A condition characterized by a loss of cognitive activity and complete indifference that has arisen as a result of dysfunction of the cerebral cortex is called apallic syndrome. This term was introduced into medicine in 1940 by the German psychiatrist E. Kretschmer.
Causes
Most often, an awake coma (this is the second name of the ailment considered in this article) occurs after a serious head injury. Often, a similar pathological disorder develops as a result of hypoxic, toxic, metabolic, vascular, infectious and other brain injuries. It was noted that this disease is diagnosed in 14% of patients in a prolonged traumatic coma. Apallic syndrome in a child most often occurs after meningoencephalitis, resuscitation, traumatic brain injury. In this case, the disease can develop quite slowly, within 2-3 months or even years. In patients who are in a coma of non-traumatic origin, a similar condition is associated with structural damage to the basal nuclei and cortex with relative preservation of the brain stem.
Clinical picture
Symptoms of this pathology become noticeable only after the patient leaves the coma. During this period, wakefulness is restored. As a rule, the eyes of a person diagnosed with apallic syndrome are open. He easily rotates them, but his gaze does not fix. There are no emotional reactions and speech. Contact with such a person is impossible, since verbal commands are not perceived by them. In more severe cases, the patient is bedridden, he makes chaotic movements with limbs. Often in patients with this pathology, paralysis, paresis, hyperkinesis, oculomotor disorders occur. This is due to the fact that in severe cases, the disease spreads to the stem and subcortical structures of the brain. At the same time, patients experience responses to various kinds of stimuli, most often painful ones, in the form of shouting of individual sounds or sudden movements. In some cases, the manifestation of grasping or oral reflexes is possible. The patient opens his mouth, and when approaching the face of objects protrudes his tongue. In this case, all vegetative functions, such as swallowing, heart function, breathing, sucking, excretion of feces and urine are preserved. A characteristic posture of a person diagnosed with apalic syndrome is that the hands are clenched into fists, the feet are in a state of plantar flexion. The face is amimic, sometimes yawning occurs. In the knee and elbow joints, slight bending is also noticeable. In patients in a waking coma, a change in the period of wakefulness and sleep, regardless of the time of day, is preserved.
Comprehensive diagnostics
Apallic syndrome (waking coma) is detected based on characteristic signs. Also, for the diagnosis of pathology, ultrasound examination of peripheral and main veins and arteries of the liver, head, limbs and kidneys is used. In addition, capillaroscopy of small vessels of the body, ECG-screening of ischemic changes in the heart muscle are performed. An assessment is made of the brain (electroencephalogram) and the state of adaptability of the vessels to emotional and physical stress, as well as a neurological and somatic examination.
Characteristics
On the EEG in the first few weeks, marked generalized changes are noted. And then for two to three months the predominance of theta activity remains. Six months later, alpha activity appears (with a low index). As a result of the study by computed tomography, atrophy of the brain is revealed, as well as ventricular expansion.
Apallic syndrome. Treatment
In the most severe cases, resuscitation measures are indicated . The methods of medical activity are determined by the characteristics of the clinic, the etiology of the disorder and the general condition of the patient.
Resuscitation and intensive care
The main directions in the treatment of this pathological condition is the normalization of the heart and breathing, blood pressure, homeostasis, hemodynamics (cerebral and general), the fight against cerebral edema and hypoxia. Patient care activities are very important. Throwing back the head, lowering the tongue should be avoided . Periodically, you should change the position of the patient's body (best of all - on the side), daily conduct a toilet of the nasopharynx, bronchi and oral cavity. The intensive observation unit monitors important indicators of the state of the body. These are blood pressure, pulse rate, EEG, body temperature, ECG, volume and frequency of respiration, as well as the acid state and gas composition of the blood. With severe respiratory failure, urgent intubation is performed, as well as artificial ventilation of the lungs (with heated and humidified air). To improve the properties of blood, plasma-replacing solutions are administered intravenously . This event is carried out under the control of venous pressure.
Prevention of ailment
Intensive resuscitation measures are necessary for patients who are in a coma for a long time to prevent the development of this syndrome. Such measures include stimulation of cardiac activity, mechanical ventilation, maintenance of blood pressure. In addition, it is recommended to use medications that activate brain metabolism and facilitate the transmission of impulses. Normal care and proper, and in some cases, parenteral nutrition is very important . A variety of symptomatic agents and vitamins should also be used.
Nursing
Feeding is best done through a percutaneous thin gastrostomy, and not through a probe. Since the latter option with prolonged use, significantly increases the risk of reflux, aspiration, ulceration and sinusitis. Monitor patient weight periodically. During feeding, the patient's body should be raised by 50-60 degrees. Food should contain proteins, vitamins and minerals, as well as saturated fatty acids. Calorie content is about 35 kcal / kg per day. To empty the intestines, it is recommended to use oral laxatives, but not more than three times a week, as well as rectal suppositories. If the patient has diarrhea, you should periodically give him “live” yoghurts and check from time to time to see if food stagnation has occurred in the stomach. To improve bowel function, foods containing large amounts of fiber should be included in the diet.
Patients with similar disorders are indicated for therapeutic massage. Some medical centers have a special rehabilitation program for people in an awake coma. It includes multisensory, physical and drug therapy, as well as a number of other methods with which you can defeat the apallic syndrome.
Forecast
Unfortunately, in most cases the outcome of this disease is unfavorable. However, it is also possible regredient course of the disease, up to almost complete restoration of functions. In the presence of progressive atrophic processes, which, as a rule, occur in older people, a state of decerebral rigidity may occur, characterized by the occurrence of seizures and other unpleasant symptoms.