Syndromes of depression of consciousness. Forms of disturbances of consciousness: stupor, stupor, coma
There are many different diseases that lead to impaired consciousness. Before touching on the causes of disorders of consciousness, we should briefly dwell on the brain structures responsible for the state of clear consciousness.
A person is characterized by alternating periods of clear consciousness (wakefulness) and sleep. There is also an intermediate state - dormancy. The ascending reticular formation located in the upper parts of the brain stem (mainly in the midbrain) is responsible for controlling the cyclic sleep-wake rhythm - the formation of the brain that connects the cerebral hemispheres with the long brain.
Types and symptoms of consciousness disorders
Based on the depth of the disturbance of consciousness, coma, stupor and stupor are distinguished.
Coma- this is an extreme degree of impairment of consciousness:
- there are no reactions to irritations (speech,);
- there is no sleep-wake cycle;
- eyes closed.
Sopor(in foreign literature the term stupor is more often used) - a milder degree of impairment of consciousness compared to coma. For stupor:
- the patient cannot be completely awakened, but there is a reaction to pain (a non-directional protective motor reaction is preserved, for example, withdrawing a hand when painful stimulation is applied to it);
- the reaction to speech is either weak (with mild stupor) or absent;
- after a short awakening (with mild stupor), the patient quickly falls back into an unconscious state and does not remember the moments of awakening in the future.
Stun- a state of incomplete wakefulness, which is characterized by loss or disruption of varying degrees of severity of the coherence of thoughts and actions due to a severe disorder of attention, drowsiness.
Stunning should be distinguished from delirium (the most common cause of which is), in which stunning is combined with psychomotor agitation, delirium, hallucinations, activation of the sympathetic nervous system (increased blood pressure, sweating, tremors, tachycardia).
In coma and deep stupor, in addition to impaired consciousness, other symptoms are observed:
Disruption of the normal breathing rhythm; in severe cases, breathing becomes chaotic; Respiratory depression may even occur.
Impaired reaction of the pupils to light.
Disturbed eye movements (observed when lifting the eyelids): or floating movements, fixation of gaze.
A variety of pathological activity may be observed: epileptic seizures, muscle twitching (myoclonus), parakinesis (involuntary movements reminiscent of voluntary ones in nature - according to the popular expression: “before death”).
There may be a sharp increase in muscle tone or, conversely, a decrease (“atonic coma”).
Glasgow scale
Opening your eyes
Spontaneous - 4
Opening for speech - 3
Opening to pain - 2
Missing - 1
Motor response
Follows verbal command - 6
Localizes pain - 5
Withdrawals a limb with flexion in response to pain - 4
Pathological flexion of all limbs from pain (decorticate rigidity) - 3
Pathological extension of all limbs from pain (decerebrate rigidity) - 2
No movement - 1
Preservation of verbal responses
Oriented and talking - 5
Confused speech - 4
Says incomprehensible words - 3
Inarticulate sounds - 2
No speech - 1
The total score is the sum of the scores of the three groups. 15 points - clear consciousness, 14-13 - mild stun, 12-11 - severe stun, 10-8 - stupor, 7-6 moderate coma, 5-4 - deep coma, 3 - death of the pulp, extreme coma.
Diagnostics
It is important to establish not only the degree of impairment of consciousness, but also its cause. In addition to the medical history, which may remain unknown either in the absence of the patient’s relatives or due to their ignorance, additional research helps clarify the diagnosis.
Blood and urine tests - general analysis, analysis of glucose levels in the blood, urine, electrolytes, creatinine, calcium, phosphates in the blood, biochemical indicators of liver function, blood osmolality.
Screening of toxic substances (carried out in specialized toxicology laboratories).
Electrocardiography (ECG).
Chest X-ray
X-ray of the skull (if TBI is suspected)
CT and MRI of the brain, revealing the presence of stroke, consequences of TBI (brain contusion, subdural hematoma, epidural hematoma, confusion of brain structures), encephalitis.
Lumbar puncture followed by examination of the cerebrospinal fluid if meningitis or subarachnoid hemorrhage is suspected.
Electroencephalography (EEG), which makes it possible to distinguish coma from mental “reactivity (with hysteria, catatonia).
Causes
Impaired consciousness (coma, stupor) can be caused by various causes: neurological, metabolic (diabetes mellitus, hypothyroidism, adrenal insufficiency, uremia, hyponatremia, liver failure), poisoning, hypoxia (asphyxia, severe heart failure), sunstroke and heat stroke.
Neurological causes of impaired consciousness:
- with damage to the reticular substance of the midbrain and associated subcortical formations (primarily the optic thalamus);
- with extensive lesions of the cortex;
- with combined damage to the cerebral cortex and midbrain.
- TBI: concussion or contusion of the brain, hematoma, traumatic intracerebral hemorrhage, diffuse axonal damage;
- stroke;
- brain tumors (impaired consciousness can be caused by blockade of the cerebrospinal fluid pathways, hemorrhage into the pituitary tumor, which increases with compression of the brain stem),
- status epilepticus,
Diabetic coma
Hypoglycemic and diabetic (ketoacidotic) comas occur with diabetes mellitus. The first one occupies 3rd place, and the second coma takes 5th place in the structure of coma. Hypoglycemic coma most often occurs in type 1 diabetes on insulin therapy (and in those patients with type 2 diabetes receiving insulin) with fasting blood glucose at a level of 3 mmol/l.
Provoking factors:
- insulin overdose,
- skipping meals or not eating enough,
- excessive alcohol intake
Taking medications can also cause a hypoglycemic state. These include: adrenergic blockers, sulfonamides, salicylates, anabolic hormones, tetracycline, lithium carbonate, monoamine oxidase inhibitors, calcium-containing drugs.
Symptoms develop quickly (usually within minutes, less often within hours). The first symptoms include profuse sweating, pale skin, a feeling of extreme hunger, trembling hands, weakness, and sometimes dizziness. Inappropriate behavior, psychomotor agitation (sometimes with aggression), impaired coordination of movements, later confusion, development of coma, and sometimes convulsions appear quite quickly.
At the first signs of hypoglycemia, the patient should eat a lump of sugar (a tablespoon of granulated sugar) or candy and drink a cup of very sweet tea. Comatose states are stopped by intravenous jet injection of 60 ml of 40% glucose, no more than 10 ml per minute. Then 5% glucose is administered intravenously (up to 1.5 liters per day) under blood glucose control.
Diabetic (most often ketoacidotic) coma when taking insufficient doses of glucose-lowering drugs or skipping insulin due to unauthorized withdrawal of medications and non-compliance with the diet. Provoking factors may include physical activity, alcohol abuse, and taking certain medications (steroids, oral contraceptives, calcitonin, saluretics, adrenergic blockers, diphenin, lithium carbonate, diacarb). Diabetic hyperglycemic coma develops more slowly than hypoglycemic coma.
With moderate ketoacidosis, asthenia and thirst increase; Dyspeptic symptoms occur, weight loss occurs, and the smell of acetone appears in the exhaled air. Subsequently, a precomatous state occurs, characterized by stunning, an increase in dyspeptic symptoms (anorexia, vomiting, abdominal pain), shortness of breath, decreased muscle tone and eye turgor, and dry skin. On examination, the tongue has a brown coating, decreased pressure and temperature, and absence of tendon reflexes.
Diagnosis is helped by laboratory data: hyperglycemia and glycosuria, increased blood ketone bodies, acidosis.
In the precoma stage, the glucose level reaches 28 mmol/l, in the coma stage - 30 mmol/l or more.
Necessary emergency measures for diabetic coma include the elimination of dehydration (dehydration), hypovolemia (reduction in circulating blood volume) and the prevention of possible hemorrhagic complications and the normalization of glucose and blood levels.
Intensive infusion therapy is carried out - saline solution 1 l/hour (up to 5-7 l) under the control of blood pressure, pulse rate, diuresis. If necessary, oxygen therapy and warming are carried out. To prevent thrombosis, 500 units of heparin (preferably low molecular weight heparin) is administered intravenously. Insulin therapy is carried out with blood glucose control.
Coma due to sunstroke
Often they encounter a coma that occurs in previously healthy people as a result of sunstroke (or heatstroke). Sunstroke can occur during heavy physical work under the scorching sun with your head uncovered, or during prolonged sunbathing on the beach. A risk factor is excessive alcohol intake. Symptoms can occur not only directly during exposure to the sun, but also several hours after exposure. In relatively mild cases (without loss of consciousness) and in a precomatous state, redness of the facial skin, increased sweating, increased body temperature (in severe cases up to 41 ° C), tachycardia, and shortness of breath occur. Subsequently, tachycardia gives way to bradycardia, breathing becomes arrhythmic, convulsions, delirium and impaired consciousness may occur.
Immediate measures for sunstroke include:
- placing the patient in a cool atmosphere;
- a cold compress (or an ice pack) on the patient’s head and wrapping the body with a sheet soaked in cold water;
- intravenous administration of 500 ml of saline, subcutaneous administration of 1-2 ml of 10% caffeine, 1-2 ml of cordiamine.
The development of heat stroke is associated with general overheating of the body, which appears when staying in a hot and humid room, during intensive work in stuffy conditions, during long hikes (military, tourist) in the heat.
Apaleic syndrome
What differs from coma is such a special state of impaired consciousness as apalic syndrome (synonyms: vegetative state, chronic persistent vegetative state, “waking” coma). The apalic state is a total disorder of the function of the cerebral cortex with preserved functioning of the brainstem (including the midbrain), which is characterized by:
- as in coma - lack of consciousness, reactions to pain, sound stimulation;
- in contrast to coma, the alternation of wakefulness and sleep is preserved (but their change is chaotic); during wakefulness, there is no fixation of gaze on any object and monitoring of others.
Some patients may then have a partial (and in the case of apallic syndrome of traumatic origin, sometimes quite good) restoration of consciousness. During the transitional stage, gaze fixation and monitoring of others, primitive emotional reactions and purposeful movements occur.
Isolation syndrome
“Isolation” syndrome (synonyms: “locked up” syndrome) is sometimes perceived by the patient’s relatives as a gross violation of consciousness and intellect. This syndrome occurs with extensive infarctions of the base of the brain stem. It is characterized by:
- total immobility (tetraplegia - paralysis of arms and legs);
- lack of speech as a result of anarthria;
- preservation of consciousness and intellect;
- preservation of voluntary eye movement and blinking, with the help of which communication with the patient is possible (for example, using Morse code, which is taught to the patient and the person caring for him).
Impaired consciousness in the form of coma and stupor should be differentiated from some mental states that outwardly resemble coma: conversion (hysterical) and catatonic (in schizophrenia) stupor. With a psychogenic disorder of consciousness, there are no involuntary slow movements of the eyeballs, the eyes are often open, there are no changes in muscle tone and changes in the EEG.
First aid for impaired consciousness
A general practitioner who finds a patient in a coma must:
- call an ambulance in order to hospitalize the patient as quickly as possible;
- find out anamnestic data from relatives or friends of the patient to make a preliminary presumptive diagnosis;
- measure blood pressure, pulse rate, breathing rate, measure body temperature, and if you have a glucometer, blood glucose;
- pay attention to the skin, turgor of the eyeballs and muscles of the limbs, the size of the pupils, reaction to light;
- administer intravenously 60 ml of 40% glucose (not dangerous even if the patient has a hyperglycemic coma) with 100 mg of vitamin B1.
Stupor is considered a pathology; it is an unproductive type of disturbance of human consciousness, occurring in a variety of situational moments and close to coma. This condition is also called subcoma, it is similar to loss and loss of consciousness and is considered something between fainting and coma.
Stupor - what is it?
Stupor is a neurological suppression of consciousness when a person loses the ability to move, but at the same time he retains all reflexes. A person in a stuporous state cannot show a reaction to environmental conditions in any way, he cannot perform simple tasks and ignores any question addressed to him. It is problematic to bring a person out of such a state; often, harsh painful effects in the form of pinches and injections are used for this.
Stupor - reasons
In neurology, a stuporous state occurs due to:
- hemorrhagic or ischemic stroke;
- brain injuries caused by bruise, hemorrhage, concussion, hematoma;
- abscess, hemorrhage, tumor processes;
- hydrocephalus;
- inflammation of the capillaries;
- infectious and inflammatory diseases;
- epistatus;
- aneurysm rupture.
Metabolic causes include:
- uremia, accompanied by excessive accumulation of protein metabolic products;
- hyponatremia, accompanied by a decrease in the concentration of sodium ions in the blood;
- renal and;
- decreased thyroid function;
- diabetes.
Also, a stuporous condition occurs due to hypoxia, asphyxia or heart failure. Often, subcoma occurs due to severe hypertensive crisis, heat stroke, hypothermia, sepsis, and toxin poisoning. Moreover, the duration of this state can take only a few seconds or several months.
Signs of stupor
The condition of stupor is characterized by the following symptoms:
- Reduced reactions to irritation, while the swallowing, breathing and corneal reflexes are preserved.
- Uncontrolled movement, in clinical cases, muttering.
- Cramps, neck muscle tension.
- Changes in the sensitivity of the skin, paralysis of the limbs, weakness of certain muscle groups.
Changes in brain reactions cause the appearance of:
- bruises around the eyes;
- blood or cerebrospinal fluid from the ear openings;
- sharp pathological odor;
- scars on the body, tongue bites;
- elevated body temperature.
What is the difference between coma and stupor?
Impairment of consciousness has several degrees, among them stupor occupies the middle place:
- Stunning, when the level of consciousness decreases, speech contacts are limited, and behavioral reactions are disrupted. Stunning causes delirium, hallucinations, rapid heartbeat, and high blood pressure.
- Coma, characterized by a complete lack of consciousness. It can be moderate when deep reflexes remain normal. A deep degree of coma is characterized by the absence of reflexes, severe hypotension, impaired breathing and functioning of the cardiovascular system. With an extreme degree of coma, the patient’s pupils are dilated, there are no reactions, and all vital functions are sharply disrupted.
The degree of conditions such as stupor and coma is determined using a special Glasgow scale, where each reaction is characterized by a certain digital value. The highest score is assigned to normal behavior, and the lowest score is assigned to the absence of reflexes. Who is confirmed if the score on the Glasgow scale is eight or less points. If we talk about what stupor is, impaired consciousness in this case is an intermediate option between stunning and coma.
How long does the stuporous state last?
The duration of the subcoma is determined by the cause that caused the condition and the degree of brain damage. So, for example, if the illness is caused by a concussion, this condition can last several minutes, although there are often cases when such a condition lasts more than a day. Deep stupor is manifested by deep stupor, a condition from which a person can only be partially extricated after repeated attempts at shaking, loud handling and injections.
How to bring a person out of stupor?
If you detect the slightest signs of loss of consciousness, you should immediately consult a doctor. To fully identify the soporous state, doctors examine a biochemical and toxicological analysis of blood and urine, conduct electroencephalography, MRI, and lumbar puncture. If stupor is detected, emergency care is carried out as follows:
- In case of a concussion or cerebrovascular accident, doctors put the patient to bed and administer dehydrating and vasodilating agents.
- Respiratory and circulatory functions are normalized, if necessary, intubation is performed.
- If there are signs of injury, the neck is immobilized using an orthopedic collar.
It is important to initially eliminate the cause of depression of consciousness; this is done in the intensive care unit, where the vital functions of the body are monitored and supported. All necessary medications are administered intravenously to the patient. Since the illness can last a long time, it is important to effectively care for the patient and carry out procedures to prevent bedsores and contractures.
Stupor - consequences
The soporous state is a complete extinction of the voluntary performance of the brain. After you come out of stupor, consequences may arise. They directly depend on the adequacy and timeliness of therapeutic assistance. If the cause of subcoma is a hemorrhagic stroke, then in most cases this ends in the death of the patient. If after three days after myocardial surgery the patient has no pupillary reaction or motor reaction to painful stimuli, then the chances of a successful outcome are minimal.
Stupor and stupor are symptoms of mental disorders that have similarities in external manifestation, but belong to different nosological units.
Stupor is a disorder of consciousness, one of the main mental processes, along with perception, thinking, memory, and attention. Consciousness in the medical sense is a level of wakefulness, which depends on the number of activating influences exerted on the cerebral cortex from the brain structures.
Disorders of consciousness are characterized by impoverishment of mental activity and an increase in the threshold of perception, and there are quantitative (unproductive) and qualitative (productive). Stupor is a stage of non-productive disturbance of consciousness, following stupor and preceding coma.
Stupor is a movement disorder characterized primarily by immobility. Along with excitement, stupor often represents a phase of the catatonic syndrome. In addition to catatonic, stupor can be reactive and depressive.
Manifestations
Stupor and stupor look similar. In a state of both stupor and stupor, a person is inactive, lethargic, looks drowsy or numb. His facial expressions are frozen, inexpressive, and monotonous. The main manifestation of both disorders is depression of mental, mental and motor activity, which is either completely absent or reduced to a minimum.
With stupor, stereotypical, meaningless actions, phenomena of negativism can be noted - resistance to any attempts to change a person’s posture, or vice versa - waxy flexibility, passive submission, which is expressed in maintaining the given position, even if it is uncomfortable.
These phenomena prove the inhibited state of the cerebral cortex during these disorders, which extends to the motor centers and speech centers. A person can remain in the fetal position for a long time, pressing his knees and head to his stomach. Mutism, which also sometimes occurs with these conditions, is the complete absence of speech. In a state of stupor, muscle tone can sometimes be increased, due to which a person is able to lie in bed with his head elevated for hours - the so-called air cushion syndrome.
With stupor, a person becomes indifferent to the situation, may not respond to calls, and reacts poorly to painful stimuli. Thus, in both of these states, a person retains only instinctive elementary reactions and reflexes.
Causes
The causes of stupor and stupor are different. Stupor is an exogenous disorder of consciousness that is observed with:
- vascular disorders, strokes;
- as a result of traumatic brain injury;
- epilepsy;
- severe poisoning;
- in the terminal stages of dying, turning into coma.
The causes of stupor can be psychogenic and endogenous:
- Psychological factors - stress, psychological trauma or shock that lead to reactive stupor. Reactive stupor can be hysterical, depressive and delusional.
- Endogenous (biological) causes are a disturbance in the exchange of neurotransmitters in the brain, for example, the occurrence of catatonia (catatonic stupor), which occurs in schizophrenia and affective disorders.
- In rare cases, catatonic stupor occurs as part of an organic disorder as a result of an infectious or degenerative disease of the brain.
Diagnostics
During stupor, in contrast to other stages of disturbance and shutdown of consciousness (coma and stupor), a person retains pain sensitivity and reflexes, and verbal contact may be absent or only partially present.
A neurological examination of stupor and stupor includes the study of pupil reactions, eye movements, breathing, motor activity and reflexes, reactions to painful stimuli. It is also necessary to identify hidden or obvious head injuries, injection marks, and examine the skin. It is important to interview relatives to clarify the circumstances of the onset of a painful condition and to collect information about the patient’s chronic diseases.
The following methods for studying the condition can be used: general and toxicological analysis of blood and urine, electroencephalography, computer and magnetic resonance imaging of the brain.
Treatment
At the initial stages of treatment, it is necessary to know or try to establish the cause of the painful condition (stupor or stupor) and provide therapeutic intervention based on the disease within which this symptom is observed.
With stupor, which can turn into coma, a deeper stage of impaired consciousness, emergency intervention is most often required: diagnosis of the causes of the condition, specific treatment to eliminate them, stabilization of the condition, care and maintenance of vital functions.
For stupor as part of catatonia, antipsychotics are used. In these cases, the patient often requires hospitalization, since the stage of stupor or lethargy often progresses and is replaced by a phase of excitement, in which a person can commit impulsive actions and pose a danger to himself or others.
If we are talking about stupor caused by stress, then the treatment may be to eliminate the traumatic situation. In some cases, with reactive stupor, a person can independently, without outside intervention, come out of a state of immobility. In other cases, specific drug treatment is required.
Thus, despite the external similarity of manifestations, stupor and stupor are different nosological units. Their diagnosis, prognosis and treatment vary significantly. It is necessary to understand that stupor is a loss of consciousness, with drowsiness and lethargy, and occurs most often in organic disorders of the brain (vascular, traumatic and other origins), and stupor is immobility, numbness, most often found in schizophrenia, depression or acute psychogenic psychosis.
Stupor is a depression of consciousness preceding coma (subcoma, pre-coma), i.e. pre-coma state. In a state of stupor, a person is able to react to loud sounds, repeatedly repeated questions, the pupils weakly, but still react to light, and the body - to painful stimuli (pinches, slaps). However, such stimuli can only bring a person out of stupor for a short time.
Stupor should be distinguished from another medical concept - “stupor”. Both of them are similar in external manifestations, but stupor is a pathology of neurological etiology, while stupor is of mental etiology. In foreign sources these concepts are differentiated differently. “Stupor” means “deep sleep,” and depression of consciousness, on the contrary, is called stupor.
In the International Classification of Diseases, 10th revision (ICD-10), stupor is classified under subparagraph R40.1.
Causes of subcoma
Stupor can occur for many reasons. Internal causes are divided into two groups: neurological and metabolic. External factors can also influence the development of depressed consciousness.
Neurological causes include:
- Acute cerebrovascular accident (ACVA), including; falling into stupor is especially characteristic when the upper parts of the brain stem are damaged as a result of a hemorrhagic stroke;
- traumatic brain injuries resulting in brain contusion, concussion, hemorrhage, or hematoma;
- abscesses, hemorrhages, brain tumors with swelling, edema, displacement of segments;
- dropsy of the brain (hydrocephalus);
- dysfunction of nerve structures as a result of inflammation of the capillaries (vasculitis);
- inflammatory processes in the brain caused by infections (meningitis, encephalitis);
- status epilepticus, in which epileptic seizures occur every half hour; the patient does not have time to fully recover between attacks, which is why dysfunction of the nervous system and internal organs increases;
- subarachnoid hemorrhage due to rupture of a cerebral aneurysm.
Metabolic factors:
- Abnormal blood glucose levels due to diabetes;
- self-poisoning of the body with uremia due to the accumulation of protein metabolic products;
- hypothyroidism (thyroid hormone deficiency);
- a sharp drop in sodium levels in the blood;
- hepatic-renal failure;
- hypoxia (lack of oxygen), asphyxia (excess carbon dioxide);
- severe hypertensive crisis;
- severe heart failure;
- blood poisoning (sepsis).
Stupor can be triggered by external factors:
- Overheating of the body (sunstroke or heatstroke);
- hypothermia (hypothermia);
- poisoning with toxins (carbon monoxide, methyl alcohol, a number of medications, for example, barbiturates).
What is the difference between coma and stupor
Stupor is a state of moderate depression of consciousness. It may be preceded by a milder form of depression of consciousness—stunning.
Coma is a more severe form, in which consciousness is lost altogether. Stupor can develop into a coma. With stupor, reflex reactions persist, while with coma they are practically absent. In both cases, reflexes slow down, but in coma the degree of slowing is much greater.
In a soporotic state, a person is not able to answer the question, but one can be sure that he hears it to some extent.
For example, by speaking loudly to him several times, you will receive a reaction in the form of opening your eyes. By pinching the hand, you can notice from the facial expressions that the person in stupor feels pain. In a coma, all this is completely impossible. Even a weak reaction to external stimuli does not occur. Breathing during coma also weakens due to depression of respiratory function.
How long does the stuporous state last?
Depending on the reasons for which it arose, the stuporous state can last from a few seconds or minutes to several months.
Then the person either leaves it or plunges even deeper into unconsciousness - into a coma.
How to properly bring a person out of stupor
It is impossible to bring a patient out of stupor without the help of doctors. He may automatically open his eyes when there is a sharp clap or scream, but immediately closes them. Later, having finally woken up, the patient does not remember anything, because... stupor is most often accompanied by amnesia.
If you notice signs of depressed consciousness in a person, you should immediately call an ambulance. Signs of a soporous state Stupor resembles a state of deep, sound sleep.
The man does not move, his body is relaxed, his eyes are closed.
Inhibitory functions predominate in the patient’s brain. With a loud sound or a pat on the cheeks, he may open his eyes for a few seconds. When pinched or slapped on the hand, pull it back and hit back. Breathing, swallowing, and corneal reflex remain normal. With the hyperkinetic form of stupor, abrupt mutterings and movements occur, but it is still impossible to establish contact with the patient.
Usually, along with signs of stupor, symptoms of the disease that caused the development of this condition appear. If stupor is caused by a traumatic brain injury, dark blue circles around the eyes may be a sign. This indicates a possible fracture of the base of the skull.
It is necessary to identify the cause-and-effect relationship of stupor with other diseases or pathological conditions. Treatment will be effective only if the disease that caused the depression of consciousness is eliminated.
To establish the causes of stupor, the doctor needs complete information about the circumstances that preceded it. To do this, a survey is conducted of the patient’s relatives or those accompanying him during the onset of stupor. The ambulance team usually examines the room in which the patient is located. Found bottles of alcohol, packaging of medicines, syringes can lead to conclusions about the body being poisoned with alcohol, drugs, or medications due to their overdose. Traces of a fight, blood on things can indicate a traumatic brain injury, injury received from a fall due to a stroke, fainting and other circumstances. Medical records and certificates that shed light on the presence of existing diseases are studied.
The patient's body is examined to identify skin rashes, bruises, hemorrhages, injection marks, and the smell of alcohol. The patient's body temperature, blood pressure, and blood glucose levels are measured. Auscultation (listening) of the heart and ECG are performed. Blood is taken for general and biochemical analyses. An MRI or CT scan of the brain, urine screening and blood tests for the presence of toxins, and a lumbar puncture may also be performed.
The list of emergency examinations depends on the existing diseases and circumstances on the basis of which the causes of stupor can be suspected.
Treatment of stupor
Treatment for stupor should begin as quickly as possible. The patient must be taken to the hospital's intensive care unit. He must be under round-the-clock supervision of medical workers, under the control of equipment.
The choice of treatment method depends entirely on the cause of the depression of consciousness. Stupor is not a separate disease. This is just one of the symptoms in the clinical picture of stroke, poison intoxication, severe hypertensive crisis and other acute conditions. The main component of therapy is measures aimed at preserving the nervous tissue of the brain.
If treatment is approached incorrectly, brain tissue cells will die, which will lead to even more disastrous consequences. To prevent this from happening, you need to ensure good blood supply to the brain and prevent tissue swelling. Depending on the cause of stupor, doctors treat liver or kidney failure, restore heart rhythm, adjust blood sugar levels, and stop bleeding (as appropriate). Therapeutic measures are supplemented by the introduction of microelements missing in the body. If stupor appears against the background of an infectious disease, antibacterial drugs are prescribed. Each etiology requires specific treatment.
In case of poisoning, the stomach and intestines are washed to stop further absorption of toxins into the blood. In case of bleeding with significant blood loss, a blood infusion is given. Blood products, saline, and plasma may also be administered. To improve the nutrition of brain cells, the doctor may prescribe thiamine, piracetam, cordarone, and magnesium preparations.
In cases where stupor was preceded by epileptic seizures, anticonvulsants are prescribed: sibazon, carbamozepine, seduxen, valprocom, relanium.
After a stroke, vascular drugs are used in therapy. If a brain hematoma has formed, emergency surgery may be required. The doctor may prescribe antibiotics, the purpose of which is to prevent congestion in the tissues if the patient has to lie down for a long time. After all, stupor can last for months.
If stupor lasts for a long time, the patient will require special care. To prevent bedsores from forming, the person needs to be turned over, wiped with water, and the muscles massaged. In addition, he will have to be spoon-fed. If this is not possible, feeding will have to be done through a tube.
Forecast and consequences
The prognosis when a person falls into a state of stupor is very ambiguous. The reasons why it arose and the degree of depression of consciousness play a big role. It is also important how quickly treatment is started.
If the processes affect vital areas of the cerebral cortex, the patient may completely lose his personal qualities.
With a small degree of depression of consciousness and proper treatment, a quick recovery is possible. However, being in a pre-coma state in any case leaves a mark on the cognitive abilities of the brain. To minimize the risks of relapse and the development of new diseases, a person who has suffered stupor urgently needs to reconsider his lifestyle. You need to set yourself up for a healthy life and eliminate any bad habits.
18. Catatonic syndromes (stupor, agitation)
Catatonic syndromes are psychopathological disorders with a predominance of motor disorders in the form of stupor, agitation, or their alternation, occurring in both adults (up to 50 years old) and children. In most cases, these syndromes are observed in schizophrenia, but can also manifest themselves in organic or symptomatic psychoses. Catatonic stupor Expressed in complete immobility, and a person can freeze in a very unusual position: with his head raised above the pillow at a certain angle, standing on one leg, with uncomfortable outstretched arms, etc. However, in most cases, patients lie motionless in the so-called “fetal position” (with eyes closed, on one side with bent legs and arms pressed to the body). Such complete immobility is usually accompanied by either absolute silence (mutism) or passive/active negativism. With passive negativism, the patient does not react at all to any appeals, suggestions, requests. With active negativism, the patient, on the contrary, actively resists all requests, for example, when asked to show his tongue, he clenches his mouth even tighter, and when asked to open his eyes, he closes his eyelids even more tightly. Cataleptic stupor (stupor with waxy flexibility) is characterized by the patient’s complete freezing for quite a long time in the position assigned to him, or in the position he himself adopted, even if it is extremely uncomfortable. During stupor, a person does not react to loud speech, but in conditions of complete silence he can spontaneously disinhibit, thereby becoming available for contact. Catatonic arousal Characterized by stereotypically repeated, chaotic, meaningless movements. Excitement is accompanied by characteristic shouts of individual words or phrases (verbigeration), or complete silence (mute excitation). A characteristic feature of excitation is that it occurs within limited spatial limits (patients can endlessly step from foot to foot, standing in the same place; jump in bed, while stereotypically waving their arms). Sometimes patients may experience copying movements (echopraxia) or the words of others (echolalia), without revealing spontaneous speech. Catatonic excitement is often combined with hebephrenic syndrome, which is characterized by non-infectious empty fun, giftedness, or mannerisms. Such patients meow, grunt, cackle, stick out their tongues, make faces, grimace; sometimes they can rhyme words meaninglessly, or mutter something inarticulate; copy the gestures and movements of others, extend a leg instead of a hand to greet, walk mincing, or throwing their legs high
19. Syndromes of switching off consciousness (stunning, stupor, coma)
Syndromes of switching off consciousness. Turning off consciousness - stunning - can have different depths, depending on which the terms are used: “nubilation” - fogging, cloudiness, “cloudy consciousness”; “stupefaction”, “doubtfulness” - drowsiness. This is followed by stupor - unconsciousness, insensibility, pathological hibernation, deep stupor; This circle of coma syndromes completes - the most profound degree of cerebral insufficiency. As a rule, instead of the first three options, a diagnosis is made “ precom" At the present stage of consideration of syndromes of switching off consciousness, much attention is paid to the systematization and quantification of specific conditions, which makes their differentiation relevant.
Stupefaction is determined by the presence of two main signs: an increase in the threshold of excitation in relation to all stimuli and an impoverishment of mental activity in general. At the same time, the slowdown and difficulty of all mental processes, the poverty of ideas, incompleteness or lack of orientation in the environment are clearly evident. Patients who are in a state of stunned, stupefied state can answer questions, but only if the questions are asked in a loud voice and repeated repeatedly, persistently. The answers are usually monosyllabic, but correct. The threshold is also increased in relation to other irritants: patients are not bothered by noise, they do not feel the burning effect of a hot heating pad, do not complain about an uncomfortable or wet bed, are indifferent to any other inconveniences, and do not react to them. With a mild degree of deafness, patients are able to answer questions, but, as already noted, not immediately; sometimes they can even ask questions themselves, but their speech is slow, quiet, and their orientation is incomplete. Behavior is not impaired, mostly adequate. You can observe easily occurring drowsiness (doubtfulness), while only sharp, fairly strong stimuli reach consciousness. Drowsiness is sometimes classified as a mild degree of stunning.
upon awakening from sleep, as well as the nullification of consciousness with fluctuations in the clarity of consciousness: slight darkenings, obscurations are replaced by clarification. The average severity of stunning is manifested by the fact that the patient can give verbal answers to simple questions, but he is not oriented in place, time and surroundings. The behavior of such patients may be inappropriate. A severe degree of stunning is manifested by a sharp increase in all previously observed signs. Patients do not answer questions, cannot fulfill simple requirements: to show where the hand, nose, lips, etc.
Sopor(from Latin sopor - unconsciousness), or soporous state, subcoma, is characterized by complete extinction of voluntary activity of consciousness. In this state, there is no longer responsiveness to external stimuli; it can only manifest itself in the form of an attempt to repeat a loudly and persistently asked question. The predominant reactions are of a passive-defensive nature. Patients resist when trying to straighten their arm, change their underwear, or give an injection. This kind of passive-defensive reaction should not be confused with negativism (resistance to any request or influence) in catatonic substupor or stupor, since in catatonia other very characteristic signs are observed: increased muscle tone, mask-like appearance of the face, uncomfortable, sometimes pretentious postures, etc. A. A. Portnov (2004) distinguishes between hyperkinetic and akinetic stupor. Hyperkinetic stupor is characterized by the presence of moderate speech excitation in the form of meaningless, incoherent, indistinct muttering, as well as choreo-like or athetoid-like movements. Akinetic stupor is accompanied by immobility with complete muscle relaxation, the inability to voluntarily change the position of the body, even if it is uncomfortable. In a soporous state, patients retain the reaction of the pupils to light, the reaction to painful stimulation, as well as the corneal and conjunctival reflexes.
Coma(from the Greek ???? - deep sleep), or coma, comatose syndrome is a state of deep depression of the functions of the central nervous system, characterized by complete loss of consciousness, loss of response to external stimuli and a disorder in the regulation of vital functions of the body.
According to the National Scientific and Practical Society of Emergency Medical Services, the incidence of prehospital coma is 5.8 per 1000 calls, and the mortality rate reaches 4.4%. The most common causes of coma are stroke (57.2%) and drug overdose (14.5%). This is followed by hypoglycemic coma - 5.7% of cases, traumatic brain injury - 3.1%, diabetic coma and drug poisoning - 2.5% each, alcoholic coma - 1.3%; Coma is diagnosed less frequently due to poisoning by various poisons - 0.6% of cases. Quite often (11.9% of cases) the cause of coma at the prehospital stage remained not only unclear, but not even suspected.
All causes of coma can be reduced to four main ones:
intracranial processes (vascular, inflammatory, volumetric, etc.);
hypoxic conditions as a result of somatic pathology (respiratory hypoxia - with damage to the respiratory system, circulatory - with circulatory disorders, hemic - with hemoglobin pathology), impaired tissue respiration (tissue hypoxia), a drop in oxygen tension in the inhaled air (hypoxic hypoxia);
metabolic disorders (primarily of endocrine origin);
intoxication (both exo- and endogenous).
Comatose states are an urgent pathology and require the use of resuscitation measures, since the severity of the subsequently developing psychoorganic syndrome depends on the duration of the coma. The leading clinical picture of any coma is the switching off of consciousness with loss of perception of the environment and oneself. If in a soporotic state the reactions are of a passive-defensive nature, then with the development of coma the patient does not respond to any external stimuli (pricking, patting, changing the position of individual parts of the body, turning the head, speech addressed to the patient, etc.). There is no reaction of the pupils to light during coma, unlike stupor.