Definition of coma signs types first aid. Emergency care for coma algorithm of actions

1) Providing the patient with complete rest, with the upper body raised. If it is necessary to transport to a medical institution, transportation with all precautions is permissible no earlier than 10-12 days of illness;

2) put an ice pack on your head, a heating pad on your feet;

3) watch the tongue so that it does not sink back and thereby close the entrances to the pharynx and larynx;

4) if the patient can swallow, give him a soothing drops (valerian, bromine) to drink;

6) monitor the intestines: with stool retention, cleansing enemas are needed, and with prolonged unconsciousness, nutritious enemas.

Coma (deep sleep) is an acutely developing pathological condition, characterized by increasing depression of the nervous system with loss of consciousness, impaired response to external conditions, increasing respiratory, circulatory and other vital functions of the body. Often, instead of the term "coma" the term "coma" is used.

Coma is not an independent disease; it occurs either as a complication of a number of diseases accompanied by significant changes in the conditions of the functioning of the central nervous system, or when the brain is damaged (for example, in severe traumatic brain injury).

Depending on the type of disorder of the body that disrupts the normal functioning of the central nervous system, various comas are possible, namely:

1) neuralgic coma, which is based on depression of the central nervous system in connection with brain damage. This includes - apoplexy coma (with a stroke), traumatic (with traumatic brain injury), coma with brain tumors, etc.

2) toxic coma, caused either by poisoning or by internal intoxication in renal failure (uremic coma), liver failure (hepatic coma);

3) coma caused by a lack of oxygen supply from the outside (suffocation), impaired oxygen transport by blood to the organs and tissues of the body with anemia, etc.;

4) coma caused by metabolism due to insufficient synthesis of hormones - their excessive production or overdose of hormonal drugs;

5) coma caused by the loss of water and energy substances by the body (for example, a hungry coma).

Coma can develop suddenly (almost instantly), quickly (over a period of several minutes to 1-3 hours), and gradually over several hours or days.

Sudden development is most often observed with a neural coma. The patient loses consciousness and in the next few minutes all the signs of a deep coma are most often revealed. Various disorders of the rhythm and depth of breathing are noted - superficial and rare respiratory movements become deep and frequent, after reaching the maximum, breathing stops, then it resumes, etc. (this is Cheyne-Stokes breathing). There are changes in blood pressure with a tendency to decrease as the coma deepens. The functions of the pelvic organs (defecation and urination) are upset.

Usually a coma is characterized by severity, which, with the gradual development of coma, correspond to its stages.

Precoma- the disorder of consciousness is characterized by confusion, moderate stunnedness; drowsiness or agitation is more common; purposeful movements are violated, all reflexes are preserved.

Coma I degree -severe stunnedness, sleep (hibernation); the patient performs simple movements, can swallow water and liquid food, turn independently; the reaction of the pupils to light is preserved; divergent squint, pendulum movements of the eyeballs are often noted.

Coma II degree- deep sleep, stopper, contact with the patient is not achieved, rare movements are not coordinated, chaotic; breathing is disturbed; involuntary urination and defecation are possible; the reaction of the pupils to light is sharply weakened; skin reflexes are absent; corneal and pharyngeal reflexes are preserved.

Coma III degree - consciousness, reaction to pain, corneal reflexes are absent; pharyngeal reflexes are preserved; there is a constriction of the pupils (miosis), there is no reaction of the pupils to light; possible periodic convulsions, both individual and the whole body; urination and defecation are involuntary; blood pressure is lowered; breathing is arrhythmic, often reduced and superficial, body temperature is lowered.

Coma IV degree - complete absence of reflexes (areflexia); muscles become flabby, their elasticity disappears (muscle atony); there is a general cooling of the body (hypothermia); cessation of spontaneous breathing, a sharp decrease in blood pressure.

Exit from a coma under the influence of treatment is characterized by a gradual restoration of the functions of the central nervous system, usually in the reverse order of their oppression. Corneal effects appear first, followed by pupillary effects. The restoration of consciousness goes through the stages of stunnedness, narrowed consciousness, sometimes delirium, hallucinations are noted. Convulsive seizures are possible, followed by a twilight state.

Coma, caused by changes in the central nervous system incompatible with life, ends in death. With a coma of IV degree, most patients die, with a coma of III degree, it is not always possible to prevent death.

First aid in all types of coma, it consists in performing measures to restore the patency of the upper respiratory tract, to prevent asphyxia due to the sinking of the tongue and to hold the toilet in the oral cavity and nasopharynx, especially with vomiting.

For this, the patient must be laid on his side (in case of vomiting - on his stomach), tilt his head back, and push the lower jaw forward and down simultaneously. Grasping with your fingers, stretch out and then fix the tongue with a bandage.

After that, free the oral cavity and pharynx with a damp cloth from mucus, food debris or vomit. If possible, oxygen is inhaled, and with rare shallow breathing or stopping it, artificial lung ventilation is performed.

In case of poisoning with oral intake of poison (in case of poisoning with morphine, regardless of the route of entry), immediately begin gastric lavage through a tube or lavage of the stomach and intestines.

The patient is transported to the car and to the hospital on a stretcher (if there is no injury that requires transportation on a rigid shield), on which the patient is placed carefully in a lateral position with the face turned downward. To fix this position during transportation, the leg on which the patient lies is bent at the knee and pushed forward, which prevents the patient from turning on the stomach; the arm of the same name is bent at the elbow and pushed back, which prevents the patient from tipping back.

8.5. Asphyxia.

Asphyxia (suffocation) - an acutely or subacutely developing and life-threatening condition caused by insufficient gas exchange in the lungs, a sharp decrease in the oxygen content in the body and the accumulation of carbon dioxide.

The immediate causes of asphyxia are mechanical obstacles to the passage of air through the respiratory tract, which arise: when the airways are squeezed from the outside (for example, when suffocating); with their significant narrowing caused by any pathological process (for example, a tumor, inflammation or edema of the larynx); when the tongue falls into a person who is unconscious; with spasms of the glottis or bronchi of the lungs; when foreign bodies (for example, water) enter the lumen of the respiratory tract; with aspiration of food and vomit; when squeezing the chest (earth, heavy objects, etc.); with injuries of the chest and lungs.

Asphyxia can develop when a person is in an atmosphere with an insufficient oxygen content and an excess of carbon dioxide, for example, with a long stay of a person in close confined spaces, in wells, mines, etc.

It is customary to distinguish several stages of the development of asphyxia: first, second, third, fourth.

The first stage is characterized by increased activity of the respiratory and cardiovascular systems. There is an increase and increase in heartbeat, blood pressure rises. The flow of blood to tissues and organs from the blood depot increases. The body is trying to enhance gas exchange in this way.

In the second stage, there is a decrease in respiratory cycles. A decrease in heart rate is noted, blood pressure decreases.

In the third stage, there is often a temporary cessation of breathing, blood pressure drops sharply, heart rhythm is disturbed, the body's reactions to external irritation fade away, consciousness gradually fades away.

In the fourth (terminal) stage, rare convulsive "sighs" appear - agonal breathing, which usually lasts several minutes, sometimes much longer. Convulsions, involuntary urination and defecation are common. Death from asphyxia usually occurs due to paralysis of the respiratory center.

The total duration of asphyxia from its onset to the onset of death can vary over a fairly wide range: from 5-7 minutes with a sudden complete cessation of breathing to several hours or more (for example, when in a confined space).

With asphyxia, mental disorders are observed. So, when self-hanging after removing from unconsciousness, the victims have a memory impairment in the form of a loss of the ability to preserve and reproduce previously acquired knowledge (amnesia). With asphyxiation caused by carbon monoxide poisoning with the development of a coma, after removal from a coma, the victim develops a disorder resembling alcohol intoxication; at the same time, various memory disorders are noted. With asphyxiation caused by a lack of oxygen, the assessment of time and space is impaired. Some of the victims have lethargy, indifference, or, conversely, agitation, irritability. Sudden loss of consciousness may occur.

In search and rescue operations, most often rescuers may encounter mechanical asphyxia.

Mechanical asphyxia is understood as acute oxygen starvation resulting from partial or complete cessation of air access to the respiratory tract and lungs due to various mechanical obstacles.

Depending on the nature of the mechanical factor, there are:

mechanical asphyxia from squeezing the neck - strangulation asphyxia (squeezing the neck with boards, logs, strangulation with a noose, strangulation by hands);

mechanical asphyxia from compression of the chest and abdomen - compression asphyxia;

mechanical asphyxia from closing the opening of the nose and mouth with soft objects, closing the airways by foreign bodies, fluids - obstructive asphyxia;

mechanical asphyxia from closing the airways with food and blood.

As a rule, mechanical asphyxia is acute and ends in death (if the asphyxia is not interrupted) within 6-8 minutes. In severely weakened patients, for example, with heart disease, death can occur in the first minutes.

First aid for asphyxiation is aimed at eliminating the cause that caused it and maintaining respiratory and cardiac activity (artificial ventilation of the lungs and chest compressions) - resuscitation.

8.4. Renal colic.

Renal colic is manifested by severe paroxysmal pain with characteristic irradiation.

The occurrence of pain is associated with spasmodic contraction of the muscles of the ureters and convulsive contraction of the renal pelvis due to blockage of the ureters with a stone and irritation of local nerve endings.

The main symptoms of renal colic are:

a) attacks of acute pain beginning in the lower back and radiating down the ureter into the groin, into the bladder, in men and in the testicles, in women - in the outer labia; pains begin cramping, often accompanied by bloating; their duration is different - from several minutes to several hours and even days;

b) nausea, vomiting, chills and fever up to 38-38.5 0;

c) at the height of the seizures - the cessation of the flow of urine into the bladder (anuria) in the presence of the urge to urinate;

d) poor health of the patient; he is pale, covered with cold sweat; pulse is small and frequent; often there is a fainting state, less often - a collapse.

When palpating the lumbar region, sharp pain is determined, it intensifies with the slightest movements and turns.

First aid for renal colic:

a) providing the patient with rest and bed rest;

b) put heating pads on the belt and stomach;

c) subcutaneously inject atropine 0.1-1 ml .;

d) inside (on the tongue) 1-2 drops of 1% alcohol solution of nitroglycerin;

e) in the absence of the effect of atropine and nitroglycerin, morphine or pantopon is injected subcutaneously, and in the presence of an individual first aid kit, promedol.

The appointment of nitroglycerin with a drop in blood pressure is contraindicated.

f) drinking plenty of water - tea, mineral water (Borjomi, Essentuki No. 20, etc.).

Coma (from the Greek.cat deep sleep) - pathological inhibition of the central nervous system, characterized by complete loss of consciousness, lack of reactions to external stimuli and dysregulation of vital body functions.

Coma is a formidable complication of various diseases. Violations of vital body functions are determined by the nature and severity of the main pathological process, as well as the rate of its development. They form very quickly and are often irreversible (for example, with severe traumatic brain injury) or develop gradually (uremic, hepatic coma).

Described about 30 types of com. Comas are conventionally divided into the following groups:

Coma caused by a primary lesion of the nervous system, or neurological coma (apoplexy coma in stroke, apoplectiform, epileptic, traumatic coma in traumatic brain injuries and coma in meningitis, encephalitis and brain tumors).

Coma with endocrine diseases, caused by metabolic disorders due to insufficient (diabetic, hypocorticoid, hypothyroid, hypopituitary) or excessive synthesis of hormones, or an overdose of hormonal drugs (thyrotoxic hypoglycemic).

Coma, primarily associated with the loss of electrolytes, water and energy substances (chlorohydropenic coma with persistent vomiting, in particular with pyloric stenosis, alimentary-dystrophic, or hungry, coma).

Coma due to impaired gas exchange (hypoxic, respiratory).

Toxic coma, which develops with toxic infections, various infectious diseases, pancreatitis, liver and kidney damage, as well as coma caused by exposure to exogenous poisons (organophosphorus compounds, alcohol, barbiturates, etc.).

The pathogenesis of coma is different. In any type of coma, there are dysfunctions of the cerebral cortex, subcortical structures and the brain stem. Of particular importance is the violation of the function of the reticular formation of the brain stem, its activating effect on the cerebral cortex is "turned off", disorders of the reflex functions of the stem and inhibition of vital vegetative centers are noted. The development of these disorders is facilitated by hypoxemia, anemia, cerebral circulation disorders, blockade of respiratory enzymes, acidosis, microcirculation disorders, electrolyte balance (especially potassium, sodium and magnesium), and the release of mediators. Swelling, edema of the brain and its membranes, leading to an increase in intracranial pressure, impaired circulation of cerebrospinal fluid and hemodynamic disorders, are of important pathogenetic significance.

Pathological examination reveals swelling of the brain, foci of hemorrhage and softening against the background of expansion of capillaries, blood stasis, plasma soaking and necrobiotic changes in the capillary walls. The originality of the pathomorphological picture in various comas is also due to etiological factors. Allocate moderate (I degree), deep (II degree) and transcendental (III degree) coma.

Moderate coma characterized by complete loss of consciousness, lack of reactions to external stimuli (except for strong painful). In response to painful stimuli, extensor and flexion movements of the extremities, tonic convulsions with a tendency to generalization, or hormetonia may appear. Protective motor reactions are not coordinated and are not aimed at eliminating the stimulus. The eyes do not open after painful exposure. Pupillary and corneal reflexes are usually preserved. Abdominal reflexes are depressed, tendon reflexes are often increased. Reflexes of oral automatism and pathological foot reflexes appear. Breathing and cardiac activity are relatively stable.

Deep coma characterized by the absence of any reactions to all external stimuli, including strong painful ones, complete absence of spontaneous movements, various changes in muscle tone (from decerebral rigidity to muscle hypotension), hypo- and areflexia, unilateral mydriasis, severe respiratory and cardiac disorders. Kernig's symptom may be caused.

Transcendental coma characterized by a gross violation of vital functions - rhythm disturbance and changes in the respiratory rate or apnea, sharp tachycardia, a significant decrease in blood pressure (or it is not determined), bilateral mydriasis, total areflexia, diffuse muscle atony.

The depth and duration of the coma are the most important predictors of prognosis. Currently, in various countries, scales have been developed that allow, based on an assessment of simple clinical symptoms, to fairly accurately determine the prognosis for coma. A.R. Shakhnovich et al (1981) proposed a scale that includes 50 neurological signs, the severity of which is assessed in points. Changes in eye micromovements, clinical and physiological signs, indicators of evoked stem and cortical potentials are taken into account. The most informative were the following 12 signs:

opening the eyes in response to the action of a sound or pain stimulus - 10 points;

following instructions - 8;

absence of mydriasis - 5;

lack of muscle atony - 5;

absence of respiratory dysfunctions - 4;

the presence of reflexes: corneal - 4;

knee - 4;

the reaction of the pupils to light - 3;

cough - 3;

absence of a symptom of Magendie - 3;

the presence of spontaneous movements - 3;

motor reaction in response to pain stimulus - 3 points.

The total number of points is 55. The first 5 signs are especially informative. The more points, the more favorable the forecast. The authors observed a favorable prognosis for a coma estimated at 22 points or more.

Emergency help coma start immediately. Be sure to take into account the reason that caused the coma. Below are the basic principles of providing emergency care for patients in this condition:

Provide oxygenation.

Maintain blood circulation.

Inject glucose.

Reduce intracranial pressure.

Stop seizures.

Start fighting infection.

Restore the acid-base state and electrolyte balance.

Normalize body temperature.

Introduce thiamine bromide.

Pick up specific antidotes.

Relieve excitement.

Coma III degree often leads to the death of the patient. Registration of brain death is very important. Over the past 20 years, a number of criteria for brain death have been proposed: Harvard (1968), Minnesota (1971) and British (1976), criteria for cooperative research in the United States (1977), etc. gas exchange (using mechanical ventilation). In this case, the following conditions must be met:

The patient must be in a state of extreme coma after completing all the appointments and therapeutic procedures. The possibility of taking hypnotics, depressants and other drugs that have a narcotic effect, as well as relaxants and drugs that can cause respiratory failure, is excluded. Hypothermia and metabolic endocrine disorders are excluded. Brain damage is irreversible.

Diagnosis of brain death: spontaneous breathing is absent when the ventilator is turned off for a period sufficient for an increase in pCO 2 to occur, exceeding the excitation threshold of the respiratory center (more than 7.98 kPa or 60 mm Hg); there are no reactions of the pupils to the bright light of an electric flashlight, as well as corneal, oculovestibular, oculocephalic and pharyngeal reflexes; there are no motor reactions carried out by cranial nerves. Isoelectric EEG. According to some experts, it is also necessary to take into account such a test as non-filling of cerebral vessels with two aortocranial injections of a contrast agent with an interval of 25 minutes. The coma should last at least 12 hours.The decision to turn off the ventilator is made by a competent commission, which includes a resuscitator and a neuropathologist with at least 5 years of experience in resuscitation, who did not take part in the treatment of this patient before and after the onset of an outrageous coma and death brain.

1. All measures to provide first aid to a patient who is in a coma should be carried out simultaneously.

2. Compulsory hospitalization

3. Restoration and maintenance of adequate breathing - sanitation of the airways to restore their patency, installation of an airway or fixation of the tongue, mechanical ventilation using a mask or through an endotracheal tube, in rare cases - tracheo- or conicotomy (opening the larynx in the interval between the cricoid and thyroid cartilage) ...

Oxygen therapy (4-6 l / min through a nasal catheter or 60% through a mask, endotracheal tube). Before tracheal intubation, premedication with 0.1% solution of atropine (0.5-1 ml) is necessary, except for cases of poisoning with anticholinergic drugs.

4. Relief of hypoglycemia. Regardless of the level of glycemia (in patients with long-term diabetes mellitus with poor compensation, hypoglycemic coma may develop against the background of normal glucose concentration), a bolus injection of 20-40 ml of 40% glucose solution is mandatory; when receiving the effect, but its insufficient severity, the dose.

5. Restoration and maintenance of adequate blood circulation

With a decrease in blood pressure, it is necessary to start drip infusion of 1000-2000 ml (no more than 1 l / m2 / day) 0.9% sodium chloride solution, 5% glucose solution, if ineffective - dopamine, norepinephrine.

In the case of coma, which has arisen against the background of arterial hypertension - not less than 150-160 / 80-90 mm Hg, intravenous administration of magnesium sulfate 5-10 ml of 25% solution for 7-10 minutes. If there are contraindications to the appointment of magnesium sulfate, it is permissible to administer 30-40 mg of bendazole (3-4 ml of 1% or 6-8 ml of 0.5% IV solution). With a slight increase in blood pressure, intravenous administration of aminophylline (10 ml of 2.4% solution) is sufficient.

6. Restoration of an adequate heart rate in arrhythmias (mainly by defibrillation).

7. Immobilization of the cervical spine in case of any suspicion of injury.

8. Catheterization of the peripheral vein. In a comatose state, almost all drugs are administered parenterally (preferably intravenous); infusion is carried out through a peripheral catheter; with stable hemodynamics and the absence of the need for detoxification, an indifferent solution is slowly introduced dropwise, which provides a constant opportunity for the rapid administration of drugs.

9. Installation of a gastric or nasogastric tube.

10. Therapeutic and diagnostic use of antidotes

11. Relief of intracranial hypertension, edema and brain swelling. Mannitol at a dose of 1-2 g / kg (in the form of 20% solution) for 10-20 minutes; to prevent a subsequent increase in intracranial pressure and an increase in cerebral edema after the completion of the mannitol infusion, furosemide is administered at a dose of 40 mg.

12. Neuroprotection and an increase in the level of wakefulness - In case of impaired consciousness to the level of a superficial coma, glycine is shown sublingually at a dose of 1 g. In deep coma, antioxidant therapy Mexidol is carried out - 6 ml of 5% solution) intravenously 5-7 minutes 3 drops of 1% solution in each nostril.

13. Measures to stop the intake of toxin in the body in case of suspected poisoning.

14. Gastric lavage through a tube with the introduction of a sorbent

15. Normalization of body temperature.

16. Relief of seizures: diazepam IV in a dose of 10 mg.

17. Stopping vomiting: metoclopramide 10 mg i / v or i / m

The nervous system is divided into central and peripheral. The brain (central nervous system and higher autonomic centers, centers of endocrine regulation) is located in the cranial cavity. It is reliably protected by bone plates from adverse environmental influences.

• Glasgow Scale
• Coma help

As the central regulator of all processes in the body, the brain works in an active metabolic mode. Its weight is only 2% of the body weight (about 1500 g). However, for the uninterrupted functioning of the brain, 14-15% of the total volume of circulating blood (700-800 ml) must flow into and out of the cranial cavity every minute. The brain uses 20% of all oxygen that the body consumes. It is metabolized only by glucose (75 mg per minute or 100 g per day).

Other changes in awareness can occur without the unconscious. They are called altered mental status or altered mental status. These include sudden confusion, disorientation, or numbness. Unconsciousness or any other sudden change in mental status should be considered a medical emergency.

The unconscious can be caused by almost any serious illness or injury. It can also be caused by substance and alcohol use. Asphyxiation of an object can lead to unconsciousness. The information provided herein should not be used during any medical emergency or to diagnose or treat any health condition. Consultation with a licensed healthcare professional is required to diagnose and treat any and all medical conditions. Call 112 for all medical emergencies.

So, the physiological functioning of the brain tissue depends on adequate perfusion with its blood, the content of sufficient oxygen and glucose in it, the absence of toxic metabolites and the free outflow of blood from the cranial cavity.

A powerful autoregulatory system ensures the smooth functioning of the brain. Thus, even with significant blood loss, CNS perfusion is not disturbed. In these cases, a compensatory reaction of the centralization of blood circulation with ischemia of less important organs and tissues is included, aimed primarily at maintaining an adequate blood supply to the brain. On another pathological condition - hypoglycemia - the body reacts by increasing blood flow to the brain and increased glucose transportation here. Hyperventilation (hypocapnia) reduces blood flow to the brain, hypoventilation (hypercapnia) and metabolic acidosis, on the contrary, increase blood flow, promoting the elimination of "acidic" substances from tissues.

Coma emergency care

Any duplication or dissemination of the information contained in this document is strictly prohibited. All cases of diabetic coma should be assessed by a qualified healthcare professional as soon as possible! Failure to obtain an assessment as soon as possible could result in serious injury or death. Call 112 right away if you are undergoing diabetic coma.

What are the causes of diabetic coma?

Diabetic coma is a condition caused by extremely high blood sugar levels and low insulin production. The condition is a medical emergency and prompt treatment. ... Diabetic coma can be caused by.

What are the signs and symptoms of diabetic coma

The onset of the signs and symptoms of a diabetic coma usually spreads over an extended period.

With significant damage to the brain tissue, insufficient autoregulation or excessive manifestations of the compensatory reaction of the inflow and outflow of blood, the brain cannot arbitrarily change its volume. The closed cavity of the skull becomes its trap. Thus, an increase in the intracranial volume by only 5% (with hematomas, tumors, overhydration, cerebrospinal fluid hypertension, etc.) disrupts the activity of the central nervous system with the loss of consciousness by the patient. In another pathology, an excessive increase in cerebral blood flow leads to hyperproduction of cerebrospinal fluid. The brain tissue is compressed between blood and cerebrospinal fluid, its edema develops, and functions are impaired.

How is first aid prescribed for a diabetic coma?

Increased thirst Increased frequency of urination Dehydration Drowsiness, confusion, or irritation Increased breathing rate Sweet breath odor Loss of consciousness. Assessing the neurological status of unconscious or comatose patients can be challenging because they cannot actively collaborate with your research. But once you master this exam, you can detect early significant changes in the patient's condition - in some cases, even before they appear on more complex diagnostic tests.

Traumatic destruction of brain tissue, edema and swelling of it, increase, impaired circulation of cerebrospinal fluid, circulatory disorders and other damaging mechanisms lead to hypoxia of cells of the central nervous system. It manifests itself, first of all, by a violation of consciousness.

Coma: symptoms, types, diagnosis

Coma - complete suppression of consciousness with loss of pain sensitivity and reflexes, with general muscle relaxation and disorders of the functions of vital organs and body systems.

Symptoms of impaired consciousness

Subtle changes in results may indicate the need for further testing. While it continues to be an integral component of the assessment for severely ill patients, many bedside nurses overlook or underestimate it.

Faster and easier than you think

The neuro-exam can be carried out quickly and easily integrated into the daily assessment. It starts the moment you meet the patient. Doing this early is critical as it helps you establish a baseline for later comparison.

Classification degrees of impairment of consciousness (Bogolepov, 1982).

• Clear consciousness
• Darkened consciousness
• Stupor
• Sopor
• Coma: moderate, deep, profound

Symptoms of impaired consciousness

Consciousness disorders	Leading signs	Common signs For accurate interpretation of the assessment results, the nurses involved in the shift and upcoming shifts should assess the patient's neurological status together during the shift or patient care. After the initial assessment is completed, subsequent assessments can be either basic or more detailed. The type of neurological exam you do depends on whether your patient can follow the commands. If so, your exam may be more complete and should include a grade. If your patient is unable to follow commands, you will only be able to assess pupils, eye opening, motor response, and a few of them. However, despite the relative brevity of this type of exam, it can provide a significant amount of information.
Clear consciousness	Cheerfulness, full orientation in time and space and in your face.	Active attention, absolute linguistic contact, thoughtful answers to questions, following all instructions. Free eye opening.
Clouded consciousness	Moderate drowsiness or euphoria, partial disorientation in time and space with full orientation in his face. Ask yourself: is there an airway patent? If so, can the patient support him? Then check vital signs: are respirators adequate? Is her blood pressure high enough to perfuse her brain and other vital organs? Keep in mind that ongoing or progressive damage to the brain and brainstem can render vital signs unstable, but this situation can be tricky: while unstable vital signs can diminish the neurological response, brain trauma itself can cause unstable vital signs.	The ability for active attention is reduced. The language contact is saved, but getting an answer sometimes requires repeating questions. Commands are executed correctly, but somewhat slower, especially complex ones.
	Deep sleepiness, disorientation in time and space, when awakening, it only performs simple commands. To properly assess the neurological status of the patient, be sure to assess oxygenation and circulation. Ideally, you should conduct a neuro-exam when the patient's blood pressure, temperature, heart rate, and heart rate are normal. Keep in mind that a temporary decrease in neurological status caused by inadequate oxygenation or circulation is still a neurological change - and leads to permanent neurological loss if the underlying problem is not corrected. Once you have established that your patient is stable enough to be assessed, begin the neuro-exam itself. To determine if a patient is unconscious and unable to follow commands, use the Glasgow Coma Scale to test for eye opening, better motor response, and best verbal response. The unconscious patient is likely to open his eyes only in response to pain, if at all; obviously you can't check your best verbal answer at all.	The state of sleep predominates, sometimes in combination with motor excitement. Language contact is difficult. Unambiguous answers. Protective reaction to pain is preserved. Control over the function of the pelvic organs is weakened.
	Pathological drowsiness, complete disorientation in time, space and in your face. In the unconscious patient, the best response is localization, in which she reaches the midline to the site of the stimulus, as if trying to stop the pain. In a semi-bubble response, she rolls back as if trying to get away or get away from the pain. Flexor motor response is marked by internal flexion of the elbows, wrists, and arms, followed by stretching and alignment of the feet. The reaction of the extension motor is straightening or rigid lengthening of the shoulders, with the wrists rotating outward, the knees and ankles rigidly straight, and the landing leg the legs. Localization of pathology in the brain The best result is 15, which indicates that the patient is awake, orientated, and follows the following commands. The lowest possible score is 3, which means that the patient does not open his eyes and does not have a motor or verbal response to a central stimulus.	He opens his eyes to painful stimuli, localizes the pain with targeted actions to eliminate it. Reflexes of the cranial nerves and vital functions are preserved.
Coma moderate	There is no consciousness.	There is no reaction to external stimuli. It responds to painful stimuli with uncoordinated defensive movements. Pupillary and corneal reflexes are increased, abdominal reflexes are decreased. Reflexes of oral automatism and pathological reflexes from the feet appear. Sphincter control is impaired. Vital functions are preserved. Student assessment includes an assessment of the size, shape, and equality of the student before and after exposure to light. Pupils are usually equal in size and are about 2 to 6 mm in diameter, but they can be as large as 9 mm. In addition, pupils can be pinpoint, small, large, or dilated. The shape of the normal pupil is round; variations include irregular, keyhole, and ovoid. To evaluate the patient's pupils, keep both eyelids open and shining light into the eyes. Pupils must contract immediately and equally on a bilateral basis; after you remove the light, they should immediately expand to the baseline. Document the answer: Is it brisk, sluggish, non-reactive, or fixed? Report any changes from the baseline immediately. In many cases, a change in pupillary response, such as unequal or dilated pupils, is the result of a progressive neurological condition.
Deep coma	There is no consciousness.	The reaction to pronounced pain stimuli in the form of limb extension was preserved. Suppression or absence of cutaneous, tendon, corneal, pupillary reflexes. Stiffness or hypotension of the striated muscles. Respiratory and cardiovascular disorders. Anatomical and functional features of the central nervous system Corrected and enlarged pupils are an ominous sign, guaranteeing immediate notification to the doctor. The results of a cranial nerve assessment can tell a lot about a patient's midbrain, pairs, and medullary functions. While some nurses find this assessment intimidating, it's not that hard. Oculocephalic and vascular tests, which show the function of the brainstem, are only performed by physicians on patients who do not respond to the exam methods described above. These tests help predict patients with severe brain damage.
Coma transcendental	There is no consciousness.	Areflexia, bilateral fixed mydriasis, muscle atony, significant respiratory and cardiovascular disorders. Hypotension (BP below 60 mm Hg)

Etiopathogenetic classification of com

5. Comas arising under the influence of physical factors (heat, cold, radiation, electric current).

It is sometimes difficult to diagnose the cause of a coma, since it is impossible to collect a history of the patient. Therefore, it is very important to ask the relatives of the victim and witnesses how this coma arose.

Anamnesis. It is necessary to find out the time of loss of consciousness, a sudden or gradual deterioration of the state, to ask if the patient did not fall or hit his head; or no fever, flu, or jaundice. It is necessary to establish whether the victim did not have diabetes, hypertension, epilepsy; whether he had in the past such cases of loss of consciousness, suicide attempts. If the coma developed gradually, then what the patient complained about, whether he had vomiting, the trial.

When examining the belongings of the victim, sometimes you can find medical documents, packages of medicines, the remains of poisons. These findings can aid in the diagnosis.

In the absence of anamnestic data, it is important to identify individual symptoms on the basis of which the disease can be recognized.

Color

skin. Sharp pallor is characteristic of massive blood loss, circulatory collapse, uremic coma, and blood diseases. Severe cyanosis is a sign of hypercapnic coma with insufficient respiratory function, asphyxia when hanging, drowning; after a seizure attack. Facial hyperemia allows one to suspect poisoning with atropine and its derivatives, carbon monoxide, hyperglycemic coma and an infectious disease.

Head position

... The head thrown back indicates meningitis, tetanus, hysteria; tilted to the side - most likely about a stroke. Hoarse breathing and a crooked mouth are common with strokes. Pathological types of breathing (Cheyne-Stokes, Biota) are observed with deep damage to the central nervous system. Deep noisy breathing (Kussmaul) indicates the accumulation of acids in the body (metabolic acidosis) of exogenous (in acute poisoning) or endogenous (diabetic ketoacidosis) origin. Hyperthermia and frequent deep breathing are characteristic signs of coma of infectious origin. With this pathology, an increase in body temperature by 1 ° C is accompanied by an increase in the respiratory rate by 5-7 per minute.

In order to examine a patient in a coma, a medical professional must approach him from the back of the head. This position is dictated by the following points: firstly, the ability to immediately provide assistance to the victim if necessary (remove the lower jaw, free the tongue from biting, clear the oral cavity of vomit, carry out artificial ventilation), and, secondly, the personal safety of the resuscitator, since an unconscious victim can injure him by pushing with his hand or foot.

Simulation, and sometimes someone of hysterical origin, can be found when trying to open the patient's eyes. A person with a completely absent consciousness does not strain the eyelids when opening them with their fingers. Conversely, even a barely perceptible resistance when trying to raise them is a sign of preserved consciousness.

By pressing on the eyeballs, you can determine their tone. "Soft" eyeballs indicate hypovolemia (blood loss, hypohydration). They occur in patients with hyperglycemic coma, with shock.

Depth

coma diagnosed by the degree of suppression of reflexes. So, the reaction to irritation of the eyelashes indicates a superficial coma. The reaction to irritation of the sclera is preserved - a coma of moderate severity. The lack of reaction of the pupils to light is a sign of a deep coma.

Pupils can be of different sizes: narrowed - in case of poisoning with hypnotics, organophosphates; very narrowed (like a poppy seed) - in case of drug poisoning; extended - with hypoxia, neuroleptic poisoning and antihistamines; very expanded - when using atropine-containing substances.

Anisocoria

(pupils of different sizes) - a characteristic sign of focal lesions of the central nervous system. Most often, this symptom occurs with traumatic brain injury with the presence. In such patients, with a detailed examination of the face and scalp, abrasions, a wound or subcutaneous hemorrhage can be found. Sometimes in them there is a deviation of the eyeballs to the right or left - in the direction of the brain damage.

The absence of knee, Achilles and abdominal wall reflexes indicates a deep depression of the central nervous system. Babinsky's pathological reflex indicates organic brain damage. Asymmetry of muscle tone is a sign of a volumetric process in the cranial cavity (stroke, tumor, hemorrhage).

A detailed examination of other organs and systems helps in establishing a diagnosis. So, CNS failure can be caused by interruptions in the work of the heart in violation of its conduction (Morgagni-Edems-Stokes syndrome). In turn, focal lesions of the brain cause disturbances in the activity of the cardiovascular system.

Hemodynamic disorders

depending on the localization of pathology in the central nervous system

Localization pathologyin the brain	Manifestations defeatcordially- vascularsystems
Lesions of the fronto-orbital zones	Bradycardia, complete atrioventricular block, atrial extrasystole
Excitation of structures of the midbrain	Extrasystole, atrioventricular block, ventricular fibrillation
Pathology of the medulla oblongata	turn it on its side; slightly lower (by 15 °) the upper part of the body, so that the mouth gap is lower than the vocal gap; remove the lower jaw and support it with your fingers; to assess the patient's breathing efficiency (color of the mucous membrane and skin, its moisture content, depth and frequency of breathing, the presence of pathological noises during breathing, retraction of the jugular notch and intercostal spaces); with difficulty breathing and the presence of gastric contents, blood, sputum in the oral cavity, it is necessary to ensure the patency of the respiratory tract (remove foreign bodies and fluids); in case of ineffective breathing, apply artificial ventilation; palpate the pulse over the main and peripheral arteries; raise the patient's upper eyelids and assess the reaction of the pupils to light; call a medical team. In some patients, against the background of a coma, hyperreflexia is noted, hyperkinesis or convulsions occur. With convulsions it is necessary: Lay the patient on a flat surface, preventing injury to him by surrounding objects; Prevent tongue biting by inserting a mouth dilator (spatula, wooden stick, spoon handle, wrapped in cloth) between the molars; Support the lower jaw and head of the patient, preventing its injury, asphyxia; Provide oxygenation of the body using oxygen supply through a mask or nasal catheter; In the interictal period, catheterize the peripheral vein by the puncture method, where, as prescribed by the doctor, inject solutions of magnesium sulfate (5-10 ml of a 25% solution), sibazon (2 ml of a 0.5% solution); Cleanse the mouth, throat from saliva, blood, possible gastric contents; In the absence of spontaneous breathing, carry out artificial ventilation. Coma is a deep disturbance of consciousness with the absence of reflexes and reactions to external influences. Coma can develop suddenly against the background of a relatively well-being of the patient. Acute development is typical for stroke, hypoglycemic coma. However, in many cases, a coma that complicates the course of the disease develops gradually. This development is typical for diabetic, uremic, hepatic coma and many other coma conditions. In each case of a coma, the patient should immediately call a doctor. Patients in a coma require constant monitoring by staff. Diabetic coma (hyperglycemic, acetonemic): there is no consciousness, the face is hyperemic; lips, tongue dry, smell of acetone from the mouth, skin dry, cold, breathing like Kussmaul, pulse is fast, small, blood pressure is low, hypotension of the eyeballs, muscle hypotension, tendon reflexes are reduced, vomiting, sugar in urine, acetone. Diabetic coma is usually preceded by increasing weakness, itching, increased thirst, nausea, and vomiting. Nurse tactics.Warm the patient. Rinse the stomach with 5% sodium bicarbonate solution or isotonic sodium chloride solution (part of the solution is left in the stomach). Put on a cleansing enema mu with a warm 4% sodium bicarbonate solution. Provide oxygen supply. Immediate hospitalization. In case of delayed hospitalization - intravenous drip of isotonic sodium chloride solution. Hypoglycemic coma(insulin): hunger, weakness, irritability, fear, sweating, trembling hands, legs, double vision, sometimes headache, bradycardia or tachycardia, pallor of the skin, high or normal blood pressure, general muscle hypertension, convulsions, delirium , hallucinations, acute mental disorder, consciousness. Nurse tactics,depends on the severity of the condition: if the patient is conscious, it is necessary to give food rich in carbohydrates (sweet tea, white bread, compote, a spoonful of jam or honey). If the patient is unconscious - intravenous jet injection of 20-50 ml of 20-40% glucose solution. In the absence of consciousness for 10-15 minutes. - intravenous drip injection of 5-10% glucose solution until the patient regains consciousness. Uremic coma(azotemic). Coma harbingers:a gradual increase in drowsiness, lethargy, headache, irritability; thirst, dry mouth, nausea, vomiting. In the vomit, sometimes streaks of blood or vomit the color of coffee grounds; the stool is liquid, watery; frequent urination, profuse, mainly at night. Visual disturbance - blurred outlines of objects in front of the eyes, narrowing of the field of vision. Observed:anxiety, visual hallucinations, seizures; the skin is of an earthy color, there are traces of scratching on it, itching; bleeding from the nose, gums, ulceration of the oral mucosa. The smell of ammonia from the mouth. The size of the liver. Seizures, pupils dilated. Nurse tactics.According to the doctor's prescription, glucose solutions, steroid hormones, vitamins are injected drip.

Increasingly, deaths in the world happen due to the fact that not every person knows how to properly provide first aid to the victim. Being in a state of shock, a person who sees a man or woman fall next to him and does not move, just stands and looks. And if he immediately pulled himself together and provided the necessary help, then as a result someone's life could be saved. It is also important for relatives of seriously ill patients to know what symptoms of exacerbation, what to do in this or that case, in order to be able to provide assistance in a timely manner. Today we will consider a very important topic: what is a coma in humans. Almost everyone should have an idea of \u200b\u200bhow to provide assistance correctly, what to do to save a person's life.

What is a human coma?

Coma is a rather serious condition, which is characterized by rapidly developing depression of the central nervous system with a profound and lack of reactions to external influences. In this condition, the patient disrupts the work of several body systems: respiratory, cardiovascular and others.

One of the reasons for the development of coma is significant damage to brain tissue. This can occur due to tissue damage, for example, in trauma or hemorrhage, as well as due to the presence of a patient with serious infectious pathologies, poisoning and other processes. First aid for coma is very important, because it is she who can save the patient's life, but the first thing to do is to determine the type of coma and identify what provoked it.

Coma stages

Coma, like many other pathologies in the human body, proceeds in several stages:

• Precoma. This condition is the precursor to true coma, and can last from a couple of minutes to two hours. At this time, a person's consciousness is confused, he is stunned, his condition changes dramatically, then he becomes too lethargic, then a certain activity, increased excitability wakes up. If reflexes are preserved, then coordination of movements may be impaired.

• Coma I degree. In this condition, all the patient's reactions to external irritating factors are sharply inhibited, contact with the patient is difficult. The muscle tone is increased, the patient is able to swallow only liquid food. Tendon reflexes are significantly increased. The reaction of the pupils to light persists, in rare cases squint may be noticeable.
• Coma 2 degrees. This form is characterized by stupor, there is no contact with the patient. The pupils do not react to light, they are narrowed, and there are no reflexes to stimuli. Also, rare chaotic movements can be noticed, limbs are tense or, conversely, relaxed, and others. Pathological breathing may be impaired if the coma is grade 2. In rare cases, involuntary emptying of the bowel and bladder may occur.
• Coma 3 degrees. At this stage, the person is unconscious, there is no response to external stimuli. There is no reaction of the pupils to light. Muscle tone decreases, and cramps may occur. blood pressure is low, breathing is impaired. First aid for a coma in this state is very important, otherwise, if the condition is not stabilized, then this stage will go into an outrageous coma.
• Extreme coma (grade 4). In this state, the pressure and temperature drop sharply, all reflexes are completely absent. The patient's condition is maintained thanks to the ventilator and parenteral nutrition.

First aid for coma is very important, but it will be more useful if you immediately determine which type of coma is observed in a patient, because there are several of them.

Diabetic coma

It is most common in patients with diabetes mellitus. Such a coma can occur in people with high sugar levels (hyperglycemia) or low sugar levels (hypoglycemia). This condition is caused by high blood glucose levels. With a diabetic coma, the smell of acetone from the mouth appears. If you correctly diagnose this type of coma, then you can very quickly bring a person out of this state.

In this case, an urgent need to measure the blood sugar level, if it is too high, then inject insulin, and if it is low, then give the patient to take carbohydrates. And it is better to immediately seek help from a doctor who will observe the patient and will be able to help him get out of this state without harm to his health.

Traumatic coma

It most often occurs in patients who have suffered a traumatic brain injury, as a result of which the brain was damaged. It differs from other types of coma by severe vomiting in the precoma. First aid for this type of coma involves taking urgent measures that will help improve blood circulation in the brain and restore its functions.

Meningeal coma

This type develops if intoxication of the brain tissue is observed, it can be triggered by the presence of meningococcal infection. The diagnosis can be clarified only after a lumbar puncture. In this state, the patient has a severe headache, he cannot lift the extended leg, and if the head passively leans forward, then involuntary bending of the leg at the knee occurs.

Also, a characteristic feature of this type of coma is a rash with areas of necrosis on the skin and mucous membranes. In this case, only qualified doctors will be able to help the patient, therefore first aid for him is calling an ambulance and hospitalization in the infectious diseases department.

Cerebral coma

It is typical for those patients who have brain diseases associated with the presence of neoplasms. A person in a coma feels:

• Violent headache accompanied by vomiting.
• Patients find it increasingly difficult to swallow food, they often gag, and can hardly even drink water.

If first aid is not provided at this time, then a coma develops. Also, these symptoms may indicate a coma caused by a brain abscess. The difference is that in the latter case, it may be accompanied by inflammatory pathologies, such as tonsillitis, otitis media or sinusitis. In this case, only a doctor can help, who, according to the signs, will quickly determine what is the matter and help the patient.

Hungry coma

This type occurs with grade 3 dystrophy, which develops as a result of prolonged fasting. Often this type is found in young people who are on a diet. There is a deficiency of protein in the body, it performs many functions in the body, therefore, when it is not enough, then almost all organs work incorrectly, the functioning of the brain is inhibited.

If this condition develops, then the following symptoms can be observed:

• Frequent fainting occurs.
• General weakness is observed.
• Heart rate increases.
• A person in a coma feels bad: body temperature and pressure are low, convulsions and even spontaneous urination occur.

In this case, it is necessary to consult a doctor, and in no case should the patient be given food, because the body must recover gradually.

Epileptic coma

It often develops as a result of a severe seizure. Patients have a characteristic dilatation of the pupils, the skin turns pale, all reflexes are inhibited. Signs of a bite often appear on the tongue, spontaneous emptying of the bladder and intestines is almost always observed.

The pressure and temperature decrease, the pulse is rapid. If the condition worsens, then the pulse becomes threadlike, breathing from the shallow becomes deep. If first aid for coma is not provided, then the patient's reflexes disappear, the pressure continues to decrease, and as a result, death occurs.

Alcoholic coma

Poisoning with alcoholic beverages often leads to an alcoholic coma, which can result in clinical death. Alcohol abuse can lead to organ dysfunction. Ethyl alcohol is a serious blow to the brain, it can even stop the respiratory system.

There are several stages of an alcoholic coma, with a coma of any stage it is very important, but especially with the third. First aid in this case is to clear the airways of mucus and vomit. The patient is laid on one side and an ambulance is called urgently.

Hepatic coma

Abnormal liver function can lead to the patient developing a coma, in which case it is called hepatic. The cause can be pathologies of this organ of any origin. The physiological mechanism for the development of this type of coma is simple: the liver is the main filter of the human body. In those cases when the work of the organ is disrupted, then metabolic products penetrate into the bloodstream, which should have been neutralized in the liver. They significantly affect brain cells, which can lead to the development of coma. This type is often accompanied by disturbances in the work of the heart, cerebral edema and general intoxication. Providing assistance with a coma of this type is an early appeal to a specialist, if this is not done, then in most cases this leads to the death of the patient.

First aid for coma

First aid in a coma is very important, any delay can lead to death. If a person is in a coma in front of you, then the first thing to do is to take a quick look at him. If he suddenly has a glucometer or insulin with him, then this means that he is a diabetic and, possibly, he has a diabetic coma, although the child should not have all this with him. The algorithm for helping adults and children with coma is very similar.

• Urgently restore and maintain adequate breathing: sanitize the respiratory organs, connect a ventilator or make a conicotomy, but this is rare and only with the permission of a specialist.

• Restoration and maintenance of adequate blood circulation: if the pressure is low, then a solution of sodium chloride and glucose is dripped intravenously, and if the pressure is above normal, then it is corrected with magnesium sulfate. The heart rate is normalized by defibrillation. The same implies first aid for coma of unclear etiology.
• A catheter is inserted into the bladder so that urine output can be monitored.
• Placement of the probe after tracheal intubation.

Emergency care for a coma is very important, so in no case should you fall into hysterics, but urgently call an ambulance and do everything possible to alleviate the patient's condition. Timely assistance can save a person's life.