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Le traitement d'urgence des comas neurologiques en réanimation

par Cornil, Arnaud ;Bottemanne, C.;Rauis, Antoine ;Ectors, Michel Paul
Référence Bruxelles médical, 54, 6, page (339-345)
Publication Publié, 1974

Article révisé par les pairs

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Résumé :

This paper is principally addressed to hospital duty doctors and generalists: it is a practical review of the initial diagnostic and therapeutic steps to be taken in cases of neurological coma (cranial traumatisms, expansive lesions, vascular accidents, epilepsy, meningitis and encephalitis). These types of coma present difficulties more frequently than do those disturbances of consciousness which are of metabolic origin; they require the acquisition of a case history, careful and repeated clinical examinations, systematic paraclinical examinations (blood, urine, radiography of the skull and thorax, intraocular scrutiny) and the commissioning of the appropriate more elaborate tests (EEG, echo EEG, lumbar puncture, arteriographies and cerebral scintigrams) selected according to the etiological line of enquiry indicated by the case history and the clinical examination. The prompt establishment of an exact etiological diagnosis is an indispensable precondition for the appropriate treatment. It is equally important that the victim be treated as soon as possible (at home, at the site of the accident etc.) by a medical team trained in techniques of resuscitation: this both enables them to discover the immediate circumstances of the onset and development of the coma and at the same time to apply classical cardiorespiratory resuscitation measures if these should be necessary and thus avoid irreversible cerebral damage. It also ensures the comatose patient is transported (by means of a special ambulance) to an intensive care unit in better condition. Treatment will comprise both specific measures dictated by the cause of the coma as well as other, nonspecific measures (of resuscitation) dictated by the common appearance of respiratory, circulatory and temperature disturbances and hydromineral and calorific disequilibria in these states. Ultimate success very often depends upon appropriate and energetic application of both types of therapeutic measure. Specific treatments for each type of etiology are briefly described. More time is then spent on discussion of nonspecific measures: clearing the airways, the possibility of artificial ventilation, adequate blood transfusions, the timely insertion of shunts, kinestherapy, action to combat thermal and circulatory disturbances, constant clinical and biological surveillance and, last but not least, the prevention of infection, of intestinal hemorrhages (gastric protection) and of bed sores. Among resuscitation measures, those guaranteeing the maintenance of normal respiratory function are emphasized.