Therapy of comatose states

Etiotropic therapy: elimination of the cause

The main goal of this stage is to stop or maximally weaken the effect of the factor that led to the development of the coma. Medical tactics strictly depend on the underlying cause of the condition:

• Traumatic coma: the primary task is to eliminate the damaging factor itself and its consequences. Adequate analgesia using analgesics or local anesthetics is mandatory, and if necessary, the patient is transferred to general anesthesia.
• Exogenous poisonings: administration of specific antidotes and antitoxins, gastric lavage, and stimulation of toxin excretion using diuretics (forced diuresis) are indicated.
• Diabetic comas: the basis is the administration of a calculated dose of insulin. To avoid a sharp drop in blood sugar levels, parenteral infusion of a dextrose (glucose) solution is performed in parallel to prevent hypoglycemic coma.
• Infectious genesis: antibiotic therapy, sulfonamides, and antiseptics specific to the microflora of the intestines or urinary tract are prescribed.

Pathogenetic therapy: breaking the vicious cycle

This is the absolute foundation of managing a comatose patient. The specialist's task is to block key links of pathogenesis: hypoxia, acid-base balance (ABB) shifts, water-ion imbalance, and the action of biologically active substances.

Antihypoxic therapy includes mechanical ventilation (MV), oxygen therapy with gas mixtures containing elevated oxygen levels, and hyperbaric oxygenation. Antioxidants (selenium preparations, glutathione, ubiquinone) and enzymes (catalase, superoxide dismutase) must be used. In parallel, vascular tone and cardiac function are normalized.

Combating intoxication

Divided into two mutually complementary directions:

1. Desintoxication therapy: aimed at reducing the degree of bodily poisoning. For this, blood plasma transfusions, plasma substitutes, and the infusion of isotonic sodium chloride solution are used.
2. Detoxification therapy: ensures the physical excretion of toxins and excess fluid. For this purpose, intravenous solutions with high-molecular organic compounds (Dextran with a medium molecular weight of 50,000–70,000 — Polyglucin, and 30,000–40,000 — Rheopolyglucin) are administered. An effective method is the combination of massive infusion therapy with diuretics. In extremely severe situations (uremic coma), switching to hardware purification—hemodialysis or peritoneal dialysis—is undertaken.

Correction of homeostasis and support of organ functions

The most critical stage is the restoration of ABB indicators, fluid balance, and ions. Buffer solutions with the required electrolyte content are used for this. Their selection is carried out strictly individually, based on laboratory data. Transfusion therapy (transfusion of blood components, plasma substitutes) is also applied.

To normalize the functioning of the heart, kidneys, and brain, optimization of the effects of biologically active substances (BAS) is carried out via replacement therapy. The patient is administered deficient adrenal hormones (glucocorticoids, mineralocorticoids, androgenic steroids, catecholamines), pancreatic hormones (insulin, glucagon), and neurotransmitters (acetylcholine, norepinephrine).

Symptomatic therapy and monitoring

Symptomatic treatment aims to optimize the functions of all systems, as well as to eliminate seizures, pain, and other distressing sensations in the precomatose and postcomatose periods. The physician uses anticonvulsants, painkillers (up to narcotic analgesics), cardiotropic and vasoactive drugs, as well as respiratory analeptics.

Given the extreme severity of regulatory disorders, continuous recording of vital functions is absolutely essential. Medical personnel perform continuous monitoring of:

• Cardiac activity.
• Respiration parameters.
• Renal excretory function.
• Level of consciousness and key homeostasis parameters.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Mechanisms of action of antioxidants (glutathione, selenium, superoxide dismutase) in brain tissue hypoxia.
• Features of using high-molecular dextrans (Polyglucin, Rheopolyglucin) for detoxification.
• Laboratory criteria for the individualized selection of buffer solutions in ABB disorders.
• Hormone replacement therapy: the role of glucocorticoids and catecholamines in hemodynamic stabilization.
• Techniques and risks of performing forced diuresis in exogenous poisonings.

Other topics in "Chapter 20. Extreme and Terminal States"

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