Coma at the prehospital stage. Emergency care for cerebral coma Features of the course of cerebral coma with various etiologies

coma

Coma is an extreme inhibition of the central nervous system caused by the influence of factors that have a depressing effect on it.

Among these factors are:

1) traumatic, primary damage to the brain tissue by foreign objects, fragments of the bones of the skull, massive cerebral hemorrhage, compression of the brain by an 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 cancer, patients with cardiovascular diseases in the terminal state), with renal, hepatic, respiratory failure.

Thus, the following types of com are distinguished:

1) cerebral (apoplexy);

2) diabetic (hyperglycemic: hyperosmolar, ketoacidotic);

3) hypoglycemic;

4) hyperlactacidemic;

5) uremic;

6) hepatic;

There is a number of coma (alcoholic, barbiturate, opiate, salicylate, unknown etiology), etc.

A common sign of coma is the lack of consciousness in the patient, the lack of speech, the eyes are closed. There are three degrees of com:

1) hemodynamic parameters are stable, there are reflexes;

2) hemodynamics is stable, deep inhibition of reflexes;

3) sharply reduced blood pressure, abnormal breathing, complete absence of reflexes, terminal state.

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

a) the eyes open spontaneously, to a call, with pain stimulation, there is no reaction, respectively, 4, 3, 2 and 1 points;

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

c) movements: executes commands, indicates a sore spot, withdraws the limb in response to pain, flexion in response to pain, extension in response to pain, no reaction (6, 5, 4, 3, 2 and 1 points). Coma 1 if scored 8 points, coma 2 if 5-7 points, coma 3 corresponds to 3-4 points on the Glasgow scale.

There are also differences in the clinical manifestations of coma, which affect the tactics of managing patients. All patients in a coma, except for hypoglycemic patients, undergo tracheal intubation.

brain coma.

Leading clinical manifestations cerebral coma are focal symptoms: anisocoria, nystagmus (eyeballs are turned towards the focus of brain damage), stiff neck, asymmetry of reflexes, if any, intracranial hypertension syndrome (repeated vomiting, injection of sclera). There may be regurgitation of gastric contents into the respiratory tract, which can often be observed in other types of coma. Convulsive syndrome is also characteristic of cerebral coma. Hyperthermic syndrome as a late complication occurs the next day after the injury.

Management of patients for prehospital stage:

1) removal of foreign objects from the oral cavity;

2) tracheal intubation;

3) suction of aspiration masses from respiratory tract;

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

5) oxygen therapy with air-oxygen mixture 5050;

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

7) control of ECG, blood sugar;

8) transportation on a stretcher, delivery to the intensive care unit of a specialized hospital.

Director of LLC "Clinic of the Brain Institute", Doctor of Medical Sciences, Professor of the Department of Nervous Diseases and Anesthesiology-Resuscitation of the Ural State Medical Academy, Chairman of the Supervisory Board of ANO "Clinical Institute of the Brain".

Deputy chief physician for medical work, kmn, neurologist

Head of the Neurological Department, Neurologist

Cerebral coma is a condition in which the central nervous system is depressed. The main symptom of CNS depression is loss of consciousness and involuntary reflexes. When a coma occurs, the vital functions of the body remain functioning, i.e. breathing and heart activity remain functioning. There are a large number of varieties of cerebral coma, however, in any form, the main one is a deep lesion of the nervous tissue of the brain.

Clinical picture and symptoms

Depending on the underlying disease or condition that led to the development of a cerebral coma, the symptoms will change. The immediate main symptom of coma is the sequential shutdown of brain structures from the vital activity of the body. The most sensitive areas of the central nervous system are the neurocytes of the cerebral cortex, the defeat of which occurs in the first place, which is manifested by depression of consciousness. Then voluntary and involuntary reflexes disappear, which is associated with damage to the deeper diencephalic structures of the brain.

Cerebral coma: causes

There are several forms and degrees of cerebral coma. The metabolic form occurs as a result of an acute violation of the metabolism and trophism of brain neurons. The epileptic form is characterized by the occurrence of compression of the brain by an abscess, a neoplasm, or as a result of an infectious process. Cerebrovascular form - occurs as a result of an acute violation cerebral circulation with hemorrhagic or ischemic stroke. According to the severity of the disease, the degrees of cerebral coma can be distinguished:

Cerebral coma of the 1st degree is characterized by inhibition. Difficulty in contact with the victim. A cerebral coma of the 2nd degree is characterized by stupor, while contact is completely impossible. The pupils of the victim are narrowed, unconditioned reflexes are preserved. A grade 3 cerebral coma is considered deep, with low blood pressure, a thready pulse, and shallow and rare breathing. Muscle tone is significantly reduced. Coma of the 4th degree is characterized by a complete absence of reflexes and muscle tone, the pupils are dilated, there are gross violations of breathing and cardiovascular activity.

Treatment

Treatment of cerebral coma should be started immediately. The tactics of the ongoing therapeutic measures largely depend on the cause of its cause. In most cases, coma develops as a result of an acute vascular accident. A cerebral coma in a stroke is a serious condition. Treatment, which is carried out in the intensive care unit. The Clinical Institute of the Brain has all the facilities necessary for the treatment of cerebral coma. The Center employs high-level specialists who are able to cope with even the most difficult cases.

Cerebral coma: complications

Cerebral coma is a complication of the underlying disease that led to its occurrence. However, in the absence of proper therapy for this condition, the rate of death is extremely high.

First aid

If you suspect the initial signs of a cerebral coma, you must urgently call an ambulance. The victim must take horizontal position, allow access to fresh air and remove constricting chest clothes Be sure to reassure the victim. Do not leave the patient before the arrival of specialists!

In a coma, only specialists can help. If there is a suspicion that a person has fallen into a coma, you should immediately call ambulance. The only thing that can be done before the doctors arrive is to ensure that the victim can breathe. Since in a coma there is relaxation of the muscles, a decrease in the swallowing and respiratory reflex, it is necessary to check the victim’s pulse, turn him over on his stomach and, if possible, clear the airways

MDC 03.02 Disaster medicine

TICKET №__________

QUESTION: Hyperglycemic coma. Causes. clinical picture. Urgent care.

STANDARD ANSWER

As a rule, it complicates the course of mild or moderate diabetes mellitus, when insulin administration is stopped, its dose is insufficient, with unrecognized diabetes, against the background of physical and mental trauma, with gross violations of the diet.

Characteristic: a slow onset of a coma (the patient falls into a coma within a few hours) against the background of pain in the muscles and heart (like angina pectoris), the pulse is frequent, weak, blood pressure is lowered, dyspepsia, abdominal pain. Shortness of breath increases, to which Kussmaul's breathing joins, the exhaled air smells of acetone, collapse, oliguria, hypothermia develop. The skin becomes dry and cold, its marble-cyanotic tone decreases. The tongue is lined, the eyeballs are sunken, the pupils are constricted, the muscle tone is lowered.

2. Urgently call a doctor, laboratory assistant.

3. Give a stable side position.

4. Control of blood pressure, pulse, respiratory rate.

5. Portable fingertip blood sugar test
glucometer.

By doctor's prescription:

Glucometry

Vein catheterization

Sodium chloride 0.9% - 1000 ml intravenously by bolus during the first hour, then 500 ml per hour

Before intubation:

Atropine 0.5 - 1 mg IV

Midazolam 5 mg or Diazepam 10 mg IV - for coma

> 6 points on the GLASGOW Coma Scale

Sanitation of the upper respiratory tract

Tracheal intubation or laryngeal tube IVL/IVL

STANDARD ANSWERS FOR COMPREHENSIVE EXAM

PM.03. Rendering medical care in urgent and extreme conditions

MDK 03.01 Fundamentals of resuscitation

MDC 03.02 Disaster medicine

TICKET №__________

QUESTION: Hypoglycemic coma. clinical picture. Urgent reasons for help.

STANDARD ANSWER

Most often occurs with an overdose of insulin, untimely food intake, large physical activity, fasting.

It is characterized by: an acute onset (within a few minutes), the patient before this is disturbed by a feeling of severe hunger, increasing weakness, sweating, trembling of the limb, sometimes severe headache, double vision. Usually there is a slight disturbance of consciousness, which is quickly stopped with the start of therapy. In the case of persistent hypoglycemia, a general motor excitation appears, turning into stupor and coma.

With a superficial coma, blood pressure is normal or slightly elevated, breathing is normal, there is no smell of acetone from the mouth. The skin is pale and moist.

With the deepening of the hypoglycemic coma, skin moisture disappears, breathing becomes faster and becomes shallow, tachycardia can turn into bradycardia, and disorders occur. heart rate, BP goes down. Vomiting, hyperemia is noted.

The sugar level can decrease to 2.2 - 1 mmol / l, there is no glucosuria and ketonuria.

Nurse care steps:

1. Fix the time of onset of coma development.

2. Call a doctor and a laboratory assistant.

3. Give the patient a stable lateral position.

4. Inspect the oral cavity.

As prescribed by the doctor, inject 20-40-50 ml of 40% glucose solution intravenously.

STANDARD ANSWERS FOR COMPREHENSIVE EXAM

PM.03. Providing medical care in emergency and extreme conditions

MDK 03.01 Fundamentals of resuscitation

MDC 03.02 Disaster medicine

TICKET №__________

QUESTION: Renal coma. Causes. clinical picture. Urgent care.

STANDARD ANSWER

uremic coma is a complication of chronic renal failure (CKD - ​​uremia). CKD is the end-stage (final) stage of progressive kidney disease. Chronic kidney failure become more complicated chronic glomerulonephritis, pyelonephritis, diabetic nephropathy, rheumatoid arthritis, gout - renal causes, long-term obstruction (blockage) of the urinary tract - postrenal, renal artery stenosis - prerenal.

Clinic. Coma develops gradually. There are 3 stages of coma development.

First stage- initial manifestations: poor appetite, nausea, vomiting, epigastric pain, smell of ammonia from the mouth, weakness, fatigue, chilliness, pruritus, insomnia, apathy.

Second stage- precoma. Patients are at first lethargic, sleepy, and then fall into stupor.

Third stage: coma. Miosis, Cheyne-Stokes or Kussmaul respiration are observed. Reflexes are reduced.

- the most common cause of damage to the structures of the central nervous system. If a severe violation of the cerebral tissue has occurred, a coma may occur, which is fraught with disability or death.

Violation of consciousness: the mechanism of appearance

After damage to the central nervous system due to a traumatic brain injury, a person loses the ability to respond to any external stimulus. The psycho-emotional state is completely disturbed, the victim cannot contact with other people. A coma sets in.

Coma in TBI is characterized by a person's immersion in a specific state, which is associated with the oppression of certain zones. The victim does not respond to pain, bright light and loud noise He has no reflexes.

Consciousness is disturbed when certain parts of the brain are damaged, which are responsible for speech, thinking, wakefulness, and reasoning. Based on the degree of damage, loss of consciousness can have a different duration:

• mild traumatic brain injury (for example, contusion): impaired consciousness does not occur or lasts no more than 5 seconds;
• trauma of moderate severity (for example, open TBI): duration of impaired consciousness - 2 hours-2 days;
• severe trauma: deep coma and vegetative states occur.

Coma after TBI is not a separate disease, but only a consequence of CNS damage. If there is severe general state, which threatens a person's life, he can be immersed in. This condition allows you to cause a controlled decrease in the activity of reflexes and vital functions.

An artificial coma is the introduction of special medicines into the body. In this case, the respiratory function is carried out by the ventilator.

Characteristic symptoms

Coma after a traumatic brain injury is primarily characterized by impaired consciousness. All symptoms of this condition can be divided according to the degree of its severity:

1. Superficial disturbance of consciousness. The person falls into a deep sleep. When trying to speak to the victim, he may open his eyes, and sometimes start a conversation. Speech is punctuated. The patient can carry out light movements of the limbs.
2. Normal coma. The patient is able to make sounds, inadvertently open his eyes and make sudden movements with his hands. The doctor can fix the limbs of the victim with special devices to avoid causing physical injury.
3. deep coma. Completely absent reflexes and mobility, respiratory function. There is no reaction to the pain syndrome, just like to the light of the pupils.

Treatment during coma

After the diagnosis of "coma due to traumatic brain injury" has been made, appropriate treatment begins. First of all, activities are carried out to increase blood flow to the brain. Emergency treatment begins already in the ambulance.

They use artificial ventilation of the lungs, inject drugs into the body that help normalize blood pressure. Requires the introduction of drugs that improve the functioning of organs such as the liver and kidneys.

In case of respiratory arrest, the ambulance doctor inserts a special tube into the tracheal cavity, which is a conductor of oxygen air coming from the respiratory apparatus.

Since, being in a coma, a person cannot eat on his own, the introduction nutrients produced by the probe method. To prevent secondary infection urinary tract and lungs are prescribed powerful antibacterial drugs.

rehabilitation period

Not all cases of impaired consciousness require a long rehabilitation period. According to statistics, recovery from a coma caused by diabetes, taking a high dose of drugs or alcohol does not last long. In such cases, impaired consciousness is present before the removal of the toxic substance from the body.

Getting out of a coma of the 3rd degree after a TBI or 1st degree equally requires rehabilitation measures. First of all, measures are taken to restore the functioning of the brain. Not in every case amnesia develops, but there is a deterioration in memory and attention.

How do you get out of a coma after a TBI? During this period, the ability to sit, walk without outside help and improvised means is lost. Confusion of consciousness is observed, a person loses orientation in space. To correct such violations caused by a long-term impairment of consciousness, such specialists help:

• neurospeech therapist (helps restore speech);
• psychologist (normalizes the psycho-emotional state);
• occupational therapist (helps improve motor skills);
• neurologist, physiotherapist, etc.

When leaving a coma after TBI, it is not necessary to immediately subject the patient to physical and mental stress on the first day. Rehabilitation should take place gradually. How many months or years it will take to fully restore the activity of the central nervous system, and what the prognosis will be, depends on the severity of the traumatic brain injury.

Rehabilitation after a coma consists in assisting the patient in all everyday activities: eating, going to the toilet and showering. It is required to conduct educational games that contribute to the restoration of motor skills, memory, and speech. It is important to normalize the diet so that it includes all useful vitamins and micronutrients.

To restore muscle tone, massage procedures are prescribed, which are carried out in the specialist's office and later at home. During the massage, you can use any essential oil. The procedure also improves blood circulation. The main condition is the continuity of therapy, even if the first positive changes are visible.

Complications

If the central nervous system was affected at the time of the traumatic brain injury, complications are likely to arise. Coma is one of them. In severe TBI, the consequences can be so serious that the patient will no longer be able to serve himself, get up, sit. In such cases, outside help and special medical equipment will be required.

Not always a coma is accompanied by such severe consequences. In some cases, a person quickly recovers from an injury and impaired consciousness, and basic functions and reflexes return to normal.

The most common consequences of a coma include amnesia or incomplete memory loss, impaired concentration, loss of the ability to self-service (eating, taking water procedures and etc.).

Being in a supine position for a long time, a person may begin to suffer from bedsores, which require other specific therapy using drugs.

Other consequences of TBI

The consequences of traumatic brain injury include not only to whom. These depend on the severity of the damage. Complications do not always occur in the first weeks or months after injury. Sometimes negative consequences develop after a long time, which is more typical for children. In the elderly, TBI is often fatal.

The consequences of traumatic brain injury include:

• external manifestations: hematoma, tissue swelling, pain, febrile syndrome, general malaise, etc.;
• paralysis of the legs and/or arms of a partial or complete nature;
• loss of sensitivity of the skin in the lower and (and) upper limbs;
• pain syndrome in the head, which is chronic;
• loss of visual, auditory, speech function, memory;
• violation respiratory function, swallowing;
• inability to control urination and defecation;
• post-traumatic epileptic syndrome with the development of convulsive seizures, impaired consciousness;
• upper and lower limbs;
• impaired concentration;
• increased irritability.

Despite such a large list of negative consequences, this does not mean that a person will have all of them. The type of consequences depends on the exact location of the head and brain injury, as well as its severity.

Some clinical picture occurs only in the early post-traumatic period. These include paralysis of the legs and arms, impaired respiratory function, which disappear after the adoption of rehabilitation measures. Headaches can begin to disturb a person for a long time after injury.

An important advice given by specialists is the continuity of treatment during the recovery period after TBI and coma. The rehabilitation course must be completed in full. This is the only way to hope for a favorable prognosis and maximum recovery of the body.

Coma, from ancient Greek, means deep sleep, drowsiness. It is characterized by a lack of consciousness, motor activity and reflexes, inhibition of the vital processes of respiration and heartbeat. A patient in a coma is deprived of an adequate response to external stimuli, for example, touch or voice, pain.

Why there is a violation of consciousness

The normal functioning of the central nervous system (CNS) is ensured by balancing excitation and inhibition. In the case of an unconscious state, the inhibitory effect of individual structures of the brain on the cortex predominates. Coma always occurs as a result of large-scale damage to brain tissue.

The causes of unconsciousness are quite varied. A cerebral coma can occur when:

• infections of the nervous system, meningitis of a viral and bacterial nature;
• injuries of the head and brain substance;
• ischemic strokes or as a result of cerebral hemorrhage;
• toxic damage to the nervous system due to overdose medicines, alcohol, also when exposed to drugs and toxic substances;
• impaired metabolism (diabetic coma with elevated, low blood sugar levels, adrenal dysfunction with hormonal imbalance, accumulation of waste products of metabolism with depressed liver and kidney function).

Symptoms

Disorders of consciousness always come to the fore in the development of a coma.

There are three main types of coma, depending on the severity of the patient:

1. superficial;
2. proper coma;
3. deep.

With a superficial form, the patient resembles a deeply sleeping person. Verbal appeal to him is accompanied by opening the eyes, sometimes the ability to answer questions. Speech disorders are manifested in inhibited and incoherent speech. Minimal movements in the limbs are preserved.

Being in a state of ordinary coma, a person can make sounds, suddenly open his eyes and come into motor excitement. Doctors sometimes even have to fix such patients with special means so that they themselves do not cause physical harm to themselves.

Deep coma is characterized by a complete absence of movement and reflexes. In this state, the patient does not swallow saliva, does not breathe. The reaction to pain is completely absent, and the pupils react poorly to light.

Separately from all types, an artificial coma is isolated. This is an anesthesia deliberately created by doctors with the help of medications. The patient's stay in deep sleep also implies the replacement of the functions of his breathing with an artificial ventilation apparatus and the maintenance of the movement of blood through the vessels with the help of medications. Such protective inhibition of the cerebral cortex ensures its speedy recovery. Controlled coma is often used for persistent convulsions in epileptics, with extensive hemorrhages and severe poisoning with toxic substances. Unlike non-drug artificial coma, it can be terminated at any time.

Diagnostics

The simplest technique in technical terms is the taking of cerebrospinal fluid using a special thin needle - lumbar puncture. This method is simple, does not require specialized equipment, and in some cases allows you to determine the cause of coma.

Relatives of patients who have been in a coma note frequent mood swings, aggression and depressive states of their loved ones.

Brain death is the extreme manifestation of coma. The complete absence of a reaction to any stimuli, all reflexes and motor activity indicates irreversible disorders in the nervous system.

Breathing and cardiac activity of brain dead patients are preserved only in the intensive care unit. Very often, brain death occurs with extensive hemorrhages or hemorrhagic strokes.

An intermediate position between the extreme outcomes of coma is occupied by the concept of "vegetative state". Prolonged stay in a coma in severe cases leads to the fact that the existence of the patient is supported exclusively with the help of special equipment. Often, patients die from concomitant diseases or complications such as pneumonia, repeated thrombosis, or infection.

As for artificial coma, patients who have undergone this condition note frequent hallucinations and nightmares. In some cases, there were infectious complications in the form of cystitis, inflammation of the lungs, subcutaneous tissue and blood vessels, through which anesthetics were administered for a long time.

A whole team of specialists is involved in the rehabilitation of patients who have been unconscious for a long time. By doing it regularly exercise, restoration of the work of mimic muscles, the victim learns to walk and serve himself again. In addition to physiotherapists, massage therapists and neurologists, speech therapists are involved in restoring speech functions. Psychologists and psychiatrists normalize the emotional and mental state of the patient, contributing to the further adaptation of a person in society.