brain, spinal cord, and nerve disorders
Stupor and Coma
Treatment of Stupor and Coma
Measures to help people breathe and to improve blood flow to the brain Treatment of the cause If a person is rapidly becoming less alert and more difficult to arouse, immediate treatment is required, often before a diagnosis is made. This rapid deterioration in consciousness is considered a medical emergency. The first steps in treatment, sometimes done by emergency medical personnel, are to check Whether the airway is open Whether breathing is adequate Whether pulse, blood pressure, and heart rate are normal (to make sure blood is reaching the brain) If possible, any problems present are corrected. People are treated first in an emergency department and then admitted to a hospital intensive care unit. In both places, nurses can monitor heart rate, blood pressure, temperature, and the oxygen level in the blood. Any abnormalities in these measurements are immediately corrected to prevent further damage to the brain. Oxygen is often given immediately, and a tube is inserted into a vein (an intravenous line) so that drugs or sugar (glucose) can be given quickly. If people have a very high or low body temperature, measures are taken to cool ( Treatment ) or warm them ( Blood pressure is closely monitored to make sure it is not too high or too low. High blood pressure can further impair consciousness and lead to other problems, such as stroke. Low blood pressure can impair consciousness because the brain does not get enough blood and oxygen. The cause of stupor or coma is treated when possible. glucose (a sugar) is immediately given intravenously. Giving glucose often results in instant recovery if the coma is caused by a low blood sugar level. Thiamin is always given with glucose because if people are undernourished (usually because of alcohol abuse), glucose alone can trigger or worsen a brain disorder called Wernicke Encephalopathy . If ahead injuryis the cause, the neck must be immobilized until doctors can check for damage to the spine. Some people in a stupor or coma after a head injury benefit from treatment with drugs that can help nerve cells function better, such asamantadine. Such treatment may help people regain some level of function more quickly. However, such treatment may not make any difference in improvement over the long term. Ifopioidoverdose is suspected, the antidotenaloxoneis given. Recovery may be almost immediate if the opioid is the only cause of impaired consciousness. If people take opioids, their doctor may prescribe analoxoneauto-injector for them. This device enables a family member or other caregiver to give themnaloxoneimmediately if an opioid overdose is suspected. Rarely, when a person may have ingestedcertain toxic substancesor drugs within about 1 hour, doctors may insert a large tube through the person's mouth and into the stomach so that the stomach can be pumped. Pumping the stomach is done to identify its contents and to prevent more of the substances from being absorbed. Activated charcoal may also be given through the tube or through a smaller tube inserted through the nose (nasogastric tube). The charcoal prevents the stomach from absorbing more of the substances. People in a deep stupor or a coma typically require a breathing tube and Mechanical Ventilation . Mechanical ventilation is especially important if breathing is too slow or shallow or otherwise impaired (for example, because the brain is damaged or malfunctions). The breathing tube is inserted through the mouth and into the windpipe (trachea)—called endotracheal intubation. Oxygen is delivered directly into the lungs through the tube. The tube also prevents people from inhaling stomach contents after vomiting. Before inserting the tube, doctors may spray the person's throat with a numbing spray or give the person a drug to prevent the muscles from contracting involuntarily (a paralytic drug). The tube is then attached to a mechanical ventilator. Mechanical ventilation can cause agitation, which can be treated with a sedative. If the pressure within the skull (intracranial pressure) is increased, the following measures may be taken to lower it: The head of the bed may be elevated. Mechanical ventilation may be used to help people breathe faster (called hyperventilation), particularly during the first half hour it is used. Breathing faster removes carbon dioxide from the lungs and reduces the level of carbon dioxide in the blood. As a result, blood vessels in the undamaged part of the brain narrow, and less blood reaches the brain. This measure quickly but temporarily lowers pressure within the skull (for about 30 minutes) and does not damage the brain further. Lowering the pressure for a time gives doctors time to start to treat the cause—for example, to do emergency brain surgery. Diuretics or other drugs may be used to reduce fluids in the brain and rest of the body. Diuretics help eliminate excess fluid by causing the kidneys to excrete more sodium and water into urine. A sedative may be given to control excess involuntary muscle contractions or agitation caused by mechanical ventilation. These problems can increase pressure within the skull. Blood pressure is lowered if it is very high. Sometimes doctors insert a drain (shunt) into the ventricles of the brain to drain cerebrospinal fluid. Removing excess fluid can help lower pressure within the skull. If pressure is increased because of a brain tumor or abscess, corticosteroids, such asdexamethasone, may help reduce pressure. However, corticosteroids are not used when increased pressure is caused by certain other disorders, such as intracerebral hemorrhage or a stroke, because corticosteroids may make these conditions worse. If other measures do not work, the following may be tried: When pressure within the skull is increased after a head injury or cardiac arrest, measures to lower body temperature may be tried. These measures may help some people who have had cardiac arrest. However, use of this measure is controversial. Pentobarbital(a barbiturate) may be used to reduce blood flow to the brain and brain activity. This treatment may improve the prognosis for some people. However, it is not beneficial for everyone, and it has side effects, such as low blood pressure and abnormal heart rhythms. The skull may be opened surgically (craniectomy), creating more room for the swollen brain and thus reducing pressure on the brain. This treatment can prevent death, but it may not improve a person's ability to function. People in a coma require comprehensive care. They are fed through a tube inserted through the nose and into the stomach (called Tube Feeding ). Sometimes they are fed through a tube inserted directly into the stomach or small intestine through an incision in the abdomen. Drugs may also be given through these tubes. Many problems result from being unable to move (immobility), and measures to prevent them are essential (see Problems Due to Bed Rest ). For example, the following can happen: Pressure Sores : Weak muscles:When muscles are not used, they waste away (atrophy) and become weak. People with muscle weakness may have trouble breathing on their own when they are taken off the ventilator. Contractures:Lack of movement can also lead to permanent stiffening and shortening of muscles (contractures) causing joints to become permanently bent. Lack of movement makes blood clots more likely to form in leg veins. The blood clots can break off, travel to the lungs, and block arteries there (called Pulmonary Embolism (PE) ). Damage to muscles and nerves in the arms and legs:Lack of movement or lying in one position for a long time can put pressure on a nerve that runs close to the surface of the body near a prominent bone, such as a nerve in an elbow, a shoulder, a wrist, or a knee. Such pressure can injure the nerve. As a result, the muscles that the nerve controls function less well. Pressure sores can be prevented by frequently repositioning the person and placing protective padding under parts of the body that are in contact with the bed, such as the heels, to protect them. To prevent contractures, physical therapists gently move the person’s joints in all directions (passive range-of-motion exercises) or splint joints in certain positions. Starting physical therapy early can help people who have not been able to move recover function. Preventing blood clots includes use of drugs and compression or elevation of the person's legs. Moving the limbs, as occurs in passive-range-of-motion exercises, may also help prevent blood clots. Because people cannot blink, their eyes may become dry. Eye drops can help. If people are incontinent, care should be taken to keep the skin clean and dry. If the bladder is not functioning and urine is being retained, a tube (catheter) may be placed in the bladder to drain urine. Catheters are carefully cleaned and regularly examined to prevent urinary tract infections from developing. 