Why does a person in a coma cry. Life without consciousness. How long can a coma last? Emergency care and treatment

Today I have gone beyond medicine. Is it worth supporting the life of a person who cannot communicate with the outside world? How to determine how deep he "gone", whether he hears what is happening around, whether he experiences emotions, or is he in a "vegetative" state, in which he can no longer be helped?

Considering that the possibility of euthanasia (voluntary departure from the life of terminally ill patients) is widely discussed in the world today, and in some countries it has already been resolved, the issue of distinguishing between such conditions in order to determine the hopelessness of the patient or the prospects for a cure is of particular importance.

deep sleep, drowsiness

To talk on this topic, of course, first you need to tell in more detail what, in fact, a coma is, what are its causes, duration in which cases there is hope for coming out of a coma, and which ones do not. The topic of hope for recovery is especially important to us, because today the views on its criteria are changing.

So, coma(Greek koma - deep sleep, drowsiness) is a life-threatening condition in which a person loses consciousness, shows little or no reaction to external stimuli. His reflexes fade until they disappear completely, the depth and frequency are disturbed, vascular tone changes, the pulse quickens or slows down, the temperature regulation mode is disturbed.

As a rule, the coma is preceded by the so-called precomatose state, during which the symptoms of deep inhibition in the cerebral cortex increase in a person, and along the way, violations occur acid-base balance in nervous tissue, oxygen starvation , ion exchange disorders and energy starvation of nerve cells .

deceit coma in that it can last only a few hours, or maybe several months, and even years. It is the duration of the coma that differs from fainting, which usually lasts for several minutes.

It is often difficult for physicians to find out cause of coma. As a rule, it is judged by the rate of development of the disease. For example, a coma suddenly develops after acute vascular disorders brain, but the gradual "extinction" of a person is typical for infectious lesions, the symptoms of a coma with endogenous (internal) intoxications in diabetes, diseases of the kidneys, and the liver increase even more slowly.

For physicians dealing with people who have fallen into coma, there are many nuances by which they determine the exact diagnosis " coma". After all, there are other states with similar symptoms. For example, the “locked-in syndrome”, when a person cannot respond to external stimuli due to paralysis of the bulbar, facial and chewing muscles, which usually occurs as a result of damage to such a brain structure as the base of the pons. The patient can only move eyeballs while being fully conscious.

In turn, such patients are similar to patients with akinetic mutism, who are also conscious and able to follow moving objects with their eyes, but cannot move due to organic lesions (trauma, vascular accidents, tumors) of some parts of the brain. Thus, until now, one of the differences between these diagnoses and coma is considered to be the presence of consciousness. But today, these criteria may be shaken, and below we will explain why.

Exit from a coma and further prognosis

Not all patients, alas, come out of coma. Sometimes, if this condition drags on and the brain damage is so severe that there is no hope for recovery, doctors, together with the patient's relatives, decide on the issue of disconnecting him from life support systems. Sometimes a person comes out of a coma, but falls into the so-called chronic vegetative state, in which only wakefulness is restored, and all cognitive functions are lost. He sleeps and wakes up, breathes on his own, his heart and other organs function normally, but at the same time he lacks movement, speech and reaction to verbal stimuli. This condition can last for months or even years, but the prognosis is poor - as a rule, as a result, the patient dies from infections or bedsores. The reason for the vegetative state is in a massive lesion forebrain, often - in the complete death of the cerebral cortex. This condition also serves as a reason to turn off the devices.

But there are still chances for patients in a coma. At proper treatment and a favorable prognosis, a person can come out of a coma. The functions of the central nervous system- reflexes, vegetative functions. Interestingly, as a rule, their restoration occurs in the reverse order of oppression. Often, the restoration of consciousness occurs through confused consciousness and even delirium, accompanied by discoordinated movements and, less often,. Even if the ability to think, speak and move returns to a person, it is very important how well they looked after him during a coma, because immobility can lead to muscle atrophy and bedsores, which requires additional treatment.

Unfortunately, in Russia today the level of care provided to patients in a coma and vegetative state is not at the proper level. This is the opinion of Sergei Efremenko, a doctor who has been dealing with such patients for many years, the head of the intensive care unit and intensive care for neurosurgical patients of N.V. Sklifosovsky Research Institute of Emergency Medicine. According to him, this level shows, firstly, the moral state of society, and secondly, the level of development of medicine. “Unfortunately,” Efremenko says, “in our country today there is not a single medical institution specialized in the treatment of such patients. In the majority of cases, patients in vegetative states are doomed to painful death, never having managed to live up to a possible improvement in the condition, while bringing unbearable suffering to their loved ones.

Happy examples of coming out of a coma

It cannot be said that history knows a lot and happy examples of a person coming out of a long coma and in some cases even returning it to normal life. Although most of these cases did not occur in Russia, but abroad.

For example, in 2003, American Terry Wallis woke up after 19 years of being in a coma after being injured in a car accident. In 2005, American firefighter Don Herbert came out of a 10-year coma following his 12-minute stay in a blockage without air. In 2007, Polish citizen Jan Grzebski woke up after 18 years in a coma. He suffered after he got into a train accident. Thanks to the departure of his wife, he got out of this state without muscle atrophy and bedsores and ... learned that now all of his four children were married and married, and that he now has 11 grandchildren. And finally, Zhao Guihua, a Chinese woman who had been in a coma for 30 years, woke up in November 2008. Her husband was selflessly next to her bed and, in addition to caring for her, maintained constant verbal contact - told her about recent events and spoke sweet words love and support. And, quite possibly, this was precisely what was of key importance - as shown latest research, many such patients retain the ability to hear and realize what they hear. And this can radically change the current opinion that a person in a coma is a person who has lost consciousness.

New opportunities for contact with a person in a coma

In general, the problem of coma, no doubt, requires careful study, because the price of a mistake here is too high. Turning off life support systems in accordance with the desire of the patient himself (in countries where euthanasia is allowed, each person can make such a request in advance) or, with the consent of his relatives, can take the life of a person who might soon come to his senses. Moreover, the attitude of most people and the doctors themselves around the world to the possibility of euthanasia is negative.

For example, Dr. Efremenko is deeply convinced that it is impossible to link the problem of coma, incurable conditions with the problem of euthanasia, since it abhors the moral principles of any doctor and opposes the main message of healing "Non nocere" - "do no harm". "The probability of error, even if it is one millionth of a percent, can also take place," says the doctor. He recalls that Orthodoxy is the titular religion of our country, and its canons categorically reject both murder and suicide. Only God is in control of our lives, as well as our suffering. However, this also applies to other religions, Efremenko adds.

This complex question is all the more relevant given that recent studies have confirmed that 30% of patients in a coma actually show signs of consciousness. A new brain-computer interface helped to determine this, with the help of which scientists were able to look into the previously inaccessible depths of the brain of an immobilized and seemingly detached person from reality.

The study, organized by the German-Belgian Group for the Study of Coma States under the direction of Professor Stephen Loris, was built using a computer, a special program of which read the results of encephalograms of two groups - patients in a coma, and healthy people from the control group. Encephalograms were obtained in the responses of the subjects to simple questions, where everyone had to choose the correct answer using simple words "yes", "no", "go" and "stop". The real sensation was that three out of ten people who were in a coma answered most of the questions correctly! This meant that doctors today do not know everything about the nuances of this condition, and that in the future they have a chance, with the help of established contact with such patients, not only to make an accurate diagnosis and calculate the chances of recovery, but also to find out from them what they are. need and are satisfied with the care.

Dr. Eben Alexander, for a long time who taught at Harvard and managed to earn a reputation as an excellent neurosurgeon, considered himself a Christian for as long as he could remember, but he never believed in the existence of an afterlife and even sympathized with those who believed that somewhere there is a God who loves us unconditionally.

“As a neurosurgeon, I didn’t believe in the OBE phenomenon. I grew up in a scientific environment, I am the son of a neurosurgeon. Following in the path of my father, I became an academic and neurosurgeon, taught at Harvard Medical School and other universities. I understand what is happening with the brain when people are on the verge of death, so I always believed that there is a reasonable scientific explanation out-of-body travel described by people who miraculously escaped death.

However, everything changed after the man himself fell into a coma in the fall of 2008. It was then, when Alexander was on the verge of life and death for a week, and the cortex of his brain, which is responsible for thoughts and emotions, ceased to function, he, in his own words, made a trip to the afterlife and, in particular, to paradise.

“In accordance with the current medical understanding of the brain and mind, it is simply impossible to imagine that I was even in a limited consciousness during a coma, and not that I made a very vivid and whole journey,” the neurosurgeon noted. “There is no scientific explanation that despite the fact that the body was in a coma and my cerebral cortex turned off, the brain itself continued to work and, moreover, went to another, much larger Universe - a dimension that I never suspected existed” .

The doctor emphasized that in general, the mystical dimension that he visited was like numerous descriptions of people who survived clinical death or other border states. According to him, it is literally new world in which we are much more than just our body and our brain, and where death is not the end of conscious existence, but only part of an endless journey.

The doctor was able to describe what this wonderful world looks like. He said that his journey began by hovering somewhere high in the clouds, and soon saw "transparent, shimmering creatures flying across the sky and leaving long, line-like trails behind them." In addition, these creatures made amazing sounds, like a beautiful song, and, as it seemed to the man, in this way they expressed the joy and grace that overwhelmed them. However, Alexander does not dare to compare them with birds or angels - they were too unlike anything that exists on our planet. They were some kind of higher creatures, he is sure.

One of these creatures - an unfamiliar young woman - joined him, and became his guide through the mystical universe. At the same time, Alexander remembered the appearance of his beautiful companion in detail - she had dark blue eyes, golden brown hair, braided, and high cheekbones. The woman's clothes were simple, but beautiful and bright - pale blue, blue and peach.

With her, as with other creatures like her, the neurosurgeon spoke without words - messages passed through him and were like the wind. He even cited one of the speeches spoken to him by a mystical woman. “You are loved and treasured forever. You have nothing to fear. There is nothing you can do wrong, she said. We will show you many things here. But in the end you will come back.”

Gradually, the woman led the doctor into “a huge void, where it was completely dark, but there was a sense of infinity, and it was very pleasant at the same time.” Alexander now believes that this void was the home of God.

Soon the man woke up. However, now, having experienced a journey in the afterlife, he is in no hurry to share his experience with colleagues, but finds solace in the church. The man also wrote the book “Journey of a neurosurgeon to the afterlife”, which should be published at the end of October.

“I am still a doctor, and I still remain a man of science,” sums up Alexander. “But at a deep level, I am very different from the person I used to be, because I saw this new picture of reality.”

What do people feel in a coma? Let's take a closer look at this issue.

Coma is such a state of a person when he is completely unconscious, reactions to stimuli are sharply weakened or completely absent, reflexes fade until they disappear completely, breathing is disturbed, the pulse slows down or quickens, etc.

When a person is in a coma, he is between life and death. And this is dangerous because, in addition to loss of consciousness, in a coma, a person’s vital functions of the body are violated. The classification of com will be presented below.

As a rule, this condition is a complication of a certain disease or appears as a result of some pathological event, such as trauma, etc. However, clinical symptoms coma can be very diverse, depending on the causes of its onset.

To bring a person out of a coma, it is necessary to carry out resuscitation measures for him, which are aimed at maintaining the basic functions of the body in order to prevent brain death.

What people feel in a coma is of interest to many.

The mechanism of action of coma

This human condition is based on two main mechanisms:

bilateral damage to the cerebral cortex;
primary or secondary lesion its trunk, where the reticular formation is located, which maintains the cerebral cortex in good shape and activity.

That's what it is cerebral coma.

Defeat brain stem occurs when a person has a stroke or traumatic brain injury. Secondary disorders, as a rule, occur when metabolic processes in the body change, for example, in case of poisoning, diseases of the endocrine system, etc.

In addition, there are cases of a combination of both mechanisms for the occurrence of a coma state, which is observed very often. It is believed that this is the line between life and death.

As a result, normal transmission nerve impulses in the human brain becomes impossible, the activity of all structures that switch to an autonomous mode is lost. Thus, the brain temporarily ceases to function and control the processes occurring in the body.

com classification

Coma conditions are divided into several varieties depending on various factors and symptoms. The main classifications are those that differ in causal factor and the depth of the coma.

Due to the occurrence of coma, it happens:

with primary neurological disorder(when it was caused by some process in ;
with a secondary neurological disorder (when the cause of the onset of coma is in no way connected with).

Establishing the cause of this condition is necessary in order to correctly determine the tactics of treating the patient.

What is an artificial coma?

FROM medical point vision, this temporary immersion of the patient in the activity of the cortex and subcortex of the brain is inhibited and all reflex functions are completely turned off.

Artificial coma is used only in the most extreme cases. That is, when there is no other way to protect the patient's body from irreversible brain changes that threaten his life. This happens with swelling of brain tissues and compression effect on them, as well as with hemorrhage or bleeding, accompanied by severe traumatic brain injuries or pathologies. cerebral vessels.

Artificial coma can be replaced by general anesthesia in cases of emergency surgical interventions large volume or directly on the brain.

Coma of neurological (primary) genesis

This type of coma happens:

With traumatic brain injury (traumatic).
In case of disruption of cardio-vascular system, as well as disorders of cerebral circulation (cerebrovascular coma). This is what happens with a stroke. A person may be in a coma for other reasons.
As a result epileptic seizures.
Coma that arose in the process inflammatory disease the brain or its membranes (meningoencephalitic).
As a consequence in the brain (hypertensive).

Secondary coma

Varieties of this condition are:

endocrine coma (for example, with diabetes mellitus), thyrotoxic, hypothyroid (with pathologies thyroid gland), hypocorticoid (acute adrenal insufficiency), hypolituitarism (acute deficiency of hormones produced by the pituitary gland);
toxic coma (during liver or kidney failure, in case of poisoning, alcohol overdose or drugs, as well as cholera;
hypotoxic form (with severe forms heart failure, as well as anemia, pulmonary obstruction);
coma that has arisen under the influence of any physical factors (hypothermia, overheating, electric shock, etc.);
coma, the cause of which is dehydration, or with a deficiency of electrolytes.

Why is coma dangerous? Is it possible to come out of a coma?

According to statistics, the most common cause of a coma is a stroke. In second place on this list is an overdose of narcotic substances, and in third place are the consequences of diabetes.

Classification of coma according to the depth of depression of consciousness: 1st degree (the so-called "subcortical" coma, mild (anterostem, average degree severity), 2nd degree (rear-stem, deep), 4th degree (outrageous, extremely serious condition).

The transition from one degree of coma to another is sometimes very abrupt, so it is sometimes quite difficult to determine the patient's stage of coma.

Coma 1 degree

This condition is called subcortical coma and is characterized by inhibition of the activity of the cerebral cortex, as well as subcortical formations of this organ. This type of coma differs from the rest in the following ways:

feeling as if the patient were in a dream;
disorientation of a person in time and location;
lack of awareness of reality, inarticulate speech;
the disappearance of reactions to painful stimuli;
increased muscle tone;
increased deep reflexes;
inhibition of surface reflexes;
preservation of the reaction of pupils to light stimuli, strabismus, spontaneity of eye movements;
saved breath;
tachycardia (increased heart rate).

Coma 2 degrees

At this stage of the cerebral coma, the activity of the subcortical zones begins to slow down, which characterizes this stage with the following conditions:

the occurrence of tonic convulsions or shudders of some parts of the patient's body;
complete lack of speech, impossibility of verbal contact with the patient;
a strong weakening of pain reactions;
sharp inhibition of both deep and superficial reflexes;
weak reaction of pupils to light stimuli, their constriction;
fever body and excessive sweating;
sudden changes in blood pressure;
tachycardia;
violation of respiratory activity (stops in breathing, different depth of breaths).

Coma 3 degrees

Pathological processes occur in the medulla oblongata. In this case, the risk to the patient's life is quite large, and the prognosis of recovery from a coma is significantly reduced. What do people in a coma feel? 3 degree is characterized by the following conditions:

reactions to pain are completely absent;
lack of reflexes;
a sharp inhibition of muscle tone;
complete absence of pupillary reactions;
its pronounced arrhythmia;
a sharp decline blood pressure;
convulsions.

What else is a coma? Coming out of a coma does not always happen.

Coma 4 degrees

In this condition, the person has absolutely no symptoms. brain activity. And it shows up like this:

lack of reflexes;
full expansion of the pupils;
muscle atony;
a sharp decrease in blood pressure (to zero levels);
absolute absence of spontaneous breathing.

Grade 4 coma is almost 100% likely lethal outcome.

Consequences of coma

The coma usually lasts from one to several weeks. However, a huge number of cases are known when this condition lasted much longer - up to several months and even years.

The return of the patient to consciousness is slow. At first, he may come to his senses for only a few minutes or hours, and over time given time increases. The return of a person to normal condition largely depends on how deep the coma occurred, as well as on a number of reasons why this condition arose.

The consequences of a coma are sometimes very severe. During this condition, brain damage occurs, so some body functions may not be restored in a person. Very often, after a coma, people cannot walk, make movements with their hands, there is a slowdown in speech activity or its complete absence.

After a coma of the first degree, a person, as a rule, quickly comes to his senses, and his body in most cases does not lose its abilities. After a coma of the third degree, the brain is destroyed almost completely. Accordingly, the field of this person no longer has the opportunity to live a full life.

The consequences of coma can also be memory impairment, changes in human behavior (aggressiveness or lethargy), decreased attention and reactions. After suffering a coma, people restore their abilities for a very long time, even in the domestic sphere - self-catering, bathing, changing clothes, etc.

How does a person in a coma feel?

The experiences and sensations of a person who is in a coma have been studied over the years in the most different countries peace. However, there are still no reliable facts about this.

Nevertheless, scientists nevertheless made some conclusions, for example, it has been scientifically proven that even those people who are in a state of deep coma experience certain states, and the brain has some activity. Thus, it turned out that the patient in a coma has an internal ability to respond to external stimuli. This fact is due to the fact that special research equipment recorded special brain waves emitted at the moments when relatives and friends speak to a person. What else do people feel in a coma?

The patient internally responds to tactile sensations, which can also be confirmed by a rapid heartbeat, a change in the intensity of breathing, or changes in blood pressure. This can confirm that a person experiencing a coma is reacting in a certain way to events occurring in the outside world and responding to them. What people feel in a coma can tell those who successfully came out of it.

Many people who have experienced such a state share their feelings and experiences. Some of them claim that they were in a kind of altered state of consciousness, when they seemed to be traveling between worlds, they could see their dead relatives and even talk to them. Other patients claim that they were conscious, heard the speech of doctors, relatives who were next to them, but could neither move nor in any way confirm their ability to understand everything. A third group of people in a coma could have had a variety of dreams, or they were in a state of unconsciousness, when, after coming out of a coma, they could remember absolutely nothing.

- this is a life-threatening state of impaired consciousness, caused by damage to special structures of the brain and characterized by a complete lack of contact of the patient with the outside world. The causes of its occurrence can be divided into metabolic (poisoning by metabolic products or chemical compounds) and organic (in which the destruction of parts of the brain occurs). The main symptoms are unconsciousness and the absence of eye opening reactions even to strong stimuli. In the diagnosis of coma important role plays CT and MRI, as well as laboratory blood tests. Treatment primarily involves the fight against the main cause of the development of the pathological process.

Coma classification

Who can be classified according to 2 groups of criteria: 1) depending on the reason that caused it; 2) according to the level of oppression of consciousness. Depending on the causes of coma, they are divided into the following types: traumatic (with craniocerebral injuries), epileptic (complication of status epilepticus), apoplexy (the result of a cerebral stroke), meningeal (develops as a consequence of meningitis), tumor (volumetric formations of the brain and skull ), endocrine (with a decrease in thyroid function, diabetes mellitus), toxic (with renal and liver failure).

However, such a division is not often used in neurology, since it does not reflect the true state of the patient. The classification of coma according to the severity of impairment of consciousness, the Glazko scale, has become more widespread. On its basis, it is easy to determine the severity of the patient's condition, build a scheme of urgent therapeutic measures and predict the outcome of the disease. The Glazko scale is based on a cumulative assessment of three indicators of the patient: speech, presence of movements, opening of the eyes. Points are assigned depending on the degree of their violation. According to their sum, the level of consciousness of the patient is estimated: 15 - clear consciousness; 14-13 - moderate stun; 12-10 - deep stun; 9-8 - stupor; 7 or less - coma.

According to another classification, which is used mainly by resuscitators, coma is divided into 5 degrees: precoma; coma I (in the domestic medical literature called stupor); coma II (stupor); coma III (atonic); coma IV (outrageous).

Coma symptoms

As already noted, the most important symptoms of coma, which are characteristic of any of its types, are: the complete absence of contact of the patient with the outside world and the absence of mental activity. The remaining clinical manifestations will differ depending on the cause that caused the brain damage.

Body temperature. Coma caused by overheating is characterized by high temperature body up to 42-43 C⁰ and dry skin. Poisoning by alcohol and sleeping pills, on the contrary, is accompanied by hypothermia (body temperature 32-34 C⁰).

Breathing rate. Slow breathing occurs in coma from hypothyroidism ( low level thyroid hormones), poisoning with sleeping pills or drugs from the morphine group. Deep respiratory movements are characteristic of a coma due to bacterial intoxication in severe pneumonia, as well as brain tumors and acidosis caused by uncontrolled diabetes or kidney failure.

Pressure and heart rate. Bradycardia (decrease in the number of heartbeats per minute) indicates a coma that has arisen against the background acute pathology heart, and the combination of tachycardia (increased heart rate) with high blood pressure indicates an increase intracranial pressure.

Skin color. Cherry red skin develops with carbon monoxide poisoning. Blue fingertips and nasolabial triangle indicate low maintenance oxygen in the blood (for example, during suffocation). Bruising, bleeding from the ears and nose, bruises in the form of glasses around the eyes are characteristic of a coma that has developed against the background of a traumatic brain injury. Pronounced pale skin integuments indicate a coma due to massive blood loss.

Contact with others. With stupor and mild coma, involuntary vocalizations are possible - the publication of various sounds by patients, this serves as a favorable prognostic sign. As the coma deepens, the ability to pronounce sounds disappears.

Grimaces, reflex withdrawal of the hand in response to pain are characteristic of mild coma.

Coma diagnostics

When diagnosing a coma, the neurologist simultaneously solves 2 tasks: 1) finding out the cause that led to the coma; 2) direct diagnosis of coma and its differentiation from other similar conditions.

To find out the reasons for the patient falling into a coma, a survey of the patient's relatives or casual witnesses helps. At the same time, it is clarified whether the patient had previous complaints, chronic diseases heart, blood vessels, endocrine organs. Witnesses are asked about whether the patient used drugs, whether empty blisters or drug jars were found next to him.

The rate of development of symptoms and the age of the patient are important. Coma that arose in young people against the background full health, most often indicates poisoning with narcotic drugs, sleeping pills. And in elderly patients with comorbidities heart and blood vessels, there is a high probability of developing a coma against a background of a stroke or heart attack.

Examination helps to establish the alleged cause of the coma. blood pressure, pulse rate, respiratory movements, characteristic bruising, bad breath, traces of injections, body temperature - these are the signs that help the doctor make the correct diagnosis.

Particular attention should be paid to the position of the patient. A tilted head with an increased tone of the neck muscles indicates irritation of the membranes of the brain, which occurs with hemorrhages, meningitis. Spasms of the whole body or individual muscles may occur if the cause of coma was status epilepticus, eclampsia (in pregnant women). Flaccid paralysis of the limbs indicates a stroke of the brain, and the complete absence of reflexes - about deep damage large surface of the cortex and spinal cord.

The most important in differential diagnosis coma from other states of impaired consciousness is a study of the patient's ability to open his eyes to sound and pain irritation. If the reaction to sound and pain is manifested in the form of an arbitrary opening of the eyes, then this is not a coma. If the patient, despite all the efforts of doctors, does not open his eyes, then the condition is considered as coma.

The reaction of the pupils to light is subjected to careful study. Its features not only help to establish the alleged location of the lesion in the brain, but also indirectly indicate the cause of the coma. Besides, pupillary reflex serves as a reliable predictor.

Narrow pupils (pupils-points) that do not react to light are characteristic of alcohol and drug poisoning. Different pupil diameters in the left and right eyes indicate an increase in intracranial pressure. Wide pupils are a sign of damage to the midbrain. The expansion of the diameter of the pupils of both eyes, together with the complete absence of their reaction to light, is characteristic of transcendental coma and is an extremely unfavorable sign, indicating imminent brain death.

Modern technologies in medicine have made instrumental diagnostics causes of coma is one of the very first procedures upon admission of any patient with impaired consciousness. Performance computed tomography(CT of the brain) or MRI (magnetic resonance imaging) allows you to determine structural changes in the brain, the presence of volumetric formations, signs of increased intracranial pressure. Based on the images, a decision is made about the methods of treatment: conservative or urgent surgery.

If it is not possible to perform CT or MRI, the patient should have an x-ray of the skull and spinal column in several projections.

Confirm or refute the metabolic (metabolic failure) nature of the coma helps biochemical analysis blood. AT urgently blood glucose, urea, ammonia levels are determined. And also the ratio of blood gases and basic electrolytes (potassium, sodium, chlorine ions) is determined.

If the results of CT and MRI indicate that there are no reasons from the side of the central nervous system that can put the patient into a coma, a blood test is performed for hormones (insulin, adrenal hormones, thyroid gland), toxic substances (drugs, sleeping pills, antidepressants), bacterial culture blood. The most important research that helps to differentiate the types of coma is electroencephalography (EEG). When it is carried out, the electrical potentials of the brain are recorded, the assessment of which makes it possible to distinguish a coma caused by a brain tumor, hemorrhage, or poisoning.

Coma treatment

Coma treatment should be carried out in 2 directions: 1) maintenance vital functions sick and preventing brain death; 2) the fight against the main cause that caused the development of this condition.

Life support begins in the ambulance on the way to the hospital and is performed on all patients in a coma even before the results of the examination. It includes maintaining patency respiratory tract(straightening of a sunken tongue, cleansing the mouth and nasal cavity of vomit, oxygen mask, insertion of a breathing tube), normal blood circulation (introduction of antiarrhythmic drugs, drugs that normalize blood pressure, indoor massage hearts). In the intensive care unit, if necessary, the patient is connected to a ventilator.

An introduction is being made anticonvulsants in the presence of convulsions, mandatory intravenous infusion of glucose, normalization of the patient's body temperature (covering and putting heating pads in case of hypothermia or fighting heat), gastric lavage if drug poisoning is suspected.

The second stage of treatment is carried out after detailed examination, and further medical tactics depends on the underlying cause that caused the coma. If it is an injury, brain tumor, intracranial hematoma, then an urgent surgical intervention. When identifying diabetic coma control sugar and insulin levels. If the cause was kidney failure then hemodialysis is prescribed.

Coma prognosis

The prognosis for coma depends entirely on the degree of damage to brain structures and the causes that caused it. In the medical literature, the patient's chances of getting out of a coma are regarded as: with precoma, coma I - favorable, complete recovery is possible without residual effects; coma II and III - doubtful, that is, there is both the likelihood of recovery and death; coma IV - unfavorable, in most cases ends in the death of the patient.

Preventive measures are early diagnosis pathological process, prescribing the right methods of treatment and timely correction of conditions that can cause the development of coma.

Coma is translated from Greek as a deep, very sound sleep, this is a state characterized by a complete loss of consciousness, breathing, reflexes, as well as a complete lack of reactions to any stimuli.

Cerebral coma is a complete depression of the nervous system and inhibition of its work without the death of body tissues with medical maintenance of basic vital important functions: breathing, heartbeat, which can stop periodically, and artificial nutrition directly through the blood.

Coma unconsciousness can develop in a person as a result of any damage to the organs of the brain, either instantly or in a few hours. A person is able to be in it in individual case from a few minutes to several years.

Classification of coma, their causes:

Coma is not independent disease- this is a symptom characterized by the shutdown of the brain under the influence of others or its defeat of any traumatic nature. There are quite a lot of varieties of coma, subdivided according to the causes of development and the nature of the course:

Traumatic coma is one of the most frequent varieties caused by traumatic brain injury.
Diabetic - develops if the glucose level of a diabetic patient has critically increased, which can be identified by the rather noticeable aroma of acetone from his mouth.
Hypoglycemic - the opposite of diabetic, which develops due to a critical drop in blood sugar. Its harbinger is severe hunger or a complete lack of saturation until the sugar level is raised.
Cerebral coma - slowly developing state due to the growth of neoplasms in the brain, such as tumors or abscesses.
Hungry is a common condition caused by extreme dystrophy and lack of protein in the body due to malnutrition.
Meningeal - due to the development of meningitis - inflammation of the membranes of the brain.
An epileptic coma develops in some people after an epileptic seizure.
Hypoxic develops due to cerebral edema or suffocation due to oxygen starvation CNS cells.
Toxic is the result of toxic damage to the brain due to poisoning, infections, or alcohol or drug abuse.
Metabolic - quite rare variety caused by a strong failure of vital metabolic processes.
Neurological coma can be called the most difficult kind not for the human body, but for his spirit, since in this state the patient's brain and his thinking are not turned off with complete absolute paralysis of the whole body.

In the layman's view, the coma has a rather cinematic image and looks like a complete loss self-fulfillment vital functions of the body, the absence of any reactions and loss of consciousness with rare glimpses of reactions to the outside world, however, in fact, medicine distinguishes as many as five varieties of coma, which differ in their symptoms:

Perkoma is a transient condition that lasts minutes to hours and may be characterized by confusion, incoordination, and sharp drops from calmness to excitement, with the preservation of basic reflexes. In this case, a person hears and feels everything, including pain.
Coma of the first degree is accompanied by an incomplete loss of consciousness, but rather by stupor, when the patient's reactions are inhibited, communication with him is difficult, and the patient's eyes usually move rhythmically from side to side or strabismus occurs. A person in a first-degree coma may be conscious, in a stupor, or like a dream. He is able to feel touch and pain, hear, understand.
During a coma of the second degree, he may be conscious, but at the same time in a deep stupor. He does not understand what is happening, does not react to light, sound, touch, does not make contact, in general, in no way. At the same time, his pupils constrict, his heart begins to beat more often, and sometimes spontaneous physical activity limbs or bowel movements.
A person in a third-degree coma is completely disconnected from the outside world and is in a state of deep sleep without any external reaction to external stimuli. At the same time, the body does not feel physical pain, its muscles rarely begin to spontaneously spasm, the pupils dilate, the temperature drops, breathing becomes frequent and shallow, and it is also believed that mental activity is completely absent.
Coma of the fourth degree is the most severe type of coma, when the vital activity of the body is completely provided artificially with the help of ventilation of the lungs, parenteral nutrition(nutrition with solutions through a vein) and other resuscitation procedures. The pupils do not react in any way, muscle tone and all reflexes are absent, and the pressure is reduced to a critical level. The patient cannot feel anything at all.

Any coma is characterized by a flow from one degree to another with respect to changes in the patient's condition.

In addition to natural comatose states, one more thing can be distinguished - an artificial coma, which is correctly called medical. Such a coma is the last necessary measure, during which, special medicines the patient plunges into a temporary deep unconscious state with the shutdown of all reflex reactions of the body and almost complete inhibition of activity, both of the cerebral cortex and subcortical structures responsible for life support, which is now supported artificially.

Artificial coma is used if necessary general anesthesia or when it is impossible to avoid irreversible changes in brain tissue in another way during hemorrhages, edema, cerebral vascular pathologies, severe injuries accompanied by severe pain shock, and other pathologies that threaten the patient's life. It inhibits not only the activity of the central nervous system, but also almost all processes in the body, which gives doctors and regeneration processes precious time.

With the help of an artificial coma, cerebral blood flow is slowed down, as well as the movement of cerebrospinal fluid, which allows narrowing the intracranial vessels, removing or slowing down cerebral edema with an increase in intracranial pressure, and as a result, avoiding mass necrosis (death) of brain tissues.

The reasons

The main cause of any coma is a violation of activity under the influence of any traumatic, toxic or other factors that can cause severe damage to brain tissues that are responsible both for the unconscious work of the body and for thinking and consciousness. Sometimes a coma is caused not by damage to the neurons of the brain, but only by the inhibition of their activity, as, for example, with artificial neurons. Almost all diseases can cause a condition on last stage, any severe poisoning or injury, as well as extremely strong pain or shock stressful effects that cause overexcitation of brain neurons, due to which their work fails.

There is also a common version that a coma, like loss of consciousness, can be one of defensive reactions organism, which is designed to protect human consciousness from shocks caused by the state of his body and painful sensations, as well as protect the body from consciousness when it needs time to recover.

What happens to a person

During a coma, a person completely stops or very strongly slows down any brain processes. With a deep coma, they become weak or absent altogether, so they are unable to even cause reflex actions organism. If the structures of the brain responsible for the sense organs are damaged, then, accordingly, the brain can in no way perceive information from the outside world.

What does a person feel

If the physiological processes that occur inside the body during a coma are fairly well studied, then there is no way to look into the thoughts of the patient.

Almost all people whose relatives are in a coma are primarily interested in how a person feels, whether he can listen to what they say and adequately perceive the speech addressed to him, feel pain and recognize loved ones or not.

A person does not feel pain or feels it badly, since in coma and unconsciousness this function is turned off primarily for self-defense of the body.

In the most, when the activity of neurons is completely absent or slowed down to such an extent that one can talk about the death of the brain, and the body still continues to function, the answer to all questions is, of course, no, but there are disputes even among doctors about other cases.

With a neurological coma, brain and, most importantly, rational activity is preserved, but the functioning of those structures that are responsible for the work of the body is completely paralyzed, so we can safely say that such patients can think, and as a result, perceive everything that happens around with the help of hearing and occasionally - vision. With complete paralysis, there is no sensation in the body.

In other cases, coma, some patients say that they felt the presence of their loved ones and heard everything they were told, others noted that they could think or saw something like dreams, and still others remembered only a complete shutdown of consciousness and all feelings.

Therefore, all doctors recommend that relatives communicate with people in a coma as if they were conscious, because, firstly, it is likely that they hear and this will support them, encourage them to fight for life more strongly, and secondly, positive signals entering the brain can stimulate its activity and accelerate the exit from this state. In addition, communication with people who are in a coma has a beneficial effect on the loved ones themselves, who at this time are in severe stress, experience separation and are afraid of the onset of death: this greatly calms them.

How to distinguish who

It would seem that everything is clear here, but in fact, to distinguish a real coma from a simple loss of consciousness or neurological or psychological states quite difficult, especially percoma or coma of the second or third degree.

Sometimes two errors occur:

For whom is taken a deep loss of consciousness.
A superficial coma is not noticed against the background of the symptoms of the underlying disease, since changes in the patient's behavior are not too noticeable.

To determine the coma, as well as its severity, doctors use the Glasgow scale, which is whole complex signs: a reaction to light, the level of reflexes or their deviations, reactions to an image, sound, touch, pain, and much more.

In addition to the Glasgow scale tests, it is necessary comprehensive examination to identify the causes, level of damage to neurons and disruption of the central nervous system:

General tests, tests for hormones or infections.
liver tests.
All types of tomography.
An EEG showing the electrical activity of the brain.
Liquor analysis.
And many others. It is very difficult for a non-physician to diagnose a coma.

Emergency care and treatment

Since in coma there is inhibition of the vital functions of the body, emergency care will be resuscitation procedures in the form artificial respiration, possibly, starting the heart, as well as helping to eliminate the causes of its occurrence: removing intoxication, hypoxia, stopping bleeding, replenishing dehydration or exhaustion, lowering or increasing glucose levels, etc.

The treatment of coma is carried out in the intensive care unit and also begins, first of all, with the treatment of its causes, followed by the elimination of brain consequences and rehabilitation. Features of therapy depend on the underlying cause of the condition and the resulting brain damage.

Forecast

Coma is a severe condition, after which there is an opportunity huge amount complications.

A short-term artificial, caused for the purpose of general anesthesia, usually passes without consequences, as soon as the person is taken out of it. Long-term has the same complications as natural.

Any prolonged coma slows down and greatly complicates absolutely everything metabolic processes in the body, so over time the patient develops encephalopathy - organic lesion brain tissue, which can develop according to the most different reasons: lack of blood supply, resulting in a shortage nutrients, oxygen, as well as in the accumulation of toxic metabolic products in the brain, stagnation of cerebrospinal fluid, etc. In addition to brain consequences, muscle atrophy develops, impaired activity internal organs and activity of the peripheral nervous system, as well as a violation of the entire metabolism. Therefore, even after a short-term coma, the patient cannot immediately regain consciousness and start talking, and even more so get up and walk, as is often shown in films.

Metabolic disorders and the gradual development of encephalopathy lead to brain death when it ceases to function, but the body does not.

Brain death is diagnosed by total absence the following phenomena:

Pupillary reactions to light.
Stopping the liquor.
The complete absence of all reflex reactions.
Absence electrical activity directly to the cerebral cortex of the patient, which is recorded using the EEG.

Brain death is declared if these fundamental signs are not present within twelve hours, but to confirm the diagnosis, doctors wait another three days during which periodic diagnostics are carried out.

At the same time, it is characteristic that the body does not die immediately, since instead of signals from the central nervous system, life in it is maintained with the help of apparatuses. In addition, the cerebral cortex dies first, which means complete loss personality and the person as such, and subcortical structures for some time they support the body as an empty shell.

Sometimes the reverse state occurs, when the brain lives, a person can even come to his senses, and his body refuses to work, as it is used to constant artificial hardware maintenance and some of its functions have atrophied.

The third option for the development of the patient's condition is the onset of a special vegetative state, when he does not come to his senses, but his body begins to show activity, respond to pain and move muscles. Most often, it ends with coming to oneself and recovery.

The prognosis of the likelihood of a favorable exit from a coma depends on the specific disease or damage that caused it, as well as on the individual ability of the body to recover.