Soporous condition: causes, signs, treatment. Stupor: causes, symptoms, diagnosis, treatment
Stupor is a deep depression of a person’s consciousness, resulting in drowsiness. In this condition, the patient’s voluntary activity is suppressed, but his reflex activity is preserved.
In particular, the sluggish reaction of the pupils of the eyes to light and a defensive reaction to pain remain. With further depression of a person's consciousness, coma develops. Thus, stupor is an intermediate state between stunned consciousness and coma. Coma is a state of severe depression of the nervous system. In this case, the person loses consciousness, his reflex activity disappears, and dysregulation of basic vital functions appears.
Causes
The causes of stupor and coma can be many serious diseases, conditions and injuries, such as: tumor diseases of the brain, traumatic brain injuries, vascular and toxic lesions of the brain, etc. Short-term loss of consciousness can occur after minor head injuries, due to decreased blood circulation to the brain or as a result of seizures. Poor blood circulation in the brain is often observed during fainting or stroke.
Serious head injuries, certain serious illnesses, toxic effects of drugs or an overdose of sedatives can lead to prolonged loss of consciousness. Metabolic disorders that affect the content of sugar, salts and some other substances in the blood can also negatively affect brain function.
Symptoms
Normally, brain activity in humans is constantly changing. Thus, the brain activity of a awake person is significantly different from the activity of a sleeping person. Also, brain activity during these conditions is different from brain activity, for example, during a difficult exam or during emergency situations that require a quick decision. Such differences in brain activity between different activities are normal. Moreover, such states can move from one to another quite quickly.
With an altered level of consciousness, the brain is no longer able to switch to different modes of operation in accordance with current circumstances. The area that is dedicated to regulating activity is located deep in the brain stem. This area actively stimulates the brain, thereby determining the level of consciousness and wakefulness. To determine the condition, the entire set of information received from the ears, eyes, skin and other sensory organs is used. Using this information, the brain changes its activity level accordingly.
If the activating system in the brain stem is damaged or its communication with certain other parts of the brain is disrupted, then sensory perceptions in the brain are no longer able to sufficiently influence the level of wakefulness and the level of brain activation. This leads to a disorder of consciousness. This can even lead to loss of consciousness.
Periods of disturbance of consciousness can be either long-term or short-term. Moreover, consciousness can change from a slight clouding of the patient’s mind to his complete non-contact.
With confusion, the patient may well remain active. At the same time, he is disoriented. This condition is often characterized by the patient being unable to differentiate between events that happened in the past and events that are happening now. In addition, the patient is agitated and often cannot correctly understand the speech of the people around him. The state of lethargy in this case is the appearance of reduced brain activity. In some cases, patients experience a condition called somnolence. This state is a state that resembles long and deep sleep. Often, in order to bring a person out of this state, you have to shout loudly and push him away.
Stupor represents a deep lack of contact, a loss of human consciousness and a condition from which a sick person can only be brought out for a short period of time. This requires repeated vigorous shaking, loud calls, or needle pricks. In this case, the person does not react to the environment, cannot answer questions posed, and does not complete any tasks. The swallowing function is preserved.
The next state, after soporosis, is coma. Coma is an unconscious state that is somewhat similar to the state of general anesthesia or deep sleep. The patient cannot be brought out of this state by trying to awaken him. In addition, a patient who is in the stages of a deep coma usually does not have any response, including pain. In this condition, it is difficult to predict the patient's likelihood of recovery. The likelihood of recovery largely depends on the cause of the coma. If the cause of the coma was a head injury, then full recovery is possible if the loss of consciousness lasts no more than three months. If the cause of the coma is cardiac arrest or cessation of breathing, the duration of the coma is more than a month, then recovery occurs quite rarely.
In some cases, after a brain injury, due to a severe illness that damages the brain or due to lack of oxygen, the patient usually goes into a vegetative state. It should be noted that in this case the patient can fall asleep, wake up, swallow and breathe normally. In addition, the patient may have a motor reaction to all loud noises. However, permanently or temporarily, he loses the ability to engage in normal conscious behavior and thinking. Patients in a vegetative state are able to perform some reflex movements, such as twitching, tension in the legs and arms.
In some cases, the patient may experience the so-called “locked-in person” syndrome. This syndrome is a rare condition in which the affected person is conscious and can think relatively normally. However, as a result of severe paralysis, the patient is able to communicate with people only by opening or closing his eyes. This is the only way he can answer questions addressed to him. This condition usually occurs with severe peripheral paralysis. The same condition can occur with some types of stroke.
The most severe form of the condition is brain death. In this condition, the brain irreversibly loses all basic vital functions, including loss of consciousness and the ability to breathe normally. If the patient is not provided with artificial ventilation and the necessary medications, death will quickly occur. In general, a person is legally considered dead if his brain loses all its basic functions, even if he still has a pulse.
It is customary to declare brain death when, twelve hours after the elimination of all treatable disorders of a person’s condition, the patient’s brain still does not respond to external stimuli. In this case, the person does not react to light and cannot breathe on his own.
If there is doubt about the state of brain activity, then electroencephalography is performed, which shows the presence or absence of brain functionality. Electroencephalography records the electrical activity of the brain. Even after brain death, some spinal cord functions may remain. In this case, a person may exhibit some reflexes.
Diagnostics
Coma and stuporous state are emergency pathologies that require resuscitation measures. This is due to the fact that the severity of the psychoorganic syndrome, which subsequently does not develop, depends on the duration of loss of consciousness. The main thing in the clinical picture of any coma is considered to be the switching off of consciousness, in which a person loses the possibility of normal perception not only of the environment, but also of himself.
Upon arrival at the scene, emergency doctors diagnose the soporous condition. In particular, they must make sure how clear the patient's airways are. In addition, they should check your breathing pulse and blood pressure. Particular attention should be paid to body temperature. If a patient has a high temperature, this may be one of the signs of an infectious disease. If the body temperature, on the contrary, is low, this may mean that the patient has been exposed to cold for a long time.
Also during the diagnosis, a skin examination is carried out. This is necessary in order to identify possible traces of infections, injuries or allergic reactions. In addition, the head is examined for bruises and wounds. In any case, a complete neurological examination is necessary. This can reveal signs of brain damage.
An eye examination is equally important. It allows you to obtain important information about the state of the central nervous system. At the same time, the position and mobility of the eyeballs are checked, the size of the pupils, the reaction to light are checked, the appearance of the retina and the patient’s ability to follow all moving objects are checked. Different pupil sizes may be a sign of compression of the brain.
Treatment
If in a soporotic state the main reactions are passive, then with the development of coma the patient, as a rule, stops responding to all external stimuli. In particular, a person in such a state does not respond to patting, changing the position of individual parts of the body, injections, turning the head, and especially to any approach to the patient. It is worth noting that in coma, unlike stupor, there is no reaction of the pupils to light.
Patients who are in a coma, the cause of which is not clear, are always tested for glycemia. If it is known for sure that the patient suffers from diabetes mellitus, and it is difficult to identify the hyperglycemic or hypoglycemic origin of the coma, then it is recommended to administer intravenous glucose. This is necessary for differential diagnosis and for the purpose of providing emergency care for hypoglycemic coma. If the patient has a low blood glucose level, then such injections improve the symptoms of the lesions. In addition, it allows the two conditions to be distinguished. In case of coma due to increased glucose levels, the administration of glucose has virtually no effect on the patient's condition. If it is impossible to measure the amount of glucose in the blood, then experimentally you need to introduce high concentration glucose.
If a rapid change in consciousness occurs, the person should receive immediate medical attention. However, it is not always possible to establish the correct diagnosis necessary for correct treatment of brain disorders in a short time. Until the test results are received, the person is sent to intensive care, where his pulse, body temperature, blood pressure and the required amount of oxygen in the blood will be constantly monitored.
After being transported to intensive care, the person is immediately given oxygen and an intravenous system is set up, which will allow the necessary medication to be administered in a timely manner. Glucose is administered intravenously until the results of blood sugar tests are obtained. If there is a suspicion that disorders of consciousness were caused by narcotic drugs, then before the results of urine and blood tests are received, the patient is given the antidote naloxone.
If it is suspected that a toxic substance has caused a disorder of consciousness, the patient’s stomach is washed. This will also prevent further absorption of the toxic substance.
To maintain a normal pulse and normal blood pressure, blood transfusions and intravenous administration of necessary medications and fluids are used.
If it is not possible to clarify the diagnosis and urgent hospitalization, the main drugs for patients in a coma are thiamine, 40% glucose solution and naloxone. The combination of these drugs is in most cases considered the most effective and safe.
In the deepest stages of coma, the brain has damage that prevents the body from normally providing vital functions. In such cases, a ventilator is used to ease the work of the lungs.
Sopor is a pathology related to non-productive types of impaired awareness. Stupor belongs to pathologically deep sleep; this manifestation can occur in a variety of situational moments; it is akin to precoma. Psychiatrists rarely encounter this manifestation; their consultation in the medical history of such a person is rather a formality. But resuscitation doctors encounter this pathology very often, so they are able to quickly distinguish this manifestation. Stupor is similar to most types of loss and loss of consciousness. All such states are quite similar to each other and have distinctive features only to the extent of loss of awareness.
Stupor - what is it?
In an adequate state, when a person is alert, she has a clear consciousness, while she adequately assesses the situation, maintains contact, assesses her life needs, is able to stand up for herself and adapt to changes around her. The level of work of the body and the synthesis of brain impulses is very different in different conditions, stress is activating, and activities with quiet rest are relaxing. A person has two brain hemispheres working, but always with different intensity, depending on the leading hand, form of activity and level of stress. But due to various pathological phenomena, people can experience states of blackout. All of them are characterized by a lack of consciousness, but with some differences that play an important diagnostic role.
The term stupor comes from the Latin language and means deep sleep, sluggish stupor, subcomatose state. Domestic terminology differs from foreign ones, where it is believed that stupor is an abnormally deep sleep, but stupor is a subcoma, but here it is exactly the opposite.
Stupor is a pathological condition in which a person lies motionless. The state of stupor is a serious signal that demonstrates abnormal brain function and subsequently leads to coma or worse pathologies. But stupor is physical immobilization, while the person is in clear consciousness (most often).
Deep stupor is a state approaching comatose; not even a facial or reflex reaction appears to all painful stimuli.
Stupor after a stroke develops due to damage to the blood vessels that penetrate the brain tissue. All this significantly disrupts his activities. You should be alarmed if there is even the slightest sign of a problem, since everything can end in massive neurological disorders, even coma.
Causes of stupor
Since stupor is an almost complete loss of consciousness, there are many reasons. They can come from completely different sources. A very significant etiological layer comes from neurology. Stupor after a stroke is quite common; a stroke with both hemorrhage and ischemia can often have a similar unfavorable outcome. This pathology is especially relevant when the superial parts of the brain stem are affected. Skull injuries are also very relevant; they become the root cause of a considerable number of pathological processes, and stupor is no exception. If a person was in neurology with a bruise, then you already need to worry. But if there was a concussion, or hemorrhage, which is even worse, then be sure to do a comprehensive study in order to avoid such problems in the future.
When neoplasia is detected in brain tissue, there is a risk of swelling, which will invariably lead to stupor, but even tumors in other parts of the body have the ability to lead to such an unfavorable outcome, due to metastasis and intoxication.
Infectious pathology has always been famous for the danger of its complications; thus, infectious processes in brain tissue can lead to abscesses, which, increasing intracranial pressure, provoke stupor. Thus, tuberculosis, various viruses, herpes, prion pathology, and sometimes can even provoke stupor. In septic conditions, a person may also fall into stupor.
Rheumatological pathology, in the form of all kinds of lupus, due to the inflammatory process in the vessels of the brain tissue, can also lead to severe precomatous conditions.
Deep stupor is often characteristic of childhood, especially in children with severe congenital pathology. , a congenital pathology with an increased composition of fluid in the brain tissue, often complicated by stupor. Problems that originate from birth also include aneurysms; if there is a congenital one, then it can burst at any time, which will lead not only to stupor, but also to mortality, unfortunately. In newborns with severe hypoxia, for example, after asphyxia during childbirth, this condition is also possible.
Stupor also occurs in certain psychiatric pathologies, for example, epilepsy. In the case of severe epilepsy and its improper treatment, the person does not return to consciousness after an attack, but the attack is repeated again and again, this pathology is called status epilepticus. In this case, there is a high probability of cerebral edema, which in turn leads to stupor or even coma. It is important to remove a person from such a state at a pace and with effective methods in order to avoid permanent changes that can provoke death.
Endocrinological pathology always entails metabolic disruptions, which in turn causes problems with brain tissue. Incorrectly docked with or will invariably lead to complications. Ketoacidotic coma occurs when there is a lack of insulin, when pathological products of fat destruction accumulate in the body. In this case, coma has several stages. The first of them is just stupor; almost every diabetic at the beginning of the disease fell into such a state. When the thyroid gland becomes too low, stupor may also occur.
Failure in the body, especially the liver and kidneys, leads to the accumulation of dangerous metabolites, and uremia occurs, which poisons the body with its own waste products; excessive accumulation of proteins and sodium leads to swelling of brain tissue and provokes stupor. in its most severe manifestations also leads to this condition, when the heart is not able to adequately fill the brain tissue with blood, especially when it is complicated.
External factors can also play an unfavorable role in the occurrence of stupor. Hypothermia is especially dangerous; if a person is frozen and has not been found for a long time, and then is not warmed up properly, then stupor is more likely to occur. Sunstroke or heatstroke received in hot working conditions can also provoke stupor, especially if a person had the prerequisites for this and a tendency to this condition.
Stupor can also be caused by toxic drugs, fumes, alcohol substitutes, many medications, barbiturate-type sleeping pills, narcotic drugs, and anesthetics.
Symptoms and signs of stupor
The state of stupor manifests itself as an insignificant reaction to external stimuli and, moreover, only to expressive ones. The personality will answer if you ask loudly and many times, but otherwise not. The response is always passive, but signs of nihilism are possible, especially in the case of an attempt to administer drugs; the person may not straighten his arms. Depending on the type of stupor, a person may react differently, with slightly different symptoms. In the hyperkinetic version, the person pronounces incoherent speeches that are completely devoid of meaning. With akinetic, there is complete immobility and the absence of any attempts to change one’s position. But still, stupor is less deep than coma and is not characterized by the absence of a reflex. Deep tendon reflexes are present with decreased muscle tone. The pupils react to light, as in a coma, but more sluggishly than in a healthy person. Pain will also set the personality in motion, coupled with the corneal ocular and conjunctival reflexes.
Stupor has its own expressive signs in the form of drowsiness with a reaction only to massive stimuli, for example, a sharp sound can force them to open their eyes. They are unable to carry out any tasks or orders, nor are they able to answer the simplest questions. Since stupor affects the cortex and subcortex of the brain, there is significant pyramidal insufficiency, which impairs the performance of the body.
Since stupor develops for a number of dangerous reasons, it makes a lot of sense to diagnose them. With brain injuries, bruises around the eyes often occur, which indicate a fracture of the base of the skull. Bruising may also appear behind the ears. A very ominous symptom is leakage of cerebrospinal fluid, brain fluid, from the nose and ears. A person may have a strong odor, which indicates poisoning with alcohol and its substitutes.
It is very important to look around, because you can find many characteristic things, packaging for poisons, medicines or toxic agents. A variety of syringes after drug use. The very appearance of a person can tell a lot; he may have tattoos indicating that he has diabetes or epilepsy. An epileptic has many tongue bites and other scars.
If there is a fever, a rash, an infection can be suspected, then to confirm, a lumbar puncture is performed under sterile conditions, which will tell many facts. With tuberculosis, the punctate contains a high level of protein and little glucose; with viral infections, there is not much protein, but with bacterial infections, especially in advanced cases, there is real pus.
To make a correct diagnosis, an electroencephalogram is used, which will help to see all the pathological waves. MRI, CT and X-ray of the brain are an expensive necessity, which in this case is simply impossible to do without. After all, lesions, pathological tissues, areas of damage and injury, and volumetric structures will be found there. It makes sense to take a blood test, because it will demonstrate many pathological changes.
Treatment of stupor
Treatment of stupor is carried out simultaneously with the pathology that caused it. It is important that the person breathes normally; in some cases, this requires an intubation procedure. If the oxygen level is low, use an oxygen mask. In case of hypoglycemia, glucose is used with insulin to process it, and in case of hyperglycemia, insulin is used. If there is poisoning, especially with substances that suppress the respiratory center, then a universal antidote, Naloxone 3 ml, is used. If there is any injury to the spine, it becomes necessary to use a rigid collar - a retainer.
If there is a suspicion of any type of poisoning, it is important to rinse, which will help stop the absorption of toxins into the body. If a person has had significant blood loss, then it is necessary to compensate for this and normalize the pressure. For this, blood transfusions, blood products, Novoseven, Plasma, Reopoliglyukin, Reosorbilact, Saline are used. Also added is Thiamine, which helps nourish the brain, Piracetam, Cordarone, Magnesia.
If the state of stupor drags on, then it is important to maintain the individual’s body at a decent level. To prevent bedsores - turning over and wiping, as well as massage. To prevent stagnation during long-term therapy, antibiotic therapy is added: Carbopenem, Azalide, Flemoclav, Ceftriaxone, Meronem.
For epileptic genesis, anticonvulsants are used: Carbamozepine, Valprocom, Seduxen, Sibazon, Relanium. Feeding is done as naturally as possible, but sometimes it is necessary to use a tube, because... It is important that a person has enough microelements.
Stupor after stroke treated with vascular drugs, and, sometimes, surgically, in the presence of a hematoma. For ischemic causes, Streptokinase and Alteplase are used to relieve its effects and preserve some neurons. It is very important to prevent cerebral edema with Furosemide, Torasemide, Manitol, Mannitol, Hypothiazide, Papaverine. Glutargin 40%, Thiamine, Pyridoxine and other vitamin preparations are used for digging.
Prognosis and consequences of stupor
Stupor is an intermediate state between nullification and coma, so its outcome depends on the speed of first aid. If the person is not found or they think that he is just a “drunk”, as often happens, then coma and then death are inevitable. Well, if an experienced doctor identifies the causes and they turn out to be treatable, then the consequences can be minimized, but still, these conditions always leave an imprint on a person’s cognitive functions.
If the vital parts of the cerebral cortex are damaged, then the personality cannot be returned; while maintaining vital functions, it is possible to preserve the “vegetable”. But with infections and even some injuries, it is possible to maintain normal functioning. After strokes, everything depends on the location of ischemia or hematoma; the most unfavorable places are in the cognitive zones and in the brain stem.
If a person has been diagnosed according to Glasgow and a low level of scores has been identified, then the prognosis is disappointing, since this indicates irreversible damage to the cerebral cortex.
After cardiac arrest, the prognosis is more disappointing than with drug poisoning, in particular barbiturates. This is due to the depth of the soporous state. Deep stupor has a poorer prognosis and more often leads to coma.
With proper care using modern means of support (nutrition, functional bed, vitamin complexes, exercise therapy, massages), after leaving this state, the person will be able to return to a typical life in a relatively short period of time. But with improper care, the consequences can be irreversible: contractures, paresis, infectious complications, nutrition problems.
It is very important for people after such conditions to adhere to a healthy life. Smoking and alcohol greatly reduce its duration and also lead to pathological intoxication. Moderate physical exercise and health improvement in sanatoriums are also indicated.
Ministry of Health of UkraineLugansk State Medical University
Department of Military Medicine, Disaster Medicine
With anesthesiology and intensive care.
Head of the department: Ph.D. Assoc. Nalapko Yu.I.
The group is led by Ass. Peycheva E.I.
Essay
“Types of disturbances of consciousness: stupor, stupor, coma.”
Prepared by:
Student 16 group 5th year
Faculty of Medicine
Ratushnikova Tatyana
Etiology
1.Supratentorial volumetric processes
Epidural hematoma
Subdural hematoma
Brain infarction or hemorrhage
Brain tumor
Brain abscess
Brainstem infarction
Brain stem tumor
Hemorrhage in the brain stem
Hemorrhage into the cerebellum
Brain stem injury
Trauma (concussion, brain injury or bruises)
Anoxia or ischemia (syncope, cardiac arrhythmia, pulmonary infarction, shock, pulmonary failure, carbon monoxide poisoning, collagen vascular disease)
Condition after an epileptic seizure
Infections (meningitis, encephalitis)
Exogenous toxins (alcohol, barbiturates, glutethimide, morphine, heroin, methyl alcohol, hypothermia)
Endogenous toxins and metabolic disorders (uremia, hepatic coma, diabetic acidosis, hypoglycemia, gyronatremia)
Psychomotor status epilepticus
Stupor is a type of movement disorder in psychiatry, which is complete immobility with mutism and weakened reactions to irritation, including pain.
There are various types of stuporous states:
catatonic,
reactive,
depressive stupor.
Being in a stupor, patients do not come into contact with others, do not react to current events, various inconveniences, noise, wet and dirty bed. They may not move if there is a fire, earthquake or some other extreme event. Patients usually lie in one position, the muscles are tense, the tension often begins with the masticatory muscles, then goes down to the neck, and later spreads to the back, arms and legs. In this state, there is no emotional or pupillary response to pain. Bumke's syndrome - dilation of the pupils in response to pain - is absent.
In case of stupor with waxy flexibility, in addition to mutism and immobility, the patient maintains the given position for a long time, freezes with a raised leg or arm in an uncomfortable position. Pavlov's symptom is often observed: the patient does not respond to questions asked in a normal voice, but responds to whispered speech. At night, such patients can get up, walk, put themselves in order, sometimes eat and answer questions.
^ Negativistic stupor characterized by the fact that with complete immobility and mutism, any attempt to change the patient’s position, lift him or turn him over causes resistance or opposition. It is difficult to get such a patient out of bed, but once raised, it is impossible to put him back down. When trying to be brought into the office, the patient resists and does not sit down on the chair, but the seated person does not get up and actively resists. Sometimes active negativism is added to passive negativism. If the doctor extends his hand, he hides his hand behind his back, grabs food when it is about to be taken away, closes his eyes when asked to open, turns away from the doctor when asking him a question, turns and tries to speak when the doctor leaves, etc.
Stupor with muscle numbness is characterized by the fact that patients lie in the intrauterine position, muscles are tense, eyes are closed, lips are pulled forward (proboscis symptom). Patients usually refuse to eat and have to be fed through a tube or undergo amytalcaffeine disinhibition and feed at a time when the manifestations of muscle numbness decrease or disappear.
At depressive stupor with almost complete immobility, patients are characterized by a depressed, pained expression on their face. You manage to make contact with them and get a monosyllabic answer. Patients in a depressive stupor are rarely untidy in bed. Such a stupor can suddenly give way to an acute state of excitement - melancholic raptus, in which patients jump up and injure themselves, can tear their mouths, tear out an eye, break their heads, tear their underwear, and can roll on the floor howling. Depressive stupor is observed in severe endogenous depression.
At apathetic In stupor, patients usually lie on their backs, do not react to what is happening, and muscle tone is reduced. Questions are answered in monosyllables with a long delay. When contacting relatives, the reaction is adequate emotional. Sleep and appetite are disturbed. They are untidy in bed. Apathetic stupor is observed with prolonged symptomatic psychoses, with Gaye-Wernicke encephalopathy.
The patient does not react to the environment, does not perform any tasks, and does not answer questions. It is possible to bring the patient out of the soporous state with great difficulty, using harsh painful influences (pinches, injections, etc.), while the patient develops facial movements that reflect suffering, and other motor reactions are possible as a response to painful irritation.
The examination reveals muscle hypotonia, depression of deep reflexes, the reaction of the pupils to light may be sluggish, but the corneal reflexes are preserved. Swallowing is not impaired. A soporous state can develop as a result of traumatic, vascular, inflammatory, tumor or dysmetabolic brain damage.
As this precomatose state deepens, consciousness is completely lost and coma develops.
Levels of impairment of consciousness according to Shakhnovich
Moderate stun
Verbal contact is possible, but difficult.
Orientation in one’s own personality, place, time, circumstances is disrupted.
Executes commands.
Verbal contact is almost impossible.
There is no orientation.
Executes (attempts to execute) commands.
Doesn't follow commands.
Opening of eyes spontaneously, in response to a shout or pain.
Purposeful motor response to pain.
Muscle tone (neck) is preserved.
Doesn't open his eyes.
Non-targeted response to pain (flexion, extension of limbs).
Muscle tone (neck) is preserved, breathing is not impaired.
The response to pain is unfocused and reduced.
Muscle tone (neck) is reduced.
Breathing disorders of central, obstructive, mixed types.
There is no reaction to pain.
Muscle atony.
Severe breathing problems.
Bilateral mydriasis.
Coma (comatose state) is an acutely developing severe pathological condition characterized by progressive depression of the functions of the central nervous system with loss of consciousness, impaired response to external stimuli, increasing disorders of breathing, blood circulation and other life support functions of the body. In a narrow sense, the concept of “coma” means the most significant degree of depression of the central nervous system (followed by brain death), characterized not only by a complete absence of consciousness, but also by areflexia and disorders of the regulation of vital body functions.
Etiology
Coma is not an independent disease; it occurs either as a complication of a number of diseases accompanied by significant changes in the functioning conditions of the central nervous system, or as a manifestation of primary damage to brain structures (for example, in severe traumatic brain injury). At the same time, in different forms of pathology, comatose states differ in individual elements of pathogenesis and manifestations, which also determines differentiated therapeutic tactics for comas of different origins.
In clinical practice, the concept of “coma” has become established as a threatening pathological condition, which often has a certain stage in its development and requires, in such cases, urgent diagnosis and treatment at the earliest possible stage of dysfunction of the central nervous system, when their inhibition has not yet reached the maximum degree. Therefore, the clinical diagnosis of coma is established not only in the presence of all the signs characterizing it, but also in the presence of symptoms of partial inhibition of central nervous system functions (for example, loss of consciousness with preservation of reflexes), if it is regarded as a stage of development of a comatose state.
Wakeful coma (lat. coma vigile) is a state of complete indifference and indifference of the patient to everything around him and to himself while maintaining autopsychic, and in some cases, allopsychic orientation.
Doubtful coma (comasomnolentum; lat. somnolentus drowsy) is a state of darkened consciousness in the form of increased drowsiness.
The Glasgow Coma Scale (GCS, Glasgow Coma Severity Scale) is a scale for assessing the degree of impairment of consciousness and coma in children over 4 years of age and adults.
The scale consists of three tests assessing the eye opening reaction (E), as well as speech (V) and motor (M) reactions. For each test a certain number of points are awarded. In the eye opening test from 1 to 4, in the speech reactions test from 1 to 5, and in the motor reactions test from 1 to 6 points. Thus, the minimum number of points is 3 (deep coma), the maximum is 15 (clear consciousness).
Accrual of points
Opening your eyes
Free - 4 points
How to react to a voice - 3 points
How to react to pain - 2 points
Absent - 1 point
The patient is oriented, quick and correct answer to the question asked - 5 points
The patient is disoriented, confused speech - 4 points
Verbal okroshka, the answer in meaning does not correspond to the question - 3 points
Inarticulate sounds in response to a question asked - 2 points
Lack of speech - 1 point
Performing movements on command - 6 points
Expedient movement in response to painful stimulation (repulsion) - 5 points
Withdrawal of a limb in response to painful stimulation - 4 points
Pathological flexion in response to painful stimulation - 3 points
Pathological extension in response to painful stimulation - 2 points
Lack of movement - 1 point
15 points - clear consciousness.
10-14 points - moderate and deep stunning.
9-10 points - stupor.
7-8 points - coma-1.
5-6 points - coma-2
3-4 points - coma-3
Guide to anesthesiology and resuscitation. Edited by Professor Yu.S. Polushina. - St. Petersburg. - 2004.
Guide to anesthesiology. Edited by M.S. Glumchera, A.I. Treschinsky K.: “Medicine” - 2008.
18. Catatonic syndromes (stupor, agitation)
Catatonic syndromes are psychopathological disorders with a predominance of motor disorders in the form of stupor, agitation, or their alternation, occurring in both adults (up to 50 years old) and children. In most cases, these syndromes are observed in schizophrenia, but can also manifest themselves in organic or symptomatic psychoses. Catatonic stupor Expressed in complete immobility, and a person can freeze in a very unusual position: with his head raised above the pillow at a certain angle, standing on one leg, with uncomfortable outstretched arms, etc. However, in most cases, patients lie motionless in the so-called “fetal position” (with eyes closed, on one side with bent legs and arms pressed to the body). Such complete immobility is usually accompanied by either absolute silence (mutism) or passive/active negativism. With passive negativism, the patient does not react at all to any appeals, suggestions, requests. With active negativism, the patient, on the contrary, actively resists all requests, for example, when asked to show his tongue, he clenches his mouth even tighter, and when asked to open his eyes, he closes his eyelids even more tightly. Cataleptic stupor (stupor with waxy flexibility) is characterized by the patient’s complete freezing for quite a long time in the position assigned to him, or in the position he himself adopted, even if it is extremely uncomfortable. During stupor, a person does not react to loud speech, but in conditions of complete silence he can spontaneously disinhibit, thereby becoming available for contact. Catatonic arousal Characterized by stereotypically repeated, chaotic, meaningless movements. Excitement is accompanied by characteristic shouts of individual words or phrases (verbigeration), or complete silence (mute excitation). A characteristic feature of excitation is that it occurs within limited spatial limits (patients can endlessly step from foot to foot, standing in the same place; jump in bed, while stereotypically waving their arms). Sometimes patients may experience copying movements (echopraxia) or the words of others (echolalia), without revealing spontaneous speech. Catatonic excitement is often combined with hebephrenic syndrome, which is characterized by non-infectious empty fun, giftedness, or mannerisms. Such patients meow, grunt, cackle, stick out their tongues, make faces, grimace; sometimes they can rhyme words meaninglessly, or mutter something inarticulate; copy the gestures and movements of others, extend a leg instead of a hand to greet, walk mincing, or throwing their legs high
19. Syndromes of switching off consciousness (stunning, stupor, coma)
Syndromes of switching off consciousness. Turning off consciousness - stunning - can have different depths, depending on which the terms are used: “nubilation” - fogging, cloudiness, “cloudy consciousness”; “stupefaction”, “doubtfulness” - drowsiness. This is followed by stupor - unconsciousness, insensibility, pathological hibernation, deep stupor; This circle of coma syndromes completes - the most profound degree of cerebral insufficiency. As a rule, instead of the first three options, a diagnosis is made “ precom" At the present stage of consideration of syndromes of switching off consciousness, much attention is paid to the systematization and quantification of specific conditions, which makes their differentiation relevant.
Stupefaction is determined by the presence of two main signs: an increase in the threshold of excitation in relation to all stimuli and an impoverishment of mental activity in general. At the same time, the slowdown and difficulty of all mental processes, the poverty of ideas, incompleteness or lack of orientation in the environment are clearly evident. Patients who are in a state of stunned, stupefied state can answer questions, but only if the questions are asked in a loud voice and repeated repeatedly, persistently. The answers are usually monosyllabic, but correct. The threshold is also increased in relation to other irritants: patients are not bothered by noise, they do not feel the burning effect of a hot heating pad, do not complain about an uncomfortable or wet bed, are indifferent to any other inconveniences, and do not react to them. With a mild degree of deafness, patients are able to answer questions, but, as already noted, not immediately; sometimes they can even ask questions themselves, but their speech is slow, quiet, and their orientation is incomplete. Behavior is not impaired, mostly adequate. You can observe easily occurring drowsiness (doubtfulness), while only sharp, fairly strong stimuli reach consciousness. Drowsiness is sometimes classified as a mild degree of stunning.
upon awakening from sleep, as well as the nullification of consciousness with fluctuations in the clarity of consciousness: slight darkenings, obscurations are replaced by clarification. The average severity of stunning is manifested by the fact that the patient can give verbal answers to simple questions, but he is not oriented in place, time and surroundings. The behavior of such patients may be inappropriate. A severe degree of stunning is manifested by a sharp increase in all previously observed signs. Patients do not answer questions, cannot fulfill simple requirements: to show where the hand, nose, lips, etc.
Sopor(from Latin sopor - unconsciousness), or soporous state, subcoma, is characterized by complete extinction of voluntary activity of consciousness. In this state, there is no longer responsiveness to external stimuli; it can only manifest itself in the form of an attempt to repeat a loudly and persistently asked question. The predominant reactions are of a passive-defensive nature. Patients resist when trying to straighten their arm, change their underwear, or give an injection. This kind of passive-defensive reaction should not be confused with negativism (resistance to any request or influence) in catatonic substupor or stupor, since in catatonia other very characteristic signs are observed: increased muscle tone, mask-like appearance of the face, uncomfortable, sometimes pretentious postures, etc. A. A. Portnov (2004) distinguishes between hyperkinetic and akinetic stupor. Hyperkinetic stupor is characterized by the presence of moderate speech excitation in the form of meaningless, incoherent, indistinct muttering, as well as choreo-like or athetoid-like movements. Akinetic stupor is accompanied by immobility with complete muscle relaxation, the inability to voluntarily change the position of the body, even if it is uncomfortable. In a soporous state, patients retain the reaction of the pupils to light, the reaction to painful stimulation, as well as the corneal and conjunctival reflexes.
Coma(from the Greek ???? - deep sleep), or coma, comatose syndrome is a state of deep depression of the functions of the central nervous system, characterized by complete loss of consciousness, loss of response to external stimuli and a disorder in the regulation of vital functions of the body.
According to the National Scientific and Practical Society of Emergency Medical Services, the incidence of prehospital coma is 5.8 per 1000 calls, and the mortality rate reaches 4.4%. The most common causes of coma are stroke (57.2%) and drug overdose (14.5%). This is followed by hypoglycemic coma - 5.7% of cases, traumatic brain injury - 3.1%, diabetic coma and drug poisoning - 2.5% each, alcoholic coma - 1.3%; Coma is diagnosed less frequently due to poisoning by various poisons - 0.6% of cases. Quite often (11.9% of cases) the cause of coma at the prehospital stage remained not only unclear, but not even suspected.
All causes of coma can be reduced to four main ones:
intracranial processes (vascular, inflammatory, volumetric, etc.);
hypoxic conditions as a result of somatic pathology (respiratory hypoxia - with damage to the respiratory system, circulatory - with circulatory disorders, hemic - with hemoglobin pathology), impaired tissue respiration (tissue hypoxia), a drop in oxygen tension in the inhaled air (hypoxic hypoxia);
metabolic disorders (primarily of endocrine origin);
intoxication (both exo- and endogenous).
Comatose states are an urgent pathology and require the use of resuscitation measures, since the severity of the subsequently developing psychoorganic syndrome depends on the duration of the coma. The leading clinical picture of any coma is the switching off of consciousness with loss of perception of the environment and oneself. If in a soporotic state the reactions are of a passive-defensive nature, then with the development of coma the patient does not respond to any external stimuli (pricking, patting, changing the position of individual parts of the body, turning the head, speech addressed to the patient, etc.). There is no reaction of the pupils to light during coma, unlike stupor.
Usual clinical stupor manifests itself in the depressed psychological state of the patient, weak reaction of the pupils to light and dulling of pain.
A soporous state can transform into a coma, which is an extreme degree of inhibition of all body functions. It is completely switched off at the reflex level. To prevent this condition, you should know what causes stupor.
What is the difference between stupor and coma
The main difference between stupor and coma is that the first state is a lack of contact with the outside world, accompanied by But a person can be taken out of it at least for a short time. This can be achieved by vigorous shaking, tingling, and a loud voice. Coma is an unconscious state that can be compared to very deep sleep or anesthesia, from which awakening is impossible. A person in a comatose state does not even respond to pain.
Cause of stupor
The most common causes of stupor include:
- complications caused by cerebral hemorrhage;
- the presence of benign or malignant neoplasms in the brain;
- chronic diseases;
- toxic damage to the body;
- viruses and infections;
- thrombophlebitis;
- atherosclerosis;
- overdose of drugs, especially tranquilizers;
- wrong lifestyle;
- disruption of metabolic processes in the body;
- severe hypertensive crisis;
- head injury;
- pronounced deviations in glucose levels in diabetes mellitus;
- decreased thyroid function (hypothyroidism);
- metabolic disorders due to nephritis;
- aneurysm rupture;
- poisoning of the body with carbon monoxide, barbiturates, opioids;
- meningitis;
- meningoencephalitis;
- cardiac ischemia;
- blood poisoning (sepsis);
- disturbance of electrolyte balance in the body;
- heatstroke.
Symptoms of the disease
If a healthy central nervous system constantly reacts to changing environmental conditions, then in a state of stupor, brain activity is inhibited. The body seems to be in a long sleep. The stuporous state can transform into a coma.
The brain cannot make any decisions. Wakefulness and sleep can abruptly replace each other.
Many people are interested in: “How long does the stuporous state last?” Blackout periods can last from a few seconds to months. It all depends on the reason that caused the process.
With stupor, the patient may feel some fog and confusion in understanding everything that is happening around. He may experience disorientation in space. The patient may confuse dates and names, may not remember events that happened yesterday, but at the same time clear pictures of the distant past emerge in his memory.
Strong irritants can cause a reaction in a person. A sharp sound causes the eyelids to open, but the patient purposefully does not look for anything. Impact on the nail bed provokes withdrawal of the limb. An injection or a pat on the cheek can cause a short-term negative reaction in the patient.
On examination, a decrease in muscle tone and inhibition of deep reflexes are noted. A pyramidal syndrome caused by suppression of central neurons is often detected. The reaction of the pupils to light is sluggish, corneal and persists.
In parallel with all these symptoms, neurological signs of a focal nature may appear, indicating local damage to certain areas in the cerebral cortex.
If the soporous state is provoked by a stroke or meningoencephalitis, then stiffness of the neck muscles and other meningeal symptoms will be detected. Uncontrollable muscle twitching may also occur.
In some cases, doctors are faced with a hyperkinetic version of stupor, in which a person says something incoherently, turns around, and makes purposeful movements. Establishing productive contact with the patient is impossible. similar to delirium, which belongs to the category of qualitative disorders of consciousness.
The stuporous state after a stroke can be characterized by a high degree of agitation or complete indifference to everything around.
Stupor during stroke
Stroke is a very dangerous disease that causes unpredictable complications. Stupor is one of them. Translated from Latin, the word “stupor” means “sleep”, “numbness”, “lethargy”, “memory loss”. In medicine, this condition is usually called subcoma, since it is a step towards the development of coma and is in many ways similar to this serious condition.
The stuporous state during a stroke is expressed in a dullness of all human reactions. The activity of consciousness is in an extremely depressed state.
Stroke is caused by pathological processes in blood vessels that provoke acute dysfunction of the brain. The effects last for more than a day. A stroke can lead to rapid death.
Stupor does not always, but quite often accompanies a stroke. It is observed in approximately one fifth of cases of all cerebral necrosis. The manifestation of this condition can be observed not only during the acute period of the disease, but also during its rehabilitation. The process is directly dependent on the area and degree of brain damage.
Such a complication cannot be ignored under any circumstances, since most often it quickly turns into a coma.
Clinical picture of stupor during stroke
The soporous state during stroke, the prognosis of which depends on the extent of cerebral necrosis, manifests itself in the patient’s drowsiness and lethargy. In parallel with this, defensive reactions to stimuli such as pain, sharp sound and light are preserved. The patient does not react to the environment around him, cannot answer questions, and is unable to complete any task. Muscle tension in the limbs is reduced, tendon reflexes are dulled, and coordination of movements is lost.
Stupor in epilepsy
Stopper always accompanies Epilepsy in medicine is called a state of increased convulsive readiness. In such patients, the appearance of seizures is provoked by a certain situation, to which healthy people do not react in this way. Many researchers believe that the disease is hereditary.
Typically, an epileptic seizure is preceded by a sharp change in the patient’s emotional background. 2-3 days before a seizure, a person becomes agitated, tense and anxious. Some patients withdraw into themselves, others show aggression towards others. Shortly before the attack, an aura appears that is difficult to describe in words. It is characterized by a variety of tactile sensations: taste in the mouth, vague sounds and smells. We can say that the aura marks an epileptic seizure.
A focus of excitation appears in the cerebral cortex of a person. It covers more and more nerve cells. The end result is a seizure. Usually the duration of the phase is 30 seconds, less often one minute. The patient's muscles are under severe tension. The head is thrown back. The patient screams and breathing stops.
The convulsive stage lasts up to 5 minutes. With it, all the patient’s muscles involuntarily contract. After the seizure ends, the muscles relax again. The patient's consciousness turns off. The stuporous state in epilepsy lasts 15-30 minutes. After recovering from stupor, the patient falls into deep sleep.
Stupor due to dehydration
Complications such as stupor can also accompany dehydration. In medicine, water deficiency is usually called exicosis. In this condition, there is a low content of electrolytes and water, which is provoked by repeated persistent vomiting and severe stomach upset.
In addition, fluid loss can be caused by pathological processes in the kidneys and lungs. Typically, exicosis develops gradually within 2-3 days from the onset of the provoking disease.
Dehydration is characterized by the patient's lethargy, loss of appetite, and refusal to drink. Ingestion of liquid causes profuse vomiting. There is a decrease in muscle tone, the patient’s body temperature, as well as blood pressure, drops sharply. Oliguria or anuria is noted.
A stuporous state from dehydration can progress to a coma.
Prognosis for stupor
What is the outcome of the disease? A stuporous condition, the prognosis of which depends on the provoking cause, must undergo timely treatment. The degree of damage to the nervous tissue and the volume of therapy play a major role.
The sooner measures were taken to correct the disorder, the higher the patient’s chance of restoring clear consciousness and regressing the symptoms of the underlying disease.
Diagnostics
Stupor caused by a stroke can be fatal. At the first mild manifestations of complications, it is necessary to carry out timely diagnosis.
Priority measures include:
- blood pressure measurement;
- checking heart rate and breathing;
- checking the reaction of the pupils to light and determining the degree of their mobility;
- measuring body temperature; if it is high, one can judge the presence of infection in the patient’s blood;
- examination of the skin for injuries, vascular lesions or allergic manifestations.
Necessary examinations
An examination that must be carried out without fail is electroencephalography. It gives medical professionals an idea of the extent of damage to brain cells.
If the presence of stupor is confirmed, hospitalization is usually indicated. In the hospital, the patient will be able to provide support for functions necessary for life and conduct more detailed diagnostics.
After electroencephalography, a spectral blood test is performed to identify high sugar levels and other provocateurs of the pathological condition. If intoxication is suspected, a blood test is also done and urine is examined for the presence of narcotic substances in the body. In some cases, a neurologist prescribes a lumbar puncture and magnetic resonance therapy of the brain.
Principles of treating stupor
A stuporous state, the consequences of which can be very severe, is not an independent phenomenon. It indicates a malfunction of the brain. Therefore, the goal of treatment should be to eliminate the underlying factor. In this case, therapy should be started as quickly as possible.
The trigger for stupor is often ischemia and swelling of the brain tissue. Early treatment prevents the brain from wedging into the natural openings of the skull and helps preserve the functionality of neurons.
Nerve cells in the penumbra (ischemic penumbra) are especially vulnerable. This is the area that is adjacent to the affected lesion in the brain. Incorrect treatment provokes an increase in symptoms due to the death of neurons in this area. In this case, the soporous state may turn into a coma, and neurological disorders will become more pronounced.
When treating stupor, the main actions are aimed at combating swelling of the nervous tissue and maintaining adequate blood circulation in the brain. The level of glucose in the blood is also corrected, the lack of microelements is compensated, and the causes of disturbances in the functioning of the heart, kidneys and liver are eliminated.
In case of infection, the use of antibiotics is indicated, and in the presence of hemorrhages, they resort to stopping the bleeding.
For stupor, all medications are administered intravenously into the body. In this case, the most effective drugs are glucose 40% and thiamine, as well as the use of these drugs with naloxone.
Further therapy for stupor depends on the degree of damage to the body and is prescribed by a doctor on an individual basis.
