is a disturbance of consciousness, it means that the condition is serious. If the elderly have mild disturbance of consciousness, such as drowsiness, they should think of serious infection and electrolyte and acid-base balance disorder. If you have symptomatic mental symptoms, you should also think that your illness is serious. I once met a 67-year-old male patient. At first, he went to see a doctor because his family found that he couldn't find his way home. Later, he was diagnosed with viral encephalitis and almost died. Such patients have cerebrovascular diseases, hepatic coma, uremia, septicemia, pituitary crisis, tuberculosis, alcohol withdrawal, pancreatic encephalopathy and so on. I once met a patient with pituitary crisis who was taken back to the hospital from a mental hospital. Unfortunately, she was misdiagnosed at 15. Therefore, any physical disease that causes consciousness or mental abnormality, even if the symptoms are mild, is a serious symptom and should not be easily transferred to a mental hospital.
[abnormal breathing]
Dyspnea includes dyspnea, respiratory distress, shortness of breath and abnormal respiratory rhythm. Among the four vital signs, abnormal breathing is ignored, probably because the quantitative concept is not as obvious as blood pressure and heart rate. Professor Lou Bincheng once warned that those who are short of breath will die, reminding us to pay attention to those who are short of breath. He pointed out:
1, abnormal breathing is the most sensitive sign of life. This is because the number of pulmonary capillary endothelial cells is the largest in the whole body, and the reaction with inflammatory mediators and cytokines is the strongest in the process of inflammatory reaction. According to the four conditions of systemic inflammatory response syndrome (body temperature >; 38 degrees, breathing > 22 beats/min, pulse >; 90 times/min, WBC> 1.2X 109//) was observed in three groups of patients. ① Mild group (upper respiratory tract infection and enteritis) 30 cases; ② 30 cases of critical reorganization (respiratory failure and heart failure); ② Death group: 30 cases. Among them, 6 cases met the four criteria, all in the death group, and the highest was 3 1 case of respiratory abnormality.
① Abnormal breathing is the highest of the four indicators: ② Once abnormal breathing occurs, it is crucial: abnormal breathing should be understood from the perspectives of anatomy and neuromodulation, as well as inflammatory reaction, such as acute lung injury, ARDS, respiratory failure and acute pulmonary edema. These pathophysiological changes exist in various critically ill patients.
2. The most serious respiratory distress is laryngeal obstruction. ① Manifestations: inspiratory dyspnea, concave sign and aphonia. ② Etiology: laryngitis, laryngeal edema (allergy), vocal cord polyp and swallowing by mistake. Treatment: tracheal intubation, ring-clamped membrane puncture.
3. Diagnosis and treatment of sitting breathing: common in acute left heart failure, asthma and pneumothorax. The most common heart and lung diseases account for about 90%. In the diagnosis of heart failure and respiratory failure, we should first rule out lung compression such as pneumothorax and pleural effusion, because tension pneumothorax can die in a short time because of different treatment principles. Pneumothorax is sudden, and tension pneumothorax is getting worse. Monitor patients every 15-30 minutes and count the number of breaths. The main sign of pneumothorax is the decrease of breathing sound on the affected side, such as the decrease of breathing sound accompanied by clear percussion sound. Thoracic puncture and exhaust should be performed immediately, because respiratory and cardiac arrest may occur during handling or examination.
4. It is easy to be complicated with acute lung injury and ARDS.
(1) Pneumonia pneumonia complicated with dyspnea indicates that the condition is critical. Pay attention to the condition of special people. Criterion of severe pneumonia formulated by Respiratory Branch of Chinese Medical Association ① Consciousness disturbance: ② Respiratory frequency >; 30 times/minute: ② PAC 02
(2) Acute Severe Pancreatitis It is very important to judge the severity of acute pancreatitis, because severe or necrotizing pancreatitis has a high mortality rate, and the lung is the most vulnerable organ. According to literature reports, 70% of patients with acute pancreatitis (AP) are complicated with respiratory insufficiency in different degrees. Sun Shi reported 27 cases of acute pancreatitis with blood gas and pulmonary complications. Among them, hypoxemia 19 cases (70.4%), edema 19 cases (68.4%), necrosis in 6 cases (4 cases of ARDS): the total decrease of PAT02 19 cases: Liu Zeng reported 79 cases of acute severe pancreatitis. Without careful observation, I just made a superficial suggestion. Acute pancreatitis must monitor the respiratory rate, and it is best to do a blood gas test. If Paco2 drops, it means hyperventilation, which should be paid attention to, especially in elderly patients.