I. Micro-consciousness means successful wake-up call
For patients in cerebral coma, the appearance of micro-consciousness is a successful wake-up call. Clinically, lumbar puncture and subarachnoid placement for decompression are found to be effective in promoting microconsciousness. Lumbar puncture is usually performed 4-8 times and subarachnoid placement is performed 6-7 days. In addition, the amount of cerebrospinal fluid protein is related to the amount of microconsciousness.
After micro-consciousness appears, it needs to be maintained for a long time to prevent recurrent instability of consciousness. While lowering the cerebral pressure, it is necessary to control the cerebrospinal fluid secretion with drugs, such as acetazolamide, which is used abroad. Now levetiracetam and phenobarbital that inhibit the secretion of cerebrospinal fluid, reduce cerebral edema, and create conditions for the patient to be conscious.
Do not do well comatose patients with increased cerebral edema, ventilator off, or face death. Therefore, the patient survived, not the same as the success of the promotion of waking up, the end of the survival of patients in a vegetative state is not uncommon. The “mystery” of wakefulness is in the early coma wakefulness and the later treatment choice. Is it a successful wake-up call? Is it death? Or is it a persistent vegetative state that remains? The choice is often here.
The emergence of micro-consciousness in a comatose patient means the result of acute coma promotion, and the later stage is the promotion of micro-consciousness. It can also be divided into overall wake-up promotion treatment, open brain coma and closed coma selective wake-up promotion treatment.
Second, micro-consciousness promotion treatment
1.Sit-to-stand training after taking off the ventilator: After micro-consciousness is restored, most patients in cerebral coma have been taken off the ventilator. Generally, 3 days after getting off the ventilator, let the patient start sitting and standing with the head of the bed elevated for half an hour; 3 days later, sit and stand with legs hanging over the bedside for half an hour to facilitate voluntary sputum excretion and reduce pulmonary infection. Increase blood sample saturation and partial pressure of oxygen.
2. Anti-epileptic drugs: levetiracetam and carbamazepine tablets, intranasal phenobarbital tablets at night. If necessary, intramuscular injection of Valium or pump sedatives, anesthetics, etc.
3, neurotrophic agents: commonly used calf serum injection, olanzapine class, large rhodiola injection, guhong injection, waking brain static, naloxone hydrochloride, etc.
4, microhormone shock therapy: dexamethasone 5mg, the order of 5, 4, 3, 2, 1 time / week, static point. That is, 5 days in the first week, 4 days in the second week, and so on, for a total of 15 times, 5 weeks to complete.
5. Rehabilitation treatment: pedicure, acupuncture, massage, brain wave magnetic stimulation, microwave, limb function training, swallowing training, standing bed, etc.
6. Treatment of complications: pneumonia, urinary tract infection, cholecystitis, etc.
7, cranial imaging review: the main measurement of the third ventricle transverse diameter is normal, not more than 6-200 px. If there is mild hydrocephalus, early ventriculoscopy, ventriculoperitoneal shunt and lumbar pool ventral shunt can be selected for treatment
(A) Open cranial injury wake-up treatment
1. Minimally invasive drilling to remove the hematoma, decompression surgery of the skull flap, etc.
2. Conventional postoperative treatment
3. Patients with hydrocephalus can undergo ventriculoscopic perforation, ventriculoperitoneal shunt, lumbar pool ventral shunt, etc.
4. Micro-consciousness promotion treatment.
5. After 3 months, if the consciousness still remains in the micro-conscious state, deep electrical stimulation or minimally invasive surgery of cervical pulp electrical stimulation can be done.
6. Cranial repair is done as early as possible after 3 months. In the process of rehabilitation treatment such as sit-to-stand training, attention should be paid to the effect of minor concussion on the patient’s skull deficit after rising and lying.
7. Neural stem cell therapy: neural stem cell therapy is beneficial to comatose patients, increasing neurological function
8. It takes 12 months for open craniosynostosis to become vegetative state, so the treatment is quite useful for patients to promote waking up
(B) closed craniocerebral injury wake up treatment
1. Lumbar puncture 4-8 times or subarachnoid tube placement 6-7 days, after the cerebrospinal fluid pressure is normal, then 2-3 times.
2. Continued use of antiepileptic drugs for more than three years and annual EEG examination.
3. Micro-consciousness promotion awakening treatment process.
4. Patients with closed cranial brain injury, hydrocephalus progresses rapidly, brain atrophy and ventricular enlargement occur rapidly, cerebral cortex thins, recovery is slow and the effect is unsatisfactory, especially in the coma from hanging, hypoglycemic coma, electroshock coma, coma from hemorrhagic shock, drowning, and coma from asphyxia. Beijing Military General Hospital recommends cervical medullary electrical stimulation and bilateral central thalamic nucleus DBS navigation therapy after the cerebral edema has disappeared for about 1 month (more than 6 lumbar punctures).