1 First aid at the comatose states.

2 Coma is a state of unconsciousness with violation of reflex activity, vital functions and systems and nonresponsiveness to external and internal stimulus. Coma is a state of unconsciousness with violation of reflex activity, vital functions and systems and nonresponsiveness to external and internal stimulus. In deep coma condition patient can not be “waked” even with strong stimulus. In deep coma condition patient can not be “waked” even with strong stimulus.

3 In most cases coma is a complication, sometimes a terminal stage of disease, internal or external intoxication (kidney, liver failure). Often coma is a consequence of primary head injury (craniocerebral injury, metabolic violations). Especially grave and deep is coma in terminal conditions (preagony, agony, clinical death). In most cases coma is a complication, sometimes a terminal stage of disease, internal or external intoxication (kidney, liver failure). Often coma is a consequence of primary head injury (craniocerebral injury, metabolic violations). Especially grave and deep is coma in terminal conditions (preagony, agony, clinical death).

4 Clinic. In spite of different nature and development mechanism of different coma states, their clinical presentations have much in common. The most typical symptoms are: unconsciousness, changing of reflex response (rise, lowering, and lack), lowering or rising of muscular tonus with falling of tongue, disorders of breathing (breathing of Biota, Chain- Stocks, Cussmaul, hypo and hyperventilation, respiratory standstill), disorders of swallowing. Often there also is lowering of blood pressure, pulse violations, olig- and anuria, disorders of water metabolism (dehydration, hyperhydration), electrolytic balance (hypokalemia, hyperkalemia, hypernatremia, e.c.t.) acid-base balance, thermal regulation. Clinic. In spite of different nature and development mechanism of different coma states, their clinical presentations have much in common. The most typical symptoms are: unconsciousness, changing of reflex response (rise, lowering, and lack), lowering or rising of muscular tonus with falling of tongue, disorders of breathing (breathing of Biota, Chain- Stocks, Cussmaul, hypo and hyperventilation, respiratory standstill), disorders of swallowing. Often there also is lowering of blood pressure, pulse violations, olig- and anuria, disorders of water metabolism (dehydration, hyperhydration), electrolytic balance (hypokalemia, hyperkalemia, hypernatremia, e.c.t.) acid-base balance, thermal regulation.

5 There are several coma classifications: according to the etiology, pathogenesis, deepness and gravity of CNS injury. There are several coma classifications: according to the etiology, pathogenesis, deepness and gravity of CNS injury. The last one is the most common. The last one is the most common.

6 Light coma. Light coma. Patient is unconsciousness, he doesn’t move and answer the questions, protecting reactions are adequate, corneal and tendon reflexes, reaction of pupil to the light are present (but might be lowered), breathing and circulation are normal. Patient is unconsciousness, he doesn’t move and answer the questions, protecting reactions are adequate, corneal and tendon reflexes, reaction of pupil to the light are present (but might be lowered), breathing and circulation are normal. Manifested coma. Manifested coma. Patient is unconsciousness; there might be not coordinated movements, trunk symptoms (violations of swallowing), violations of breathing (pathological rhythm), circulation, and function of pelvic organs. Patient is unconsciousness; there might be not coordinated movements, trunk symptoms (violations of swallowing), violations of breathing (pathological rhythm), circulation, and function of pelvic organs.

7 Deep coma. Deep coma. Patient is unconsciousness, protecting reactions are lost, there is lack of corneal reflex, muscular atony, areflexia, often hypothermia, and hard breathing and circulation disorders, disorders of internal organs’ functions. Patient is unconsciousness, protecting reactions are lost, there is lack of corneal reflex, muscular atony, areflexia, often hypothermia, and hard breathing and circulation disorders, disorders of internal organs’ functions. Terminal coma. Terminal coma. Patient is unconsciousness, protecting reactions are lost, there is areflexia, mydriasis, critical disorder of vital functions (blood pressure is minimal or absent, apnoea), what needs special measures for correction of life functions. Patient is unconsciousness, protecting reactions are lost, there is areflexia, mydriasis, critical disorder of vital functions (blood pressure is minimal or absent, apnoea), what needs special measures for correction of life functions.

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12 Glasgow Coma Scale Clinical featuresPoints Eyes opening Spontaneous To the verbal stimulus To the pain stimulus No Movement React verbal commands Purposeful reaction to pain Not purposeful reaction to pain Tonic flexion to the pain Tonic extension to the pain No Language Oriented Tangled Incomprehensible words Incomprehensible sounds No

13 According to the Glasgow Coma Scale clinical features are pointed. To receive the information you need to summarize the points. The highest score means the lowest rate of CNS inhibition. If the sum is: According to the Glasgow Coma Scale clinical features are pointed. To receive the information you need to summarize the points. The highest score means the lowest rate of CNS inhibition. If the sum is: 15 – no coma; 15 – no coma; – torpor – torpor – spoor – spoor 4-9 – coma 4-9 – coma 3 – death of brain 3 – death of brain

14 One of the main purposes of coma treatment is maximal blood oxygenation for the prophylactic of hypoxia. That is why 100% Oxygen is used. Another important detail is providing of air path. If pulmonary ventilation is not effective or deepness of coma is <8 points ALV is started. One of the main purposes of coma treatment is maximal blood oxygenation for the prophylactic of hypoxia. That is why 100% Oxygen is used. Another important detail is providing of air path. If pulmonary ventilation is not effective or deepness of coma is <8 points ALV is started. If necessary, intubation and gastric tubes are used. Gastric contents are especially important in case of poisonings. If necessary, intubation and gastric tubes are used. Gastric contents are especially important in case of poisonings.

15 Ketoacidosis Ketoacidosis The main principle of this diabetes complication is correct dosage measurement of insulin and correction of water-electrolytic balance. Therapy is started with the checking of the glycemia level and i/v injection of insulin. The main principle of this diabetes complication is correct dosage measurement of insulin and correction of water-electrolytic balance. Therapy is started with the checking of the glycemia level and i/v injection of insulin.

16 To correct the violations of water- electrolytic balance and with the purpose of acute lowering of plasma osmolarity first of all immediately isotonic solution of 0,9% NaCl and Ringer-solution are injected. Insulin is used with the speed of 6-10 AU, but glucose level should be measured every hour. To correct the violations of water- electrolytic balance and with the purpose of acute lowering of plasma osmolarity first of all immediately isotonic solution of 0,9% NaCl and Ringer-solution are injected. Insulin is used with the speed of 6-10 AU, but glucose level should be measured every hour.

17 Hyperosmolar non ketoacidic coma. Hyperosmolar non ketoacidic coma. This type of coma is characterized with absence of metabolic acidosis and ketonuria in addition to high hyperosmolarity of blood plasma (because of the hyperglycemia it might be nearly mosmol/l). In this condition might appear convulsions. For the treatment are used: insulin, large infusions of isotonic solutions and electrolytic correction. This type of coma is characterized with absence of metabolic acidosis and ketonuria in addition to high hyperosmolarity of blood plasma (because of the hyperglycemia it might be nearly mosmol/l). In this condition might appear convulsions. For the treatment are used: insulin, large infusions of isotonic solutions and electrolytic correction.

18 Hypoglycemic coma. Hypoglycemic coma. This condition might develop as a consequence of insulin overdose (or other ant diabetes medicines) or tumors of pancreatic islands. The level of blood glucose might be 2,2 mmol and lower. This condition might develop as a consequence of insulin overdose (or other ant diabetes medicines) or tumors of pancreatic islands. The level of blood glucose might be 2,2 mmol and lower.

19 Features of hypoglycemia: Features of hypoglycemia: sudden appearance of strange or aggressive behavior of the patient; sudden appearance of strange or aggressive behavior of the patient; sudden unconsciousness of patient, who takes insulin; sudden unconsciousness of patient, who takes insulin; hyperhidrosis, tachycardia, hard pulse, paleness; hyperhidrosis, tachycardia, hard pulse, paleness; pathological neurology symptoms, e.g. Babinskyi, hemiparesis, which disappear soon during the treatment. pathological neurology symptoms, e.g. Babinskyi, hemiparesis, which disappear soon during the treatment.

20 The diagnostic of the hypoglycaemic coma might be a difficult task, as it’s difficult task to take the anamnesis (e.g. to prove the fact of diabetes and insulin treatment). The diagnostic of the hypoglycaemic coma might be a difficult task, as it’s difficult task to take the anamnesis (e.g. to prove the fact of diabetes and insulin treatment). I f diagnosis of hypoglycemia is doubtful; the patient should be treated and diagnosed with the i/v injection of ml of 40% glucose solution. If the reason of coma was hypoglycemia, patient will become consciousness in few minutes. I f diagnosis of hypoglycemia is doubtful; the patient should be treated and diagnosed with the i/v injection of ml of 40% glucose solution. If the reason of coma was hypoglycemia, patient will become consciousness in few minutes.

21 Thank you for attention!