Malarial coma

Description:

The malarial coma — very heavy complication of malaria, most often tropical, but in rare instances of a lump can develop also at a tetrian fever. More often the coma is observed in August and September, and it develops at patients with a fresh disease. Now in connection with sharp reduction of incidence of malaria meets extremely seldom.

Reasons of a malarial coma:

The coma pathogeny, according to most of clinical physicians, consists in disturbance of cerebral circulation as a result of mechanical obstruction of capillaries of a brain the blood clots consisting of the changed erythrocytes, leukocytes and plasmodiums of malaria.
S. G. Vaysbeyn calls damage of a brain at this coma a peculiar encephalitis.

Symptoms of a malarial coma:

The beginning of a coma can be sudden, within several hours, more often it develops gradually, within 2 — 3 days. Distinguish 3 periods during a malarial coma: 1) prekomatozny, 2) period of excitement and 3) depression period. In a prekomatozny state at the patient the most severe headache, concern, reduction of chewing muscles, a black-out is noted. The periods of excitement are replaced by the braking periods, patients are passive, sleepy, are not mobile. In an initial stage of a coma — the excitement period consciousness is absent, the patient raves, the muscle tone and tendon jerks are raised, pathological Babinski's reflexes, Kerniga and Brudzinsky, a stiff neck, tonic and clonic spasms, a clonus of feet, an ischuria and a calla are observed. During the late period — the period of a depression is observed complete prostration, decrease in a muscle tone, fading of tendon jerks, an involuntary urination and defecation. At a research of the patient who is in a coma critical condition, the person одутловато, voskovidno attracts attention or землисто, zheltushno, eyes are half-open, scleras of a zheltushya, the mouth is half-open or open, the lips baked, dry, on teeth a plaque, language dry, is laid densely over, high temperature, the breath which is speeded up superficial. Pulse is speeded up, small, blood pressure low, cardiac sounds deaf. Diffusion bronchitis is often observed. The stomach is blown up owing to intestines paresis, the liver and a spleen are increased. At a research of a thick drop of blood in a smear find a plasmodium of tropical malaria. From the general blood test hypochromia anemia, an erythrocyte dimentation test is accelerated, the leukopenia (is more often at usual malaria lymphocytosis). In urine an urobilinuria, a microalbuminuria, a microhematuria and single cylinders.
The diagnosis is not difficult in the epidemic centers and at the patient in whose anamnesis malaria attacks are noted. Unconditional confirmation of the diagnosis is detection in blood of plasmodiums of malaria.

Treatment of a malarial coma:

As soon as the malarial coma is suspected, it is necessary to begin treatment, without waiting for results of a blood analysis on a malaria plasmodium since even 1 — 2 hour matter for rescue of life of the patient. Treatment specific — quinacrine or quinine to enter parenterally, in sufficient doses.
Quinacrine of 4% solution of 2,5 ml is entered intravenously with glucose within 3 — 5 minutes (bystry introduction gives a collapse) and at the same time 5 ml of the same solution of quinacrine intramusculary, in 8 hours to repeat an injection. During a day of quinacrine 0,3 — 0,6 g are entered E. M. Tareev recommends a quinacrine dose to lead up in the first days to 0,8 (on 0,2 in 6 hours), in the second — to 0,6.
Quinine in the first day is entered once intravenously in the form of 50% of solution of two-muriatic quinine of 1 ml (0,5 g) into 20 ml of 40% of solution of glucose or normal saline solution, at the same time 1 ml of 50% of solution is entered intramusculary, and then on 1 ml in 8 hours intramusculary. Daily dose of 2 g. Before intravenous injection it is necessary for the prevention of a collapse to enter caffeine or Cordiaminum. At consciousness return quinine is appointed inside 2,0 in days with Plasmocidum of 0,06 g a day.
At decline of cordial activity, sharp exhaustion of the patient to enter quinine intravenously contraindicated, it is necessary to apply it intramusculary. It is possible to carry out the combined treatment of a coma by quinacrine and quinine. L. A. Lushnikova recommends to enter intravenously 5 ml of 2% of solution of quinacrine and at the same time intramusculary 2 ml of 25% of solution of quinine. 2 — 4 hours later repeatedly intramusculary enter 5 ml of 2% of solution of quinacrine. If the patient did not recover consciousness, then in 8 — 10 hours again intravenously enter 5 ml of 2% of solution of quinacrine (enter very slowly). Except quinacrine and quinine (by experience of treatment of a tropical malarial coma in Tashkent), apply Bigumalum (Paludrinum) intravenously on 10 ml of 1% of solution 2 times a day, and then it is appointed inside on 0,1 g by 3 times a day within 5 days.
For the prevention of cardiovascular insufficiency 2 — 3 times a day or 1 ml of 10% of solution of caffeine subcutaneously enter 2 — 3 ml of 20% of solution of camphor. At the developed heart failure intravenously 0,25 — 0,5 mg of strophanthin from 10 ml of 40% of solution of glucose. At vascular insufficiency subcutaneously enter normal saline solution of 500 ml, transfuse blood in number of 100 — 200 ml, enter adrenaline, noradrenaline. For reduction of swelling of brain fabric intravenously of 10 ml of 40% of solution of urotropin, for a trichangiectasia of a brain intravenous administration of 2 — 5 ml of 1% of solution of niacin with glucose of 40% is shown.