Soporous condition: causes, signs, treatment. Sopor: causes, symptoms, diagnosis, treatment
Sopor is a deep depression of human consciousness, which appears as drowsiness. In this state, the patient's voluntary activity is suppressed, but his reflex activity is preserved.
In particular, a sluggish reaction of the pupils of the eyes to light, a protective reaction to pain, remains. With further oppression of human consciousness, a coma develops. Thus, stupor is an intermediate state between stunning consciousness and coma. Coma is a state of severe depression of the nervous system. At the same time, a person loses consciousness, his reflex activity disappears, and disorders in the regulation of basic vital functions appear.
Causes
The causes of stupor and coma can be many serious diseases, conditions and injuries, such as tumor-like diseases of the brain, craniocerebral injuries, vascular and toxic brain damage, etc. A short-term loss of consciousness can occur after minor head injuries, due to a decrease in brain blood circulation or as a result of seizures. Violation of the blood circulation of the brain, often observed with 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. Also, a metabolic disorder that affects the content of sugar, salts and some other substances in the blood can also negatively affect the function of the brain.
Symptoms
In a normal person, brain activity, as a rule, is constantly changing. Thus, the activity of the brain in a waking person is significantly different from the activity of a sleeping person. Also, the activity of the brain in these conditions differs from the activity of the brain, for example, during a difficult exam or during emergency situations that require a quick solution. Such differences in brain activity during 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 its work in accordance with current circumstances. The area that is dedicated to regulating activity is located deep in the brainstem. This area actively stimulates the brain, thereby determining the level of consciousness and the state of wakefulness. To determine the state, the entire set of information received from the ears, eyes, skin and other sensory organs is used. Using this information, the brain changes its level of activity accordingly.
If the activating system in the brainstem is damaged or its connection with some other parts of the brain is disrupted, then the sensory perceptions in the brain are no longer able to sufficiently influence the level of wakefulness and the level of activation of the brain. This leads to a disorder of consciousness. This can go as far as loss of consciousness.
The periods of disorder of consciousness can be both long-term and short-term. Moreover, consciousness can change from a slight clouding of the patient's mind to its 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 fact that the patient is unable to distinguish 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 inhibition in this case is the appearance of reduced brain activity. In some cases, patients manifest a condition called somnolence. This state is a state resembling a long and deep sleep. Often, in order to get a person out of this state, you have to shout loudly and push him aside.
Sopor represents a deep non-contact, a loss of human consciousness and a state from which a sick person can be brought out only for a short period of time. To do this, you have to repeatedly carry out vigorous shaking, loud appeals or needle injections. At the same time, a person does not react to the environment, cannot answer the questions posed, and does not perform any tasks. The function of swallowing is preserved.
The next condition, after soporous, is coma. Coma is an unconscious state that is somewhat similar to a state of general anesthesia or a state of deep sleep. The patient cannot be brought out of this state by attempts to awaken him. In addition, a patient who is in the stages of a deep coma usually does not have any responses, including pain. In this condition, it is difficult to predict the likelihood of recovery of the patient. The likelihood of recovery largely depends on the cause of the coma. If the cause of the coma was a head injury, then a full recovery is possible if the loss of consciousness lasts no more than three months. If the cause of the coma was cardiac arrest or cessation of breathing, the duration of the coma is more than a month, then recovery is quite rare.
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 while the patient can normally fall asleep, wake up, swallow and breathe. In addition, the patient may have a motor reaction to all loud noises. However, permanently or temporarily he loses the ability to normal conscious behavior and thinking. Patients in a vegetative state are able to perform some reflex movements, such as twitching, leg and arm tension.
In some cases, the patient may experience the so-called “locked-in” 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. Only in this way can he answer questions addressed to him. A similar condition, as a rule, occurs with severe peripheral paralysis. The same condition can occur with some types of stroke.
The most severe form of the disorder is brain death. In this state, the brain already 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 medicines, then a fatal outcome 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 state brain death when, twelve hours after the elimination of all treatable disorders of the human condition, the patient's brain still does not respond to external stimuli. In this case, a 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 functions of the spinal cord may be preserved. In this case, a person may show some reflexes.
Diagnostics
Coma and soporous condition are urgent pathologies that require the use of 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 the loss of consciousness. The main thing in the clinical picture of any coma is the turning off of consciousness, in which a person loses the possibility of normal perception of not only the environment, but also himself.
Upon arrival at the scene, ambulance doctors diagnose the soporous condition. In particular, they must make sure that the patient's airways are free. In addition, they should check the breathing pulse and blood pressure. Particular attention should be paid to body temperature. If the patient has a high temperature, then this may be one of the signs of an infectious disease. If the body temperature, on the contrary, is low, then this may mean that the patient has been exposed to cold for a long time.
Also during the diagnosis, a skin examination is performed. 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 should be performed. This allows you to identify signs of brain damage.
Equally important is the eye examination. It allows you to get important information about the state of the central nervous system. This checks the position and mobility of the eyeballs, checks the size of the pupils, the reaction to light, checks the appearance of the retina and the patient's ability to follow all moving objects. Different sizes of pupils can serve as a sign of squeezing the brain.
Treatment
If in the soporous state the main reactions are passive, then with the development of coma, the patient, as a rule, ceases to respond to all external stimuli. In particular, a person in this state does not respond to patting, changing the position of individual parts of the body, to injections, to turning the head, and even more so to any appeal to the patient. It is worth noting that in coma, unlike sopor, there is no pupillary reaction to light.
Patients who are in a coma, the cause of which is not clear, are always tested for glycemia. If the patient is known to be diabetic and it is difficult to identify the hyperglycemic or hypoglycemic origin of the coma, intravenous glucose is recommended. This is necessary for differential diagnosis, and for the purpose of providing emergency care for hypoglycemic coma. If the patient had a low blood glucose level, then such injections improve the symptoms of lesions. In addition, it allows you to distinguish between these two states. In the case of coma due to increased glucose content, the administration of glucose has practically no effect on the patient's condition. If it is not possible to measure the amount of glucose in the blood, then experimentally it is necessary to introduce high concentration glucose.
With the onset of a rapid change in consciousness, a person should be given immediate medical attention. However, it is not always possible to establish the correct diagnosis in a short time, which is necessary for the correct treatment of impaired brain activity. Until the results of the tests are obtained, the person is sent to the intensive care unit, where his pulse, body temperature, blood pressure and the required amount of oxygen in the blood will be constantly monitored.
After delivery to the intensive care unit, a person is immediately supplied with oxygen and a system designed for intravenous administration is set up, which will allow timely administration of the necessary medicine. Glucose is given intravenously until the blood sugar test results are available. If there is a suspicion that mental disorders 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 led to a disorder of consciousness, the patient's stomach is washed. This will also prevent further absorption of the toxic substance.
In order to maintain a normal pulse and normal blood pressure, blood transfusions and intravenous administration of necessary drugs and fluids are used.
If there is no possibility of clarifying the diagnosis and urgent hospitalization, thiamine, 40% glucose solution and naloxone are considered the main drugs for patients in a coma. The combination of these drugs in most cases is considered the most effective and safe.
In the case of the deepest stages of coma, the brain has damage that does not allow the body to normally provide vital functions. In such cases, a ventilator is used to facilitate the work of the lungs.
Sopor is a pathology related to unproductive types of impaired awareness. Sopor belongs to a 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, therefore they are able to quickly distinguish this manifestation. Sopor 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 in the degree of loss of awareness.
Sopor - what is it?
In an adequate state, when a person is cheerful, she has a clear consciousness, while she adequately assesses the situation, maintains contact, evaluates her life needs, is able to stand up for herself and adapt to changes around her. The level of body work and the synthesis of brain impulses is very different in different conditions, stress is activating, and activities with a quiet rest are relaxing. A person has two cerebral hemispheres, but always with different intensity, depending on the leading hand, the form of activity and the level of stress. But due to a variety of pathological phenomena, people can visit states of unconsciousness. All of them are characterized by the absence of consciousness, but with some differences that play an important diagnostic value.
The term sopor comes from the Latin language and means deep sleep, flaccid stupor, subcomatose state. Domestic terminology differs from foreign, where it is believed that stupor is an abnormally deep sleep, but stupor is a subcoma, and we have exactly the opposite.
Sopor is a pathological condition in which a person lies motionless. The state of stupor is a serious signal that demonstrates incorrect brain work and subsequently leads to a coma or worse pathologies. But stupor is immobilization in the physical plane, while the person is in a clear mind (most often).
Deep stupor is a condition approaching coma, even not all pain stimuli have a mimic or reflex reaction.
Sopor after a stroke develops due to damage to the vessels penetrating the brain tissue. All this impressively disrupts his activities. You should be alarmed if there are already the slightest signs of a problem, since everything can end with massive neurological disorders, up to coma.
Causes of sopor
Since sopor is an almost complete shutdown of consciousness, there are many reasons. They can come from completely different sources. A very significant etiological layer comes from neurology. Sopor after a stroke is quite common, a stroke with both hemorrhage and ischemia can often have a similar adverse outcome. This pathology is especially relevant in case of damage to the superial parts of the brain stem. Skull injuries are also very relevant, they become the root cause of a considerable number of pathological processes, and sopor is no exception. If a person was lying in neurology with a bruise, then you already need to worry. But if there was a concussion, or a hemorrhage, which is even worse, then it is imperative to do a comprehensive study in order to avoid such problems in the future.
If neoplasia is detected in the brain tissues, there is a risk of their edema, 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 moments.
Infectious pathology has always been famous for the danger of its complications, thus, infectious processes in brain tissues can lead to abscesses, which, by increasing intracranial pressure, provoke stupor. So, tuberculosis, various viruses, herpes, prion pathology, and sometimes even can provoke stupor. In septic conditions, a person can 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 tissues, can also lead to severe precomatous conditions.
Deep sopor is often characteristic of childhood, especially in children with severe congenital pathology. , a congenital pathology with an increased composition of fluid in the brain tissues, is often complicated by stupor. Problems that originate from birth 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 lethality, unfortunately. In newborns with severe hypoxia, for example, after asphyxia during childbirth, such a condition is also possible.
Sopor also occurs in certain psychiatric pathologies, for example, in epilepsy. In the case of a severe course of epilepsy and its incorrect treatment, the person does not return to awareness after an attack, but the attack repeats again and again, such a 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 irreversible changes that can provoke a fatal outcome.
Endocrinological pathology always entails metabolic disruptions, which in turn causes problems with brain tissues. Incorrectly docked with or invariably lead to complications. Ketoacidotic coma occurs when there is a lack of insulin, when pathological products of the destruction of fats accumulate in the body. In this case, the coma has several stages. The first of them is just sopor, almost every diabetic at the beginning of the disease fell into such a state. With a decrease in the work of the thyroid gland to a state, stupor may also occur.
Deficiency in the body, especially of 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 the brain tissues and provokes stupor. in the most severe manifestations, it 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 their unfavorable role in the occurrence of sopor. Hypothermia is especially dangerous, if a person is frozen and has not been found for a long time, and then it is also incorrectly warmed up, then the occurrence of stupor is more likely. Sunstroke or heat, received in hot working conditions, can also provoke stupor, especially if a person had the prerequisites for this and a tendency to this condition.
The state of sopor can also be caused by toxic drugs, fumes, alcohol surrogates, many drugs, barbituric hypnotics, narcotic drugs, and anesthetics.
Symptoms and signs of stupor
The state of stupor manifests itself as an insignificant response to external stimuli and, moreover, only to expressive ones. The personality will answer if you ask loudly and many times, otherwise not. The reaction is always passive, but there may be signs of nihilism, especially in the case of an attempt to administer drugs, the person may not extend his arms. Depending on the type of sopor, a person may react differently, with slightly different symptoms. With the hyperkinetic variant, the person makes incoherent speeches that are completely devoid of semantic load. With akinetic, there is complete immobility and the absence of any attempts to change one's position. But still, the sopor is less deep than the 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, along with the corneal ocular and conjunctival reflexes.
Sopor has its own expressive signs in the form of drowsiness with a reaction only to massive stimuli, for example, a sharp sound can make them open their eyes. They are not able to perform any tasks and orders, as well as answer the simplest questions. Since sopor affects the cortex and subcortex of the brain, there is an expressive pyramidal insufficiency, which impairs the body's performance.
Since stupor develops in the case of a number of dangerous causes, it makes significant 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 formidable symptom is streaks of cerebrospinal fluid, cerebral fluid, from the nose and ears. A pungent odor may come from a person, which indicates poisoning with alcohol and its surrogates.
It is very important to look around, because you can find many characteristic things, packages of 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 that tell that he has diabetes or epilepsy. The epileptic has many tongue bites and other scars.
If there is a temperature, a rash, an infection can be suspected, then a lumbar puncture is performed under sterile conditions for confirmation, which will tell a lot of facts. With tuberculosis, a high level of protein and little glucose is observed in punctate, with viral infections there is not much protein, and with bacterial infections, especially in advanced cases, there is real pus.
For the correct diagnosis, an electroencephalogram is used, which will help to see all the pathological waves. MRI, CT and X-ray of the brain is an expensive necessity, without which it is simply impossible to do without in this case. After all, there will be found lesions, and pathological tissues, and areas of damage and injury, and three-dimensional structures. It makes sense to take a blood test, because it will demonstrate many pathological changes.
Sopor treatment
Treatment of the stupor condition is carried out simultaneously with the pathology due to which it arose. It is important that the person breathes normally, in some cases this requires an intubation procedure. If the oxygen level is too low, use an oxygen mask. In hypoglycemia, glucose is used with insulin to process it, and in hyperglycemia, insulin is used. If there is poisoning, especially with substances that suppress the respiratory center, then the universal antidote, Naloxone 3 ml, is used. In the presence of any injuries in the spine, it becomes necessary to use a rigid collar - a fixator.
If any type of poisoning is suspected, it is important to flush, which will help stop the absorption of toxins into the body. If a person had a significant loss of blood, then it is necessary to compensate for this and normalize pressure. For this, blood transfusion, blood products, Novoseven, Plasma, Reopoliglyukin, Reosorbilact, Physiological solution are used. Thiamine is also added, which contributes to the nutrition of the brain, Piracetam, Cordarone, Magnesia.
If the state of stupor drags on, then it is important to maintain the body of the individual at a decent level. To prevent bedsores - turning over and wiping, as well as massage. To prevent congestion during long-term therapy, antibiotic therapy is added: Carbopenem, Azalide, Flemoklav, Ceftriaxone, Meronem.
In epileptic genesis, anticonvulsants are used: Carbamozepine, Valprokom, Seduxen, Sibazon, Relanium. Feeding is done as naturally as possible, but sometimes you have to use a tube, because. it is important that a person has enough trace elements.
Sopor after a stroke it is treated with vascular preparations, and, sometimes, surgically, in the presence of a hematoma. For ischemic causes, Streptokinase, Alteplase is used to relieve its consequences and preserve part of the neurons. It is very important to prevent cerebral edema with Furosemide, Torasemide, Manita, Mannitol, Hypothiazid, Papaverine. For digging, Glutargin 40%, Thiamine, Pyridoxine and other vitamin preparations are used.
Forecast and consequences of sopor
Sopor is an intermediate state between obnubilation and coma, so its outcome depends on the speed of first aid. If a person is not found or they think that this is just a "drunk", as often happens, then a coma, and then death, is inevitable. Well, if an experienced doctor identifies the causes and they turn out to be manageable, then the consequences can be minimized, but nevertheless, these conditions always leave an imprint on the cognitive functions of a person.
If the vital parts of the cerebral cortex have been damaged, then the personality cannot be returned; while maintaining life, it is possible to save the “vegetable”. But with infections and even some injuries, it is possible to maintain normal life activity. 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 was diagnosed according to Glasgow and revealed a low score, 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 worse prognosis and is more likely to lead to coma.
With proper care using modern means of support (nutrition, functional bedding, vitamin complexes, exercise therapy, massages), having left this state, a 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, nutritional 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 activity and health improvement in sanatoriums are also shown.
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 impaired consciousness: stupor, stupor, coma."
Prepared by:
Student of the 16th group of the 5th year
Faculty of Medicine
Ratushnikova Tatiana
Etiology
1. Supratentorial volumetric processes
epidural hematoma
subdural hematoma
Cerebral infarction or hemorrhage
Brain tumor
brain abscess
brain stem infarction
brain stem tumor
Hemorrhage in the brain stem
Hemorrhage in the cerebellum
brain stem injury
Trauma (concussion, brain injury, or bruises)
Anoxia or ischemia (syncope, cardiac arrhythmia, pulmonary infarction, shock, pulmonary insufficiency, carbon monoxide poisoning, vascular collagen diseases)
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 - in psychiatry, one of the types of movement disorders, which is complete immobility with mutism and weakened reactions to irritation, including pain.
There are various options for stuporous conditions:
catatonic,
reactive,
depressive stupor.
Being in a stupor, patients do not come into contact with others, do not react to ongoing events, various inconveniences, noise, wet and dirty bed. They may not move if a fire, earthquake, or some other extreme event occurs. Patients usually lie in one position, the muscles are tense, the tension often begins with the chewing muscles, then descends to the neck, and later spreads to the back, arms and legs. In this state, there is no emotional and pupillary reaction to pain. Bumke's syndrome - dilated pupils for pain - is absent.
With stupor with wax 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 answers 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 position of the patient, lift him or turn him over causes resistance or opposition. It is difficult to get such a patient out of bed, but, having lifted, it is impossible to put him down again. When trying to enter the office, the patient resists, does not sit on a chair, but the seated one does not get up, actively resists. Sometimes active negativism joins passive negativism. If the doctor holds out his hand to him, he hides his behind his back, grabs food when they are about to take it away, closes his eyes when asked to open it, 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 an intrauterine position, the muscles are tense, the eyes are closed, the lips are stretched forward (proboscis symptom). Patients usually refuse food and have to be tube-fed or amytal-caffeine disinhibition and fed at a time when the manifestations of muscle numbness will decrease or disappear.
At depressive stupor with almost complete immobility, patients are characterized by a depressive, suffering facial expression. It is possible to make contact with them, to receive a monosyllabic answer. Patients in a depressive stupor are rarely untidy in bed. Such a stupor can suddenly be replaced by an acute state of arousal - melancholic raptus, in which patients jump up and injure themselves, they can tear their mouths, tear out their eyes, break their heads, tear their underwear, they can roll on the floor with a howl. Depressive stupor is observed in severe endogenous depressions.
At apathetic in stupor, patients usually lie on their backs, do not react to what is happening, muscle tone is reduced. Questions are answered in monosyllables with a long delay. When in contact with relatives, the reaction is adequate emotional. Sleep and appetite are disturbed. They are untidy in bed. Apathetic stupor is observed with prolonged symptomatic psychosis, with Gaye-Wernicke encephalopathy.
The patient does not respond to the environment, does not perform any tasks, does not answer questions. It is possible to bring the patient out of the soporous state with great difficulty, using gross pain effects (tweezing, injections, etc.), while the patient has mimic movements that reflect suffering, and other motor reactions are possible as a response to painful irritation.
Examination reveals muscle hypotension, depression of deep reflexes, pupillary reaction to light may be sluggish, but corneal reflexes are preserved. Swallowing is not disturbed. Soporous condition can develop as a result of traumatic, vascular, inflammatory, tumor or dysmetabolic brain damage.
With the deepening of this pre-coma state, consciousness is completely lost, coma develops.
Levels of impaired consciousness according to Shakhnovich
Moderate stun
Verbal contact is possible but difficult.
Orientation in one's own personality, place, time, circumstances is broken.
Executes commands.
Verbal contact is almost impossible.
No orientation.
Executes commands (tries to execute).
Doesn't execute commands.
Spontaneous opening of the eyes, to a cry, pain.
Purposeful motor response to pain.
The tone of the muscles (neck) is preserved.
Doesn't open eyes.
Non-targeted reaction to pain (flexion, extension of the limbs).
The tone of the muscles (neck) is preserved, breathing is not disturbed.
The reaction to pain is unfocused, reduced.
Muscle tone (neck) is reduced.
Respiratory disorders of the central, obstructive, mixed types.
There is no response to pain.
Muscle atony.
Severe respiratory problems.
Bilateral mydriasis.
Coma (coma) is an acutely developing severe pathological condition characterized by progressive depression of the central nervous system functions with loss of consciousness, impaired response to external stimuli, increasing disorders of respiration, circulation and other life-support functions of the body. In a narrow sense, the concept of "coma" means the most significant degree of CNS depression (followed by brain death), characterized not only by a complete lack of consciousness, but also by areflexia and disorders in 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 conditions for the functioning 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, coma differs in individual elements of pathogenesis and manifestations, which also determines differentiated therapeutic tactics for coma of various origins.
In clinical practice, the concept of "coma" has been established as a threatening pathological condition, often having a certain staging in its development and requiring in such cases urgent diagnosis and therapy at the earliest possible stage of CNS dysfunction, when their inhibition has not yet reached the limiting degree. Therefore, the clinical diagnosis of coma is established not only in the presence of all the signs characterizing it, but also with symptoms of partial inhibition of the functions of the central nervous system (for example, with loss of consciousness with preservation of reflexes), if it is regarded as a stage in the development of a coma.
Awakening coma (Latin coma vigile) is a state of complete indifference and indifference of the patient to everything around him and to himself, while maintaining an autopsychic, in some cases, allopsychic orientation.
Somnolent coma (comasomnolentum; lat. somnolentus drowsy) - a state of clouded consciousness in the form of increased drowsiness.
The Glasgow Coma Scale (GCS, Glasgow Coma Severity Scale) is a scale for assessing the degree of impaired consciousness and coma in children over 4 years of age and adults.
The scale consists of three tests assessing the reaction of opening the eyes (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 test of speech reactions, from 1 to 5, and in the test for motor reactions, from 1 to 6 points. Thus, the minimum score is 3 (deep coma), the maximum is 15 (clear consciousness).
Scoring
eye opening
Free - 4 points
As a reaction to the voice - 3 points
As a reaction 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 does not correspond in meaning to the question - 3 points
Inarticulate sounds in response to a question - 2 points
Lack of speech - 1 point
Performing movements on command - 6 points
Expedient movement in response to pain irritation (repulsion) - 5 points
Withdrawal of the limb in response to pain stimulation - 4 points
Pathological flexion in response to pain stimulation - 3 points
Pathological extension in response to pain stimulation - 2 points
Lack of movement - 1 point
15 points - clear consciousness.
10-14 points - moderate and deep stunning.
9-10 points - sopor.
7-8 points - coma-1.
5-6 points - coma-2
3-4 points - coma-3
Guide to anesthesiology and resuscitation. Under the editorship of Professor Yu.S. Polushina. - St. Petersburg. - 2004
Guide to anesthesiology. Edited by M.S. Glumcher, A.I. Treshchinsky 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 both in adults (up to 50 years old) and in children. In most cases, these syndromes are observed in schizophrenia, but they can also manifest themselves in organic or symptomatic psychoses inconveniently outstretched arms, etc. However, in most cases, patients lie motionless in the so-called "embryonic position" (with closed eyes, 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 absolutely does not respond to any appeals to him, suggestions, requests. With active negativism, the patient, on the contrary, actively resists all requests, for example, when asked to show his tongue, he squeezes his mouth even tighter, and when asked to open his eyes, he closes his eyelids even tighter. A cataleptic stupor (stupor with waxy flexibility) is characterized by a complete fading of the patient for a sufficiently long time in a position given to him or in a position taken by himself, even if it is extremely uncomfortable. During the course of a stupor, a person does not respond to loud speech, however, in conditions of complete silence, he can spontaneously disinhibit, thereby becoming available for contact Catatonic excitation It is characterized by stereotypically repeated, chaotic meaningless movements. Excitation is accompanied by characteristic cries of individual words or phrases (verbigeration), or complete silence (mute excitement). A characteristic difference of excitation is that it proceeds within limited spatial limits (patients can endlessly step from foot to foot, standing in the same place; bouncing in bed, while stereotypically waving their arms). Sometimes patients may copy movements (echopraxia), or the words of others (echolalia), without revealing spontaneous speech. Catatonic excitation is often combined with hebephrenic syndrome, which is characterized by non-contagious empty fun, daring, or mannerisms. Such patients meow, grunt, cackle, show their tongue, make faces, make faces; sometimes they can senselessly rhyme words, or mumble something inarticulate; copy the gestures and movements of those around them, for a greeting they stretch out a leg instead of an arm, walk with a seed, or toss their legs high
19. Syndromes of turning off consciousness (stunning, stupor, coma)
Syndromes of turning off consciousness. Turning off consciousness - stunning - can have a different depth, depending on which the terms are used: "obnubilation" - fogging, cloudiness, "cloudiness of consciousness"; "stunning", "drowsiness" - drowsiness. This is followed by sopor - unconsciousness, insensibility, pathological hibernation, deep stunning; completes this circle of coma syndromes - the most profound degree of cerebral insufficiency. As a rule, instead of the first three options, the diagnosis is " precoma". At the present stage of consideration of syndromes of turning off consciousness, much attention is paid to the systematization and quantification of specific states, which makes their differentiation relevant.
Stunning is determined by the presence of two main features: an increase in the threshold of excitation in relation to all stimuli and the impoverishment of mental activity in general. At the same time, the slowdown and difficulty of all mental processes, the scarcity of ideas, the incompleteness or lack of orientation in the environment are clearly visible. Patients who are in a state of stupor, stunned, 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 raised in relation to other irritants: patients are not disturbed by noise, they do not feel the burning effect of a hot heating pad, they do not complain about an uncomfortable or wet bed, they are indifferent to any other inconveniences, they do not react to them. With a mild degree of stupor, patients are able to answer questions, but, as already noted, not immediately, sometimes they can even ask questions themselves, but their speech is slow, not loud, their orientation is incomplete. Behavior is not disturbed, mostly adequate. One can observe easily occurring drowsiness (somnolence), while only sharp, rather strong stimuli reach consciousness. Sleepy states are sometimes referred to as a mild degree of stunning.
upon awakening from sleep, as well as obnubilation of consciousness with fluctuations in the clarity of consciousness: slight blackouts, obscurations are replaced by clarification. The average degree 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 inadequate. 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: show where the hand, nose, lips, etc. After leaving the state of stunning, the patient retains in his mind separate fragments of what was happening around.
Sopor(from lat. sopor - unconsciousness), or a soporous state, subcoma, is characterized by the complete extinction of voluntary activity of consciousness. In this state, there is no longer responsiveness to external stimuli; it can manifest itself only in the form of an attempt to repeat a loudly and persistently asked question. The prevailing reactions are passive-defensive. Patients resist when trying to straighten their arm, change their linen, and give an injection. This kind of passive-defensive reactions should not be confused with negativism (resistance to any request and influence) in case of catatonic substupor or stupor, since other very characteristic signs are observed during catatonia: increased muscle tone, mask-like 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 mumbling, as well as choreoid or athetoid-like movements. Akinetic sopor is accompanied by immobility with complete relaxation of the muscles, inability to voluntarily change the position of the body, even if it is uncomfortable. In the soporous state, patients retain the reaction of the pupils to light, the reaction to pain irritation, as well as the corneal and conjunctival reflexes.
Coma(from Greek ???? - deep sleep), or coma, coma syndrome - a state of deep depression of the functions of the central nervous system, characterized by a complete loss of consciousness, loss of response to external stimuli and a disorder in the regulation of vital body functions.
According to the National Scientific and Practical Society of Emergency Medicine, the frequency of coma at the prehospital stage is 5.8 per 1000 calls, and their 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 often due to poisoning with various poisons - 0.6% of observations. Quite often (11.9% of cases), the cause of coma at the prehospital stage remained not only not clarified, 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).
Coma states are related to urgent pathology, require the use of resuscitation measures, since the severity of the subsequently developing psychoorganic syndrome depends on the duration of the coma. Leading in the clinical picture of any coma is the turning off of consciousness with the loss of perception of the environment and oneself. If in the soporous state the reactions are passive-defensive in nature, then with the development of a coma, the patient does not respond to any external stimuli (prick, pat, change in the position of individual parts of the body, turn of the head, speech addressed to the patient, etc.). Pupillary reaction to light in coma, unlike stupor, is absent
The usual clinical stupor manifests itself in a depressed psychological state of the patient, a weak reaction of the pupils to light and a dulling of pain.
A soporous state can transform into a coma, which is an extreme degree of inhibition of all body functions. There is a complete shutdown at the reflex level. To prevent this condition, you should know what provokes the appearance of stupor.
What is the difference between stupor and coma
The main difference between sopor and coma lies in the fact that the first state is non-contact with the outside world, accompanied by But, a person can be brought out of it at least for a short time. This can be achieved by vigorous shaking, tingling, loud voice. Coma, on the other hand, is an unconscious state that can be compared to a very deep sleep or anesthesia, from which it is impossible to wake up. A person in a coma does not even respond to pain.
Cause of stupor
The most common causes of constipation include:
- complications caused by cerebral hemorrhage;
- the presence of benign or malignant neoplasms in the brain;
- diseases that occur in a chronic form;
- toxic damage to the body;
- viruses and infections;
- thrombophlebitis;
- atherosclerosis;
- an overdose of drugs, especially tranquilizers;
- wrong way of life;
- violation of metabolic processes in the body;
- severe hypertensive crisis;
- head injury;
- pronounced deviations of the glucose index in diabetes mellitus;
- decreased thyroid function (hypothyroidism);
- violation of metabolic processes in nephritis;
- aneurysm rupture;
- poisoning of the body with carbon monoxide, barbiturates, opioids;
- meningitis;
- meningoencephalitis;
- ischemia of the heart;
- blood poisoning (sepsis);
- electrolyte imbalance in the body;
- heatstroke.
Symptoms of the disease
If a healthy central nervous system is constantly responding to changing environmental conditions, then in a state of stupor, brain activity is in a state of inhibition. The body seems to be in a long sleep. A soporous state can transform into a coma.
The brain cannot make any decisions. Wakefulness and sleep can abruptly replace each other.
Many are interested in: "How long does the soporous state last?". Shutdown 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 cloudiness, confusion in understanding everything that is happening around. He may show disorientation in space. The patient may confuse dates and names, not remember the events that happened yesterday, but at the same time, distinct pictures of the distant past emerge in his memory.
A reaction in a person can cause strong irritants. A sharp sound causes the eyelids to open, but purposefully the patient is not looking for anything. Impact on the nail bed provokes twitching of the limb. A prick, a pat on the cheek can cause a short-term negative reaction in the patient.
On examination, there is a decrease in muscle tone and depression of deep reflexes. Often found pyramidal syndrome caused by the suppression of the central neurons. The reaction of the pupils to light is lethargic, corneal and persists.
In parallel with all these symptoms, neurological signs of a focal nature may appear, indicating a local lesion of certain areas in the cerebral cortex.
If the soporous condition is provoked by a stroke or meningoencephalitis, then neck stiffness and other meningeal symptoms will be detected. Uncontrollable muscle twitches may also occur.
In some cases, doctors are faced with a hyperkinetic variant of stupor, in which a person says something incoherently, scoffs, and makes purposeful movements. Establishing a productive contact with the patient is impossible. similar to delirium, which belongs to the category of qualitative disorders of consciousness.
A soporous state after a stroke can be characterized by a high degree of agitation or complete indifference to everything around.
Sopor with a stroke
Stroke is a very dangerous disease that causes unpredictable complications. Sopor is one of them. Translated from Latin, the word "sopor" means "sleep", "numbness", "lethargy", "loss of memory". In medicine, this condition is usually called a subcoma, since it is a step towards the development of a coma and is in many ways similar to this serious condition.
The soporous state in stroke is expressed in the blunting of all human reactions. The activity of consciousness is in an extremely depressed state.
A stroke is caused by pathological processes in the vessels that provoke acute brain dysfunction. The duration of the effects is more than a day. A stroke can lead to rapid death.
Sopor not always, but quite often accompanies a stroke. It is noted in about one fifth of cases of all cerebral necrosis. The manifestation of such a condition can be observed not only in the acute period of the disease, but also during its rehabilitation. The process is directly dependent on the area and degree of brain damage.
It is impossible to ignore such a complication under any circumstances, since most often it quickly turns into a coma.
The clinical picture of stupor in stroke
The soporous state in stroke, the prognosis of which depends on the degree of prevalence of cerebral necrosis, manifests itself in drowsiness and lethargy of the patient. In parallel with this, protective reactions to stimuli such as pain, sharp sound and light are preserved. The patient does not respond to his surroundings, cannot answer questions, is unable to perform any task. Muscle tension in the limbs is reduced, tendon reflexes are dulled, coordination of movements is lost.
Sopor 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.
Usually, an epileptic seizure is preceded by a sharp change in the emotional background of the patient. 2-3 days before the seizure, the person becomes agitated, tense and anxious. Some patients withdraw into themselves, others show aggression towards others. Shortly before the attack, there is an aura 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.
In the human cerebral cortex, a focus of excitation occurs. It covers more and more nerve cells. The end result is a seizure. Typically, the duration of the phase is 30 seconds, rarely one minute. The patient's muscles are in great tension. The head is tilted back. The patient screams, breathing stops.
The convulsive stage lasts up to 5 minutes. With it, all the muscles of the patient involuntarily contract. After the seizure ends, the muscles relax again. The patient's consciousness is turned off. Soporous state in epilepsy lasts 15-30 minutes. After coming out of the stupor, the patient falls into a deep sleep.
Sopor during dehydration
A complication such as stupor can also accompany dehydration. In medicine, water deficiency is commonly called exsicosis. In this condition, there is a low content of electrolytes and water, which is provoked by repeated persistent vomiting and severe indigestion.
In addition, fluid loss can be caused by pathological processes in the kidneys and lungs. Usually, exsicosis develops gradually within 2-3 days from the onset of the provoking disease.
Dehydration is characterized by lethargy of the patient, loss of appetite, refusal to drink. Fluid intake causes profuse vomiting. There is a decrease in muscle tone, the patient's body temperature, as well as pressure, drops sharply. Oliguria or anuria is noted.
A soporous state from dehydration can go into a coma.
Prognosis for sopor
What is the outcome of the course of the disease? Soporous condition, the prognosis of which depends on the provoking cause, should be treated in a timely manner. The degree of damage to the nervous tissue and the volume of therapy play an important role.
The earlier measures were taken to correct the disorder, the higher the patient's chance of restoring clear consciousness and regression of the symptoms of the underlying disease.
Diagnostics
Stupor caused by a stroke can be fatal. At the first mild manifestations of the complication, it is necessary to conduct a timely diagnosis.
The priority measures should include:
- measurement of blood pressure;
- checking heart rate and respiration;
- checking the reaction of pupils to light and determining the degree of their mobility;
- measurement of body temperature, with its high rate, one can judge the presence of an infection in the patient's blood;
- examination of the skin for the presence of 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.
In case of confirmation of the presence of sopor, as a rule, hospitalization is indicated. In the hospital, the patient will be able to provide support for the functions necessary for life, and conduct a more detailed diagnosis.
After electroencephalography, a spectral blood test is performed to detect a high sugar level and other provocateurs of a pathological condition. If intoxication is suspected, a blood test is also done, urine is examined for the presence of narcotic substances in the body. In some cases, a neuropathologist prescribes a lumbar puncture and magnetic resonance therapy of the brain.
Sopor treatment principles
A soporous condition, 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 soon as possible.
The trigger mechanism 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 to preserve the functionality of neurons.
Especially vulnerable are the nerve cells in the penumbra (ischemic penumbra). This is an area that is adjacent to the affected focus in the brain. Improper treatment provokes an increase in symptoms due to the death of neurons in this area. In this case, the soporous state can turn into a coma, and neurological disorders will become more pronounced.
In the treatment of sopor, the main actions are aimed at combating swelling of the nervous tissue, maintaining full blood circulation in the brain. The level of glucose in the blood is also corrected, the lack of trace elements is replenished, the causes of disruption 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 bleeding.
With sopor, all drugs are injected into the body intravenously. At the same time, the most effective drug is glucose 40% and thiamine, as well as the use of these drugs with naloxone.
Further therapy of sopor depends on the degree of damage to the body and is prescribed by the doctor on an individual basis.
