Etiotropic Therapy: Eliminating the Cause
The main goal of this stage is to halt or maximally attenuate the factor that led to the coma. Clinical tactics strictly depend on the underlying etiology:
- 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 transitioned to general anesthesia.
- Exogenous poisonings: Administration of specific antidotes and antitoxins, gastric lavage, and enhancement of toxin excretion via diuretics (forced diuresis) are indicated.
- Diabetic comas: The cornerstone is the administration of a calculated dose of insulin. To prevent a sharp drop in blood glucose, parenteral infusion of a dextrose (glucose) solution is performed simultaneously to prevent hypoglycemic coma.
- Infectious origin: Antibiotic therapy, sulfonamides, and antiseptics specific to the microflora of the gastrointestinal or urinary tract are prescribed.
Pathogenetic Therapy: Breaking the Vicious Cycle
This is the absolute foundation of comatose patient management. The clinician's task is to block key links in the pathogenesis: hypoxia, acid-base balance (ABB) disturbances, water-electrolyte imbalance, and the effects of biologically active substances.
Antihypoxic therapy includes mechanical ventilation, oxygen therapy with oxygen-enriched gas mixtures, and hyperbaric oxygenation. Antioxidants (selenium preparations, glutathione, ubiquinone) and enzymes (catalase, superoxide dismutase) must be used. Simultaneously, vascular tone and cardiac function are normalized.
Combating Intoxication
Divided into two mutually reinforcing directions:
- Desoxication therapy: Aimed at reducing the degree of systemic poisoning. Plasma transfusions, plasma expanders, and infusions of isotonic sodium chloride solution are used.
- Detoxification therapy: Ensures the physical elimination of toxins and excess fluid. For this purpose, intravenous solutions containing high-molecular-weight organic compounds (Dextran with an average molecular weight of 50,000–70,000 — Polyglucin, and 30,000–40,000 — Reopolyglucin) are administered. An effective method is the combination of massive infusion therapy with diuretics. In extremely severe situations (uremic coma), clinicians switch to extracorporeal blood purification: hemodialysis or peritoneal dialysis.
Correction of Homeostasis and Organ Function Support
A critical stage is the restoration of ABB parameters, fluid balance, and electrolyte levels. Buffer solutions with the required electrolyte content are used for this purpose. Their selection is strictly individualized based on laboratory data. Transfusion therapy (blood components, plasma expanders) is also utilized.
To normalize the function of the heart, kidneys, and brain, optimization of the effects of biologically active substances (BAS) is performed 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 organ systems, as well as to eliminate seizures, pain, and other distressing symptoms during the pre-comatose and post-comatose periods. The physician uses anticonvulsants, analgesics (up to narcotic analgesics), cardiotropic and vasoactive drugs, and respiratory stimulants.
Given the extreme severity of regulatory disorders, continuous monitoring of vital functions is absolutely essential. The medical staff continuously monitors:
- Cardiac activity.
- Respiratory parameters.
- Renal excretory function.
- Level of consciousness and key homeostasis parameters.