notes by dr. Claudio Italiano
A coma is defined as a lasting loss of consciousness and other vital functions (motility,
sensitivity) including the vegetative functions that can sometimes be altered,
that is the breath and the cardioregulation activity. In summary it is due to
alteration of the central nervous system metabolism that we know depends on fuel
and oxidizing agent, that is glucose and oxygen, so when those factors of the
metabolism are no longer derives a suffering with the shutdown of the state of
vigilance and, therefore, the coma. But it is not that the subject immediately
falls into a deep coma, that is, it does not suddenly plunge into the deepest
state of torpor! Sometimes this happens gradually. But basically whenever the
brain no longer has glucose and oxygen, then in this case the coma
is determined. And let's see why.And let's see why.
Coma from intracranial lesions: on an inflammatory basis, eg meningitis,
encephalitis; on a vascular basis, for example, the stroke that may be ischemic
or hemorrhagic, ie due to blood that does not pass and does not "nourish" the
brain in a specific area, for example if there was an embolic event that
occluded a cerebral artery (see fibrillation and arrhythmias, source of embolism)
or if there was a rupture of a vessel in the brain, then a hemorrhage; traumatic,
species with lesions of the ascending reticular substance (see K.O. of boxers!),
or neoplastic. These are the most frequent causes.
And here the speech becomes more difficult, for example if we must speek about
the coma due to metabolic causes or intoxication;
The metabolic coma is due to the fact that the brain has no more glucose to use,
for example this occurrence is in the diabetic coma, when for the absolute
insulin deficiency the glucose does not enter the nerve cells and the cells go
into distress;
The hypoglycaemic coma represents the opposite case, when an excess of insulin
sends the blood sugar down, the classic example is represented by a patient who
is excessively self-medicated with insulin! He presents a drop in blood sugar and this is
an hypoglycemic coma; another reason for having a diabetic coma is when, due to a
tumor, a glycemic drop occurs.
The ketoacidotic coma instead is determined in the patient during hyperglycemia
due to increased metabolic needs in diabetes, especially during a febrile
episode or in the case of a child's fever, which burns the available glucose and
then burns the blood fat, which gives origin, in the metabolism to acid ketone
bodies.
The uremic coma is determined in the condition of renal failure, in the
glomerulopathies referred to in this site, leading to intoxication from
nitrogenous waste, until the collapse of metabolisms.
The hepatic coma is that of the terminal hepatic failure of the cirrhotic,
characterized by high ammonium and false transmitters in the circulation that
have depressing action on the Central Nervous System, or in the intoxication of
the witches that make toxic potions that cause abortion, for example the apiol.
The hypercapnic coma is that of the respiratory insufficiency of the patient,
when the lung is no longer able to exchange the respiratory gases and the
subject becomes drunk with carbon dioxide. In this condition where the carbon
dioxide is retained in the body, the pH of the blood is lowered, up to acid
values, a condition that is called respiratory acidosis. The partial pressure of
carbonic anhydrite is high and the coma is determined. Still the alcoholic coma
of the patient who drank alcohol, sedating with the action of alcohol the
Central nervous system, the coma of those who want to kill with barbiturates,
which is a kind of pharmacological coma, not what the anesthetist gets suitably
with anesthetic drugs and gases! The drug coma, for example, opiates! Finally
the heatstroke coma, with hyperpyrexia, see the sickness of summer.
However, the first thing to do is try to gather ideas, which are always few and
well confused, while the relatives surround you like Apaches and want the
miracles of St. Pius (!) While the doctor has to evaluate the etiology of the
coma and its depth layer. follows a concrete example.
Being available in the hospital, subjected to endless shifts, arrival on Sunday in the ward: a patient of 70 years is in a coma, operated a few days ago. After the surgery, he has not woken up again. The patient's relatives are nervous and protest against the doctors in the surgical ward. These to avoid legal problems preferred to transfer to me in the medical department the patient for continued subintensive care. Relatives circle me with big muscular arms and a threatening tone of voice. They gathered in the family to make a decision and demand the transfer of the patient in a neurosurgical environment with the first 118 passing helicopter, as they saw on TV in the Gray's Anatomy series.
The dott. Claudio Italiano and his personal
collaborator, S.Pio, with whom he has an incurable
debt, but this is another story!
I pray my collaborator S.Pio, I collect the ideas, I take a breath and I begin to visit the lady: hemogas in the
norm, blood sugar in the norm, ammoniemia in the norm, good analysis, soporous
but awakening patient, spiked pupils! Yes, spiked pupils! He had performed
various anesthesia and pain medications with opioids e.v. otherwise it was also
dehydrated. I ask for a brain CT scan: negative CT scan for ischemic-hemorrhagic
lesions. At this point my doctor's thinking is directed towards a metabolic coma
condition caused by dehydration and accumulation of sedative pharmacological
substances. Start to hydrate, correct saturation; the patient hydrates, urinates
more and begins to awaken more easily. After a few days he is alert and
collaborating. The relatives are happy and now they extend their arms and bring
the sweets for the department as a sign of affection and excuses. Problem:
that's why I'm becoming obese!
- Is it in spontaneous breathing? Did you check the hemogas and acid-base
balance?
- Cardiac activity, performed an ECG? Are there arrhythmias? The heart pump is
effective
- Is it? Is there liver failure?
- Do you use drugs? Did you want to kill? Did you take psychotropic drugs?
- Is he diabetic? Have you checked your blood sugar levels?
- Are the pupils dilated? Do you use cocaine? - Are the pupils spiked, small as
dots? Use heroin? Do you have signs of venipuncture?
-He was in excellent health, conversing and suddenly he said he was sick and he
collapsed, now his mouth is crooked and his arm and leg are omolateral and
flaccid? I think of a stroke.
- Is he vigilant, collaborating, oriented, that is, he speaks, knows you, knows
where he is, what time is it? Or not? Do you wake up if you pinch his shoulder?
-COMA I, called the coma vigilant, if the patient speaks, but with slow and
slurred speech, as if he were sleepy (and here eye open and you soon make a
diagnosis!); he wakes up if he is dozing, he hears noises, he feels the pain.
-COMA II, coma properly said, with weak reactivity, the patient reacts only to
intense pain, for example if you hold his chest in his hands to pinch it, the
corneal reflex fades to light;
-COMA III, or coma carus or deep, abolished reflexes, including swallowing (never
give water and sugar to resume a patient in a coma, because the patient is not
vigilant, not swallowed and could then present a bronchial pneumonia ab ingestis!)
-COMA IV: o coma surpassed or as depassè: the EEG is flat, the tendon reflexes
are abolished, there is tachycardia, hypotension and the patient is usually
assisted with the respirator, cfr resuscitation At this point they can also ask
relatives to donate the organs!
There have been and still are, at times, controversies and lawsuits about the
decision whether to keep long-time people in a coma alive with the aid of life
support machines, practicing therapeutic fury or detaching them from such aids
and practicing to them, in fact, a form of euthanasia, given the difficulty of
forecasting a reawakening even partial.
The most common cause of death for patients in a vegetative state is the
infections like pneumonia
-
Adrenal system of insufficiency of the adrenal gland with skin bronzin
-
Coma of Basedow's disease, see thyroid
-
Mixed myxedosis of hypothyroidism, see thyroid
-
Hyperparathyroidism coma with calcemia greater than 16 mg%
- Coma during a meningitis characterized by a patient with legs "rifle dog" bent signs of Kernig and
Brudzinski (neck stiffness, to patient supine, you can not bend the nape that is
tense and stiff and this maneuver is painful and the patient bends his legs ).
Babinski's sign: to the tickling of the sole of the foot, extends the fingers