2Traumatic damages at extraordinary situations

Diagnosis and treatment of emergency conditions at the scene

Emergency medical services in mechanical injuries

 

 

Traumatic damages at extraordinary situations

Quantitative characteristic of injuries:

Trauma- injury of the body, it’s tissues or parts caused by the influence of mechanic, physical, chemical or mental factors, which is conducted with local and general reactions.

Isolated trauma- is every single injury at any anatomic and functional region of the body or organ.

Multitrauma- few injuries at one anatomic and functional region.

Associated trauma- few injuries, at different anatomic and functional regions.

Combined trauma- injury, which appears as a result of simultaneous or sequential influence of several traumatic agents.

Polytrauma- severe multiple and combined injuries, which cause the beginning of traumatic disease (wound dystrophy) and need immediate medical help by life-saving indications.

Obligatory condition for using of term polytrauma is the occurrence of traumatic shock and life-threatening injury or a combination of such injuries.

In case of associated trauma dominates the syndrome of mutual complexification, what means that every single injury might be not lethal, but together injuries might become life-threatening.

(Fracture+ rupture of intestine+ injury of liver, spleen)

 Polytrauma is characterised with: syndrome of mutual complexification, atypical symptoms of damages, complicacy of diagnostic, necessity of permanent estimation of the patient’s state, immediate need in adequate treatment, development of traumatic disease, large number of complications and high lethality.

 “Traumatic disease” – is a phase pathologic process, which gradually develops in case of severe injuries, which are based on homeostatic disorders, disorders of general and local adaptation processes; it’s clinic depends on the character, quantity and localisation of damages.

Traumatic disease is usually divided into 4 periods:

 

 

I – shock

II – period of early manifestations of traumatic disease

III – period of late manifestations of traumatic disease

IV – period of rehabilitation

 

According to the conception of “golden hour” all injuries were divided into 3 groups:

1. Unrecoverable, extremely severe damages, in case of which even immediate medical help will not bring positive consequences.

2. Damages, in case of which consequences of trauma (death or invalidity) depend on the timeliness and quality of the medical help. To those patients medical aid should be provided at the place of accident and they should be hospitalized to the specific department of medical institution ( in the USA trauma centres of I level) or to the multifield hospital for the specific treatment during 1 hour from the moment of injuring.

3. Damages, in case of which specific medical aid might be delayed for 1 hour from the moment of injuring without risk for the life and health of the patient.

 

Periods of lethality after injury:

First pick of lethality  falls on the moment of injury, when death comes in first few seconds or minutes from the moment of injury, what first of all is caused because of the damage of life-important organs, e.g. brain, heart, big vessels. In most cases such injuries are fatal, although in-time treatment at the place of accident might save a certaiumber of victims. At this period nearly 60% of victims die because of:

1. Damage of brainstem.

2. High damage of the spinal marrow.

3. Damage of the heart.

4. Damage of aorta or other great vessels.

 

Second pick of lethality falls on the time between first few minutes and few hours from the moment of injury, when the frequency of fatal outcomes might be reduced with prophylactic measures and treatment of ventilate, haemic and tissue hypoxia through conducting of artificial lung ventilation, arrest of external and internal bleedings, adjustment of circulating blood volume and tissue perfusion. In this period the reasons of death are next:

 

1. Subdural and epidural haematoma.

2. Haemopneumothorax

3. Splenic rupture

4. Damage of liver

 

Fracture of the pelvic bones or/and other injuries associated with large blood loss.

The third pick of lethality appears in few days or weeks after moment of injury and is usually connected with multiple organ failure and sepsis.

Polytrauma in most cases is connected with traffic accident and fall from a height.

After fall from a height (accidental), polytrauma is stated in 66-76% cases, what includes 63% of cranial-skeletal trauma, 52% of thoracic-skeletal trauma. Craniocerebral trauma as an isolated injury exists only in 35,3% of cases.

Victims with polytrauma have associated injuries of limbs (closed and open fractures) in 76-90% of cases, associated craniocerebral trauma and fractures of cranial bones in 66-76% of cases, associated thoracic trauma in 62-80% of cases. The most common combination of injuries is head+limbs (63%) thorax+limbs (52%).

 

Actions of emergency team at the place of accident.

Emergency team at the place of accident should first of all:

  1. Carefully examine the place of accident.

  2. Get to know, what happened?

  3. Determine the quantity of victims

Identification of the injury-mechanism and inspection of the place of accident let the emergency team to give objective evaluation of accident complicacy and to prognose the probable traumatic injuries of victims.

Emergency medical aid is often provided in extreme conditions, when additional factors might harm not only patients, but also their rescuers. In such cases medical workers should follow next rules:

 1. Check the safety of the place of accident and 

     if necessary ask professional rescuers or

     police to help.

 2. Determine the quantity of victims, way of

     injuring, sources of danger in environment.

 3. To define the necessity in additional

     emergencies in case of many victims.

 

Emergency medical aid

The main purpose of EMA to injured at this stage is prevention of development of early and late complications- hypoxia, reperfusion ischemia and multiple organ failure. Positive results should come as a consequence of  transportation time reduction (to the place of accident and to the hospital). During pre hospital stage priority of first medical aid is the detection of life-threatening states, such as:

Shock

Obstruction of upper air passages

Massive bleeding

Severe damages of thorax, which might cause the development of respiratory distress syndrome

Severe craniocerebral trauma and cervical spine trauma

Extent of medical help at pre hospital stage is limited with immediate measures of returning and maintenance main vital functions (breathing and circulation).

Programme oh help at pre hospital stage consists of next steps:

Evaluation of severity  of  patients condition, detection of life-threatening disorders of breathing and circulation.

Resuscitation ain case of acute disorders of vital functions

Anaesthetization and immobilisation

Immediate hospitalization to the special in-patient department.

 

Components of emergency medical aid at the pre hospital stage:

Primary inspection ABCC’

Medical sorting

Intensive therapy

Secondary inspection (ABCDE)

Constant observation of the patients condition

Qualified and specialised medical help airways

B-breathing

Circulation

C’- cervical spine- with using of neck collar

Traumatic shock-is a hard pathologic process, which appears as a general response to severe mechanic damage of tissues and organs and becomes evident through disorders of systemic circulation, microcirculation and metabolic reactions in tissues. In this shock (hypovolemic, traumatic) condition there are two phases: erectile and torpid. Erectile phase appears not always. It develops at pre hospital stage, lasts for a short period (few minutes or 10-20 minutes) and is characterised with the excitement of the patient. Torpid phase is characterised with depression of vital systems.

 

Classification of shock

 

 

 

 

 

 

Open fracture of forearm bones

 

 

 

Probable complication of fracture or transportation without immobilisation

Mechanism ofradial nerve damage

 

 

Splintered open fracture of both bones of right forearm at the level of lower 1/3

   Combined MOS  2

 

3                   4            

 5

 

Fractures of the pelvis

Without breaking of pelvic circle continuity

A.B. Fractures of the wing of ilium

C.D. Fractures of sacrum

E. Fractures at the level of iliosacralis articulation

F. Fractures of ishiadic and pubic bone

G. Fracture of pubic bone (horizontal ramous)

H. fracture of ishiadic bone

I. Fracture of pubic articulation

 

Fractures of the pelvis

With breaking of pelvic circle continuity (Malign)

1. Fracture at iliosacralis articulation with dislocation.

2. Fracture of pubic bone with dislocation.

3. Fracture of the ischiadic bone with dislocation

 

Fracture-displacement of half-pelvis

Fracture of pelvic and iliosacralis  articulation with dislocation of pelvic circle

 

Fractures of the pelvis

Mechanisms of injury- direct and indirect

Clinic: pain, deformation of the pelvic circle, specific position of the limb, depends on the type of fracture, pathologic mobility. Usually the clinic of pelvic fracture with rupture of pelvic circle is completed with trauma or haemorrhagic shock. In case of pelvic fractures intrapelvic haematoma have 2-2,5 l. As a complication might appear damage of intrapelvic soft organs (uterus, urinary bladder, intestine).In such cases first of all is conducted catheterisation of urinary bladder, what gives a possibility to examine quantity and quality of urine, find damages of urethra, urinary bladder.

 

Transportation of the patient with pelvic fracture

Patient with pelvic fracture should be transported on the stretcher in position with flexed (30º-40º) knees and femoral articulation (abduction 10º). This position is the most physiological for the muscles, which are connected with the pelvis and doesn’t cause additional dislocation (so called “frog-position”).

 

Shaft of femur fractures

Fractures of this localisation consist 40% of all femoral fractures.

Mechanism of the trauma: direct and indirect.

Clinic: pain, oedema, pathologic mobility, bone fragments crepitating. The specific feature of this trauma is often development of trauma shock and blood loss (0,5-1,5 l), and if the patient is transported without immobilisation, the risk of fat embolism growth.

 

There are fractures of upper, middle and lower 1/3 of femoral bone.

 

          

 

Clinical examples

 

 

 Combined trauma: fracture of heel bone+burns (treatment- mod apparatus of Elizarov with compression of bone fragments).

 

 

Displacements of foot

Subtalar open displacement of the foot

  

 

 

 

Transporting immobilisation

The main principle is the immobilisation of joints, which are above and lower than fracture

a – immobilisation with Cramer’s splint in case of crus’ fracture; b – immobilisation with Diterichs’ splint.

 

Emergency aid and principles of intensive care of injured patientsFirst of all you should stop arterial bleeding pressing artery to the bone above the place of injury or using arterial tourniquet or garrot above the place of trauma. You also need to notice the exact time of this manipulation.Then you will have to inspect the state of the victim (central and peripheral pulse, degree of consciousness’ depression, air path, effectiveness of breathing).You should provide the correct position of the injured. If he (or she) is unconsciousness, you turn him (her) on one side. Specific position demands a vertebral fracture (on the hard surface) and pelvic fracture (described before). You should not move the head if the fracture of cervical part of backbone is suspected!!!

 

Use the rule of 4 catheters:

Nasal for oxygen

Gastric for evacuation of its contents (when patient is unconscious)

Intravenous for infusions

Urinary for measuring of diuresis

 

Also important part of treatment is infusion therapy.

Anaesthetization:

a narcotic analgesics-morphine hydrochloride10-20 mg, omnopon 10-20 mg,

promidon 20-40mg, fentanil 0,05-0,1 mg, dipidolor 7,5-15 mg i/v

or i/m:3-4 times aday under control of breathing:

b tramal 50-100 mg, stadol 2-4mg, nubain 0,15-1,3 mg/kg, pentazocyn 30-45 mg, buprenorfin 0,3-0,6 mg i/v or i/m

c  nonsteroid anti-inflammatory- ketanov 30-60 mg, dicloberl 75 mg

i/m 2-3 times a day

a – general anaesthetics- NO with O2  2:1

b – ketamin 0,5-1 mg i/v or 3-5 mg i/m, Na oxybutyrat 20-30 of 20% solution ml i/v slowly

c – novocaine blocks of fracture places, blocks of nerves and nervous interlacement, vago-sympatic blocks , paravertebral and epidural anaesthesia (if CHD is stabil)

Glucocorticoids like in case of hypovolemic shock. Immobilisation of fractures- standard and improvisational splints, contra shock clothes.

A/B therapy, beginning from “wide” antibiotics (cyfran, zanocyn, cephalosporins). Prevention of supercooling- warm coats, the optimal climate control, warm liquids for drinking (except abdominal trauma), warm infusion solutions 35º- 40º. Symptomatic syndromes and corrective therapy.

Transportation of patient with polytrauma.Treatment of patients at pre hospital stage needs experienced medical workers and expensive medical equipment. Every delay might cause life-threatening complications. Those statements cause the necessity of hospitalisation of such patients to the specific in-patient departments, where exists the possibility to involve into treatment surgeons, neurosurgeons, traumatologists, anaesthesiologists.

All victims with polytrauma should be hospitalized to the intensive care department or antishock ward.

 

 

Genesis of Damage:

•        primary (squashing.  haematoma, hemorrhage);

•        second (violation of circulation of the blood and spinal fluid, edema – swelling, hyperaemia of brains ,  infectious inflammation);

 

Types of SBТ:

•        isolated ;

•        united;

•        combined;

 

By descent:

•        closed (without violation of integrity of skin cover and damage of aponeurosis);

•        open (wounds  + damages aponeurosis; breaks and damages  soft tissues, break of basis of skull + pour out spinal fluid);

•        penetrable (with  damage of ТМО);

•        Not penetrable.

 

By severe:

•        Easy degree (13-15 by Glazgo scale)

•        Middle degree (8-12 by Glazgo scale+ sub sharp and  chronic compression);

•        Heavy degree (3-7 by Glazgo scale)

 

Clinical forms of  SBТ :

•        Concussion of the head brain;

•        Backwall of cerebrum – easy degree

•        Backwall of cerebrum – middle degree

•        Backwall of cerebrum – heavy degree;

•        Compression of brain;

•        Compression of head;

 

By Compression of brain:

•        – sharp (threatening clinical growth during 24 hours after  CBТ);

•        –  sub sharp (threatening clinical growth 24 hours after CBТ );

•        –  chronicle (threatening clinical growth >15 days after CBТ);

 

Gradation of the state of consciousness CBТ:

•        Clear  consciousness –complete orientation, adequate reaction. Retrograde amnesia is possible.

•        Moderate stunning– moderate somnolence , insignificant errors  of orientation in time , some slow  implementation of commands  and instructions , enhance able level of perception .

•        Deep stunning – deep somnolence , disorientation, elementary instructions are implemented , elementary linguistic contact is possible.

•        Sopor – linguistic contact is absent , presence of coordinated protective reactions, eyes opening as a reaction on pain, verbal commands are not implemented.

•        Moderate  comma –eyes are not opening, not coordinated protective reactions without localization of pain. Pupil and corneal reflexes are present.

 

General brain symptoms :

•        Disorder of memory;

•        Nausea, vomit;

•        Head pain;

•        meningeal symptoms;

•        Change of tone of muscle;

•        Vegetative reactions.

                                                                                                                                                                                                       

Diagnostic criteria:

w       Break of vault and basis of skull;

w       Focus changes on CS

 

 

 

Bruise cerebrum of easy degree

•         10-15% patients with a SBТ

•        14 – 15%by Glazgo scale

 

Clinic:

•        Lost of consciousness 30 min. – 1 hour. Amnesia  not more then  1 hour.

•        Cerebral and meningeal symptoms.

•        Insignificantly expressed  focal symptoms  (anisocoria, decline of cornea reflexes, inertia convergence, increase or decline of reflexes of tendon, s-м

Marinecku – Radovichi)

•        Absence of barrel disorders.

 

Treatment :  

•        duration (8 – 14 days)

•        Analgesics, sedation, nootropic agent;

•        Dehydration.

•        Bruise cerebrum  middle degree

•         8 – 10% patients with a CBТ.

 

Clinic:

•        Lost of consciousness (10min.- few hours, amnesia > 1 hour.);

     Retro and anterograde amnesia is expressed , disorders of vital functions  (bradycardia, tachycardia, increase of BP, tachypnoae, mild pyrexia)

•        Barrel systems : nistagm, bilateral pyramid signs;

•        Clear  focal symptoms.

 

Bruise cerebrum heavy degree

•         5 – 7% patients with a CBТ.

 

Clinic:

•        Threatening violation of congratulatory functions;

•        Prevailing of initially barrel symptoms (swimming of eyeballs, paresis of look, convergence of eyeballs, decerebrate rigidity, bilateral pathological signs);

•        paresis, paralysis;

•        Cramps;

•        Vegetative disorders (decline of BP, increase of body temperature, hypersalivation);

•        Lethality  30 – 40%

 

Epidural haematoma:

•        1% in all cases of  CBТ;

 

Starts from:

•        branch  a meningea media

•        sinus and parasagittal veins

•        Forming rate – 2 –3 hours.

 

Phases of motion:

1.     “light interval”

2.     Growth of  cerebral symptoms with oppression of consciousness; cerebral hemisphere symptoms

3.     Barrel located symptoms.

4.     Terminal phase (comma, apnoe, decline of BP).

 

Diagnostics:

•        Estimation of neurological status;

•        craniography;

•        sonography;

•        CS;

•        In case of absence CS – searching trepanation.

 

TREATMANT

•        Surgical  (in first  3 hours after hospitalization)

•        Lethality 8 – 50%

 

Quo bene interrogat – bene diagnostit;

 

Subdural hematoma:

•                    40% from all intracranialhaematomas;

•                    Source:

•                    Parasagittal vein

•                    focal of squashing of brain.

 

After the term of origin :

•                    sharp – till  3 days

•                    Sub sharp – till 20 days

•                    Chronicle –  more then 21 days.

 

 

Diagnostics :

•                    Breaks of bones, vault, basis;

•                    CS;

 

Diagnostics:

•                    CS:increase of  volume of the brain, compression lateral  and  ІІІ ventricle, cisterns, subarachnoid spaces, microfocus hemorrhage in white  matter, barrel.

 

Signs of heavy cranial-cerebral trauma.

•                     Different pupils.

•                     Different mobile activity.

•                     Opern cranial-cerebral trauma with effusion spinal fluid.

•                     Neurological worsening.

•                     Break of bones of the  skull.

•                     The second review is executed parallel with conducting of measures of intensive therapy.

During conducting of the second review it follows to examine a head of  suffering and make  palpation bones of skull, to estimate a size and symmetry  of pupils, presence of paraorbital heamatomas, examine  aural channels (presence of blood or spinal fluid can testify to the break f basis of skull).

 

Stage of operation removal subdural haematom

Absolute testimonies for application Neck collar:

1. Polytrauma.

2. A close trauma higher level of collar bones.

3. Violation of consciousness is as a result of trauma or sharp poisoning.

4. Jaw-facial trauma.

5. Changes of configuration of spine or feeling suffering pain in the back.

 

 

If during conducting of manipulation there was pain which grows, will appear

 

Advanced Life Support Algorithm

 

Objectives

To understand:

The function of the advanced life support (ALS) algorithm

The treatment of shockable rhythms The treatment of non-shockable rhythms The indications and technique for giving a precordial thump

The potentially reversible causes of cardiac arrest

 

 

Traumatic Pneumothorax

What is a traumatic pneumothorax?

A traumatic pneumothorax is a condition in which air collects in the pleural space (the space between your lung and chest wall). A traumatic pneumothorax is caused by an injury that causes air to leak into your pleural space. A traumatic pneumothorax can be caused by a broken rib that tears your lung. Other causes include injuries that allow air to enter from the outside, such as a knife wound. The air that builds up in the pleural space stops the lung from filling with air, and the lung collapses. A pneumothorax can happen in one or both lungs. It can heal on its own, or it can become a persistent posttraumatic pneumothorax (PPP). A PPP is a pneumothorax that does not heal within a certain period of time after treatment.

A traumatic pneumothorax can develop into a traumatic tension pneumothorax. This means your pneumothorax becomes serious enough to affect the way your heart and lungs work. With a traumatic tension pneumothorax, one or both of your lungs may completely collapse. A traumatic tension pneumothorax can result in death if not treated quickly.

What are the causes of a traumatic pneumothorax?

Some injuries that cause a traumatic pneumothorax include:

A bicycle accident or a fall.

A motor vehicle accident.

An accidental injury that happens during a medical procedure, such as a lung biopsy.

A gunshot wound.

What are the signs and symptoms of a traumatic pneumothorax?

You may have one or more of the following symptoms if you have a traumatic pneumothorax:

Shortness of breath.

Soft bulges under your skin caused by air bubbles. These bubbles may be found anywhere, such as your chest or neck.

Chest pain.

Uneven chest movement when you breathe.

Rapid heartbeat.

In rare cases, a person may also have a cough.

What are the signs and symptoms of traumatic tension pneumothorax?

If you develop a traumatic tension pneumothorax, you may have any of the symptoms of a traumatic pneumothorax. You may also have any of the following symptoms:

Sweating.

Feeling like you are going to pass out.

Your fingernails, toenails, or lips begin to turn blue.

Your neck veins become larger than usual.

Your throat or the front of your neck is pushed to one side.

How is a traumatic pneumothorax diagnosed?

 

A traumatic pneumothorax or a traumatic tension pneumothorax can be diagnosed with one or more of the following:

Chest x-ray: Chest x-rays are pictures of the bones, lungs, and other tissues in your chest. Caregivers use chest x-rays to see if you have broken ribs. These x-rays may show your caregiver how large your pneumothorax is. Chest x-rays may also show fluid around the heart and lungs.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Computerized tomography scan: This test is also called a CT or CAT scan. A CT scan uses a special x-ray machine to take pictures of your chest and lungs. A CT may help caregivers find a pneumothorax that did not show up on chest x-rays. You may be given dye through an IV before the pictures are taken. The dye helps the pictures show up better. People who are allergic to iodine or shellfish (lobster, crab, or shrimp) may be allergic to this dye. Tell caregivers if you are allergic to shellfish or you have other allergies.

 

Physical examination: Your caregiver listens to your breathing and your lungs. He may also check the level of oxygen in your blood and your blood pressure. If you are on a ventilator to help you breathe, caregivers will check your airway pressure. An increase in airway pressure can mean that a traumatic tension pneumothorax has developed.

 

Ultrasound: An ultrasound uses sound waves to show pictures of your organs and tissues on a TV-like screen. An ultrasound may be used to see if you have a pneumothorax.

 

 

 

 

How is a traumatic pneumothorax treated?

Your treatment options may change if your pneumothorax gets worse. You may have one or more of the following treatments. With fast and proper treatment, your pneumothorax may get better.

Medicines:

 

Antibiotics: Antibiotics may be given to you to prevent an infection caused by germs called bacteria.

 

Pain medicine: Caregivers may give you medicine to decrease your pain. Tell caregivers if the pain does not go away or it comes back.

 

Sedation: Caregivers may give you medicine to relax you.

 

Procedures: You may receive a medicine called local anesthesia to make you feel more comfortable during your procedure or surgery. A shot of this medicine put into your skiumbs the area and dulls your pain. You may still feel pressure or pushing during the procedure or surgery after you get this medicine.

 

Decompression: A needle may be put in between your ribs to remove air from around your lungs. Your caregiver may put a catheter (rubber tube) through your skin and into your pleural space. A valve that lets air out of your pleural space may be connected to the catheter.

 

Pleurodesis: If your pneumothorax is not healing, caregivers may put blood, talc, or antibiotics into the pleural space. These products cause your lung to stick to the visceral pleura (a thin layer of tissue attached to your lung). Attaching the lung to the visceral pleura stops air from getting into your pleural space. These products can be placed during surgery or with the use of chest tubes.

 

Thoracostomy: A thoracostomy is a procedure in which caregivers put a chest tube through an incision (cut) in your skin. The chest tube is then placed into your chest. Chest tubes remove air, blood, or fluid from around your lungs or heart.

 

Thoracotomy: You may need surgery to treat injuries that cannot be treated in other ways. These injuries include tears in your lungs, bleeding blood vessels, and other injured tissues.

 

Video-assisted thoracoscopic surgery: This surgery is also called VATS. If air or blood continues to leak from around your lung, you may need VATS. During VATS, catheters are inserted through a cut in your skin and into the lung area. One catheter has a camera at the end that allows caregivers to see the lung. Other catheters may have special devices attached that are used to treat your lung injuries.

 

Treatments:

Oxygen: You may need extra oxygen to help you breathe more easily.

Ventilation: You may need a machine called a ventilator to help you breathe. Caregivers may also put in a chest tube to decrease the risk of a traumatic tension pneumothorax.

What are the risks of having or treating or having a traumatic pneumothorax?

Some treatments may cause breathing problems or problems in your heart or blood vessels. Treatments that require cuts in your skin to get to the area around your lung may lead to empyema. Empyema is an infection in the lung area. You could get a traumatic tension pneumothorax if you are put on a ventilator without chest tubes. You can also get a traumatic tension pneumothorax during pleurodesis.

 

During decompression, the needle used for the procedure may injure your lung or cut a blood vessel. This can cause bleeding around the lung. Chest tubes could be painful, become kinked or clogged, or could fall out or leak. Chest tubes could also cause a lung infection, or fluid could fill the lung instead of air. Chest tubes could damage blood vessels or other organs and cause bleeding, injury, and even death.

 

Without treatment of your traumatic pneumothorax, your lungs may completely collapse. Your heart could stop working, and you could die. Ask your caregiver if you have any questions about your treatment, condition, or care.

 

 

First aid at acute diseases and damages of head, neck and spine.

 

Genesis of Damage:

·       primary (squashing.  haematoma, hemorrhage);

·       second (violation of circulation of the blood and spinal fluid, edema – swelling, hyperaemia of brains ,  infectious inflammation);

 

Types of SBТ:

·       isolated ;

·       united;

·       combined;

 

By descent:

•        closed (without violation of integrity of skin cover and damage of aponeurosis);

•        open (wounds  + damages aponeurosis; breaks and damages  soft tissues, break of basis of skull + pour out spinal fluid);

•        penetrable (with  damage of ТМО);

•        Not penetrable.

 

By severe:

•        Easy degree (13-15 by Glazgo scale)

•        Middle degree (8-12 by Glazgo scale+ sub sharp and  chronic compression);

•        Heavy degree (3-7 by Glazgo scale)

 

Clinical forms of  SBТ :

•        Concussion of the head brain;

•        Backwall of cerebrum – easy degree

•        Backwall of cerebrum – middle degree

•        Backwall of cerebrum – heavy degree;

•        Compression of brain;

•        Compression of head;

 

By Compression of brain:

•        – sharp (threatening clinical growth during 24 hours after  CBТ);

•        –  sub sharp (threatening clinical growth 24 hours after CBТ );

•        –  chronicle (threatening clinical growth >15 days after CBТ);

 

Gradation of the state of consciousness CBТ:

•        Clear  consciousness –complete orientation, adequate reaction. Retrograde amnesia is possible.

•        Moderate stunning– moderate somnolence , insignificant errors  of orientation in time , some slow  implementation of commands  and instructions , enhance able level of perception .

•        Deep stunning – deep somnolence , disorientation, elementary instructions are implemented , elementary linguistic contact is possible.

•        Sopor – linguistic contact is absent , presence of coordinated protective reactions, eyes opening as a reaction on pain, verbal commands are not implemented.

•        Moderate  comma –eyes are not opening, not coordinated protective reactions without localization of pain. Pupil and corneal reflexes are present.

 

Coma state answers

 

Q:  Dreams in different states

A: Wrong person to ask about coma and vegetative state – this is outside my expertise but I suspect the answer is that we don’t know for certain but by definition the frontal lobes will be showing little or no activity and so dreaming should not be possible. My info is that people dream during REM sleep which doesn’t happen under anaesthesia. People remember dreams of they are very nearly awake or do awaken transiently during their REM sleep. having said all this I always chat to my patients about what they want to dream about and a proportion wake up saying they had a lovely dream about what we had been discussing. This may just happen as the anaesthesia wears off out I remain unconvinced about it all.

 

Q:  Сoma state

A: My best suggestion for that would be to have her develop a postoperative intracranial bleed. A possible scenario might be for her to have surgery for an intracranial tumor. Postoperatively the patient doesn’t wake up. The surgeons do a CAT scan and find a large hematoma causing pressure on the cerebellum and increase intracranial pressure. If it is reoperated quickly, she will recover but if not, it will become permanent.

 

Q: Сoma after General Anesthesia

A: I wish I could help you with this question. I assume the Neurologist will do  all test to find out why it is rare but we all know that anytime anyone goes under Anesthesia we are taken a chance on our lives that is why we have to sign a waver in case our body reacts to it. I agree with you on the trip for the evaluation that can be done locally. I would try to find out why this happen in your best health. I wish I could help more.

 

Q: Сould a coma last only or less than one day?

A: A “coma” refers to a period after injury in which the person is unconscious – i.e., they are not awake or responsive; eyes are closed all the time – there is no sleep-wake cycle; there is only reflexive movement, no voluntary movements (e.g., moving to be more comfortable); there is no language used or understood. So usually a coma would be defined as a period during which these conditions are true and are able to be determined. It would be unusual, for example, to consider someone “comatose” if they hadn’t had the chance to establish a sleep-wake cycle, but if  they meet all the other requirements (e.g., not responding to pain or other environmental stimulation; not using language; not moving “on purpose”, then they may be considered in a state like that a coma.

 

Q: How high does your blood sugar have to be before you go into a coma?

A: There is no clear cut answer to that question as it will vary between individuals. The coma occurs not just due to the high blood sugar but the other physiological processes that occur with a lack of insulin. If you have Type 1 diabetes, when you have a lack of insulin your body begins to use fat for energy and produces ketones. Ketones alter the blood chemistry resulting in a chain of events that can lead to a coma. We recommend that people with Type 1 diabetes test for ketones when their blood sugar is high to avoid the potential acute complication called Diabetic Ketoacidosis. The onset of DKA is often rapid, within 24 hours. Common symptoms of DKA include frequent urination, dehydration, extreme tiredness, vomiting, fruity smell to breath, and confusion. People with Type 2 diabetes usually have to have much higher blood sugars before their blood chemistry alters. Blood sugars greater than 600 can put you at risk. DKA is less common in people with Type 2 diabetes, more common is a condition known as hyperosmolar nonketotic state (HNS). You are at risk for this condition during an infection, heart attack, stroke or another acute illness. Both conditions cause frequent urination which can cause fluid loss so drinking plenty of liquids is when ill or when blood sugar is high is recommended. Always call your health care provider when you have persistent hyperglycemia, frequent urination, vomiting and/or drowsiness. If untreated both of these conditions can lead to death. Testing your blood sugar more frequently when you are sick or if your blood sugar is high is very important. The best prevention is to develop a personal sick day plan with your diabetes educator or health care provider so you are prepared.

 

Q: If your in a coma can you still open your eyes

A: In medicine, a coma is a profound state of unconsciousness. A comatose person cannot be awakened.

 

Q: Can someone experience cardiac arrest while in a coma?

A: Coma is a state of profound unconsciousness. During this period the heart and other vital activities are functioning but ‘brain is sleeping'(in common language). Coma causes certain progressive irreversible damage to brain even on recovery. So, it is possible that a patient of coma experiences cardiac arrest. Hope this helps.

 

Q: What is the Glasgow coma Scale?

A: The Glasgow coma Scale (GCS) is a commonly used assessment tool if a person has a head injury, is unconscious or is in a coma. It was developed in the 1970s at the University of Glasgow, hence its name. Two neurology specialists, Graham Teasdale and Bryan Jennet, are credited with its development. It is in wide use in medical facilities around the world, though there are other assessment tools that can be used to determine level of consciousness as well. There are three things that the Glasgow coma Scale assesses to evaluate degree of consciousness and these are eye response, movement, and verbal response. Higher scores, with 15 being the highest indicate greater level of consciousness, and in fact, a fifteen would mean a person was fully awake and aware. A three is the lowest score and suggests an extremely deep state of unconsciousness. Scores in all areas are added together to produce total score.

 

In the eye response assessment, people may get up to a four in score. The following ratings apply:

1. Eyes don’t open.

2. Eyes open if pain is applied.

3. Eyes open if the person is addressed.

4. Eyes open on their own.

 

In motor response on the Glasgow Coma Scale, responses are rated as such:

1. There is no movement.

2. The body extends when painfully stimulated.

3. The body withdraws abnormally when painfully stimulated.

4. The body withdraws normally in response to pain.

5. The body responds normally where the pain occurs.

6. The person can move and use the body at request of a doctor “Raise your arm, wiggle fingers,” etc.

 

The verbal response on the Glasgow Coma Scale is assessed in the following way:

1. There is no verbal sound.

2. The person makes sounds that can’t be understand.

3. The person says things that don’t make sense.

4. The person can respond to conversation but appears confused, and doesn’t always respond appropriately.

5. The person speaks normally with appropriate conversational response.

 

It’s easy to see why the Glasgow Coma Scale would be useful in assessing adults and children, but might not be as useful in assessing infants who are pre-language. There is a pediatric coma scale adapted from the GCS, which can be used instead, and is in fact often used when children are injured or are hospitalized to continue to assess wellness. Comatose Glasgow Coma Scale Head Injury Coma Scale A Coma Coma Prognosis Coma Work.

 

It’s also not always possible to get a completely accurate score on the GCS because of injuries or things like intubation, where a person has a breathing tube. Facial injury may affect eye movement, and injury to the body, particularly paralysis, could affect motor response to pain. A person with a breathing tube cannot speak, though if they are fully conscious, they could write answers and show level of consciousness in this manner.

 

Q: What is a coma?

A: A coma is generally understood to be a state of unconsciousness from which a patient cannot be awakened. While unconscious, the patient is unable to engage in voluntary actions, does not exhibit a cycle of waking and sleeping, and does not register any reaction to any type of stimulus. Essentially, the comatose patient remains alive, but is completely unable to relate to the world at large.

 

Drawing the name from the Greek word koma, which means deep sleep, a coma can result from a number of different events. Problems with the central nervous system can invoke a coma. Medical crises such as a stroke may also result in the patient entering a comatose state. There are instances where intoxication resulted in the individual falling into a coma for an extended period.

 

Q: Coma after anesthesia

A: You give alot of information but because you don’t know the specific techniques and drugs they used, it is hard to interpret your findings. Let me give you some thoughts however. You say they used the short tube to keep your mouth open. I interpret this as an LMA (as opposed to an endotracheal tube). You also refer to an EEG during the procedure (we call it a BIS or PSA) but if they used that on you, the anesthesiologist would have given more anesthetic if it showed you awake. You also mention that your respirations were 2/min but you were not intubated. This is unlikely since you would not last long at that rate and they would have had to intubate you. It is hard to know what you think you hear during surgery and what is really being said. I have had patients tell me they heard something but I know that nothing was said. This is an effect of some of the drugs we give you put you into a dreamlike state. There are several other points you made which confuse me but all that being said, here are some issues to be addressed. There are very few things in anesthesia that would make you not wake up (that are specific to anesthesia and not things like stroke, etc). The first is pseudocholinesterase deficiency. This is related to the inability to metabolize succinylcholine (a drug used to paralyze you for surgery). Normally sux wears off in 2 minutes but with the deficiency it can be hours (not days). But if they used the LMA, they would not have used sux so this is unlikely. The deep muscle test which refers to a muscle biopsy to rule out Malignant hyperthermia but you don’t describe any other symptoms of this so it is also unlikely. Without reviewing the chart, it would be impossible to make any other conclusions but you certainly should be evaluated. I would go back to the hospital where you had the surgery and speak with the anesthesiologist there to determine what tests you should have (based on his/her review of your chart). You probably should see a neurologist to determine the cause of the seizures. I don’t know what rare forms of cancer you refer to but it’s DEFINITELY not related to this. As for blood work and testing, I don’t see any reason why it can’t be done locally (the exception, the muscle biopsy is done only in California to my knowledge).

 

Q: Coma after Meningioma brain surgery

A: A meningioma is a benign tumor of the lining of the brain, not a tumor of the brain itself. Its treatment is entirely surgical. I’m not a neurosurgeon or a surgeon, I’m a medical oncologist and radiation therapist with experience of treating brain tumors. Your question is therefore outside my area of expertise here and should be directed to a neurosurgeon or to a neurologist. However your description of the situation does not look good. Has any recent CT or MRI scans of his brain been done (after this happened)?

 

Q: Metastatic brain coma and death

A: Without any complication including pneumonia, thrombosis-embolia etc. she can hold on for many weeks provided hydration continues. It is usually considered inhumane and unethical to stop or deny hydration. But I have no idea what the local rules may be where you are. You will have to find that out on your own. No there is no legal or ethical way to speed up the process – outside a few countries. And it in most cases not nice to die of dehydration!

 

Q: Can people hear you if they are in a coma?

A: It dosen’t normally happen but their have been cases of people waking up and have reported hearing loved ones while in a coma state.

 

Q: Coma care

A: Well, if the patient can breathe unaided, then the need for constant blood work isn’t that important, but I would mention something to the effect of not knowing what her lab values were causing concern (if you were writing a book). Generally there are no written instructions on how to set up a IV line per se, and a gastric feeding tube needs an OR with xray to confirm placement into the stomach (or intestine depending on patient status. Some patients need the feedings into their intestines due to their state). If he did nothing other than wait for help then I would suspect that first your patient would become dehydrated. From the dehydration would come infection then it would snowball from there. I would go with 3 days for unaided care. After the three days then you can bet the problems would arise.

 

Q: What does being in a coma feel like?

A: Being in a coma is the same as what it feels like to be a rock. You would have to ask a rock, and the rocks aren’t talking. Nobody knows what a coma is like, which leads me to believe it’s like death, for all intents and purposes.

 

Q: What to do for someone in diabetic coma?

A: Diabetic comma is a life threatening condition that can be treated only in a hospital. High levels of glucose can be decreased with crystal insulin (fast acting) but should be administered together with intake of lot of intra venous infusions of NaCl 0.9%-solution according to a special protocol. When the glucose level is normalized and the person is stabilized, he can use insulin (slow acting) by himself according to the doctor’s prescription.

 

Q: What happens when a person is in a coma?

A: You are in your own world you have to have water, food pump in your blood.

 

Q: Can coma be misdiagnosed?

A: The most common misdiagnosis of coma is blindness coupled with inability to speak. Another is so called “locked in syndrome” in which the person is completely paralyzed, or nearly so, though their mental faculties remaiormal. These possibilities should be thoroughly checked.

 

Q: What is a coma?

A: A coma is a sleep-like state where the injured person does not open his/her eyes, does not speak and is unable to obey commands. Comas are divided into several layers based on the responsiveness of the patient to eye-opening, speaking, and movement of his/her extremities. If a patient is able to open his/her eyes, speak and respond to simple commands, they are no longer considered to be in a coma.

 

There are no current medications that can shorten the length of time a person remains in a coma. As mentioned before, there are medications that enable a doctor to deepen the level of a patient’s coma to help in the healing process.

 

COMA is a sleep-like state in which the injured person does not open his/her eyes, does not speak, and cannot obey commands like “Stick out your tongue!” or “Hold up one finger!”. There are several levels of coma. A number scale called the Glasgow Coma Scale is often used to describe the responses of people in coma. There is nothing magic about this scale, it just attaches numbers to the responsiveness of the head injured person in terms of eye-opening, speaking, and moving his/her extremities. People are usually no longer considered to be in coma if they open their eyes, speak, or can obey simple commands.

 

Coma is defined as a prolonged state of unconsciousness. A person in a coma does not respond to external stimuli. There is no speech, the eyes are closed and the person cannot obey commands. Coma can last from hours to days, depending on the severity of the brain damage. It is possible for a person to remain in a comatose state for months and sometimes years. A person may eventually open his/her eyes, but if he/she remains unresponsive, the person could be in what is termed a “vegetative state.”

 

Q: What is “permanent coma”?

A: Permanent coma means a profound state of unconsciousness caused by disease, injury, poison or other means and for which it has been determined that there exists no reasonable expectation of regaining consciousness.

 

Q: WHAT IS DIABETIC COMA?

A: Diabetic coma is an unfortunate event, it occurs in two different ways. One is due to hypoglycemia, where a low blood sugar level causes fairly sudden loss of consciousness. Secondly, when the insulin dependent diabetic starts to develop high blood sugar level ( hyperglycemia).

As the sugar level rises due to lack of insulin, the cells are starved of ‘fuel’. They have burn something to keep alive, and so they start getting through fat instead. Used- up fat produces waste product called ketones, and it is the presence of excess ketones which characterises the sort of diabetes which requires treatment with insulin.

 

Q: Is it useful for the coma worker to “know” the person before the coma?

A: It is useful to gather as much information concerning the person’s physical, mental and emotional well being before they entered coma. It is important to know all these factors because if the person begins to return to everyday life, they may be confronted with these deep and everyday issues once again. However do not stress this in communication attempts if you get no positive feedback, because the person may not be relating to this information in their altered state.

 

Q: WHAT IS THE DIFFERENCE BETWEEN BRAIN DEATH AND COMA?

A: Coma is a state of unconsciousness that occurs because the brain is injured in some way. The brain still functions and this can be seen in the tests that are performed. The person will be able to breathe on his own without the help of a respirator. The brain, in fact, may heal.

 

Q: How long does a coma last?

A: Generally, the deepest level of coma lasts from two to four weeks. If the person does not waken from the coma, she enters into various stages of semi comatose states, so called vegetative states that include sleep wake cycles. These varying stages of altered states occur in people suffering from traumatic brain injury and in people undergoing metabolic comas from changes in blood chemistry near death.

 

Q: DO PEOPLE IN COMA FEEL PAIN?

A: Being in coma may be compared to being under anesthesia. People in coma may well react to pain by moving, or even groaning, but most often have no memory of pain.

 

Q: DO PEOPLE IN COMA HEAR?

A: People in coma sometimes show signs that they are able to hear and understand. Often these signs are just simple reflexes — like squeezing a hand, or sucking, in response to a touch. Occasionally people in coma seem to become calm when they hear a familiar voice. Since they almost never remember these events, it is impossible to decide if they actually recognized a void or understand what was said. However, as a rule, it is good to talk to and about people in coma as though they could hear and understand what was being said.

 

Q: Are Coma and Brain death same thing?

A: No. Coma is decrease in brain function and thee is a chance that person may regain consciousness. Brain death is irreversible loss of brain function. There is no chance of recovery after brain death.

 

Q: Is the coma patient unconscious or asleep?

A: We believe that some level of consciousness is present as long as there is breath. And that we can communicate with people in any state of consciousness, including sleep or supposed unconsciousness. People with traumatic brain injury usually remain in a so called true coma for about two weeks to a month, where they have no sleep/wake cycle. They then change to a vigil coma, commonly called vegetative state, where they exhibit sleep/wake cycles, including opening and closing their eyes. The vigil coma is also known as minimal consciousness or severely altered consciousness. Patients in true coma may be more or less aware at any one time of what is happening around their beds. People in vegetative states or altered consciousness are more aware and less aware at times, like all of us. If possible, time your visits for their more aware times of day.

 

Q: How much can I touch the person in coma?

A: Touch is almost always beneficial. It is comforting and breaks the sense of isolation of the one in altered consciousness. Please introduce yourself and ask permission first! Tell the person what you are going to do and report as you are touching. For instance, “Now I’m going to touch your right forearm. Here comes. There.” And theotice feedback. All human rights apply to a person in coma. If you try a communication three times and notice no change in the patient, then change to something else or take a break.

 

Q: How important is knowing personal history of the person before onset of coma or altered consciousness?

A: It is useful to gather as much information as possible concerning the person’s physical, mental, and emotional well being before they entered coma. It is important to know these factors because if the person begins to return to everyday consciousness, they may be confronted with these circumstances once again, and they will need help navigating through their life.

 

When working with someone in coma or altered consciousness refrain from stressing personal history if you get no positive feedback, because the person may be relating to other things in their altered consciousness state. ~ Sometimes we just do not know the patient’s personal history, so must work only with what is presented in the moment through medical records, sensory grounded signals, and our own intuitive perceptions.

 

Q: How can coma work help patients, families, and caregivers?

A: Coma work furthers the internal and external communication of patients in altered consciousness. This can aid patients to complete inner work and spontaneously come closer to the surface, and at times even all the way out of coma or other altered consciousness. With metabolic comas emergence can be quick and dramatic. With coma from traumatic brain injury and other causes progress is usually slow, but measurable. Families and caregivers are often relieved to find ways to communicate with loved ones and clients about treatment options, life and death decisions, and love and personal connection. Family and caregivers often feel validated about their perceptions of subtle cues they have noticed.

 

Also as a caregiver or friend, please if you are able, take time to listen to the feelings of the family and friends without judgment. They may feel angry, incompetent, bereaved, guilty, overwhelmed, helpless, loving, etc. all at the same time, and may express their feelings in what seem irrational ways. Listen to them in a private place, rather than above the patient lying in bed. Commiserate, companion, and encourage. Suggest professional or pastoral counselling. Refer them to this and other coma work websites and reading materials.

 

Q: What are all the machines and tubes in and around the coma patient?

A: The machines around the bed are to monitor the patients’ progress and to keep them stable. Please ask the medical staff for further information on what they are and what they do. Some of the more common are:

 

Arterial line:

A very thin tube, which is attached to a monitor, is inserted into an artery usually in the arm. This allows measurement of the blood pressure and the concentration of oxygen and carbon dioxide in the blood.

 

Catheter:

This is a flexible tube for withdrawing fluids from or introducing fluids into the body and is frequently used to drain the urinary bladder.

Electrocardiogram (EKG):

This monitors the patient’s heart rate and rhythm. Round electrode pads are located on the chest and are linked to a monitor.

Intracranial pressure (ICP) monitor:

This measures the pressure within the brain and is attached to the patient’s skull.

Intravenous (IV):

Tubing inserted into a vein through which fluids and medications can be given.

Nasogastric tube:

A tube that passes through the patient’s nose and throat and ends in the stomach. This tube allows for direct “tube feeding” and removal of stomach acids, and is used for short term tube feeding.

Percutaneous endoscopic gastrostomy (PEG) tube:

Same function as the nasogastric tube, but directly through the stomach wall, used for long term tube feeding.

Respirator, ventilator:

A machine that does the breathing work for the patient. It delivers humidified air with the appropriate percentage of oxygen at the appropriate rate through an endotracheal tube.

Tracheostomy tube (trache):

A tube inserted into a surgical opening at the front of the throat providing access to the trachea and windpipe to assist in breathing.

 

Q: What will cause a coma when shot in the heart?

A: If you are shot in the heart you will most likely die. Coma would be induced medically so that they could intubate (put a tube down the trachea for artifical breathing). However with the loss of blood and insuffiency of the pump (the heart) there would not be enough circulating blood to get to the brain. The brain controls ALL bodily functions. With the brain getting fuel you will die.

 

Q: How can someone in a coma get pneumonia?

A: One family has a friend, who tried to kill himself this past saturday. He overdosed on pills. He was unconscious that night, and had to put him on Life Support. He has been in a coma since then but on Monday, they took him off it, with him surviving 24 breathes a minute. They discovered later on that he has pneumonia. I was wondering, out of all of this, how could he have got pneumonia?

 

He could have aspirated when he was unconscious on Saturday or later. Sometimes people take pills that make them unconscious, but they vomit and it goes from the esophagus (food tube) into the mouth and down the trachea (wind pipe) because they have no gag reflex because of the medications. Sometimes this happens even with saliva. If he was on a ventilator, he still could have aspirated (inhaled into his lungs) either vomit or saliva because even though the tube in the trachea has a balloon that is blown up to prevent this and to deliver oxygen without it leaking out through his mouth, liquid can still get around it. People on ventilators are heavily sedated and have no gag reflex. Also, pneumonia takes a day or two to show up on a chest xray and develop after this happens, because the chemical reaction or bacteria take a while to grow. It is no one’s fault and happens. Also, people in his condition, aren’t able to cough and clear their secretions like you or I do on a regular basis, so secretions settle and set him up for an infection. Unfortunately there are nosocomial (hospital acquired) infections in the hospital that can be passed from patient to patient which is less likely, however you or I being healthy, would not be likely to develope a pneumonia from it. This is less likely. Thankfully it is usually able to be treated. Take care.

 

Q: What causes a person to go into a coma if they got shot in the hand?

A: Blood loss can cause a person to become hypovolemic (loss of fluid) and it probably could. The only way  that much blood loss with a GSW to the hand is if it hit the wrist and tore through the radial artery. People have had amputations with very little blood loss due to the bloods ability to clot. If the hand got infected and caused sepsis then yes I can see them going into a coma. Sepsis is an infection of the blood and can be fatal. If caught early enough it is survive able.

 

Q: What usually happens to long term coma patients if they were to wake up?

A: Say someone was in a coma going on for six years now and there’s no reason to think he might wake up but he doesn’t need more than a nurses care to remain stable, would it be common or at least within the realm of possibility for the patient to be brought to a family members house to lower extended hospital costs? Also, is it true that they typically have no control over their bowels upon waking and for how long?

 

No, it would not be common for a patient like that to be out a long-term care facility. The person would be unable to eat and require tube feedings. They would be incontinent of urine and stool and likely require regular bowel care such as enemas to prevent constipation. They would require regular and frequent repositioning to avoid bedsores. Someone would have to be with the patient at all times.

 

All that being said, it is not impossible for a patient in this condition to be cared for in a home setting. It would just be very difficult and require extensive preparation.

 

The chances of someone who has been comatose for six years waking spontaneously is close to zero.

 

Q: What’s the different from being asleep, in a coma, or being dead?

A: I know when you are in a coma, you can hear but not responds. The heiress just died that was in a coma for twenty eight years. Why did it take so long before she died? Sleep is a natural state of bodily rest observed throughout the animal kingdom. A coma is a profound state of unconsciousness. A comatose person cannot be awakened, fails to respond normally to pain or light, does not have sleep-wake cycles, and does not take voluntary actions. Death is the permanent termination of the biological functions that define living organisms.

 

Q: How long are you hospitalized after a coma?

A: It all depends on progression of the patient.. they just don’t go… “well your 2 weeks is up.. time to check out” it all depends on the severity of the injuries.. and therapy. Also, depending on the hospital medical coverage has a big say.

 

Q: What are the chances of someone coming out of coma?

A: There are a lot of factors/variables that this type of condition entails. Sometimes people pull through, sometimes they don’t. There is a LOT of technology that can help the chances of a good outcome. Sometimes doctors will induce a coma medically to help the body rest and recuperate. Ask the Doc to be honest with you. He/She would be have more answers because like I said there are a lot of different variables to your friend’s condition.

 

Q: What are some possible causes of a 2+ week coma in an apparently healthy 22 year old male?

A: I am assuming this is hypothetical.

 

vascular events (CVA)

 

demyelination

 

infection, such as cerebral abcess

 

focal head injury

 

infection, such as meningitis or encephalitis

 

epilepsy

 

hypoxia and hypercarbia

 

drugs, poisoning and overdoses ( including alcohol)

 

metabolic/endocrine causes, such as diabetic coma, hepatic or renal failure, hypothyroidism, severe electrolyte disturbances

 

hypotension, or hypertensive crisis

 

diffuse head injury

 

subarachnoid haemorrhage

 

hypothermia, hyperthermia

 

sometimes, people just pretend !

 

Pick one! I personally will go with the electrolyte in-balance myself, due to loss of essential ‘salts’ during exercises. He may have drank too little water, or too much and created a saturation within his system.

 

 

 

The Coma CARE approach is deeply respectful of the individual and their inner journey. In our understanding, comas are an extreme altered state of consciousness in which the person is not relating to ordinary reality.

 

However, people in comas are experiencing potentially meaningful experiences and can often be reached through special communication methods.

 

Generally coma, from the Greek word “koma,” is understood to mean a deep sleep, a state of extreme unresponsiveness, in which an individual exhibits no voluntary movement or behaviour. Furthermore it is believed that in a deep coma, even painful stimuli (actions which, when performed on a healthy individual, result in reactions) are unable to affect any response, and normal reflexes may be lost.

 

Description

 

Coma lies on a spectrum with other altered states of consciousness. The level of consciousness required by, for example, someone reading this passage lies at one extreme end of the spectrum, while complete brain death lies at the other end of the spectrum. In between are such states as confusion, drowsiness and stupor. All of these are conditions which, unlike coma, still allow the individual to respond to stimuli, although such a response may be slowed down, brief in duration and require stimulus of longer thaormal duration and greater thaormal intensity.

 

In order to understand the loss of function suffered by a comatose individual, it is necessary to first understand the important characteristics of the conscious state. Consciousness is defined by two fundamental elements: awareness and arousal.

 

Awareness allows one to receive and process all the information communicated by the five senses and thus relate to oneself and to the outside world. Awareness has both psychological and physiological components. The psychological component is governed by an individual’s mind and mental processes. The physiological component refers to the functioning of an individual’s brain, and therefore that brain’s physical and chemical condition. Awareness is regulated by cortical areas within the cerebral hemispheres, the outermost layer of the brain that separates humans from other animals by allowing for greater intellectual functioning.

 

Arousal is regulated solely by physiological functioning, as demonstrated by predictable reflex (involuntary) responses to stimuli. Arousal is maintained by the reticular activating system (RAS). This is not an anatomical area of the brain, but rather a network of structures including the brainstem, the medulla, the thalamus and nerve pathways, which function together to produce and maintain arousal.

 

Causes and symptoms

 

Coma is the result of something that interferes with the functioning of the cerebral cortex and/or the functioning of the structures which make up the RAS. In fact, a huge and varied number of conditions can result in comas. A good way of categorizing these conditions is to consider the anatomic and the metabolic causes of coma. Anatomic causes of coma are those conditions that disrupt the normal physical architecture of the brain structures responsible for consciousness, either at the level of the cerebral cortex or the brainstem, while metabolic causes of coma consist of those conditions that change the chemical environment of the brain, thereby adversely affecting function.

 

There are many metabolic causes of coma, including:

The presence or absence of certain substances that disrupt the functioning of neurons.

Drugs or alcohol in toxic quantities can result in neuronal dysfunction, as can substances normally found in the body, but that, due to some diseased state, accumulate at toxic levels.

Electrolyte disorders (sodium, calcium, magnesium imbalance), inadequate glucose (sugar), acid-base disorders.

Hyposmolar states (uremia, ethanol alcohol, nonketotic hyperglycemic coma).

Hypoxia (lack of oxygen which can result in massive diffuse brain damage), carbon monoxide poisoning, carbon dioxide excess (due to severe asthma attack).

Hepatic (accumulated ammonia due to liver disease), uremia (from kidney dysfunction), hypertension, hypothyroidism, adrenal insufficiency, diabetes, thiamine deficiency.

Changes in chemical levels in the brain due to the electrical derangements caused by seizures.

 

Diagnosis

 

As in any neurological condition, history and examination from the cornerstone of diagnosis when the patient is in a coma. However, history must be obtained from family, friends and medical records.

 

The Glasgow Coma Scale is a system of examining a comatose patient. It is helpful for evaluating the depth of the coma, tracking the patient’s progress, and predicting (somewhat) the ultimate outcome of the coma. The Glasgow Coma Scale assigns a different number of points for exam results in three different categories:

Opening the eyes

Verbal response (using words or voice to respond)

Motor response (moving a part of the body).

 

Fifteen is the largest possible number of total points, indicating the highest level of functioning. The highest level of functioning would be demonstrated by an individual who spontaneously opens his/her eyes, gives appropriate answers to questions about his/her situation, and can carry out a command (such as “move your leg” or “nod your head”). Three is the least possible number of total points and would be given to a patient for whom not even a painful stimulus is sufficient to provoke a response. In the middle are those patients who may be able to respond, but who require an intense or painful stimulus, and whose response may demonstrate some degree of brain malfunctioning (such as a person whose only response to pain in a limb is to bend that limb in toward the body).

 

When performed as part of the admission examination, a Glasgow score of three to five points often suggests that the patient has likely suffered fatal brain damage, while eight or more points indicates that the patient’s chances for recovery are good. Expansion of the pupils and respiratory pattern are also important.

 

The reliability of the results from the use of any scales is dependent on enough time been given to the test as well as consistency through trained staff in their use. They indicate external observation and are not necessarily a record of internal experience. They are often used to diagnose the status of the coma patient and even a prognosis of their recovery and resultant treatment plan.

 

Metabolic causes of coma are diagnosed from blood work and urinalysis to evaluate blood chemistry, drug screen, and blood cell abnormalities that may indicate infection. Anatomic causes of coma are diagnosed from electroencephalogram, X-ray images, computerized tomography (CT) scans or magnetic resonance imaging (MRI).

 

Treatment

 

Comas are medical emergencies, and attention must first be directed to maintaining the patient’s respiration and circulation (possibly using intubation and ventilation), administration of intravenous fluids or blood (as needed) and other supportive care. If head trauma has not been excluded, the neck should be stabilized in the event of a possible fracture.

It is obviously extremely important for a physician to determine quickly the cause of a coma, so that potentially reversible conditions are treated immediately. For example: an infection may be treated with antibiotics, a brain tumour may be removed and brain swelling from an injury can be reduced with certain medications. Various metabolic disorders can be addressed by supplying the individual with the correct amount of oxygen, glucose, or sodium; by treating the underlying disease in liver disease, asthma, or diabetes; and by halting seizures with medication. Because of their low incidence of side effects and potential for prompt reversal of coma in certain conditions, glucose, the B-vitamin thiamine, and Narcan (to counteract any narcotic-type drugs) are routinely given.

 

Prognosis

 

Some conditions that cause comas can be completely reversed, restoring the individual to his or her original level of functioning. However, if areas of the brain have been sufficiently damaged due to the severity or duration of the condition which led to the coma, the individual may recover from the coma with permanent disabilities, or may eveever regain consciousness. Take, for example, the situation of someone whose coma was caused by brain injury in a car accident. Such an injury can result in one of three outcomes:

In the event of a less severe brain injury, with minimal swelling, an individual may indeed recover consciousness and regain all of his or her original abilities.

In the event of a more severe brain injury, with swelling that resulted in further pressure on areas of the brain, an individual may regain consciousness, but may have some degree of impairment. The impairment may be physical (such as paralysis of a leg) or may even result in a change in the individual’s intellectual functioning and/or personality.

The most severe types of brain injury, short of death, result in states in which the individual loses most abilities to function and remains mainly unresponsive. An individual who has suffered such a severe brain injury may remain in a coma like state indefinitely. This condition is termed persistent or permanent vegetative state, an unpopular phrase amongst family members, care givers and some medical staff.

 

Outcome from a coma is therefore quite variable and depends a great deal on the cause and duration of the coma. In the case of drug poisonings, extremely high rates of recovery can be expected following prompt medical attention. Patients who have suffered head injuries tend to do better than those patients whose comas were caused by other types of medical illnesses.

 

Leaving out those people whose coma followed drug poisoning only about 15% of patients who remain in a coma for more than just a few hours make a good recovery. Those adult patients who remain in a coma for greater than four weeks have almost no chance of eventually regaining their previous level of functioning. This makes it incumbent on family, friends, and coma care givers to relate to and work with patients as soon as medically possible. This means after major brain swelling has gone down in traumatic brain injury situations. On the other hand, children and young adults have regained functioning even after two months in a coma.[1]

 

And there are those few individuals, who regain consciousness after years in so called permanent vegetative states. Patients in all of the above situations can benefit from Coma CARE to expand their potential to the maximum.

 

Latest Brain Research

 

Modern technological brain research is catching up to our abilities to medically sustain life. Doctors Nicholas D. Schiff and Joy Hirsch have been conducting research utilizing functional magnetic resonance imaging (fMRI) with people in permanent vegetative states at the Centre for Head Injuries at the J.F.K Johnson Rehabilitation Institute in Edison, New Jersey. With one young man who had been in coma for over four years, they saw little on his fMRI to indicate any meaningful mental life. They played a tape of his sister speaking to him and later analysed the images. They found nothing missing from his brain functioning. The young man’s brain behaved identically to a healthy person’s.[2]

 

Coma CARE Approach

 

Findings like these have significant implications for administering Coma CARE, with our belief that as long as there is breath there is some form of consciousness and reason to hope for communication and growth.

This article was
excerpted from 

“Coma – A Healing Journey”
by Dr. Amy Mindell
 

Coma – A Healing Journey by Amy Mindell, Ph.D.

Recent advancements in medical technology have made it possible in some cases to keep someone alive longer than would have been possible even ten years ago. Yet, along with these remarkable developments, we are presented with new and serious difficulties. Vital functions can be maintained mechanically; at the same time, new and complex questions arise about the ethical and emotional issues concerning the continuance or discontinuance of life support, the type and extent of care for a person in a persistent vegetative state, where a person on life support should be cared for, long-term care issues associated with managed care in the United States, and insurance issues.

Many of the people who survive brain injuries are between eighteen and twenty-four years of age, have vital young bodies, and may need long-term care. For families, frustration and anguish are further exacerbated by questions about the best form of care, insurance coverage, and moving the comatose person from site to site — not to mention the “baseline” trauma of the family resulting from the loved one’s sudden coma, and their reliance on the predictions of medical staff about outcome.

Although far more people are in long-term vegetative states today than in the past, most caregivers know little more about how to communicate with these individuals than people knew centuries ago. Medical staff rarely have enough time to communicate effectually with a comatose person and — more to the point — are not trained in interacting with people in altered states of consciousness.

This lack of training may stem from the prevalent viewpoint in the field of medicine, in which altered states of consciousness such as coma have not been understood as meaningful aspects of our experience. The comatose person is assumed to be unconscious and unaware. In general, modern medical interventions for coma emphasize the importance of focusing on sustaining life and arousing people from the comatose state. If the person does not awaken or does not respond to questions, the situation is sometimes viewed as a medical failure, a factor further depressing everyone involved.

Currently, we do not have methods of communicating with someone in this state and helping that person follow her inner experiences. Because we are unable to communicate directly with her, no one is ever really certain about the comatose person’s wishes. This results in greater stress and agony for all. An updated training must include special methods geared toward sensitively communicating with the person in this all-too-frequent state of consciousness. We have been encouraged by positive feedback from professional caregivers who have applied our coma methods successfully.

The advent of home hospice care has reminded us of the possibility of creating a warmer, more intimate environment for those in the last stages of life, many of whom may fall into a coma at some point. Hospice care helpers offer loving support and care; yet, family members and friends may be unprepared for — and afraid of — a home-based hospice situation. 

Most of us are unaccustomed to being with people who are in comatose states or near-death conditions. If you are assisting a loved one who is in a comatose state, in addition to the medical issues, you also must contend with pressing personal concerns, such as feeling fearful and uncertain about being with someone who is in a coma, perhaps suffering anguish yourself about your loved one who is “hanging on” so long. Even basic questions can tax you: “Should I stay in the room all the time?” “Will she ever wake up?” “How can I communicate with him now that he is so far away?” “Can the person hear me?” “How do I deal with the possible death of this person I love?”

We ponder unfinished relationship issues, religious beliefs, family ties and separations, hopes of recovery, or relief from pain. Much of our distress comes about because we do not know what the person in coma is experiencing.

 

Process-Oriented View: A Path with Heart

The process-oriented view of comatose states is that they are due to mechanical and chemical problems and that they reflect deep, altered states of consciousness in which the person is going through potentially meaningful inner experiences. We do not focus on the comatose person solely from the viewpoint of pathology — that the person is ill and must be healed — but from a phenomenological viewpoint. That is, we observe and try to assist the person’s inner experiences. People do not operate as simply as machines that can break down and be repaired; people are full of potential growth in all states of consciousness — even up to and perhaps beyond the moment of death. 

Some people in coma may be unconsciously searching for the chance to go deeply inside without the disturbances of, or having to relate to, everyday life. In coma work, we assume that if the heart is still beating, we should make the attempt to communicate and not rule out the possibility of reaching these little-known corners of life.

Comatose individuals inevitably appreciate the assistance of someone who is able to relate to them in special ways and who lovingly assists them in following and unfolding inner experiences. Coma work makes it possible for individuals in coma to communicate with a helper if they like, and to have a voice in decisions about their care.

I remember a particularly moving case Arny told me about. He was working with a six-year-old European boy who had a brain tumor and had fallen into a coma. The boy was expected to die very soon. Arny used special communication methods he had developed to ask the boy yes-and-no questions and receive answers. Arny had noticed that the skin on the boy’s cheeks would sometimes turn very red. Arny set up a communication system: when the skin became very red, this meant yes. When there was no color change, the answer was no. He asked the boy a number of basic children’s questions:

·                     “Are you in a coma because you hate your brother and sister?” No response.

·                     “Are you in a coma because you don’t want to go to school?” No response.

After exhausting many possibilities, Arny asked his last question:

·                     “Are you in a coma because you want to be closer to God?” The little boy’s cheeks grew bright red. At that point the father said, “No! He cannot become a priest!”

What a shock! Arny asked the parents to step outside so he could continue to discuss with the child his religious desires. Later, he talked with the parents about their opposition to their son becoming a priest. A number of weeks later, Arny heard that the child had come out of the coma, and today he is studying theology at a university.

Further material on: Communication and Love as Goals; and How to Communicate with Comatose People. 

 

 

 

Sources of information:

1.     American Heart Association in collaboration with the International Liaison Committee on Resuscitation (ILCOR)/ International Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. A Consensus on Science // Resuscitation. – 2000. – 46. – P. 103 – 252.

2.     European Resuscitation Council. Immediate life support. 1- st Edition. Published by European Resuscitation Council Secretariat VZW, 2006.

3.     Lattore F., Nolan J., Robertson C. et al. The ALS working group of the European Resuscitation Council. The European Resuscitation Council Guidelines 2000 for Adult Advanced Life Support Resuscitation. 2000. – 48. – P. 211 – 212.

4.     Safar P, Bircher NG. Cardiopulmonary and cerebral resuscitation. 3rd ed. London: WB Saunders, 1988.

5.      John Campbell. International Trauma Life Support. USA. New Jersey 2008. P. 289.

 

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18.      http://pidruchniki.ws/17540906/bzhd/samodopomoga_vzayemodopomoga_nadzvichaynih_

19.       http://www.bibliofond.ru/view.aspx?id=492657.