coma
Introduction
Coma introduction Coma is in a state of non-responsiveness to external stimuli and often has dramatic changes in vital signs. And can not be awakened to know themselves or the surrounding environment, is the most serious disturbance of consciousness, that is, the continuous loss of total consciousness; is also one of the main manifestations of brain failure. Intracranial lesions and metabolic encephalopathy are two common causes. basic knowledge The proportion of sickness: 0.01% Susceptible people: no specific population Mode of infection: non-infectious Complications: hemorrhoids respiratory infections
Cause
Coma cause
Intracranial lesions (20%):
Commonly, bleeding, vascular infarction, inflammation, trauma and tumors.
1. Cerebral hemorrhagic disease: common in cerebral hemorrhage and subarachnoid hemorrhage. However, a small amount of cerebral hemorrhage since CT application, including basal ganglia hemorrhage, and cerebral hemorrhage rarely cause coma.
2. Cerebral infarction such as cerebral embolism, cerebral thrombosis, etc. can also cause coma.
3. Inflammation: such as various encephalitis, brain abscess, meningitis and so on.
4. Trauma: such as concussion, brain contusion, traumatic intracranial hematoma.
5. Others such as epilepsy, toxic encephalopathy, etc.
Acute infectious diseases (25%):
It is found in severe infections of the whole body, including various bacteria, viruses, spirochetes, and parasites. Common in sepsis, pneumonia, scarlet fever, diphtheria, whooping cough, typhoid fever and urinary tract infections.
Endocrine and metabolic disorders (15%):
Coma caused by uremia, liver disease, thyroid crisis, diabetes, hypertonic diabetes, hypoglycemia, and chronic adrenal insufficiency.
Poisoning (10%):
Exogenous poisoning includes industrial poisoning, pesticide poisoning, drug poisoning, plant poisoning, animal poisoning, etc.
Cardiovascular disease (15%):
Cardiovascular diseases such as arrhythmia, myocardial infarction, pulmonary encephalopathy and hypertensive encephalopathy.
Water and electrolyte balance disorder (5%):
Dilute hypouricemia caused by water and electrolyte balance disorders such as chronic congestive heart failure and chronic adrenal insufficiency.
Prevention
Coma prevention
(1) Dietary care should be given to patients with high calorie and digestive liquid food; nasal feeding should not be given to swallows, and nasal feeding foods can be milk, rice soup, vegetable soup, broth and juice water, etc. In addition, milk, eggs, Starch, vegetable juice, etc. are blended together to make a mixture of porridge-like mixed milk, nasal feeding to the patient, each feeding amount of 200-350 ml, 4 to 5 times a day, when nasal feeding, the tableware should be cleaned and disinfected. .
(2) Keep the airway open and prevent colds. The patient's body resistance is low during long-term coma. It is necessary to pay attention to keep the patient warm, to prevent cold, cold, and to turn the face to one side regardless of the position of the patient, in order to facilitate the respiratory tract. Drainage of secretions; when the patient has sputum or secretions and vomit in the mouth, it should be sucked out or sputum in time; each time the patient changes his position, he or she gently buckles the back of the patient to prevent inhalation or fallopian pneumonia. occur.
(3) Prevention of hemorrhoids, the most fundamental way to prevent acne in patients with coma is to turn over regularly, usually every 2 to 3 hours to turn over, in addition, also to change the wet sheets, bedding and clothes in time, now introduce: people turn over the law The patient is in the left lateral position as an example): The first step family is standing on the right side of the patient, first making the patient supine, and then bending the patient's lower limbs; the second step is to put the left arm under the patient's waist and the right arm. In the lower part of the patient's thigh, then lift the patient and move it to the right (family side), then place the left hand on the lower part of the patient's shoulder, the right hand under the waist, lift it up, and move to the right side; the third step is the patient's head. The neck and torso are simultaneously turned to the left side, that is, the left side lying position; finally, a pillow is placed on the back of the patient to support the body position and make the patient comfortable.
(4) Prevention of burns, long-term coma patients with poor peripheral circulation, winter hands, feet become more and more cold, family members in the use of hot water for patients to warm, you must pay attention to the temperature can not be too high, generally less than 50 degrees Celsius, In order to avoid burns.
(5) to prevent constipation, patients who stay in bed for a long time are prone to constipation. In order to prevent constipation, the patient can be given some bananas, honey and food containing more cellulose every day. Massage the abdomen to the patient every morning and evening. If you have not had stool for 3 days, you should take it. Laxatives such as Ma Ren Run Chang Pill or Rhubarb Soda Tablets can be used to help defecation if necessary.
(6) to prevent urinary tract infection, if the patient can urinate on his own, it is necessary to change the wet clothes, sheets and bedding in time. If the patient needs to use a catheter to help urinate, pay attention to aseptic operation every time the patient's urine bag is cleaned. The urinary catheter should be replaced regularly. When the patient is turned over, the urine bag should not be raised above the patient's lying position to avoid urinary tract infection caused by urine reflux.
(7) To prevent falling of the bed, patients who are restless should install a bed block and use a protective tape if necessary to prevent the patient from falling into bed and falling.
(8) to prevent conjunctiva, keratitis, the eyes can not be closed, the patient can be coated with antibiotic eye ointment and covered with wet gauze to prevent knots, keratitis.
Complication
Coma complication Complications, acne respiratory infections
Asphyxia: Due to the weakening or disappearance of various reflexes in comatose patients, oral secretions or vomits are caused by inhalation.
Recession of the tongue: due to the fall of the tongue root blocking the throat passage, causing complete or partial obstruction of the respiratory tract. Control measures: be sure to keep the airway open, take the lateral position, head side to the side, raise the oral secretions in time, such as the tongue drop and use the tongue clamp to pull out, in case of emergency, the endotracheal tube or trachea can be used first. Cut open.
Hemorrhoids: Due to the high inhibition of cerebral cortex in comatose patients, systemic metabolic nutrition and various physiological functions are affected, and long-term in a certain passive position, skin compression, especially subcutaneous fat, bone prominent and poor blood flow is the easiest Hemorrhoids occur. Control measures: The condition should be turned over early, every 2 hours, and the skin of the pressed part is massaged with safflower alcohol. If the patient is in a serious condition and should not be turned over, gently extend the hand to the patient's compression site for massage. Take care to keep the skin clean and dry, and the sheets are smooth and wrinkle-free. If it has occurred, it should be treated as early as possible for each period of hemorrhoids. And put a cushion on the protruding part of the bone to reduce the pressure.
infection:
1. Oral infection: The stunned patient's swallowing is slow or disappears, and the secretions in the mouth and nose are accumulated, which may cause bacterial or fungal infection.
2. Respiratory tract infection: due to the stunned respiratory center is in a state of inhibition, throat secretions accumulate, vomit aspiration, etc., caused by hypostatic pneumonia. Control measures: pay attention to oral cleansing, strengthen oral care, scrub the oral cavity 2 times with 2% su-water every day, if the fungal infection can be coated with bacteriocin glycerin. There are oral ulcers that can be rubbed with tin. It is necessary to keep the airway open, and turn over the back regularly to facilitate the movement of the body to promote the discharge of the endocrine secretions or to facilitate the attraction. The action should be light when attracting, to ensure its effectiveness, and not to damage the mucosa.
Symptom
Symptoms of common symptoms Common symptoms Respiratory irregular deep coma fainting urination and retention high fever hypertensive shock intracranial hemorrhage toxic coma intracranial infection
1. Light coma: clinical manifestations of blinking reaction disappeared or occasionally semi-closed state, language loss, spontaneous movement is rare, all kinds of stimulation and internal needs of the outside, completely unaware and reaction. However, strong painful stimuli can be seen in patients with painful expressions, paralyzed or limb defenses and increased breathing. Brainstem reflexes such as swallowing reflexes, cough reflexes, corneal reflexes, and pupils are still present for light reflections, and ocular brain reflexes may also be present. There is no significant change in breathing, pulse, and blood pressure. Defecation or incontinence.
2. Moderate coma: The patient's blink, language and spontaneous movement have been lost, and there is no response to various external stimuli. For strong pain stimuli, defensive reflexes may occur. There is no movement in the eyeball, the corneal reflex is weakened, the pupil is slow to reflect light, and the breathing is slowed or increased. Central respiratory disorder such as periodic breathing and central neuron hyperventilation can be seen. Pulse and blood pressure have also changed. With or without limb tonic extension and angulation (de-cortical rigidity). Defecation or incontinence.
3. Deep coma: Muscle relaxation in the whole body, and strong pain stimulation can not lead to escape response and cortical rigidity. The eyeball was fixed, the pupil was significantly enlarged, and the pupil was completely lost to light reflection, corneal reflex, anterior chamber reflex, swallowing reflex, cough reflex, and sacral reflex. Irregular breathing, blood pressure may drop, incontinence, and even detention.
4. Brain death: manifested as unresponsive deep coma, spontaneous breathing stopped, pupil dilated and fixed, brainstem reflex disappeared, accompanied by decreased body temperature and blood pressure. EEG is silent, and cerebral angiography is not developed. At this time, even if the heartbeat is still maintained, the whole brain function will never recover, and the heartbeat will stop in a certain period of time.
Examine
Coma check
Lumbar puncture examination (cerebrospinal fluid cytology, biochemistry, viral cell series), cranial CT and magnetic resonance imaging are of great value in the diagnosis of central nervous system diseases. Blood detection of carboxyhemoglobin contributes to the diagnosis of CO poisoning. Urine routine abnormalities are common in uremia. Symptoms, diabetes, acute uroporphyria, suspected hepatic coma patients with blood ammonia and liver function, blood sugar and renal function tests can help diabetic acidosis, hypoglycemia coma and uremic coma diagnosis, electrocardiogram can diagnose myocardial infarction, heart rate An abnormality leads to a coma.
Diagnosis
Coma diagnosis
diagnosis
First, the medical history question
1. Focus on the urgency and onset of coma onset. Acute onset is common in trauma, infection, poisoning, cerebrovascular disease and shock.
2. Understand whether coma is the first symptom. If it occurs during the course of the disease, you should know what is the disease before coma. For example, diabetics may have hyperosmolar coma and hypoglycemia coma. Patients with cirrhosis may have hepatic coma. Hyperthyroidism patients may develop hyperthyroidism. Like and so on.
3. Whether there is a history of trauma.
4, with or without pesticides, gas, sleeping pills, poisonous plants and other poisoning.
5, there are no medical diseases that can cause coma, such as diabetes, kidney disease, liver disease, severe heart and lung disease.
6, for patients with transient coma, should pay attention to epilepsy or syncope and other diseases.
Second, physical examination found
1, should carefully observe body temperature, breathing, blood pressure, pulse, skin and head and neck situation, high fever should pay attention to serious infection, heat stroke, pons bleeding, atropine poisoning, etc., low body temperature should pay attention to shock, mucous edema, hypoglycemia, sedative poisoning, Frostbite, etc.; pulse slowness should pay attention to intracranial hypertension, atrioventricular block or myocardial infarction, heart rate is too fast in the heart ectopic rhythm, fever and heart failure; respiratory rhythm changes can help determine brain lesions Part, pay attention to breathing odor (diabetic acidosis has fruit odor, uremia has urinary odor, liver coma has rancid smell, alcoholism has alcoholic taste, organic phosphorus poisoning has garlic odor); hypertension can be seen in cerebral hemorrhage, Hypertensive encephalopathy and intracranial hypertension, hypotension is common in shock, myocardial infarction, sleeping pills poisoning, etc.; skin is cherry red for CO poisoning, skin blemishes are seen in sepsis, epidemic meningitis, anticholinergic drug poisoning or heatstroke The skin is dry, and the skin is wet and sweaty during shock; pay attention to the evidence of trauma such as bleeding or discharge in the ear, nose and conjunctiva.
2, nervous system examination should pay attention to the presence or absence of focal neurological signs, pupil and fundus conditions, heavy pressure on the upper edge of the sputum with or without defense response and expression response, re-scratch the foot with or without limb escape response, pay attention to eye position, tendon reflex Symmetry and pathological reflex; patients with intracranial hypertension and subarachnoid hemorrhage often have optic edema and hemorrhage; bilateral dilated pupils are found in cerebral hypoxia, atropine poisoning, severe midbrain lesions, bilateral pupillary needle-like reduction Seen in the pons of the pons, hemorrhage, organic phosphorus and morphine poisoning, one side of the pupil dilated in the ipsilateral brain hook back; one side narrowed in the Horner's sign or ipsilateral brain hook back early.
3, pay attention to the presence or absence of meningeal irritation, common in central nervous system infections and intracranial hemorrhagic diseases.
Differential diagnosis
Many different behavioral states can behave like coma or confused with coma, and patients who are initially comatose can gradually develop into one of these states after varying lengths of time, once the patient has a sleep-wake Cycles, true coma no longer exists, and the identification of these states with true coma is important for proper treatment and prognosis.
(1) Atresia syndrome: Locked-in syndrome is also called deafferented state. The patient remains alert and aware of his situation, but the paralysis of the limbs and the cranial nerves below the eye movement. Bilateral cerebral ventral lesions, involving the corticospinal tract, cortical pons and cortical medullary bundle, the patient is conscious, but can only be indicated by vertical movement of the eye and blinking. This disease is common in pons infarction caused by basilar artery thrombosis. Other causes include brain stem tumors and central pontine myelinolysis. Severe polyneuropathy, especially Guillain-Barré syndrome, myasthenia gravis and neuromuscular junction blockers may also exhibit similar atresia. The paralyzed state of the syndrome.
(2) Persistent vegetative state: A persistent vegetative state in which a patient loses cognitive neurological function, but retains autonomic functions such as cardiac activity, breathing, and maintenance of blood pressure. This state occurs after a coma and is characterized by unconsciousness of the surrounding things. Or cognitive function is absent, but the sleep-wake cycle is maintained, spontaneous movements can occur, and external stimuli can blink, but they do not speak, do not obey orders, and many syndromes that are not exactly defined are used as persistent plants. Synonyms of status, including alpha coma, neocortical death, and permanent unconsciousness. These names lack precision and are avoided as much as possible. The diagnosis of this disease should be cautious and can only be done after a long period of observation. Out.
(3) Akinetic mutism: akinetic mutism The patient does not speak, has no spontaneous activity, does not move under the excitation, can blink around, has no reaction to pain stimulation or only partial reaction, size Incontinence, there is a sleep awakening cycle, multiple lesions can cause subacute communicating hydrocephalus, the third ventricle posterior and aqueduct tumor, bilateral frontal lobe lesions involving the cingulate cortex (bilateral anterior cerebral thrombosis), The reticular formation of the bilateral brainstem and the localized lesions of the midbrain nucleus of the thalamus. The common feature of these lesions is the damage of the dynamic reticulum activation system that accepts internal and external environmental information.
(4) The lack of will: abulia is a serious apathy. At this time, the patient's feelings, driving force, and psychological activities are slow, behavioral performance is not speech, no voluntary activities, serious cases. Similar to apathetic mutism, but the patient can remain alert and aware of his situation.
(5) Tension disorder: patients with catatitis (catatonia) are silent, exercise is obviously reduced, stay in bed, can maintain the ability to stand or sit, but fixed a posture with little change, seen in schizophrenia, should be with the instrument The difference between the stupor caused by sexual lesions.
(6) False coma: pseudo coma (pseudocoma) behaves like a coma, does not blink, does not speak, does not move, does not evade pain, but there is no abnormality in the examination, this is a "coma" pretending to evade responsibility, not hysteric Drowsiness, sometimes difficult to distinguish between the two.
