Coma is a severe pathology that threatens life. The central nervous system is depressed, the person loses consciousness. The operation of critical systems is also disrupted.

The main reason lies in damage to the structure of the brain. It can be caused by injury, fall, hemorrhage (stroke) or be the result of a disease, including cancer. So, the main reasons:

1. mechanical damage to the brain (hemorrhage due to hemorrhagic or ischemic stroke, trauma, road accident, tumor due to oncology);
2. infectious diseases;
3. poisoning, drowning, disruption of the glands, etc.

When treating coma, it is important to eliminate the cause that provoked it. Then procedures are carried out to eliminate the collapse. Everything needs to be done as quickly as possible. The patient needs to restore the oxygen supply and normalize the acid-base balance. The brain of a newborn often suffers if the umbilical cord is entangled. A comatose patient is always classified as severe. Often you have to struggle with the consequences for a long time. The prognosis is influenced by many factors - the severity of the condition, the cause, timely qualified assistance, age, the presence of chronic diseases, etc. The situation is worse with stroke and cancer.

If a coma overtakes a child, it is important not to waste a minute and begin treatment. If symptoms characteristic of precoma appear, call an ambulance immediately. In children, the condition can worsen quickly. The liver, lungs, heart, kidneys, and, of course, the brain are immediately affected. That's why it's important to watch for warning signs.

The rate of development of coma can be:

• Unexpected. Consciousness is sharply lost, signs of coma develop (heart rhythm disturbance, breathing, blood pressure drops).
• Slow. Precoma develops first. Reactions are slow, the person is drowsy or overly excited. At this stage, hallucinations and delusions may occur. Signs of the underlying disease gradually increase. Over time, all functions of the central nervous system are disrupted.
• Fast. Symptoms develop over a period of several minutes to several hours.

Stages

Coma occurs in several stages.

Prekoma

This stage precedes the immediate onset of coma. Its length varies from 5 minutes to 1-2 hours. At this time, the patient's consciousness is confused. His lethargy and stupor are periodically replaced by unhealthy excitement. Reflexes are still preserved, but coordination of movements is impaired. The condition is serious. Its severity directly depends on the cause. A relatively mild condition can quickly turn into a serious one.

1st degree

Its main causes are hormonal crisis, intoxication, shock, brain inflammation, and metabolic problems. In a first-degree coma, the reaction is clearly inhibited. While a person is aware of his actions, he feels pain. It is difficult to establish contact with the patient. The muscles are in good shape. The patient has difficulty swallowing. Mostly he drinks. May eat something liquid. The pupils continue to react to light. If a 1st degree coma has begun, the chances of survival are high.

If the liver fails, the body can be poisoned by its own waste products. From the intestines, poisons enter the circulatory system. The body is quickly poisoned and the central nervous system suffers. Hepatic encephalopathy begins.

Before coma, vomiting is often observed. This is a signal that the body is trying to get rid of poisons that have begun to poison it.

2nd degree

In the second degree, stupor is observed and contact is lost. The reaction to stimuli is impaired. Sometimes the patient may make chaotic movements. The muscles either relax or tense again. Serious breathing problems occur. The intestines and bladder may empty themselves involuntarily. The chances of survival are quite high. It is often possible to achieve a full recovery. The exit from the stupor will be gradual. Its duration depends on the general condition of the patient and the timeliness of the care provided by doctors.

This type of coma often occurs with severe alcohol poisoning.

When stage 2 coma develops, the chances of survival depend on timely medical care and quality care. You can't give up. The scenario can develop positively for the patient. It is important to quickly restore spinal and brainstem reactions, restore breathing, and restore consciousness.

3rd degree

If a person is in a stage 3 coma, the chances of survival depend on comprehensive medical treatment and the general condition of the body. The patient is unconscious. There are no reactions at all. The pupils narrow. Seizures may develop. Body temperature decreases, arterial pressure. Breathing loses rhythm. The condition needs to be stabilized. If a 3rd degree coma has begun, the chances that a person will come out of it are not so high. There is a possibility of mortality. Young and middle-aged adults are more likely to survive.

The development scenario of the third stage is often unfavorable. The medulla oblongata is severely affected. This is extremely life-threatening.

The danger of death is signaled by the following preceding symptoms:

• the patient does not move his limbs and does not respond to the injection;
• muscles are inactive;
• blood pressure is low;
• shallow breathing;
• pupils are dilated and do not react to light;
• convulsions are observed.

Doctors consider the third degree the most mysterious. It is its symptoms that closely resemble the signs of death. However, some patients came out of it. At the same time, they describe their state as a dream in which there are no dreams. At the same time, the body devotes all its resources to recovery, and the survival program is activated.

It is those patients who have emerged from the third degree who tell contradictory stories about the journey to God in empty space. At the same time, they heard voices, but did not perceive them.

In order for the victim to survive, resuscitation should begin immediately. It is important to restore blood circulation as soon as possible. This way, the maximum number of brain cells will survive.

4th degree

At the fourth stage there are no reflexes. Temperature and pressure drop sharply. This has an overall effect on the condition. It is supported by mechanical ventilation.

Coma 4 degrees – terminal condition.

How to come out of a coma

To bring the patient out of a coma, urgent treatment and resuscitation are necessary. Its goal is to restore the functioning of the brain, central nervous system, and stimulate reflexes. It is important that the doctor prescribe therapy as soon as possible. Whether a person survives depends on this. At proper treatment and favorable development, consciousness gradually returns to the patient. At first, delusions, hallucinations, anxiety, chaotic movements, and loss of coordination may occur. Consciousness may be periodically impaired. Convulsions are a concern.

Kinds

Who should not be considered a disease. This is the result of serious pathological changes. They damage brain tissue and disrupt the functioning of the central nervous system. The type of coma directly depends on the disease or mechanical damage that caused it. The less damage, the higher the chance of survival.

Diabetic coma

The reason for its development is the advanced stage of diabetes mellitus. Coma can be hypoglycemic or hyperglycemic. At the first, the glucose level goes off scale. The first sign of impending danger is the strong smell of acetone from the patient’s mouth. It is important to quickly establish a diagnosis and bring the patient out of a coma.

Hypoglycemic coma

It also develops in diabetes mellitus. Its reason, on the contrary, lies in a sharp decrease in blood glucose (less than 2 mmol/l). In the precoma stage there is severe hunger. It is characteristic that the patient experiences irresistible hunger, regardless of when he last ate.

Coma traumatic

The reason is a head injury, bruise in an accident, fall, fight, etc. This damages the skull and brain. Characteristic manifestations are nausea and vomiting. The goal of treatment is to restore blood supply to the brain and resume its normal functions.

Meningeal coma

The reason is brain intoxication due to the penetration of meningococcal infection into the body. A lumbar puncture will definitely be required. It will help to accurately identify the presence of infection. In precoma, this type is characterized by severe headaches. The patient has problems with simple physical functions. He cannot lift his leg in a supine position or straighten it. A test for the presence of Kernig's sign can be performed. The patient will not be able to bend his leg only hip joint. She will also involuntarily bend at the knee.

Another test is for Brudzinski's symptom. The patient's head should be tilted forward passively. At the same time, he will bend his knees. This movement is involuntary.

Another sign of this coma is that a rash appears on the skin, areas of necrosis form, including non-mucosal areas. These are tiny hemorrhages. They can also be observed on internal organs. This leads to a malfunction in their work.

Despite the listed groups of tests and symptoms, the final diagnosis is made after a lumbar puncture. If the cerebrospinal fluid is cloudy, has a high protein content, and a high number of blood cells, then the test is positive.

Coma cerebral

Occurs when brain tumors form. The previous disease develops slowly. Clinical symptoms varied. It all starts with regular headaches. They are often accompanied by vomiting. Over time, the patient finds it difficult to swallow liquid food. He often chokes. He also has difficulty drinking. These are the symptoms bulbar syndrome. It can last quite a long time. The life and health of the patient is already at risk.

The sooner the doctor prescribes treatment, the higher the chances that the patient will live. Comatosis due to tumors can be very deep. Intervention by a neurosurgeon is often required. Even with a favorable outcome, disability is possible. All sorts of complications from the central nervous system, partial and even complete paralysis are common.

During this period, it is important to provide the patient with full qualified therapy. Otherwise, a coma may develop. The tumor itself can be easily detected using MRI and CT. CSF analysis will show abnormal high level protein, leukocytes. It is important to remember that if there is a tumor in the posterior cranial fossa, it is strictly forbidden to take a puncture of the cerebrospinal fluid. This can cause death.

Similar symptoms are observed with a brain abscess. But this species has its own differences. Coma is preceded by inflammatory processes (otitis, sinusitis, tonsillitis, etc.), an increase in temperature, and the level of leukocytes increases. It is important here that the patient is examined by an infectious disease specialist.

Coma epileptic

This is a consequence of a severe epileptic seizure. In this case, the patient’s pupils will be dilated, the skin will become pale, and most of the reflexes will decrease. Characteristic sign the fact that the coma was a consequence of epileptic seizures - bites on the tongue. There is also involuntary bowel movement, Bladder. The pulse is frequent, the pressure is low. As the condition worsens, the pulse will become thready. Shallow breathing can be replaced by deep breathing and vice versa. Cheyne-Stokes respiration may be observed. It consists in the fact that between periods of deep and shallow breathing there are short pauses when a person stops breathing altogether. Then the breath appears again.

When the condition worsens, blood pressure drops to a maximum and reflexes completely disappear. It is extremely important that the patient receives as much please help doctors. Otherwise, death occurs.

Coma hungry

The reason for its development is the third degree of dystrophy. Fasting leads to it. Often people who are on a protein diet bring themselves to such a pathological state. In this case, the body experiences a protein deficiency. His role cannot be underestimated! Protein performs essential functions in the body. Its deficiency causes serious disruptions in the functioning of almost all systems and organs. This includes serious depression of brain function.

This pathological condition develops gradually. The first alarm signal to which the patient must respond is hungry fainting. Over time, they become more frequent, as the body experiences an increasing lack of vital protein. Fainting is accompanied by increased heartbeat, general weakness, and rapid breathing. When a hungry coma sets in, a person’s temperature drops significantly, blood pressure drops, and convulsions appear. In this case, the intestines and bladder may spontaneously empty.

A blood test will reveal reduced levels of white blood cells, cholesterol, protein, and platelets. The amount of glucose in the blood is greatly reduced.

Artificial coma

In case of severe traumatic injuries and other conditions, the patient may be put into a coma on purpose. This is a medicinal form, artificial.

Danger of condition

Coma is dangerous because the brain suffers from hypoxia. At the same time, its cells die. The primary task is to resume its blood circulation and restore functions. The patient undergoes detoxification measures. In case of uremic type, hemodialysis may be prescribed. When hypoglycemic - glucose.

If intoxication begins, shock develops, and brain tissue experiences energy deficiency. The consequences may be as follows:

1. The condition is getting worse.
2. Lethality sets in.
3. Energy deficiency increases, oxygen starvation of the central nervous system increases, and neurons die. Even if such a patient survives, the risk of disability is high.

Developmental brain dysfunction due to traumatic brain injury can be caused by:

1. damage to the skull and secondary compression of the brain by bone fragments. The most serious is a fracture of the base of the skull, accompanied by bleeding and cerebrospinal fluid leakage from the nose, pharynx, and ears;
2. brain contusion, i.e. contusional damage to the brain substance at the site of impact and in the area of ​​counter-impact. During an impact (concussion), the brain is displaced in the cranial cavity in the direction of the impact. In addition to the cerebral hemispheres, the brain stem is damaged; often it is the brain stem symptoms that become leading in the clinical picture cerebral coma.

In the cases listed above, epi-, subdural, subarachnoid, intraventricular, and parenchymal bleeding are possible. Subarachnoid bleeding and subdural hematomas are more often observed, contributing to brain dislocation and compression, and the development of cerebral coma.

Circulatory disorders, hypercoagulation, hypoxia, lactic acidosis and irritation of the meninges with blood and detritus are the main causes of impaired consciousness and features of the clinical symptoms of cerebral coma.

Morphologically, hemorrhages and necrosis of brain tissue are detected, mainly at the site of direct injury. With increasing edema-swelling of the brain, these phenomena can become diffuse until complete aseptic or septic (in case of open injury) melting.

Often, cranial coma develops gradually (after a light interval of several hours), which is associated with the growth of intracranial hematoma. In this case, complete loss of consciousness is preceded by somnolence, stupor, and stupor. The most important clinical signs increases in intracranial pressure are headache and the symptom of vomiting, which is part of the cerebral syndrome.

General cerebral phenomena in cerebral coma are always accompanied by meningeal and focal symptoms. In TBI they are affected cranial nerves, develop in varying degrees severe paresis and paralysis. Disturbances in the rhythm of breathing and pulse may be a sign of damage to the trunk. Brain dislocation is accompanied by anisocoria, hyperthermia, and bradycardia.

Diagnosis of TBI is based on medical history, M-echography of the skull (deviation of the echo signal by more than 2 mm from the axis), computed tomography or nuclear magnetic tomography. Diagnostic lumbar puncture must be performed with great care. EEG and angiography complement the main examination methods.

Principles of treatment of cerebral coma in TBI:

• ensuring vital functions, starting from the moment of transportation, the patient is transferred to a lying position on his side or on his back, be sure to turn his head to the side (in order to prevent aspiration of vomit or blood and cerebrospinal fluid in case of a fracture of the base of the skull);
• oxygen therapy while maintaining spontaneous ventilation or during mechanical ventilation;
• restoration of bcc and microcirculation in blood vessels using plasma substitutes (albumin, rheopolyglucin);
• neurovegetative blockade;
• broad-spectrum antibiotics (in some cases, dexazone - as a means to prevent swelling);
• neurosurgical intervention is performed urgently when verifying a hematoma, depressed or comminuted fractures skull bones.

Brain coma due to inflammation

Primary inflammation of the brain in children can be in the form of meningitis (inflammation of the soft membrane), encephalitis (parenchymal inflammation), meningoencephalitis, and meningoencephalomyelitis.

The causes of cerebral coma of an inflammatory nature are very diverse. Their causative agents can be bacteria, viruses, fungi, and rickettsia. Among the bacterial group, the most common in children are meningococcal, pneumococcal, staphylo- and streptococcal, as well as tuberculous meningitis or meningoencephalitis, meningitis caused by Haemophilus influenzae. Enteroviral and mumps etiology of serous meningitis has recently dominated among viral meningitis.

The causative agents of meningitis penetrate into brain tissue mainly hematogenously, but lymphogenous and perineural penetration is also possible. Usually, inflammatory process is developing rapidly, clinical manifestations meningitis often become maximum by the 3-4th day (except for tuberculosis).

The main pathogenetic factors causing the symptoms of cerebral coma are brain edema, hypoxia, and toxic-hypoxic cell damage. Dystrophic and necrotic changes are observed at the site of inflammation. General cerebral and meningeal symptoms occur against the background of a febrile reaction, external manifestations of a specific infectious disease. With encephalitis (meningoencephalitis), severe impairment of consciousness and the appearance of focal symptoms are also observed. Cranial nerves are most often affected.

When diagnosing cerebral coma accompanied by brain damage, the full range of conventional studies is used, including mandatory spinal puncture with microscopy, biochemical examination and culture of cerebrospinal fluid.

Cerebral coma of this etiology is treated as follows:

• targeted antibacterial and antiviral therapy, the choice of which is determined by the diagnosis of the disease. Typically, intramuscular and intravenous methods of drug administration are used. The dose of antibiotics is determined by their ability to penetrate the blood-brain barrier under pathological conditions. In this regard, penicillins, for example, are administered in high doses;
• fight against cerebral edema (diuretics, plasma expanders, corticosteroids) and its hypoxia (oxygen therapy, mechanical ventilation);
• detoxification (fluid infusion in a volume of 20-50 ml/kg per day);
• symptomatic therapy (anticonvulsants in the presence of seizures, neurovegetative blockade in case of agitation, antipyretic therapy, etc.).

– the most common cause of damage to central structures nervous system. If severe damage to cerebral tissue occurs, coma may occur, which can lead to disability or death.

Impaired consciousness: mechanism of occurrence

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 disrupted, the victim cannot contact the people around him. Coma sets in.

Coma due to TBI is characterized by the immersion of a person in a specific state, which is associated with inhibition of certain zones. The victim does not respond to pain syndrome, bright light and loud sound, he has no reflexes.

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

• mild traumatic brain injury (for example, bruise): loss of consciousness does not occur or lasts no more than 5 seconds;
• moderate injury (for example, open head injury): duration of disturbance of consciousness – 2 hours-2 days;
• severe injury: deep coma and vegetative states occur.

Coma after TBI is not a separate disease, but only a consequence of damage to the central nervous system. If 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 involves the introduction of special medications into the body. In this case, the respiratory function is performed by a ventilator.

Characteristic symptoms

Coma after 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 deep sleep. When trying to talk to the victim, he may open his eyes and sometimes start a conversation. Speech with punctuation. The patient can make slight movements of the limbs.
2. Ordinary coma. The patient is able to make sounds, unintentionally open his eyes and make sudden movements with his hands. The doctor can fix the victim’s limbs with special devices to prevent physical harm.
3. Deep coma. Reflexes, mobility and respiratory function are completely absent. There is no reaction to pain, just like there is to the light of the pupils.

Treatment during coma

Once a diagnosis of coma due to traumatic brain injury has been made, appropriate treatment is begun. First of all, measures are taken to increase blood flow to the brain. Emergency treatment begins already in the ambulance.

Use artificial ventilation and inject into the body medicines, helping to normalize blood pressure. It requires the introduction of drugs that improve the functioning of organs such as the liver and kidneys.

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

Since, while in a coma, a person cannot eat on his own, nutrients are administered by tube. To prevent secondary infections of the urinary tract and lungs, powerful antibacterial drugs are prescribed.

Rehabilitation period

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

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

How do you recover from a coma after a TBI? During this period, the ability to sit and walk without assistance and available means is lost. Confusion of consciousness is observed, the person loses orientation in space. The following specialists help correct such disorders caused by prolonged impairment of consciousness:

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

When recovering from a coma after a TBI, there is no need 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 of assisting the patient in all everyday activities: eating, going to the toilet and showering. Developmental games are required to help restore motor skills, memory, and speech. It is important to normalize your diet so that it includes everyone healthy vitamins and micronutrients.

To restore muscle tone it is prescribed massage treatments which are carried out in a specialist’s office and subsequently at home. During the massage you can use any essential oil. The procedure also helps improve blood circulation. The main condition is 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 occur. Coma is one of them. With severe TBI, the consequences can be so serious that the patient will no longer be able to care for himself, stand up, or sit. In such cases, outside help and special medical equipment will be required.

Coma is not always accompanied by such severe consequences. In some cases, a person quickly recovers from injury and impairment of consciousness, and basic functions and reflexes return to normal.

The most common consequences of coma include amnesia or incomplete memory loss, impaired concentration, loss of the ability to independently care (eating, taking water procedures, etc.).

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

Other consequences of TBI

The consequences of traumatic brain injury include not only coma. 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 old age, TBI is often fatal.

The consequences of traumatic brain injury include:

• external manifestations: hematoma, tissue swelling, pain, febrile syndrome, general malaise, etc.;
• partial or complete paralysis of the legs and/or arms;
• loss of sensitivity of the skin in the lower and/or upper extremities;
• chronic pain in the head;
• loss of visual, auditory, speech function, memory;
• impaired respiratory function, swallowing;
• inability to control urination and bowel movements;
• post-traumatic epileptic syndrome with development seizures, impaired consciousness;
• upper and lower extremities;
• 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. This may include paralysis of the legs and arms, impaired respiratory function, which disappear after taking rehabilitation measures. Headaches can begin to bother a person for a long time after injury.

The important advice that experts give is 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.

is a life-threatening state of impaired consciousness caused by damage to special structures of the brain and characterized by a complete lack of contact between the patient and the outside world. The causes of its occurrence can be divided into metabolic (poisoning by metabolic products or chemical compounds) and organic (in which destruction of parts of the brain occurs). The main symptoms are unconsciousness and lack of eye opening reactions even to strong stimuli. CT and MRI play an important role in the diagnosis of coma, as well as laboratory research blood. Treatment primarily involves combating the main cause of the development of the pathological process.

ICD-10

R40.2 Coma, unspecified

General information

Classification

Who can be classified according to 2 groups of criteria: 1) depending on the reason that caused it; 2) according to the level of depression of consciousness. Depending on the causes, comas are divided into the following types:

• traumatic (for traumatic brain injuries)
• epileptic (complication of status epilepticus)
• apoplexy (the result of a cerebral stroke), meningeal (develops as a consequence of meningitis)
• tumor (space-occupying formations of the brain and skull)
• endocrine (with decreased function thyroid gland, diabetes mellitus)
• toxic (with renal and liver failure).

However, such a division is not often used in neurology, since it does not reflect the true condition of the patient. The classification of coma based on the severity of impaired consciousness - the Glazko scale - has become more widespread. Based on it, it is easy to determine the severity of the patient’s condition, build a scheme of emergency treatment measures, and predict the outcome of the disease. The Glazko scale is based on a cumulative assessment of three patient indicators: speech, presence of movements, eye opening. Points are assigned depending on the degree of their violation. Based on their sum, the patient’s level of consciousness is assessed: 15 – clear consciousness; 14-13 – moderate stunning; 12-10 - deep stun; 9-8 – stupor; 7 or less – comatose state.

According to another classification, which is used mainly by resuscitators, coma is divided into 5 degrees:

• precom
• coma I (in Russian medical literature called stupor)
• coma II (stupor)
• coma III (atonic)
• coma IV (extreme).

Coma symptoms

As already noted, the most important symptoms of coma, which are characteristic of any type of coma, are: complete lack of contact of the patient with the outside world and lack of mental activity. Other clinical manifestations will vary depending on the cause of the brain damage.

Body temperature. Coma caused by overheating is characterized by high temperature body up to 42-43 C⁰ and dry skin. Poisoning with alcohol and sleeping pills, on the contrary, is accompanied by hypothermia (body temperature 32-34 C⁰).

Breathing rate. Slow breathing occurs during coma from hypothyroidism (low levels of thyroid hormones), poisoning from sleeping pills or drugs from the morphine group. Deep respiratory movements are characteristic of a coma due to bacterial intoxication in severe pneumonia, as well as for brain tumors and acidosis caused by uncontrolled diabetes or kidney failure.

Blood pressure and heart rate. Bradycardia (decrease in the number of heart beats per minute) indicates a coma caused by acute heart pathology, and the combination of tachycardia (increased heart rate) with high blood pressure indicates an increase in intracranial pressure.

Skin color. Cherry-red skin color develops from carbon monoxide poisoning. Blue discoloration of the fingertips and nasolabial triangle indicates low oxygen levels in the blood (for example, due to suffocation). Bruising, bleeding from the ears and nose, and spectacle-shaped bruises around the eyes are characteristic of a coma that has developed as a result of a traumatic brain injury. Pronounced pale skin indicates a comatose state due to massive blood loss.

Contact with others. With stupor and mild coma, involuntary vocalizations are possible - the production of various sounds by patients, this serves as a favorable prognostic sign. As the coma deepens, the ability to make sounds disappears.

Grimaces and reflexive withdrawal of the hand in response to pain are characteristic of a mild coma.

Diagnosis of coma

When diagnosing coma, the neurologist simultaneously solves 2 problems: 1) finding out the cause that led to the coma; 2) direct diagnosis of coma and its differentiation from other similar conditions.

Interviewing the patient's relatives or random witnesses helps to find out the reasons for the patient's falling into a coma. At the same time, it is clarified whether the patient had previous complaints, chronic diseases heart, blood vessels, endocrine organs. Witnesses are questioned about whether the patient used medications and whether empty blisters or jars of medications were found near him.

The speed of development of symptoms and the age of the patient are important. Coma that occurs in young people against the background of complete health most often indicates poisoning with narcotic drugs or sleeping pills. And in elderly patients with concomitant diseases of the heart and blood vessels, there is a high probability of developing coma due to a stroke or heart attack.

The examination helps determine the probable cause of the coma. The level of blood pressure, pulse rate, respiratory movements, characteristic bruises, bad breath, traces of injections, body temperature - these are the signs that help the doctor make the correct diagnosis.

Particular attention should be paid to the patient's position. A thrown back head with increased tone of the neck muscles indicates irritation of the membranes of the brain, which occurs with hemorrhages and meningitis. Convulsions of the whole body or individual muscles may occur if the cause of the coma is status epilepticus or eclampsia (in pregnant women). Flaccid paralysis of the limbs indicates a cerebral stroke, and a complete absence of reflexes indicates deep damage to the large surface of the cortex and spinal cord.

The most important thing in the differential diagnosis of coma from other states of impaired consciousness is the study of the patient’s ability to open his eyes to sound and pain stimulation. If the reaction to sound and pain manifests itself in the form of voluntary opening of the eyes, then this is not a coma. If the patient, despite all the efforts of the doctors, does not open his eyes, then the condition is considered comatose.

The reaction of the pupils to light is carefully studied. Its features not only help to establish the expected location of the lesion in the brain, but also indirectly indicate the cause of the coma. In addition, the pupillary reflex serves as a reliable prognostic sign.

Narrow pupils (pupils-points), which do not react to light, are characteristic of alcohol and drug poisoning. Different pupil diameters in the left and right eyes indicate an increase in intracranial pressure. Wide pupils are a sign of damage to the midbrain. The dilation of the diameter of the pupils of both eyes, combined with the complete lack of their reaction to light, is characteristic of an extreme coma and is an extremely unfavorable sign, indicating imminent brain death.

Modern technologies in medicine have made instrumental diagnosis of the causes of coma one of the very first procedures upon admission of any patient with impaired consciousness. Performance computed tomography(CT brain) or MRI (magnetic resonance imaging) allows you to determine structural changes in the brain, the presence of space-occupying formations, and signs of increased intracranial pressure. Based on the images, a decision is made on treatment methods: conservative or emergency surgery.

If it is not possible to perform a CT or MRI, the patient should undergo radiography of the skull and spinal column in several projections.

It helps to confirm or refute the metabolic (metabolic failure) nature of the coma biochemical analysis blood. Blood glucose, urea, and ammonia levels are urgently determined. The ratio of blood gases and basic electrolytes (potassium, sodium, chlorine ions) is also determined.

If the results of CT and MRI indicate that there are no reasons from the central nervous system that can put the patient into a coma, a blood test is performed for hormones (insulin, adrenal hormones, thyroid hormones), toxic substances (narcotics, sleeping pills, antidepressants), bacterial blood culture . The most important test that helps differentiate the types of comas is electroencephalography (EEG). When it is carried out, the electrical potentials of the brain are recorded, the assessment of which makes it possible to distinguish a coma caused by a brain tumor, hemorrhage, or poisoning.

Treatment of coma

Treatment of coma should be carried out in 2 areas: 1) maintaining the patient’s vital functions and preventing brain death; 2) combating the main cause that caused the development of this condition.

Support of vital functions begins already in the ambulance on the way to the hospital and is carried out for all patients in a coma even before receiving the results of the examination. It includes maintaining airway patency (straightening a sunken tongue, clearing the mouth and nasal cavity of vomit, oxygen mask, inserting a breathing tube), normal blood circulation (administration of antiarrhythmic drugs, blood pressure normalizing drugs, indoor massage hearts). In the intensive care unit, if necessary, the patient is connected to a ventilator.

The administration of anticonvulsants in the presence of seizures, mandatory intravenous infusion of glucose, normalization of the patient’s body temperature (covering and covering with heating pads for hypothermia or fighting fever), and gastric lavage if drug poisoning is suspected.

The second stage of treatment is carried out after a detailed examination, and further medical tactics depend on the main cause of the coma. If it is a trauma, brain tumor, intracranial hematoma, then urgent surgery is performed. When a diabetic coma is detected, sugar and insulin levels are taken under control. If the cause is kidney failure, hemodialysis is prescribed.

Forecast

The prognosis for coma depends entirely on the degree of damage to brain structures and the causes that caused it. In the medical literature, the patient’s chances of emerging from a comatose state are assessed as: in case of precoma, coma I - favorable, complete recovery without residual effects is possible; coma II and III – doubtful, that is, there is both a likelihood of recovery and death; coma IV - unfavorable, in most cases ends in the death of the patient.

Preventive measures come down to early diagnosis of the pathological process, prescribing correct methods treatment and timely correction of conditions that may cause the development of coma.

Coma

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

These factors include:

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

2) exotoxic: poisons, medications in toxic dosages;

3) endotoxic: for severe infectious diseases, at endocrine diseases(diabetic, hypoglycemic coma), lactic acidemia (in cancer patients, patients with terminal cardiovascular diseases), with renal, hepatic, respiratory failure.

Thus, the following types of comas are distinguished:

1) cerebral (apoplectic);

2) diabetic (hyperglycemic: hyperosmolar, ketoacidotic);

3) hypoglycemic;

4) hyperlactacidemic;

5) uremic;

6) hepatic;

There are a number of comas (alcoholic, barbiturate, opiate, salicylate, unknown etiology), etc.

A common sign of a coma is the patient's lack of consciousness, lack of speech, and eyes closed. There are three degrees of coma:

1) hemodynamic parameters are stable, there are reflexes;

2) hemodynamics are stable, deep depression of reflexes;

3) sharply reduced blood pressure, pathological breathing, complete absence of reflexes, terminal condition.

The Glasgow scale is used to determine the severity of coma:

a) opens eyes spontaneously, to a call, to painful stimulation, no reaction, respectively, 4, 3, 2 and 1 point;

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

c) movements: follows commands, points out the 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 point). Coma 1, if the score is 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 management of patients. All patients in a coma, except for hypoglycemic ones, undergo tracheal intubation.

Brain coma.

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

Management of patients at the prehospital stage:

1) removal of foreign objects from the oral cavity;

2) tracheal intubation;

3) suction of aspiration masses from the 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, magnesium sulfate 25% -10 ml.

7) monitoring ECG, blood sugar;

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