Comas

Description:

Coma (coma) (from Greek κῶμα  — a deep sleep) — sharply developing serious morbid condition which is characterized by the progressing oppression of the TsNS functions with consciousness loss, disturbance of reaction to external irritants, the accruing disorders of breath, blood circulation and other functions of life support of an organism. In narrow sense the concept "coma" means the most considerable extent of oppression of TsNS (behind which follows already brain death) which is characterized not only by total absence of consciousness, but also an areflexia (lack of one or several reflexes) and disorders of regulation of the vital functions of an organism.

Symptoms of Comas:

The coma can suddenly develop (almost instantly), quickly (for the period of several minutes to 1 — 3 h) and gradually — within several hours or days (slow development of a coma). In the practical relation the classification assuming allocation of a prekoma and 4 severity (development stages) of coma has certain advantages.

Prekoma. Disorder of consciousness is characterized by the confusion moderated by an oglushennost; block, drowsiness or psychomotor excitement are more often observed; psychotic states (for example are possible, at a toxic, hypoglycemic coma); purposive movements are insufficiently coordinate; vegetative functions and the somatic status correspond to character and weight of the basic and associated diseases; all reflexes are kept (their changes are possible at the primary and cerebral coma and a coma caused by neurotoxic poisons).

Côme I of degree. The expressed oglushyonnost, a dream (hibernation), braking of reactions to strong irritants, including painful; the patient carries out the simple movements, can swallow of water and liquid food, independently turns in a bed, but the contact with it is considerably complicated; the muscle tone is raised; reaction of pupils to light is kept, the dispersing squint, the pendulum movements of eyeglobes is quite often noted; cutaneous reflexes are sharply weakened, tendinous — are raised (at some types of a coma are reduced).

Côme II of degree. Deep sleep, sopor; the contact with the patient is not reached; sharp weakening of reactions to pain; the rare spontaneous movements are not coordinate (are chaotic); pathological types of breath are noted (noisy, stertorozny, Kussmaulya, Cheyna — Stokes, etc., is more often with a tendency to a hyperventilation); involuntary urinations and defecation are possible; reaction of pupils to light is sharply weakened, pupils are often narrowed; corneal and gag reflexes are kept, cutaneous reflexes are absent, pyramidal reflexes, muscular dystonia, spastic reductions, fibrillations of separate muscles, a gormetoniya (change of a sharp muscle tension of extremities by their relaxation and emergence of an early contracture of muscles) come to light.

Côme III of degree (or "atonic").
Consciousness, reaction to pain, corneal reflexes are absent; gag reflexes are oppressed; the miosis is often observed, reaction of pupils to light is absent; tendon jerks and a tone of muscles are diffuzno lowered (periodic local or generalized spasms are possible); the urination and defecation are involuntary, Arterial pressure is reduced, breath is arrhythmic, often oppressed to rare, superficial, body temperature is lowered.

Côme IV of degree (ultraboundary).
Full areflexia, atony of muscles; mydriasis; a hypothermia, deep disturbance of functions of a myelencephalon with the termination of spontaneous breath, a sharp lowering of arterial pressure.

Getting out of coma. Getting out of coma under the influence of treatment is characterized by gradual recovery of the TsNS functions, usually as it should be, the return to their oppression. In the beginning there are corneal, then pupillary reflexes, extent of vegetative frustration decreases. Recovery of consciousness takes place stages of an oglushyonnost, the confused consciousness, the nonsense, hallucinations sometimes are noted. Quite often in the period of an exit from a coma the sharp motive concern with the chaotic dicoordinated movements against the background of the deafened state is observed; convulsive attacks with the subsequent twilight state are possible.

Reasons of Comas:

The coma is not an independent disease; it arises or as a complication of a number of the diseases which are followed by considerable changes of operating conditions of TsNS or as manifestation of primary damage of structures of a brain (for example, at a severe craniocereberal injury). At the same time at different forms of pathology comas differ on separate elements of a pathogeny and manifestations that causes also the differentiated therapeutic tactics at koma of a different origin.

Treatment of Comas:

The combination of artificial substitution of functions of vitals and etiopatogenetichesky therapy is necessary. The main objective of treatment – maintenance of optimum transport of oxygen in this connection even short-term episodes of a hypoxia and arterial hypotension are very dangerous. All measures providing free passability of respiratory tracts have to be taken. At I and II stages for this purpose it is possible to use an air duct, at III and IV – an intubation of a trachea or a tracheostomy. At hypoventilation or a hyper ventilating syndrome which meets at patients with a craniocereberal injury more often artificial ventilation of the lungs is shown. During artificial ventilation control not only PaO2, but also PaCO2 is very important. Take measures for normalization of body temperature, and at indications resort to a hypothermia. For treatment and dynamic control of biochemical parameters carry out catheterization of the central vein. The careful nosotrophy (danger of formation of decubituses), antibacterial therapy, parenteral and enteral probe food are necessary.