The brain coma used to be known as an apoplexic coma, and the main cause of it is primary or secondary lesions of the brain as a result of the violation of the blood supply to the cerebral tissue.

The reasons

The cause of the cerebral coma is an extensive lesion of the brain under the influence of toxic and, less often, traumatic factors. Among the toxic factors in the first place is alcoholic and narcotic intoxication, coma against the background of carbon monoxide poisoning. Closed brain injuries - leading traumatic etiology Brain coma. Despite the overall similarity of pathogenetic processes, disorders arising in the main brain departments differ in different types Komach.

However, with any form and type of coma there are lesions at the level of the cortex of the brain, reticular formation, basal nuclei and limbic system. It is the vastness of such violations (transient or chronic) leads to the fact that the body loses the possibility of coordinating activities, which entails the disorder of almost all functions.

Symptoms

Brain coma, first of all, manifests the loss of consciousness while preserving the main reflexes, which indicates the preserved viability of the brain. The second group of symptoms is the lack of reaction to stimuli - tactile primarily. The victim seems to be falling asleep, especially since the brain coma is accompanied by a rough state - the eyes are closed, the person literally "failed" into sleep.

At the first stages of the cerebral coma in the patient, at least the minimum volume of movements was preserved - it is able to change the position of the body, swallows saliva. The deeper the brain defeat, the more pronounced the depression of consciousness clinic, up to the disconnection of self-breathing. Cramps, vomiting, body temperature increases are also signs of brain coma.

Diagnosis and treatment

The diagnosis of cerebral coma is impossible to install only with the help of inspection, although typical signs of coma and may indicate its development. A thorough neurological inspection is needed using special estimated scales. Electroencephalogram, computed tomography are also necessary for the diagnosis of brain coma.

The treatment depends on the cause of the coma, that is, if the brain coma is toxic, the reason that caused it is eliminated, disinfecting therapy is carried out. Trachee intubation, dynamic assessment and maintenance of basic life functions, careful care - all this requires hospitalization in the intensive care unit.

Forecast

The forecast is entirely dependent on the etiological cause of coma. Some comes lead to slow fuse brain Functionswhich is almost impossible to stop and the person moves to the vegetative existence. The brain coma of toxic origin is easier than therapy. General averaged mortality in the case of a brain coma can reach 35%. It should be remembered that no coma is passed for the body without a trace.

MDK 03.02 Medicine Catastrophe

Ticket number __________

Question: Anaphylactic shock. Forms. Urgent Care.

Reference standard

Anaphylactic shock

IN complex processobserved during anaphylactic shock, you can allocate three stages:

The first stage is immunological. It covers all changes in the immune system, arising from the moment of the admission of allergen in the body; the formation of antibodies and / or sensitized lymphocytes and the compound of them with the allergen repeated or persistent in the body;

The second stage is Patochimic, or the stage of formation of mediators. Incentive to the emergence of the latter is the compound of allergen with antibodies or sensitized lymphocytes at the end of the immunological stage;

The third stage is the pathophysiological, or the stage of clinical manifestations. It is characterized by the pathogenic effect of the formed mediators on cells, organs and tissues of the body.

Urgent Care

Adrenaline 0.5 mg V / Motor

Pulse oximetry

Inhalation oxygen

With insufficient effect

Sodium chloride 0.9% - 500 ml in / venously drip

References for an integrated exam

PM.03. Providing medical care for urgent and extreme states

MDK 03.01 Basics of Resuscitation

MDK 03.02 Medicine Catastrophe

Ticket number __________

Question: Anaphylactic shock. Types of flow. Urgent Care.

Reference standard

Anaphylactic shock - This is an immune response of an immediate type, which develops with a re-introduction into an allergenic organism and accompanied by damage to its own tissues.

You can highlight 5 types of flow

- from pretty lesion of cardio-vascular system.

The patient suddenly develops collapse, often with loss of consciousness. In this case, other manifestations of an allergic reaction (skin rashes, bronchospasm) may be absent;

- from the preferably defeat system of respiratory organs in the form of acute bronchospasm (asphisical or astmoid option). This option is often combined with a chichany, a cough, a feeling of heat in the whole body, redness of the skin, urticule, pouring sweat. Be sure to join the vascular component (decreased blood pressure, tachycardia).

- from pretty lesion of skin and mucous membranes. The patient is experiencing a sharp itching with the subsequent development of the urban or allergic edema of the type of quinque. At the same time, symptoms of bronchospasm or vascular failure can occur. A special danger represents the angioemical swelling of the larynx, manifested in initially stridorous breathing, and then the development of asphyxia.

- with a preferably defeat of the central nervous system (cerebral version). The forefronts are neurological symptoms - psychomotor arousal, fear, sharp headache, loss of consciousness and convulsions resembling epileptic status or violation of cerebral circulation.

- from preferably defeat organs abdominal cavity (abdominal). In these cases, the symptoms of the "acute abdomen" (sharp pain in the epigastric area, signs of irritation of peritoneum), leading to the formulation incorrect diagnosis Perforation of ulcers or intestinal obstruction.

Urgent Care

Contact with allergen

Position with a raised foot end

Adrenaline 0.5 mg V / Motor

Pulse oximetry

Inhalation oxygen

Vienna catheterization or intraoste

Prednisolone 120 mg or dexamethasone 16 mg V / Venitary

Sodium chloride 0.9% - 500 ml in / venously drip

With insufficient effect

Epinephrine 0.5 mg V / Venitary or in the dilution of sodium chloride

0.9% - 250 ml in / Venitary drip 10 - 20 cap. in min. (after

installations of the second intravenous catheter)

Sodium chloride 0.9% - 500 ml in / venously drip

References for an integrated exam

PM.03. Providing medical care for urgent and extreme states

MDK 03.01 Basics of Resuscitation

MDK 03.02 Medicine Catastrophe

Ticket number __________

Question: Cerebral Coma. Urgent Care.

Reference standard

Coma - pathological condition with an extreme degree of oppression of brain activity, which is accompanied by the loss of consciousness, lack of reaction to any external stimuli and disorders of various vital functions (violation of thermoregulation, respiration, slowing down the pulse, reduction of the tone of vessels).

Causes of cerebral coma

The causes of this state are primary or secondary toxic and traumatic factors. To the most frequent reasons include:

· Head and brain injuries;

· Strokes;

· Brain infectious damage;

· Brain damage due to lack of oxygen;

· Toxic damage to poisonous substances, some drugs, drugs;

· Alcoholic poisoning;

Symptoms of cerebral coma

At the initial stages of the coma, the person seems just asleep, the eyes are closed, the minimum possibility of movements remains. The victim can move in a dream, swallow saliva, some reflexes are saved. In addition, it is believed that in the initial stage of the brain coma, a person may feel pain. With deeper stages of the coma, there is an increasing inhibition of the central nervous system and respiration, muscle atony, heart activities.

Coms

Coma is the proceedable braking of the central nervous system caused by the impact of factors that affect the inhibitory effect.

Among these factors differ:

1) traumatic, primary damage to brain tissue foreign objects, bone fragments of skull, massive hemorrhage in the brain, brain compression intracranial hematoma with the development of intracranial hypertension;

2) exotoxic: poisons, medicines in toxic dosages;

3) endotoxic: with severe infectious diseases, with endocrine diseases (diabetic, hypoglycemic coma), lactacidemic (in oncological, patients with cardiovascular diseases in terminal state), with renal, liver, respiratory failure.

Thus, the following types of homes differ:

1) brain (apoplexic);

2) diabetic (hyperglycemic: hyperosmolar, ketoacidotic);

3) hypoglycemic;

4) hyperlaccitsemic;

5) uremic;

6) liver;

There are also a number of com (alcoholic, barbituate, opiate, salicylate, unclear etiology), etc.

The general sign of whom is the lack of consciousness in the patient, the lack of speech, the eyes are closed. Distinguish three degrees com:

1) hemodynamic indicators are stable, there are reflexes;

2) hemodynamics is stable, deep depression of reflexes;

3) Abruptly reduced blood pressure, pathological respiration, complete absence of reflexes, terminal state.

To determine the severity of the coma used the scale of Glasgow:

a) the eyes opens spontaneously, on the eye, with pain irritation, there is no reaction, respectively, 4, 3, 2 and 1 score;

b) speech clear, confused, incoherent words, unintelligible sounds, no reaction, respectively, 5, 4, 3, 2, 1 point;

c) movement: performs teams, indicates a sore place, separates the limb in response to pain, flexing in response to pain, extension in response to pain, no reaction (6, 5, 4, 3, 2 and 1 point). Coma 1, if 8 points are recruited, coma 2, if 5-7 points, coma 3 corresponds to 3-4 points on the Glasgow scale.

There are differences in clinical manifestations of whom that affect the tactics of patients. All patients who are in a coma, except hypoglycemic, conducts trachea intubation.

Brain coma.

Leading clinical manifestations of the brain coma is focal symptoms: anisocorium, nistagm (eyeballs are facing the focus of brain lesions), the rigidity of the occipital muscles, asymmetry of reflexes, if there are, intracranial hypertension syndrome (multiple vomiting, the injection of the scler). There may be regurgitation of gastric content in the respiratory tract, which can often be observed at other types of com. The convulsive syndrome is also characteristic of a cerebral coma. Hyperthermic syndrome as later complication comes the day after injury.

Patient maintenance by chipboard:

1) Removal foreign objects from the oral cavity;

2) intubation of the trachea;

3) suction of aspiration masses from respiratory tract;

4) artificial ventilation of the lungs is carried out in moderate hyperventilation mode within two hours in order to reduce the influx and improving blood outflow from the skull cavity, thereby reducing intracranial hypertension and brain edema;

5) oxygen therapy with an air-oxygen mixture 5050;

6) intravenously mexidol 5% -4 ml, magnesia sulfate 25% -10 ml.

7) control of ECG, blood sugar;

8) transportation on stretchers, delivery to the intensive care unit of the profile hospital.

Consider all the neurological (and leaving for neurology) aspects of comatose states in one message are not possible (it is confident that it is not necessary to clarify the reason for this, since everyone who studies the above state knows the reasons for this and without my reflection on this matter). The purpose of this communication is to summarize and summarize: the main objectives (tasks) of the neurologist in the examination of the patient in the coma; Patient inspection plan located in comatose state With a more detailed presentation (explanation) of some of its items (since the lack of systematization is clarity - the "neurological aspects of the comatose state" leads to an increase in the time of inspection, to diagnostic errors and, accordingly, to incorrect churation of patients). For those who need it, at the end of the message will indicate additional literature on this topic (articles, lectures, guidelines, presentation) with active references [for reading].

Coma is a pathological condition in which the patient is unconscious and looks sleeping (Greek. Koma is a deep sleep). He does not respond to anything and is not aware of neither external incentives or domestic needs. The patient staying in a coma is unable to communicate with others. The coma occurs either when bilateral dysfunction of the hemispheres of the brain, or with the damage to the reticular activating system (RAC) [more about structural - neuro-anatomical - basics of coma -].

Dysfunction of the hemispheres of the brain or the mass of the brain stem may be a consequence of organic or metabolic lesions. The organic damage to the stem of the brain is usually accompanied by focal neurological symptoms, since the cores of many cranial nerves are located near the brain barrel, ascending and descending paths begin. As for the hemispheres of the brain, their organic defeat should be extensive to call anyone. In the absence of focal neurological symptoms of Coma, it is usually the result of general intoxication or metabolic suppressions of the hemispheres of the brain and / or races.

for more information on each point of the Plan, you can read in the Neurology Book of Marco Mimenaler, Heinrich Mattle; Per. with it.; under total. ed. O.S.levina; 2nd ed., 2009 (or 3rd ed., 2011) - M.: Medpress-Inform [read: p.1 - p.2 - p.3 - p.4 - page 5]

NOTE :

Eye movement in a patient in a coma. In the comatose state, the fixation of the view is absent, so there are no tracking movements and, in most cases, also saccada and nystagm. Deviation eye apples Aside, testifies to the pathological focus either in the ipsilateral hemisphere, or in the contralateral departments of Varoliev Bridge. Only as epileptic seizures Coming nastagm and tonic rotation of the eye to the side opposite to the hearth may be observed.

Slow floating eye movements at a shallow coma testify to the safety of the trunk functions. Other spontaneous eye movements, such as the type of bobbing or ping-pong, always serve as a sign of brain damage.

The eyepiece Bobbing (from the English. Bobbing - a blow or squatting) is a quick drive of eyeballs down, accompanied by a longer return to the initial position. Reflex eye movements in a similar state are not called. Bobbing indicates, as a rule, to the heavy lesion of Barolic Bridge. Reverse Bobbing (or eyed dipping - from the English. Dipping - immersion) is an allogical movement in the opposite direction.

Ping Pong (periodic alternating deviation of the gaze in the horizontal plane) - Eye apples change the direction of movement every few seconds, which indicates a diffuse bilateral damage to the crust.

Study of eye movements. The only opportunity to evaluate overall functions In a patient in a coma is a study of vestibular and oculocyphal (dip-cefalic) reflexes. Based on the study of the two these reflexes, we can conclude about the state of the middle brain, the bridge, the oblong brain. [ !!! ] Before investigating the oculcephalous reflex, you need to make sure that there is no injury with a fracture or sublifting of the cervical vertebrae (in this message, the ocylvestigate reflex will not be considered, since in the receiving department [and this message is oriented primarily on neurologists working in the reception office] it is not so "Comfortable" within the limited time allotted to examine the patient).

Okulcephalic RFacks (OCR). The patient's head in a coma lying on the back is covered with two hands and rotate on the sides (in the horizontal plane), with the help of large fingers lift the eyelids to watch the movement of the eyes. The normal reaction is that the eyeballs are first slightly rotated passively along with their heads, but then move the movement in the opposite direction (positive OCC \u003d phenomenon of the eye of the doll). The pathological reaction lies in the fallout of the oculcephalus reflex: the eyeballs remain stationary relative to the eye and passively follow the turn of the head (negative OCR). Then the patient's head is tilted forward and returned to the initial position (performing movement in the sagittal plane). With the preserved function of the brain trunk, the eyeballs in this case also move towards the opposite direction of the head of the head (the phenomenon of the eye of the doll). When the medium brain is defeated, the OCC study causes normal eye movements in the horizontal plane, while in the vertical plane they cannot be called, sometimes it is possible only to move their eyes down. Under the defeat of Varoliev, the ACR bridge turns out to be negative or pathological in both planes. Violation of the friendly eye movements during the ACR testifies to the inter-identity ophthalmoplegia or the defeat of the sublicthe structure, for example, a disturbing nerve [

This is a threatening life intensive condition, because, in addition to the loss of consciousness, there are violations of the functions of vital important organs (breathing and cardiac activity).

Being in a state of coma, a person is not aware of neither the world nor himself.

Coma is always a complication of any disease or pathological condition (poisoning, injury). All coma have a number general signs, regardless of the cause of their occurrence. But there are differences in clinical symptoms when different types com. Coma treatment should be carried out under the conditions of the intensive care unit. It is aimed at maintaining the vital functions of the body and prevent the death of cerebral tissue. From this article, you will learn about what comes are what they are characterized and what the basic principles of treatment of comatose states exist.

What is at the base of the coma?

Coma is based on two mechanisms:

• bilateral diffuse damage to the cortex of the brain;
• primary or secondary brain trunk lesion with reticular formation located in it. The reticular formation supports the tone and the active state of the bark of large hemispheres. When the "shutdown" of the reticular formation develops deep braking in the cerebral cortex.

Primary lesion of the brain trunk is possible with such states as stroke, cranial and brain injury, tumor process. Secondary disorders arise in metabolic changes (with poisoning, endocrine diseases, etc.).

It is possible a combination of both mechanisms for the development of coma, which is most often observed.

As a result of these disorders, it becomes an impossible normal transmission of nerve pulses between the cells of the brain. At the same time, coordination and coordinated activity of all structures are lost, they go to the offline regime. His managerial functions over the whole body of the brain loses.

Classification

Comatous states are customary to divide on various features. The most optimal are two classifications: for the causal factor and in the degree of oppression of consciousness (the depth of the coma).

When dividing for the causal factor, the all comes are classified on coma with primary neurological disorders (when the basis for the development of coma was the process in the nervous system itself) and secondary neurological disorders (When the brain damage arises indirectly during a pathological process outside the nervous system). Knowledge of the reason coma allows you to correctly determine the tactics of the patient's treatment.

So, depending on the cause, led to the development of coma, there are such types of companies: neurological (primary) and secondary origin.

Neurological (primary) genesis:

• traumatic (under cerebral injury);
• cerebrovascular (with acute vascular circulatory disorders in the brain);
• epileptic (evidence of epipripads);
• meningoencephalitic (the result of inflammatory diseases of the brain and its shells);
• hypertensive (due to tumor in the brain and skull).

• endocrine (diabetic sugar diabetes (their several species), hypothyroid and thyrotoxic for diseases thyroid gland, hypocorticoid as acute insufficiency adrenal glands, hypopitative with a total shortage of pituitary hormones);
• toxic (with renal or liver failure, with poisoning with any substances (alcohol, drugs, carbon monoxide and so on), during cholera, in the overdose of drugs);
• hypoxic (with severe heart failure, obstructive lung diseases, with anemia);
• coma when exposed to physical factors (thermal in overheating or supercooling, with electric shock);
• coma with a significant shortage of water, electrolytes and food (hungry, with indoorable vomiting and diarrhea).

According to statistics, the most frequent cause of the development of the company is a stroke, in second place there is an overdose of drugs, on the third - complications of diabetes.

The need for the existence of a second classification is due to the fact that in itself the causal factor does not reflect the severity of the patient's condition in coma.

Depending on the severity of the state (the depth of the oppression of consciousness), it is customary to allocate the following types of com:

• I degree (light, subcorter);
• II degree (moderate, administrative, "hyperactive");
• III degree (deep, rendering, "sluggish");
• IV degree (proven, terminal).

The sharp separation of the degrees of the coma is pretty difficult, since the transition from one stage to another can be very fast. This classification is based on different clinical symptomscorresponding to a certain stage.

Signs of coma

Coma I degree

It is called subcortical, because at this stage there is a braking of the cerebral cortex and the development of deeper ones of the lying brain, referred to as subcortical formations. It is characterized by such manifestations:

• feeling that the patient is in a dream;
• full disorientation of the patient in place, time, personality (it is impossible to crush the patient);
• the lack of answers to the questions asked. Perhaps insensitive soaps, publishing various sounds out of connection with what is happening from the outside;
• the lack of a normal reaction to the pain irritant (that is, the reaction is weak and very slow, for example, when a needle, the patient's needle does not pull it away immediately, but only weakly bends or extension after some time after applying pain);
• spontaneous active movements are practically absent. Sometimes sucking, chewing, swallowing movements may occur as a manifestation of brain reflexes, which are normal in the norm are suppressed by the crust of large hemispheres;
• muscular tone is increased;
• deep reflexes (knee, achilles and others) increase, and surface (corneal, plantar and others) are oppressed;
• possible pathological and stop symptoms (Babinsky, Zhukovsky and others);
• the reaction of pupils on the light is preserved (narrowing), the squint can be observed, spontaneous movements of the eyeballs;
• lack of control over the activities of the pelvic authorities;
• usually self-breathing is preserved;
• from heart activities, an increase in heart rate (tachycardia) is observed.

Coma II degree

At this stage, the activities of subcortical formations will slow down. Violations are lowered to the front sections of the brain. This stage is characterized by:

• the appearance of tonic seizures or periodic shudders;
• lack of speech activities, verbal contact is impossible;
• a sharp weakening of the reaction to pain (a slight movement of the limb when applying an injection);
• oppression of all reflexes (and superficial, and deep);
• narrowing of pupils and weak response to light;
• increasing body temperature;
• increased sweating;
• sharp fluctuations in blood pressure;
• pronounced tachycardia;
• breathing disruption (with pauses, with stops, noisy, with different inhalation depths).

Coma III degree

Pathological processes reach the oblong brain. Risk to life increases, and the prediction for recovery is worse. Stage is characterized by the following clinical signs:

• protective reactions in response to pain stimulus are lost completely (the patient does not even move the limb in response to the injection);
• surface reflexes are absent (in particular, corneal);
• there is a sharp decrease in muscle tone and tendon reflexes;
• pupils are expanded and not react to light;
• breathing becomes superficial and arrhythmic, little productive. Additional muscles (muscles of the shoulder belt) participate in the respiratory act, which is not observed;
• blood pressure decreases;
• periodic cramps are possible.

Coma IV degree

At this stage, there are no signs of brain activity. This manifests itself:

• lack of all reflexes;
• the maximum possible expansion of pupils;
• muscle atoni;
• lack of self-breathing (only artificial ventilation of the lungs supports the provision of an organism with oxygen);
• blood pressure drops to zero without medication;
• falling the body temperature.

The achievement of the Coma IV degree has a high risk of fatal outcome approaching 100%.

It should be noted that some symptoms of various stages of coma may differ depending on the cause of the coma. In addition, certain types of comatose states have additional features, in some cases are diagnostic.

Clinical features of some species com

Cerebrovascular Coma

It always becomes the result of a global vascular catastrophe (ischemic or hemorrhagic stroke, an aneurysm break), therefore it is developing suddenly, without harbing. Usually consciousness is lost almost instantly. At the same time, the patient has a red face, hoarse breathing, high blood pressure, strained pulse. In addition to neurological symptoms inherent in the comatose state, focal neurological symptoms are observed (for example, face breakdown, the inflation of one cheek with breathing). The first stage of the coma may be accompanied by psychomotor excitation. If subarachnoid hemorrhage occurred, then positive meningeal symptoms are determined (muscle rigidity, the symptoms of Kernig, Brudzinsky).

Traumatic Coma

Since it is usually developing as a result of severe brain injury, it is possible to detect damage to the skin on the head of the patient. It is possible to bleeding from the nose, ear (sometimes leaky leakage), bruises around the eyes (symptom of "points"). Quite often, pupils have a different size on the right and left (anisocorium). Also, as in cerebrovascular coma, there are focal neurological signs.

Epileptic Coma

It is usually a consequence of repeating one by one epipripads. With this coma, the patient's face acquires a blue tint (if the attack was quite recent), pupils become wide and do not respond to light, traces of bite of the tongue, foam on lips are possible. When the attacks stop, the pupils still remain wide, the muscle tone is reduced, reflexes are not called. Tachycardia arise and rapid breathing.

Meningoencefalitic Coma

Arises against the background of the existing inflammatory disease Brain or his shells, so rarely there is a sudden. There is always an increase in body temperature, varying degrees of severity of meningeal signs. Possible rash on the body. In the blood, there is a significant increase in the content of leukocytes and ESO, and in the liquor - an increase in the amount of protein and leukocytes.

Hypertensional Coma

It occurs as a result of a significant increase in intracranial pressure in the presence of additional education in the cavity of the skull. The coma is developing due to the compression of some parts of the brain and its infringement in the cutting of cerebellae, or a large occipital opening. This coma is accompanied by bradycardia (slowdown in heart rate), resignation of breathing frequency, vomiting.

Hepatic coma

Develops gradually against the background of hepatitis or liver cirrhosis. From the patient, a specific liver smell (the smell of "raw meat" occurs). Skin coats are yellow, with spot hemorrhages, places of mass. Tempile reflexes are increased, cramps may be observed. Blood pressure and heart rate are low. Pupils are expanded. The patient's liver is increased in size. In stock There may be signs of portal hypertension (for example, "head of jellyfish" - the expansion and convolutions of the subcutaneous veins of the abdomen).

Kidney coma

Also develops gradually. From the patient the smell of urine (ammonia) comes. Skin surfaces dry, pale gray (as if dirty), with traces of combs. There are edema in the zone of the waist and lower extremities, finedness of the face. Blood pressure is low, tendon reflexes are high, pupils are narrow. Inclusive muscle twitching in separate muscle groups are possible.

Alcohol Coma

Develops gradually when abuse of alcohol and taking too much dose. Naturally, the smell of alcohol is felt (however, it should be borne in mind that if there is a sign of a coma, there may be another, for example, traumatic. Just a person could use alcohol before injury). The heart rate increases, and the blood pressure decreases. Skin red, wet from sweat. Muscular tone and reflexes are low. Pupils are narrow.

Coma with carbon monoxide poisoning

This coma is accompanied by low arterial pressure tachycardia, superficial breathing (palsy of breathing). Special pupils are characterized with the lack of reaction to light. A very specific symptom is the complexion of the face and mucous membranes: the cherry-red (such painting gives carboxygemoglobin), the limbs can be blue.

Coma in the poisoning of sleeping pills (barbiturates)

Coma is developing gradually, being a continuation of sleep. Brandcardia (low heart rate) and low blood pressure. Breathing becomes superficial and rare. Skin pale. The reflex activity of the nervous system is so depressing that there is no response to pain, tendon reflexes are not caused (or they are sharply weakened). Increased salivation.

Coma for the overdose of drugs

It is characterized by a falling of blood pressure, a decrease in the frequency of heart abbreviations, a weak pulse, superficial breathing. Lips and finger tips have a blue color, dry skin. Muscular tone sharply loosened. Characterized so-called "point" pupils, so they are narrowed. There may be traces of injection (although it is not necessarily, since the method of drug use can be, for example, intranasal).

Diabetic Coma

It will be more correct to say no coma, but coma. Because they can be somewhat in diabetes. This is ketoacidotic (with the accumulation of fats metabolism products and increasing glucose levels), hypoglycemic (when the level of glucose levels and an excess of insulin), hyperosmolar (with severe dehydration) and lactacidemic (with an excess of lactic acid in the blood). Each of these varieties has its clinical signs. For example, with a ketoacidotic coma there is a smell of acetone from the patient, the skin is pale and dry, the pupils are narrowed. In the hypoglycemic coma, extraneous smells from the patient are not felt, the skin is pale and wet, and the pupils are expanded. Of course, in determining the variety of diabetic coma, additional research methods play the main role (the amount of blood glucose, in the urine, the presence of acetone in the urine and so on).

Principles of treatment KOM.

Coma is a state, first of all, requiring urgent measures to maintain the vital activity of the body. These measures are being taken regardless of which reason caused someone. The main thing is not to give the patient to die and maximize the cerebral cells from damage.

Measures that provide vital functions of the body include:

• support breathing. If necessary, the respiratory tract is carried out to restore their passability (removed foreign bodies, smelled of the tangled language), an air duct is installed, an oxygen mask, artificial ventilation of the lungs is carried out;
• support for the circulatory system (the use of funds that increase blood pressure in hypotension and reduced in hypertension; funds normalizing heart rate; normalization of circulating blood volume).

Symptomatic measures are also applied to remove existing disorders:

• large doses of vitamin B 1 with suspected alcohol poisoning;
• anticonvulsant drugs in the presence of cramps;
• antiwheat preparations;
• sedatives during excitation;
• glucose intravenously introduced (even if the reason for the coma is not known, because the risk of brain damage from the low blood glucose content is higher than from high. Introduction of a certain amount of glucose at high content of it in the blood will not cause much harm);
• stomach wash with suspected drug poisoning or poor-quality food (including mushrooms);
• preparations to reduce body temperature;
• if there are signs of the infectious process, the use of antibiotics is shown.

With the slightest suspicion of injury cervical department The spine (or in the absence of it is possible to exclude it) is necessary to stabilize this area. Typically, the tire is used for this purpose in the form of a collar.

After establishing the reason that caused someone, the main disease is treated. Then the specific therapy is appointed against a specific illness. It may be hemodialysis when renal failure, Introduction Naloxone in the overdose of drugs and even surgical intervention (for example, under the hematoma of the brain). View and volume medical events Depends on the established diagnosis.

Coma is a complication of a number of pathological conditions. It requires immediate medical care, because it can lead to a death. The varieties of whom there is a great set due to a large number of pathological conditions that can be complicated. The coma treatment is carried out under the conditions of the intensive care unit and is aimed at preserving the life of the patient. At the same time, all activities should ensure the preservation of brain cells.

Brain Koma

Brain coma is a condition at which the inhibition of the central nervous system occurs. The main symptom of oppression of the CNS is the loss of consciousness and involuntary reflexes. In the occurrence of the comatose state, the vital functions of the body remain functioning, i.e. Breathing and cardiac activity remain functioning. There are a large number of brain-coma varieties, however, with any form, it is a deep lesion of the nervous tissue of the brain.

Clinical picture and symptoms

Depending on the main disease or condition, which led to the development of a cerebral coma, the symptomatology will change. Directly the main symptom of coma is a sequential shutdown of brain structures from the vital activity of the body. The most sensitive areas of the central nervous system are neurocytes of the crust of large hemispheres, the defeat of which occurs primarily, which is manifested by the oppression of consciousness. Then the arbitrary and involuntary reflexes are disappeared, which is associated with the damage to the deep-haul diancephal structures of the brain.

Brain Coma: Causes

Several forms and degrees of the brain coma. The metabolic form arises as a result of an acute impairment of metabolism and trophic brain neurons. The epileptic form is characterized by the occurrence of a brain compression with an abscess, neoplasm or as a result of an infectious process. Cerebrovascular shape - arises as a result of an acute violation of cerebral circulation in hemorrhagic or ischemic strokes. By gravity of the disease, you can select the degree of brain coma:

Brain coma 1 degree is characterized by an oilinance. Difficult to contact with victims. Brain Koma 2 degrees is characterized by the opposite, and the contact is not possible at all. Pupils of victim are narrowed, unconditional reflexes are saved. The brain coma of 3 degrees is considered to be deep, the blood pressure is reduced with it, the pulse is threaded, and the breath is superficial and rare. Muscular tone is significantly reduced. Coma 4 degrees is characterized by the complete absence of reflexes and muscle tone, pupils are expanded, there are rude respiratory disorders and cardiovascular activities.

Treatment

The treatment of the brain coma must be started immediately. The tactics of the medical measures carried out largely depends on the cause of it caused. In most cases, the Coma is developing as a result of an acute vascular disaster. Brain coma in stroke is a difficult state. Treatment, which is carried out under conditions of resuscitation. The clinical institution of the brain has all the necessary capacities for cerebral treatment. In the center there are high-level specialists who can cope even with the most severe cases.

Brain Coma: Complications

Brain coma is a complication of the main disease, which led to its occurrence. Nevertheless, in the absence of due therapy of such a state, screenshots are extremely high.

First aid

If you suspected the initial signs of the brain coma necessary to urgently cause an ambulance aid. The victim need to take a horizontal position, make access for fresh air and remove the grinding chest of clothing. Be sure to calm the victim. Do not leave the patient before the arrival of specialists!

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Primary cerebral coma. Primary cerebral, or neurological (brain) coma - a group of comatose states, based on oppression. - Presentation

Presentation on the topic: "Primary cerebral coma. Primary cerebral, or neurological (brain) coma - a group of comatose states, which are based on oppression. " - Transcript:

1 Primary cerebral coma

2 Primary cerebral, or neurological (brain) coma - a group of comatose states, based on the oppression of the CNS functions due to the primary lesion of the brain, include this group: an apoplestic to the epileptic to whom the traumatic coma during encephalitis, meningitis, brain tumors And his shells

3 apoplexic coma reasons: blood hemorrhage. Acute Local Brain Ischemia, with an outcome in a heart attack (with thrombosis or embolism of a large artery of the brain). Risk factors: arterial hypertension (especially periods hypertensive crimes). Atherosclerotic changes of the walls of the vessels of the brain. Most exposed people aged 45 - 60 years

4 leading pathogenetic factors of apoplexic coma are: Ischemia and brain hypoxia (as a result of a local or extensive circulatory disorder in it); Significant increase in the permeability of the walls of the microsuds; Quickly increasing the ebony of the brain substance. The stroke is characterized by secondary circulatory disorders around the brain ischemia zone with rapidly increasing signs of loss of sensitivity and movements.

5 manifestations of apoplexic coma - the patient suddenly loses consciousness; - his face (in typical cases) the crimson; - Visible vessels are expanded and noticeably pulsed; - pupils do not react to light; - tendon reflexes are reduced or missing (hyphotexia), there are pathological reflexes (Babinsky et al.); - due to the damage and irritation of the substance of the brain, respiratory disorders increase intensively (it is noisy, hoarse); - broken swallowing; - Hypertensive reactions and bradycardia are noted.

6 In the apoplexic coma, due to ischemic stroke, it is usually observed: - repeated episodes of fast passing dizziness; - unstable gait; - violations of speech; - sensitivity disorders; - often fainting (these disorders are the result of transient circulatory disorders in the vessels of different brain regions with the development of transient ischemia it); - disorders of consciousness, up to its loss;

7 - arterial hypotension; - Bradycardia; - heart arrhythmias; - rare superficial breathing; - pale and cold skin Covers and mucous; - With long-term ischemia (depending on the affected section of the brain), the hyporeflection is detected: - motion disorders, - sensitivity disorders.

8 The consequences of hemorrhage into the brain or ischemic stroke. Depend on: scale and topography of damage, degree of hypoxia and brain edema, the number of foci of damage, severity of arterial hypertension, the severity of atherosclerosis, the age of the patient. The apoplexic coma refers to the most unfavorable comatose states, fraught with death or disabling patient.

9 First Aid Action: Call an "ambulance" or a doctor (if the incident occurred in the hospital). Provide patient peace and bed mode. Release the patient from the upper clothes. Ensure the influx of fresh air to the room. Release the mouth of the patient from the vomit (with repeated vomiting, turn the head of the side to the side and remove the vomit masses from the mouth). With apoplexic coma put on my head bubble with ice or cold water. In convulsions, carefully hold the head and limb.

10 epileptic coma usually develops in patients with genuine and symptomatic epilepsy With epileptic status. In the pathogenesis of coma, hemodynamic, lycorodynamic and metabolic disorders in the brain play a major role. Manifestations: The beginning is usually sudden in the intergreacy period Consciousness is not restored to the body temperature rises to 39 degrees

11 breaks the rhythm of breathing and cardiac activity, muscle hypotonium color spots vomiting, the severity and duration of convulsion decreases, the breath becomes superficial, and then periodic by the type of Chene - Stokes are stopped, the muscle atmosphere is observed, the absidation is increasing, the brain is growing. And death.

12 ACTION ACTIVITIES TO CALL ACCEPT ACCEPT ACCOUNT BEFORE THE CONCHER OF THE CP brigade to put the patient into a steady provision to release the respiratory tract from vomiting, mucus, foreign objects to prevent the spare of the language to free the patient from constraints of clothing to exclude possible injuries

13 Traumatic Coma (at CMT) Causes: Brain Brain Breeding Brain Compression Against the Background of His Efferent and Grinding Brain Without Concomitant Effacts Closed and Open CMT

14 manifestations: a) concussing the brain loss of consciousness lasting from a few minutes to several hours of vomiting soon after the injury after the recovery of consciousness, the patient complains about dizziness, noise in the ears, headache, nausea, weakness, sleep disorder, pain when moving eyeballs retrograde and anterograde Amnesia with late diagnosis of concussion or under its absence, the condition deteriorates and can grow into anyone.

15 b) The bruise of the GM and CMT turning off consciousness can continue from a few minutes (in easy cases) up to several days or weeks. Easy degree: loss of consciousness does not exceed one hour, moderately pronounced headache, dizziness, nausea, re-vomiting is possible. As a rule, there are amnesia. The body temperature usually remains within the normal range, the respiratory function is not violated. However, with a light degree of brain injury, fractures of the skull bones are possible and an admixture of blood in the spinal fluid. Special research data identifies signs of brain edema and point hemorrhages in the brain substance. middle degree: The duration of the loss of consciousness is an average of 46 hours.

16 The symptoms of the injury are pronounced: there is a strong headache, multiple vomiting, pronounced changes in heart rate (slowdown, and freight), significant shortness of breath, an increase in body temperature. Possible impaired psyche. Neurological sympathets are clearly manifested by the reactions of the pupils, the movements of the eyeballs, express sensitivity and speech disorders. Along with the fractures of the bones of the skull, hemorrhage under the brain shell is also often noted. CT scan Under the data, the injuries reveals hemorrhages in the substance of the brain of small-scale character or moderate impregnation of the blood of the brain area in the injury zone. Heavy degree: The duration of the shutdown of consciousness can vary in the range from several hours to several weeks.

17 severe brain damage correspond to pronounced clinical manifestations, threatening violations of life functions: a sharp slowdown or a sharp increase in heart rate, a significant increase in blood pressure, pronounced rhythm and respiratory impairment, often marked motor excitement, the body temperature is significantly increased, the floating movements of the eyeballs are significantly increased, Bilateral expansion or narrowing of pupils, swallowing disorders, a change in muscle tone, depression of tendon reflexes. Palances may be detected, there are more convulsive seizures. As a rule, there are fractures of the arch and base of the skull and massive hemorrhages under the brain shell.

18 Activities for first aid: immediately call the brigade of the joint venture to dismissed clothes, release the upper respiratory tract when the fracture of the bones of the victim's bones is better to fix in the state in which it is to warn the spares of the tongue if possible, attach to the head cold Wound to follow external species and breathing, pulse, hell to maximize the movement of the victim

19 First Medical Help: As with all urgent states, the following situations are possible: - There is anamnesis, the preceding diseases of the internal organs, in which a comatose state may develop; With an objective examination, there are characteristic symptoms of one or another pathology: the foci of strokes, traces of injury, jaundice, etc. In these cases, the diagnosis of the cause of the comatose state is usually not difficult; - The clinical situation in which there is no history, the history of the disease, but have characteristic clinical symptoms or laboratory - instrumental data of a disease.

20 Medical assistance: 1. Mandatory immediate hospitalization in the intensive care unit, and with cranial and cerebral injury or subarachnoid hemorrhage - to the neurosurgical department. Despite the mandatory hospitalization, urgent therapy for coma in all cases should be started immediately. 2. Restoration (or maintenance) of the adequate state of vital functions: a) breathing

21 - Sanitation of the respiratory tract for restoring their passability, installation of the air duct or fixation of the language, artificial ventilation of the lungs with a mask or through the intubation tube, in rare cases - tracheo - or conicotomy; oxygen therapy (4-6 l / min through a nasal catheter or 60% through a mask, intubation tube); tracheal intubations in all cases should precede the premedication of 0.1% atropine solution at a dose of 0.5 ml (with the exception of cholinolithic poisoning); b) blood circulation - in the fall of blood pressure - drip administration of a ml of 0.9% sodium solution chloride, 5% glucose solution or ml of dextran 70 or ml .. Reforgetan with connection with ineffectiveness

22 infusion therapy pressing amines - dopamine, norepinephrine - in the case of coma on the background of arterial hypertension - the correction of increased blood pressure to the values \u200b\u200bexceeding the "workers" on the MM RT Article (in the absence of anamnestic information - not lower / mm RT ST): a) by reducing intracranial Pressure b) by introducing mg of magnesium sulfate Bibles for 7-10 minutes or drip) c) with migrane contraindications by the introduction of bendazole mg (bolus 3-4 ml of 1% or 6-8 ml of 0.5% solution), d) with insignificant Increased adhesion administration (10 ml of 2.4% solution), - during arrhythmias - restoration of adequate heart rhythm.

23 3. Immobilization of the cervical spine with any suspicion of injury. 4. Ensuring the necessary conditions for treatment and control. Rule of three catheters (peripheral veins catheterization, bladder and the installation of the gastric, better than a nastastric, probe) when maintaining a com on the pre-hospital stage is not so categorically: during comatose state, drugs are administered only parenterally (with oral reception high danger of aspiration) and preferable - intravenously; Mandatory installation of the catheter in the peripheral vein; Infusion is carried out through it, and with stable hemodynamics and the absence of the need for disintellation

24 The indifferent solution is slowly injected slowly, which ensures a permanent opportunity to enter medications; The bladder catheterization should be carried out according to strict indications, since in conditions of a pre-hospital assistance, this manipulation is associated with the danger of septic complications, and during transportation it is difficult to ensure the necessary degree of fixation; Introduction of the gastric probe with a preserved dumplex reflex without preliminary intubation of the trachea and its sealing of a bloated cuff is fraught with a coma possible development Aspiration of gastric contents (potentially lethal complications, for the warning of which the probe is installed).

25 5. Fighting intracranial hypertension, edema and brain swelling and brain shells: a) the most effective and universal method is the IVL in hyperventilation mode, however, due to many severe side effects, especially in the absence of adequate control, it can only be applied on life indications on life testimony; b) in the absence of high osmolarity of blood (existing, for example, with hyperglycemia or hyperthermia) and in the absence of a threat of development or bleeding (observed, for example, during injury, the impossibility of exclusion of the hemorrhagic stroke nature) dehydration is achieved by the introduction of Osmotic Diuretics - Mannitol in quantity 500 ml of 20% solution for minutes (1-2 g / kg);

26 To prevent the subsequent increase in intracranial pressure and the increase in the brain edema (ricochet syndrome), after completion of the mannitol infusion, up to 40 mg of furosemide is introduced; c) the use of glucocorticoid hormones that reduce the vascular permeability and tissue edema around the focus of brain damage is based on their proven effect in cases with the presence of perifocal inflammation; glucocorticoids are used with minimal accompanying mineralocorticoid activity, and therefore not delaying sodium and water; It is the highest security efficiency, it is the permissible alternative to which dexamethasone can serve (dose - 8 mg).

27 6. Symptomatic therapy: a) normalization of body temperature - when heocoled - warming the patient without the use of the heating floor (in the absence of consciousness, burns are possible) and intravenous administration Heated solutions - with high hyperthermia - hypothermia with physical methods (cold compresses on the head and large vessels, wiping with cold water or solutions ethyl alcohol and table vinegar in water) and pharmacological agents (drugs from the group of analgesics - antipirectikov); b) relief convulsion - the introduction of diazepam in a dose of 10 mg;

28 c) Pvtzoz reluction - the introduction of metoclopramid at a dose of 10 mg intravenously or intramuscularly. 7. With all comes, ECG registration is required.

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