The term Disorder of consciousness / alteration of consciousness Refers to an alteration of the level of consciousness (obnubilation, stupor, coma, etc.) as well as to an alteration in the content of consciousness (temporal or spatial disorientation or difficulty in maintaining care). (De Castro, 2008).
In figures, between 30% and 40% of individuals suffering from severe brain damage have altered levels of consciousness. The causes of these alterations can be diverse, and originate by injuries at focal or diffuse level, concretely in the brainstem Or in related structures, such as the thalamus and association cortex (Mas-Sesé et al., 2015).
The most recent studies show that there is a significant increase in the number of patients with this type of condition after vascular lesions. This is due to the drastic reduction of the numbers of road accidents that were attended with serious head injuries.
In general, the figures tend to vary between studies, with 44% of cases of vascular origin and 72% of cases with a traumatic origin (Más-Sesé et al., 2015).
In Spain, the most frequent etiology is Stroke Since of the more than 400,000 people with acquired brain damage, 78% are due to this type of etiology (Mais-Sesé et al., 2015).
In addition, the suffering of this type of alterations represents a serious medical urgency. Correct diagnosis and treatment is essential to prevent them from triggering irreversible injuries or even death (Puerto-Gala et al., 2012)
Awareness
The term awareness Is defined as the state in which an individual has knowledge of himself and his environment (Puerto-Gala et al., 2012). However, in consciousness, the terms of Arousal Y Awareness Are essential in their definition.
- Arousal : Refers to the alert level as"being aware"and is responsible for maintaining the ability to stay awake and regulate the sleep-wake rhythm (Mas-Sesé et al., 2015).
- Awareness : Refers to the alert level as"being aware"and refers to the ability we have to detect the stimuli coming from the environment and be aware of them and ourselves (Mas-Sesé et al., 2015).
When we refer to altered consciousness, we can refer to both the level of activation or vigilance as well as the ability of the patient to interact with the offender.
Therefore, an individual may present a level alteration and present a state of dizziness, stupor or coma Or presenting an alteration of content presenting a disorientation, with or without delusional type ideas (De Castro, 2008).
Up to about mid-twentieth century no precise descriptions of alterations of consciousness were found beyond the first descriptions of Ronsenblath in 1899. It was in the 1940s that multiple references to these states began to appear with the discovery of structures of Reticular formation Of the brainstem (Mais-Sesé et al., 2015).
Thus, the role of SRA (Reticular activating system) in the regulation of alert levels. The ability to stay awake will depend on the correct functioning of the structures that make up this system (De Castro, 2008).
The capacity of human beings to think, perceive, respond to stimuli is due to the functioning of the cerebral cortex, but this will not show an efficient execution if the participation of other structures and without the maintenance of a state of Alert. When we are sleeping, it is necessary for the Cortex To wake us up (Hodelín-Tablada, 2002).
Any injury to the structures that make up it will lead to a decrease or loss of the level of consciousness (Castro, 2008). Consciousness is impossible if SRRA is seriously injured or harmed (Hodelín-Tablada, 2002).
States of decreased consciousness
The absence of response is not always comparable to a total loss of consciousness. For example, babies with botulism They do not present any type of response to stimulation, but they are still on alert (Puerto-Gala et al., 2012).
Therefore, awareness or level of activation can be represented in a continuum, from a mild state to a severe state of total absence of response. Thus, we can distinguish intermediate states between the waking state (alert) and the state of total absence of response (coma) (Puerto-Gala et al., 2012).
- Confusion : The individual is not able to think clearly and quickly. It responds to simple verbal commands, but shows difficulty with complex ones.
- Drowsiness : The patient is asleep, but can be awakened without difficulty in sensory or sensory stimuli and presents an adequate response to verbal commands, both simple and complex.
- Obnubilation : Responds to simple verbal commands and painful stimuli, but there is no adequate response to complex verbal commands.
- Stupor : Wakes up only with very intense and persistent stimuli and the verbal responses are slow or null; The patient makes some effort to avoid painful stimuli.
- Coma : Represents the maximum degree of alteration of the level of consciousness, and can vary in the level of gravity from the superficial (there is only response to deep painful stimuli with movement of the extremities) to the deep one (there is no response to painful stimuli nor presence of No kind of reflection).
- Brain death : Irreversible loss of all brain functions and inability to maintain autonomous breathing.
Coma
The term coma is used to define a state of diminished level of consciousness characterized by the absence of responses to external stimuli.
Normally, individuals present themselves in a closed-eyes state, with no signs of voluntary behavior or response to orders or any type of stimulation (Leon-Carrión, Domínguez-roldan, & Domínguez-Morales, 2001).
Etiology
Coma, from its definition, originates from a structural or functional (metabolic) dysfunction of the ascending reticular reticular system, but may also be the consequence of diffuse cortico-subcortical damages (De Castro, 2008).
Therefore, in the etiology of the coma can be distinguished numerous alterations that will give rise to the suffering of this one:
Between the Structural type injuries We can find cerebral haemorrhages, cerebral infarction, Subdural hematomas Y Epidurals , Brain tumors , Infectious and demilinating processes (Puerto-Gala et al., 2012).
On the other hand, alterations of Toxic metabolic type : Endogenous intoxications (liver, renal, adrenal insufficiency, hypercapnia, pancreatitis, hyperglycemia or hyperrosmolar).
- Exogenous intoxications (sedatives, Barbiturates , Amphetamines, alcohol, MAO inhibitors, antiepileptics, opioids, cocaine, methanol, ethylene glycol, neuroleptics, etc.).
- Metabolic deficit (bronchopneumopathies, CO poisoning, shock, cardiovascular diseases, Wernicke, B6 and B12 deficiency and folic acid deficiency).
- Hydroelectrolytic and acid-base changes).
- Disorders of temperature.
- Epilepsy (Puerto-Gala et al., 2012).
Thus, these factors will cause a comatose situation when they affect large areas of the Diencephalon And of the brainstem, and / or in the cerebral hemispheres. There is evidence that the most common causes of coma are diffuse axonal damage, hypoxia and secondary lesions that will affect the brain stem (Leon-Carrión, Domínguez-roldan, & Domínguez-Morales, 2001).
Coma evaluation
When an individual presents in a hospital emergency department with total absence of answers and without being fully aware, it is essential to control the physical conditions that may pose a risk before determining the degree of affectation and the type of altered consciousness Vital for the life of the person (De Castro, 2008).
In a situation of lack of awareness, the collection of information from people close to the affected individual is going to be essential: information about associated diseases, Cranioencephalic trauma (1) and (2), and (3), we present the results of the present study.
In addition, a general examination of individuals of physical variables: blood pressure (BP), rhythm and heart rate (HR) and respiratory rate, temperature, blood glucose, palpitations of the neck and skull and meningeal signs (Puerto-Gala et al., 2012 ).
Once the conditions that require immediate treatment have been ruled out and the pathologies that pose a vital risk to the patient have been controlled, neurological assessment is performed (De Castro, 2008). The neurological assessment will explore: the level of consciousness the respiratory pattern, trunk-encephalic reflexes, eye movements and motor responses (Puerto-Gala et al., 2012).
Among the instruments that are used to evaluate the depth of comma states, the Glasgow Coma Scale (GCS) is the most accepted instrument for this type of assessment (León-Carrión, Domínguez-roldan, & Domínguez-Morales, 2001). This scale uses three categories of evaluation: eye opening (spontaneous, verbal order, pain, no response), better motor response (obeys verbal commands, locates pain, withdrawal, anromal flexion, prone-extension and no response) And better verbal response (oriented response, disoriented response, inappropriate words, incomprehensible sounds, no response). Therefore, the score that an individual can obtain in the scale ranges from 3 to 15 points (León-Carrión, Domínguez-roldan, & Domínguez-Morales, 2001).
Getting a low GCS score will be indicative of the comma depth. A lower score of 9 is indicative of severe brain damage; A score between 3 and 5 is indicative of very deep brain damage and the existence of a deep coma (Leon-Carrión, Domínguez-roldan, & Domínguez-Morales, 2001).
Prognosis and treatment
When the individual is in the ICU (intensive care unit) the priority is the survival of the ICU. Medical treatment in the acute phase will include stabilization of the patient, control of preexisting medical problems and those caused by the situation, prevention of complications. Usually pharmacological and surgical treatments are used.
The prognosis of the evolution and recovery of the patients in coma is variable. In many cases, its survival is threatened by different complications in the acute phase (infectious processes, metabolic alterations, need for catheters and so forth, etc.) and in sub-acute phases (epileptic seizures, immobility, etc.) Sesé et al., 2015).
Nursing intervention is essential for the prevention of infections and complications, management of incontinence and nutrition (Mais-Sesé et al., 2015).
In the sub-acute phase, when the individual fails to emerge from the coma, an intensive neurological and neuropsychological intervention will be performed. The actions will be aimed at achieving an emergency from an altered state of consciousness to a higher one, through the use of multisensory stimulation that acts on three areas: somatic, vibratory and vestibular, trying to enhance the patient's perceptual capacity (Mas-Sesé et al. Al., 2015).
In addition, the participation of a physiotherapist will be essential for the control of the muscular atrophy . Physiotherapy mainly involves postural control and maintenance of muscle tone and osteoarticular system (Mas-Sesé et al., 2015).
If the patient leaves the coma, it is likely that he may present significant neurocognitive, behavioral, affective, and social deficits. All of these will require specialized intervention (León-Carrión, Domínguez-roldan, & Domínguez-Morales, 2001).
CONCLUSIONS
When severe brain damage results in a loss of consciousness, urgent and specialized medical attention will be essential to control survival and future complications.
The condition of a coma situation is a very limiting condition not only for the individual but also for their relatives. In most cases, the family will have to receive support, guidance or even psychotherapy to deal with the situation (Mais-Sesé et al., 2015).
Whether the patient progresses favorably or whether the coma continues to lead to a persistent state, it will be essential for the family to work in a coordinated and organized way with medical and rehabilitation teams.
References
- De Castro, P. (2008). Patient with altered consciousness in the emergency room. An. Sanit. Navar. 2008, 31 (1), 87-97.
- Of Puerto Gala, M., Ochoa Linares, S., Pueyo Val, J., & Cordero Torres, J. (2012). Alteration of the level of consciousness. In SemFYC, Emergency and Emergency Handbook (Pages 29-44).
- Hodelín-Tablada, R. (2002). Persistent vegetative state. Paradigm of current discussion about alterations of consciousness. Rev Neurol, 34 (11), 1066-109.
- León-Carrión, J.; Domínguez-Rondán, J.M; Domínguez-Morales, R.; (2001). Coma and Vegetative State: Medical-legal aspects. Spanish Journal of Neuropsychology , 63-76.
- More-Sesé, G., Sanchis-Pellicer, M., Tormo-Micó, E., Vicente-Más, J., Vallalta-Morales, M., Rueda-Gordillo, D.,. . . Femenia-Pérez, M. (2015). Attention to patients with altered states of consciousness in a hospital of chronic patients and long stay. Rev Neurol, 60 (6), 249-256.