Moderate coma

Introduction The blinking of the moderately comatose patients, the language and spontaneous movement have been lost, and there is no response to various external stimuli. For strong pain stimulation or defensive reflex, there is no movement of the eyeball, the corneal reflex is weakened, and the pupil is slow to light reflection. Respiratory slowing or increasing, visible periodic breathing, central neurological hyperventilation and other central respiratory disorders, pulse, blood pressure also changed, with or without limbs tonic extension and angular arch reversal (decortical tonic ), defecation or incontinence.

Cause

Coma (coma) is in a state of non-responsiveness to external stimuli, and cannot be awakened to recognize itself or the surrounding environment. It is the most serious disturbance of consciousness, that is, the loss of persistent consciousness is completely lost; it is also one of the main manifestations of brain failure, intracranial Lesions and metabolic encephalopathy are two common causes.

(1) Causes of the disease

There are many schools at home and abroad on the classification of the causes of coma, among which the following three categories are well-known.

1.Adams coma classification

This classification is mainly based on the presence or absence of focal cerebral symptoms, meningeal irritation and cerebrospinal fluid changes. The causes of coma are divided into three categories, which are advocated by Adams (1977). This classification can objectively explain the cause of coma. A differential diagnosis is suitable for use by doctors with certain clinical experience.

(1) No focal symptoms and changes in cerebrospinal fluid:

1 poisoning: such as alcohol, barbital, opium and so on.

2 metabolic disorders: diabetic acidosis, uremia, Edison crisis, hepatic encephalopathy, hypoglycemia, cerebral hypoxia, pulmonary encephalopathy.

3 serious infections: pneumonia, typhoid fever, malaria, waffle syndrome, etc., cerebrospinal fluid or leukocytosis, often no focal symptoms.

4 cycle shock.

5 epilepsy.

6 hypertension and eclampsia.

7 high temperature and low temperature.

8 concussion.

(2) There are signs of meningeal irritation, cerebrospinal fluid or leukocytosis, often without focal symptoms:

1 subarachnoid hemorrhage.

2 acute meningitis.

3 some meningitis.

(3) There are focal symptoms with or without cerebrospinal fluid changes:

1 brain hemorrhage.

2 brain infarction.

3 brain abscess.

4 subdural or epidural hematoma, brain contusion.

5 brain tumors.

6 other: intracranial phlebitis, certain viral encephalitis, disseminated or encephalitis after vaccination.

2. Classification of Plum School

The Plum School (1979) is the most widely used classification for the classification of coma. They are based on bedside monitoring of pupillary changes, eye movements, breathing patterns, motor functions and other brain functions, from the perspective of neuropositioning diagnosis. The causes of coma are classified into three categories:

(1) On-screen mass lesions:

1 brain hemorrhage.

2 brain infarction.

3 subdural hematoma.

4 epidural hematoma.

5 brain tumors.

6 brain abscess.

7 brain parasitic diseases.

(2) Under the lumps or destructive lesions:

1 cerebellum or pons bleeding.

2 brain stem infarction.

3 cerebellar abscess.

4 cerebellum or brain stem tumors.

(3) caused by diffuse and metabolic causes:

1 intracranial diffuse lesions:

A. Intracranial infection (encephalitis, meningitis).

B. Extensive brain contusion.

C. Subarachnoid hemorrhage.

D. Hypertensive encephalopathy.

E. Epilepsy.

2 metabolic encephalopathy:

A. Hypoxia or ischemia.

B. Hypoglycemia.

C. Coenzyme deficiency.

D. Endogenous organ failure.

E. Exogenous poisoning.

F. Endocrine disease.

G. Temperature regulation disorder.

3. The coma classification proposed by the Sichuan Medical College in China in 1980

The coma is divided into two major categories: systemic diseases and intracranial lesions.

(1) Intracranial disease:

1 localized lesions:

A. Cerebrovascular disease: cerebral hemorrhage, cerebral infarction, transient ischemic attack, etc.

B. Intracranial space-occupying lesions: primary or metastatic intracranial tumors, brain abscesses, brain granuloma, brain parasitic cysts, etc.

C. Craniocerebral trauma: brain contusion, intracranial hematoma, etc.

2 diffuse brain lesions:

A. Intracranial infectious diseases: various encephalitis, meningitis, arachnoiditis, ependymitis, intracranial sinus infection.

B. Diffuse brain injury.

C. Subarachnoid hemorrhage.

D. Brain edema.

E. Brain degeneration and demyelinating lesions.

F. Seizures.

(2) Extracranial disease (systemic disease):

1 acute infectious diseases: various sepsis, infection with toxic encephalopathy.

2 endocrine and metabolic diseases (endogenous poisoning): such as hepatic encephalopathy, renal encephalopathy, pulmonary encephalopathy, diabetic coma, mucous edema coma, pituitary crisis, thyroid crisis, adrenal insufficiency coma, Lactic acidosis and the like.

3 Exogenous poisoning: including industrial poisons, drugs, pesticides, plant or animal poisoning.

4 lack of normal metabolites:

A. Hypoxia (normal cerebral blood flow): normal blood oxygen partial pressure and decreased oxygen content, carbon monoxide poisoning, severe anemia and degenerative hemoglobinemia; blood oxygen partial pressure and decreased oxygen content have lung disease, Asphyxiation and mountain sickness.

B. Ischemia (reduced cerebral blood flow): various arrhythmias, heart failure, cardiac arrest, myocardial infarction, hypertensive encephalopathy with increased cerebral vascular resistance, hyperviscosity, and decreased blood pressure Kind of shock and so on.

C. Hypoglycemia: such as insulinoma, severe liver disease, postoperative gastrectomy, excessive insulin injection and starvation.

5 water, electrolyte balance disorder: such as hyperosmolar coma, hypotonic coma, acidosis, alkalosis, hypernatremia, hyponatremia, hypokalemia.

6 physical damage: such as sun sickness, heat shock, electric shock, drowning and so on.

(two) pathogenesis

Consciousness refers to the state of perception of oneself and the surrounding environment. It can be expressed through words and actions. The content of consciousness includes awakening state and conscious content and behavior. The state of awakening depends on the so-called switch system-brain network The integrity of the ascending structure activates the system, and the content and behavior of consciousness depend on the integrity of the advanced nerves of the cerebral cortex.

When the brainstem reticular formation up-regulation system is inhibited, or the non-specific projection system of the thalamus is damaged, or the cerebral cortex is extensively damaged on both sides, the arousal state is weakened, and the consciousness content is reduced or changed, which may cause disturbance of consciousness.

Intracranial lesions can directly or indirectly damage the cerebral cortex and the upward activation system of the reticular structure, such as the brain's extensive acute inflammation, the supratentorial space-occupying lesions causing the hook back, the compression of the brainstem and the brain stem hemorrhage, etc., can cause severe disturbance of consciousness.

Extracranial diseases primarily affect consciousness by affecting the energy metabolism of the neurotransmitters and brain.

For example, ischemia and hypoxia caused by extracranial lesions can cause brain edema, cerebral palsy, or reduce or stop the excitatory neuronal norepinephrine synthesis, which can indirectly affect the brain stem network upward activation system. Thalamic or cerebral cortex; liver dysfunction during liver disease, phenethylamine in the metabolic process can not be completely detoxified, forming a pseudo-media (norformin, phenylethanamine), replacing norepinephrine (competitive inhibition) Hepatic encephalopathy occurs; in the case of various acidosis, the sensitivity of the postsynaptic membrane is reduced, which may also cause different degrees of disturbance of consciousness; hypoglycemia may cause hypoglycemia due to a decrease in energy supply to the brain and interference with energy metabolism. Sexual coma.

an examination

Related inspection

Brain CT examination, brain ultrasound, EEG diffuse slow wave

Diagnostic criteria

The standard for coma diagnosis mainly refers to the state of high-level neurological inhibition, which is manifested by the disappearance of conscious responses to sound, light, pain, and other stimuli.

First, the medical history question

1. Focus on understanding the urgency and onset of coma. Acute onset is common in trauma, infection, poisoning, cerebrovascular disease and shock.

2, to understand whether coma is the first symptom, if it occurs in the course of the disease, you should know what is the disease before coma. For example, diabetic patients may have hyperosmolar coma and hypoglycemia coma, liver cirrhosis patients may have hepatic coma, hyperthyroidism patients may have hyperthyroidism crisis.

3. Whether there is a history of trauma.

4, with or without pesticides, gas, sleeping pills, poisonous plants and other poisoning.

5, whether there are medical diseases that can cause coma, such as diabetes, kidney disease, liver disease, severe heart and lung disease.

6, for patients with transient coma, should pay attention to epilepsy or syncope and other diseases.

Second, physical examination found

1, should carefully observe body temperature, breathing, blood pressure, pulse, skin and head and neck. High fever should pay attention to severe infection, heat stroke, pons bleeding, atropine poisoning, etc., people with hypothermia should pay attention to shock, mucous edema, hypoglycemia, sedative poisoning, frostbite, etc.; pulse slowness should pay attention to intracranial hypertension, atrioventricular block or Myocardial infarction, heart rate is too fast, common in cardiac ectopic rhythm, fever and heart failure; respiratory rhythm changes type can help determine the brain lesions, pay attention to respiratory odor (diabetic acidosis has fruit odor, uremia has urine Stinky, hepatic coma with rancid smell, alcoholism with alcohol, organic phosphorus poisoning with garlic odor; high blood pressure can be seen in cerebral hemorrhage, hypertensive encephalopathy and intracranial hypertension, hypotension is common in shock, myocardial infarction, Sleeping medicine poisoning, etc.; skin is cherry red for CO poisoning, skin sputum is seen in sepsis, epidemic meningitis, anti-cholinergic drug poisoning or heatstroke when the skin is dry, skin is wet and sweaty during shock; attention to ear, nose, conjunctiva No evidence of trauma such as bleeding or discharge.

2, nervous system examination should pay attention to the presence or absence of focal neurological signs, pupil and fundus conditions, heavy pressure on the upper edge of the sputum with or without defense response and expression response, re-scratch the foot with or without limb escape response, pay attention to eye position, tendon reflex Symmetry and pathological reflex; patients with intracranial hypertension and subarachnoid hemorrhage often have optic edema and hemorrhage; bilateral dilated pupils are found in cerebral hypoxia, atropine poisoning, and severe midbrain lesions. Bilateral pupillary needle-like narrowing is seen in the pons of the pons, hemorrhage, organophosphate and morphine poisoning. One side of the pupil dilated is seen in the ipsilateral brain hook back; one side is narrowed to the early stage of the Horner's sign or the ipsilateral brain hook.

3, pay attention to the presence or absence of meningeal irritation, common in central nervous system infections and intracranial hemorrhagic diseases.

Differential diagnosis

First, mild coma

Also known as light coma or semi-coma. The patient's voluntary movement is lost, and there is no response to the surrounding things as well as the sound, light and other stimuli, but the strong pain stimulation (such as compression of the supraorbital nerve) shows that the patient has painful expression, sputum and defensive reflexes of the lower limbs. Swallowing reflexes, cough reflexes, corneal reflexes, and pupils still reflect light. There is no significant change in breathing, pulse, and blood pressure. Defecation or incontinence. Some patients are accompanied by convulsions and convulsions.

Second, moderate coma

No response to surrounding things and various stimuli, for violent stimulation or defensive reflex; corneal reflex weakened, pupils are slow to light reflection, no rotation of the eyeball; breathing, pulse, blood pressure have changed; defecation or incontinence.

Third, deep coma

Muscle relaxation, no response to various stimuli; sputum reflex, swallowing reflex, cough reflex, corneal reflex and pupil to light reflex disappeared; irregular breathing, blood pressure or decreased, incontinence, occasional retention; vital signs Unstable.

Some special coma can occur in some areas of the lesion:

1 wake up coma. Also known as the cortical state. Extensive lesions on both sides of the cerebral hemisphere.

2 no motion mutism. The reticular structure and the ascending activation system lesions.

3 atresia syndrome. Ventral ventral lesions. Dyeing, poisoning, cerebrovascular disease and shock.

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