昏迷-上海中醫(yī)藥大學(xué)

1、昏 迷coma,沈燕 2006－4－20,昏迷搶救18.rmvb,當(dāng)我們身邊突然出現(xiàn)疑似昏迷的病人時(shí)，鑒別病人是否昏迷最簡(jiǎn)單的辦法是…在護(hù)送病人去醫(yī)院途中，要注意做好……,?,用棉芯輕觸一下病人的角膜，正常人或輕癥病人都會(huì)出現(xiàn)眨眼動(dòng)作，而昏迷特別是深昏迷病人毫無(wú)反應(yīng)。當(dāng)確定病人昏迷時(shí)，應(yīng)盡快送病人到醫(yī)院搶救。,教學(xué)目標(biāo),了解： 昏迷量表的使用； 昏迷與暈厥、癔癥性昏睡、木僵狀態(tài)、閉鎖綜合征的鑒別診斷熟悉

2、： 昏迷的常見(jiàn)病因； 昏迷病人瞳孔的觀察,掌握： 昏迷的定義； 昏迷的臨床分級(jí)； 昏迷的急救護(hù)理,Definition,意識(shí)－－機(jī)體對(duì)自身及外界環(huán)境感知并能作出正確反應(yīng)的狀態(tài)。意識(shí)障礙－－機(jī)體對(duì)外界環(huán)境的刺激缺乏反應(yīng)的一種病理狀態(tài)?；杳裕菄?yán)重的意識(shí)障礙，其主要特征為隨意運(yùn)動(dòng)喪失，對(duì)外界刺激失去正常反應(yīng)并出現(xiàn)病理反射活動(dòng)。,判斷意識(shí)障礙程度disturbance of consciousness,區(qū)分

3、嗜睡、意識(shí)模糊、昏睡、昏迷嗜睡somnolence ：病人呈持續(xù)睡眠狀態(tài)，但可被輕度刺激喚醒，醒后能正確簡(jiǎn)單回答問(wèn)題，但反應(yīng)遲鈍。意識(shí)模糊confusion ：病人對(duì)時(shí)間、地點(diǎn)、人物的定向能力發(fā)生障礙，思維混亂，可有錯(cuò)覺(jué)、幻覺(jué)、精神錯(cuò)亂、譫妄等表現(xiàn)?；杷痵tupor ：病人處于沉睡狀態(tài)，僅能被壓眼眶、用力搖動(dòng)身體等較強(qiáng)刺激喚醒?；杳詂oma：是最嚴(yán)重的意識(shí)障礙。,Summary：,Disturbance of conscious

4、ness is impediment(障礙) of having an awareness of one’s environment and one’s own existence,sensations and thoughts.According to the degree of disturbance of consciousness, it can be divided: somno

5、lence, confusion, stupor,coma.,What is Coma and Persistent Vegetative State?,A coma is a profound or deep state of unconsciousness. An individual in a state of coma is alive but unable to move or respond to his environm

6、ent. Coma may occur as a complication of an underlying illness, or as a result of injuries, such as head trauma.,A persistent vegetative state ( “brain-death”) sometimes follows a coma. Individuals in such a state have l

7、ost their thinking abilities and awareness of their surroundings, but retain non-cognitive function and normal sleep patterns. Even though those in a persistent vegetative state lose their higher brain functions, other k

8、ey functions such as breathing and circulation remain relatively intact. Spontaneous movements may occur, and the eyes may open in response to external stimuli. They may even occasionally grimace(痛苦的表情), cry, or laugh.,E

9、tiology,1.顱內(nèi)病變 cerebral disease（1）顱內(nèi)感染：如腦膜炎 (meningitis) 等（2）顱腦疾患：腦膿腫；腦血管疾??；顱腦外傷；腦寄生蟲(chóng)?。话d癇、癲癇發(fā)作后昏迷。2.全身性疾病 general disease（1）急性感染性疾?。?）內(nèi)分泌與代謝障礙（3）水電解質(zhì)平衡紊亂（4）外因性中毒（5）物理性損害,Assessment,History collectionThe degree o

10、f disturbance of consciousnessVital signsLaboratory examinationDifferentiate diagnosis,History collection,發(fā)病方式：發(fā)病過(guò)程、時(shí)間急或緩首發(fā)癥狀伴隨癥狀發(fā)病年齡和季節(jié)發(fā)病現(xiàn)場(chǎng)病人思想情緒生活情況既往史,The degree of disturbance of consciousness昏迷程度的臨床分級(jí),淺昏迷：

11、病人的隨意運(yùn)動(dòng)喪失，對(duì)周?chē)挛锖吐曇?、?qiáng) 光等刺激均無(wú)反應(yīng)，僅對(duì)強(qiáng)烈的疼痛刺激，有 肢體簡(jiǎn)單的防御性運(yùn)動(dòng)和呻吟伴痛苦表情。各 種生理反射存在。脈搏、呼吸、血壓無(wú)明顯變 化?？沙霈F(xiàn)大小便潴留或失禁。中度昏迷：對(duì)周?chē)挛锛案鞣N刺激全無(wú)反應(yīng)，對(duì)劇烈刺 激偶可出現(xiàn) 防御反射。各種生理反射均減

12、 弱。脈搏、呼吸、血壓有所變化，大小便潴 留或失禁。深昏迷：全身肌肉松弛，對(duì)周?chē)挛锖透鞣N刺激全無(wú)反 應(yīng)，各種反射均消失。呼吸不規(guī)則，血壓下 降，大小便失禁。,The degree of disturbance of consciousness,格拉斯哥昏迷分級(jí)計(jì)分法（P187）,Vital signs,T

13、：體溫升高：如腦炎、腦膜炎等 急驟高熱提示腦干出血、中暑等 體溫過(guò)低：見(jiàn)于休克、低血糖等P：脈搏變慢見(jiàn)于顱內(nèi)壓增高等 脈搏增快見(jiàn)于高熱或感染性疾病等 脈搏先慢后快伴血壓下降考慮腦疝壓迫腦干R：呼吸深大見(jiàn)于代謝性酸中毒、糖尿病等 呼吸減弱見(jiàn)于肺功能不全、鎮(zhèn)靜劑中毒等 呼吸異常伴氣味異常,Vital

14、 signs,BP：血壓升高見(jiàn)于高血壓腦病等 血壓速降見(jiàn)于休克、心肌梗塞等 Pupil：雙側(cè)瞳孔散大：瀕死狀態(tài)、嚴(yán)重尿毒癥等雙側(cè)瞳孔縮?。河袡C(jī)磷類(lèi)農(nóng)藥中毒、腦橋出血等一側(cè)瞳孔散大：動(dòng)眼神經(jīng)麻痹、小腦幕切跡疝一側(cè)瞳孔縮?。耗X疝發(fā)生早期、頸交感神經(jīng)麻痹eyeground：視神經(jīng)乳頭水腫等,Vital signs,Meningeal signs：陽(yáng)性反應(yīng)見(jiàn)于蛛網(wǎng)膜下腔出血skin：紫紺提示缺氧

15、 櫻桃紅提示一氧化碳中毒 皮膚色素沉著:腎上腺皮質(zhì)功能減退mobility：深昏迷時(shí)肌張力完全松弛reflection：昏迷時(shí)雙側(cè)對(duì)稱性各種反射減弱或消失,Laboratory examination,routine：blood、urine、stool special：ECG、X線、B超,Differentiate diagnosis,暈厥 突然發(fā)生，短暫的意識(shí)喪

16、失狀態(tài)，是由于大腦一時(shí)性供血不足所致。癔癥性昏睡 表現(xiàn)為臥床不語(yǔ)、雙目緊閉，對(duì)針刺無(wú)反應(yīng)，但翻開(kāi)其眼瞼可見(jiàn)眼球轉(zhuǎn)動(dòng)。生命體征平穩(wěn)。木僵狀態(tài) 表現(xiàn)為不動(dòng)不語(yǔ)，不進(jìn)飲食，對(duì)外界刺激無(wú)反應(yīng)，甚至可出現(xiàn)瞳孔改變、尿潴留等癥狀，無(wú)意識(shí)障礙。閉鎖綜合征 表現(xiàn)為四肢癱瘓，不能張口、不能言語(yǔ)、眼球不能向兩側(cè)轉(zhuǎn)動(dòng)，但意識(shí)尚清。,Is there any treatment?,Once an individual is out o

17、f immediate danger, the medical care team focuses on preventing infections and maintaining a healthy physical state. This will often include preventing pneumonia and bedsores（褥瘡） and providing balanced nutrition. Physi

18、cal therapy may also be used to prevent contractures（攣縮）(permanent muscular contractions) and deformities （畸形）of the bones, joints, and muscles that would limit recovery for those who emerge from coma.,Nursing,observatio

19、n1. 病情嚴(yán)重者每15～30分鐘監(jiān)測(cè)一次生命體征2. 病情穩(wěn)定者每4小時(shí)一次Keep airway openKeep balance of water/electrolytes/acid-basse,Nursing,對(duì)癥處理1. 消除腦水腫：應(yīng)用高滲溶液脫水2.促進(jìn)腦功能恢復(fù)3.保持有效低溫冬眠療效 有效標(biāo)志：鎮(zhèn)靜好、但呼之能應(yīng)、病人對(duì)物理降溫?zé)o御寒反應(yīng)，體溫控制在預(yù)定范圍。 降溫的要求：早、低、足、穩(wěn)、緩,

20、Nursing,Etiology treatment1. 顱內(nèi)占位病變2. 腦中風(fēng)3. 藥物中毒4. 一氧化碳中毒、放射損傷5. 顱內(nèi)感染或全身感染6. 低血糖性昏迷、高血糖性昏迷7. 肝昏迷8. 糾正休克,Nursing,Preventing complications1. 口腔護(hù)理2. 防止墜積性肺炎3. 預(yù)防褥瘡4. 做好留置尿管的護(hù)理,What is the prognosis?,The outcome

21、for coma and persistent vegetative state depends on the cause, severity, and site of neurological damage. Individuals may emerge from coma with a combination of physical, intellectual, and psychological difficulties that

22、 need special attention.,Recovery usually occurs gradually, with some acquiring more and more ability to respond. Some individuals never progress beyond very basic responses, but many recover full awareness. Individuals

23、recovering from coma require close medical supervision. A coma rarely lasts more than 2 to 4 weeks. Some patients may regain a degree of awareness after persistent vegetative state. Others may remain in that state for ye

24、ars or even decades. The most common cause of death for someone in a persistent vegetative state is infection, such as pneumonia.,轉(zhuǎn)運(yùn)途中注意事項(xiàng),（1）病人平臥，頭側(cè)向一側(cè)，保持呼吸道通順。 （2）病人有活動(dòng)性假牙，應(yīng)立即取出以防誤入氣管。 （3）注意給病人保暖，防止受涼。 （4）密切觀察病情變化，經(jīng)