Chinese and Western medicine diagnosis and treatment of coma
I. Overview
Coma is a state of unresponsiveness to external stimuli and cannot be awakened to recognize oneself or the surrounding environment, characterized by loss of random movements, loss of normal response to external stimuli and pathological reflex activity. Coma can be caused by both central nervous system lesions and the consequences of systemic diseases, such as acute infectious diseases, endocrine and metabolic disorders, cardiovascular diseases, poisoning and electric shock, heatstroke, hypoxia, and altitude sickness can cause coma. Intracranial lesions and metabolic encephalopathy are the most common (70% of cases). Complications of heart, lung, kidney and central nervous system function can occur and can be life-threatening in severe cases.
The patient should be sent to the hospital as soon as possible to monitor vital signs, actively carry out relevant examinations, timely lumbar puncture (cerebrospinal fluid cytology, biochemistry, viral cell series), cranial CT and magnetic resonance examination are of great value for the diagnosis of central nervous system diseases, blood test carboxyhemoglobin helps to diagnose CO poisoning, urinary routine abnormalities are common in uremia, diabetes mellitus, acute uroporphyria, patients suspected of hepatic coma Blood ammonia and liver function, blood glucose and renal function tests can help diagnose diabetic acidosis, hypoglycemic coma and uremic coma, and electrocardiogram can diagnose myocardial infarction and cardiac arrhythmia leading to coma. And should be actively combined with Chinese and Western medicine to save the treatment.
In Chinese medicine, coma is a critical condition characterized by confusion and is a cardio-cerebral condition. The Inner Classic states, “The heart is the house of the spirit, the heart contains the gods, and the heart is the change of the gods.” That is, spirit, consciousness and thinking are all related to the heart. “The heart is the master of the mind”, “the head is the meeting of all the yang”, the qi of the viscera is injected into the brain, and out of the five organs and nine orifices. The brain is the medulla oblongata, the house of the gods, which contains the divine mechanism, the clear orifices are the place of access, and the spinal cord is the hub of access.
The heart is the master of the blood vessels, and the blood and qi flow upward to the brain, the brain marrow is nourished, and the divine mechanism is as usual. If the external epidemic evil, poisonous heat attack, or internal phlegm, stagnation and fire poison, resulting in Qi, blood, yin and Yang rebellion, can disturb the heart and brain, resulting in the orifices and ligaments closed and blocked, the nervous system is not used, the development of coma. The basic pathogenesis of the disease is external epidemic, internal attack by heat and toxin, internal injury to yin and yang, and Qi and blood rebellion, resulting in the disturbance of the orifices by evil qi, resulting in the loss of mental clarity, or the defeat of vital energy, resulting in the disorganization of mental clarity. The disease is located in the heart and brain, and the symptoms are in the liver, spleen, lung and kidney. The disease is often divided into four types of treatment: blood stasis blocking the orifices, yin exhaustion and yang loss, phlegm clouding, and epidemic and poison. This disease has the same meaning as “coma” in modern medicine, and can be treated with reference to this disease regardless of the intracranial and extracranial causes of coma.
This disease is also often called “mental fainting”, “fainting”, “fainting”, “fainting”, “fainting”, “fainting”, “fainting”, “fainting” and so on. “The common descriptions of this disease include unconsciousness, delirium, collapse, violent collapse, mental consciousness like blindness, amnesia, and the appearance of a corpse. The main clinical features of coma are confusion, inability to respond to calls, lack of knowledge, or even no response to external stimuli. It can occur in many diseases, such as stroke, bulging, retention of urine, warm disease, syncope, pain, heat stroke, poisoning, thirst, pulmonary distension, epidemic dysentery and other critical stages.
Diagnostic criteria and differentiation of class evidence in Chinese medicine
(A) Diagnostic criteria
1. Medical history
Detailed medical history can be obtained from the corresponding history of miscellaneous internal injuries before the onset of the disease, such as stroke, thirst, pulmonary distension, wheezing, blood, bulging, syncope, etc.; or history of external evil poisoning, such as heat stroke, acute yellow, epidemic poisoning dysentery, etc.; or history of accidental ingestion, overdose of toxic drugs and food; or history of exposure to toxic gases, such as natural gas leakage, gas poisoning, etc.; or history of trauma such as bruises and injuries.
2.Clinical manifestations
Sudden onset or gradual change in mental state during the development of various diseases, with the lighter cases being drowsy and dazed and not responding to calls, and the heavier cases being drowsy and not knowing, or even not responding to external stimuli.
Clinically, there are four levels according to the degree of dizziness, namely, trance, delirium, coma and confusion.
Trance: firstly, indifference to emotion or emotional irritability is seen, followed by unclear recognition of things and dazedness, but the answer to a strong call can be answered, and the answer to a question is not accurate enough.
Delirium: A drowsy and hazy state, with the patient waking up after a strong call, but immediately falling asleep.
Coma: The patient is unconscious and cannot control his bowels.
Confusion: The coma is so severe that not only does not respond to the call, but also does not respond to various stimuli, and is often accompanied by the eyes being round, the mouth being open and the eyes being closed, the tongue being rolled and shrunken, the feet being cold from sweating, the hands being wet, the nose being snoring and panting, or the breath being weak and so on.
If the fainting is accompanied by high fever, delirium, irritability, convulsions, or epistaxis, with red and vivid tongue and fine pulse, the disease is in the heart and lungs, and heat is trapped in the heart and ying.
Dizziness with coughing and wheezing, phlegm and saliva congestion, greasy and cloudy coating, moist pulse, the disease is in the heart and lung, and the disease is due to phlegm clouding the mind.
Delirium is mainly due to delirium and irritability, accompanied by hot flashes in the day and night, abdominal fullness and pain, yellow and dry moss, and a sunken and solid pulse, which is due to Yang Ming’s internal organs and heat disturbing the mind.
Delirium is mainly delirium like madness, accompanied by hard fullness and acute pain in the abdomen, blue lips and claws, vivid tongue, sunken thin and astringent pulse, which is due to stasis and heat interruption, heat entering the blood chamber, and the disease affecting the heart and brain.
The fainting is mainly due to unconsciousness, or fainting but sometimes waking up, accompanied by deep jaundice, epistaxis, or abdominal distension like a drum, with a vivid tongue and greasy coating, which is due to damp heat in the liver and gallbladder and internal trapping in the heart and battalion.
Sudden fainting and unconsciousness, accompanied by twitching of limbs and snoring and phlegm, are the characteristics of liver yang, which causes liver wind and disturbs the heart and brain, resulting in loss of mental clarity.
The fainting occurs during the process of blood loss and vomiting and diarrhea, which means that the vital energy is defeated and the mind is scattered.
3.Auxiliary tests
The diagnosis and differential diagnosis of comatose patients can be facilitated by laboratory tests based on the condition. Generally, routine tests, such as three routine tests, liver and kidney function, electrolytes, chest X-ray, electrocardiogram, abdominal ultrasound, etc., should be performed first. function and determination of blood concentration of toxic substances, etc.
(II) Differential diagnosis
1.Convulsive evidence
When syncope occurs, the face is pale and the extremities are cold, and the patient can wake up gradually within a short period of time without hemiplegia, aphasia, orophonia, etc.; while coma has a heavy onset and lasts longer, and it is not easy to wake up within a short period of time, and after waking up, there are often symptoms related to the original disease or hemiplegia and unfavorable speech, which can be distinguished.
2.Multi-sleeping
It is also known as polysomnia, polysomnolence, which is called episodic sleep disease in modern medicine, and it is manifested as going to sleep when it is impossible to fall asleep, and it does not distinguish between day and night, and it is a disease of wanting to sleep at times and being able to wake up after calling, and it is a disease of going back to sleep after waking up, but there is no mental disorder and it is easy to be woken up, which can be distinguished from coma.
3.Hysteria
Hysteria is a mental disorder disease, common in young and middle-aged women, manifested as paroxysmal narrowing of consciousness, may have muteness, lethargy, and even tonic syncope, which can be relieved by itself, or relieved by suggestive treatment, without obvious sequelae, can be repeated, but there are more obvious mental factors before the onset.
4.Drowsiness
It is the early manifestation of disorder of consciousness, in the sleep state, awakening orientation is basically intact, but inattentive, poor memory, if not continue to answer, and then into sleep.
5.Drowsy state
In a deeper sleep state, awakened only by heavy pain or verbal stimulation, make simple and vague answers, and fall asleep soon.
6.Blurred consciousness
Or hazy state, the scope of consciousness is reduced, often with disorientation, more obvious is the illusion, hallucinations are rare, emotional reactions are related to the illusion.
7.Syncope
It is a transient state of loss of consciousness due to a momentary lack of blood supply to the whole brain, and the patient falls to the ground during the attack due to loss of muscle tone. It usually occurs suddenly, lasts for a short time and recovers quickly.
Western medical diagnostic criteria and differential diagnosis
(A) Diagnostic criteria
1. Medical history
A detailed systematic medical history review can mostly obtain the history of related diseases and the causative factors of coma.
2. Clinical manifestations
(1) According to the stimulus response and reflex activity, there are four degrees.
Shallow coma: casual activity disappears, response to painful stimuli, various physiological reflexes (swallowing, coughing, corneal reflex, pupil response to light, etc.) exist, body temperature, pulse and respiration are not significantly changed, and may be accompanied by delirium or agitation.
Moderate coma: the response to painful stimuli disappears, physiological responses exist, and vital signs are normal.
Deep coma: the random activity completely disappears, no response to various stimuli, various physiological reflexes disappear, there may be irregular breathing, blood pressure drops, urinary and fecal incontinence, generalized muscle relaxation, deafferentation and so on.
Extreme coma: also known as brain death. The patient is in a near-death state, no voluntary breathing, various reflexes disappear, the EEG is pathologically electrically resting, and the loss of brain function lasts for more than 24 hours, excluding the influence of drug factors.
(2) Common cerebrovascular disease manifestations
① Cerebral infarction: those with risk factors for cerebral infarction, with onset in a quiet state, the condition peaks within 1 to 3 days, and the symptoms and signs can be summarized as a cerebral functional deficit in a certain cerebral artery blood supply area. The symptoms and signs can be generalized to a certain cerebral artery supply area. Most of them have no obvious headache, vomiting, consciousness disorder and meningeal irritation signs, normal CSF, and cranial CT can help confirm the diagnosis. The clinical picture is often divided into the following six types.
Complete stroke: the disease peaks within 6 hours of onset and is severe and may include coma.
Progressive stroke: Gradual progression of limited cerebral ischemia with a stepwise worsening over several days.
Slowly progressive stroke: progressive symptoms even after 2 weeks of onset.
Massive infarct type stroke: caused by larger arteries or extensive infarction, often with marked cerebral edema, increased cranial pressure, loss of consciousness, and severe disease.
Reversible ischemic neurological deficit: symptoms and signs last more than 24 hours but recover completely within 2 to 3 weeks without sequelae.
Lacunar cerebral infarction: microinfarction produced by hypertension-induced microatherosclerosis of deep penetrating branches.
② Cerebral embolism: sudden onset is its main feature, symptoms develop to peak within seconds or minutes, it is the fastest onset of all cerebrovascular diseases, mostly complete stroke, often with varying degrees of impaired consciousness, but the duration is shorter than cerebral hemorrhage.
(3) Cerebral hemorrhage: It usually occurs in people over 50 years old, with a history of hypertension, sudden onset during physical activity or emotional excitement, rapid development, early symptoms of increased intracranial pressure such as impaired consciousness, headache and vomiting, localization signs such as hemiparesis and aphasia, and signs of meningeal irritation, etc. A high-density hemorrhagic shadow can be detected at an early stage of CT, which can reveal the location and size of the hematoma, the adjacent cerebral edema zone, brain displacement and whether it has broken into the ventricles. (iv) Subarachnoid space
Subarachnoid hemorrhage: The hemorrhage may be caused by sudden exertion, mental agitation, strenuous exercise, etc. It is characterized by severe headache, nausea and vomiting, positive meningeal irritation signs, and may be accompanied by paralysis of one side of the motor nerve, impaired consciousness or neurological localization signs (mostly due to vasospasm). Lumbar puncture shows uniform and consistent hemorrhage, which is the most reliable diagnostic basis for this disease. Cranial CT can mostly show confined blood, and some patients can still provide clues to the site and etiology of hemorrhage.
⑤ Neonatal intracranial hemorrhage: The clinical manifestations of neonatal intracranial hemorrhage vary depending on the amount and site of hemorrhage. The main manifestations are restlessness immediately after birth, cerebral screaming, or convulsions and other excitatory symptoms, and in severe cases, they soon enter a state of inhibition, manifesting as drowsiness, coma, hypotonia, weakened or absent reflexes, refusal of breast milk, irregular breathing or even suspension. There is often a history of fetal distress, birth injury, and obstructed labor. Neurological excitation followed by inhibition is the typical clinical manifestation, and cranial ultrasonography or CT examination is a reliable basis for diagnosis.
It is difficult to distinguish mild cerebral hemorrhage from cerebral infarction, especially for those with obvious consciousness disorder, it should be distinguished from obstruction of large intracranial vessels (such as the main trunk of middle cerebral artery), and lumbar puncture or cranial CT examination can help to distinguish.
3.Physical and chemical examination
Biochemical tests, three routine tests, abdominal ultrasound, electrocardiogram, chest X-ray, cranial CT, and nuclear magnetic resonance are very important to clarify the cause, determine the condition, and guide the treatment, and invasive tests such as lumbar puncture, bone aspiration, and thoracoabdominal puncture are also needed when necessary.
(B) Differential diagnosis
1.Epilepsy
Epilepsy mostly presents sudden seizures, falling to the ground, unconsciousness, twitching of limbs, foaming at the mouth, eyes upward, or mouth like a pig or sheep cry, wake up when moving, wake up as normal, but can not recall the seizure situation, often have a similar history of repeated seizures; coma without active treatment, more difficult to recover on their own, and often have a history of primary disease, can be distinguished.
2.Delirium state
Delirium state patients have obvious fluctuations in the level of consciousness, and symptoms are light day and heavy night. Orientation and self-awareness are impaired, attention is lax, and normal contact with the outside world is not possible; accompanied by obvious delusions and hallucinations, most of which are horrific, so that the patient is emotionally frightened and easily provoked, and under the domination of hallucinations and delusions can produce impulsive behavior or self-injury or injury to others.
3.Atresia syndrome
The patient is alert and aware of his situation, but the limbs are paralyzed and the cerebral nerves below the oculomotor nerve are paralyzed, caused by bilateral ventral lesions of the cerebral bridge, involving the corticospinal tract, corticobulbar tract and cortical medulla oblongata.
4.Persistent vegetative state
Patients in persistent vegetative state lose cognitive neurological functions but retain autonomic functions such as cardiac activity, respiration, and maintenance of blood pressure. This state occurs after coma and is characterized by lack of awareness of peripheral objects or cognitive deficits, but maintains the sleep-wake cycle. Spontaneous movements may occur, and the eyes may open in response to external stimuli, but there is no speech and no compliance with commands.
5.Akinetic mutism
Patients with akinetic mutism do not speak, do not have spontaneous movements, do not move when stimulated, can open their eyes and look around, do not respond to painful stimuli or only have local responses, are incontinent, have a sleep-wake cycle, and have multiple lesions including subacute hydrocephalus, posterior third ventricle and aqueduct tumors, bilateral frontal lobe lesions involving the cingulate cortex (bilateral anterior cerebral artery thrombosis), bilateral reticular structures in the upper part of the brainstem The common features of these lesions are The common feature of these lesions is the impairment of the power reticular activation system that receives information from the internal and external environment.
6. Volitional deficit disorder
Volitional deficit disorder is a severe indifference, when the patient’s senses, drives, and mental activities are retarded, and the behavior shows no speech and no autonomous activity. Severe cases resemble inactive mutism, but the patient is able to remain alert and aware of his or her situation.
7. Catatonia
The patient with catatonia is silent, has significantly reduced movement, is bedridden, and can maintain the ability to stand or sit, but fixes a posture and rarely changes, as seen in schizophrenia. It should be distinguished from organic lesion-induced miosis.
8.Pseudocoma
Pseudoconsciousness is similar to coma, not opening eyes, not speaking, not moving, not avoiding pain, but no abnormalities on examination. This is to avoid responsibility and pretend “coma”, not hysterical coma, but the two are sometimes not easy to distinguish.
IV. Chinese medicine treatment
(a) Emergency treatment
1.Quickly make the patient lie down quietly, with the jaws elevated to make breathing smooth.
2. Loosen the belt and collar buckle, tilt the head to the side, and remove the secretions from the oropharynx at any time.
3.Pinch and press Renzhong or acupuncture Renzhong, Yongquan, and Foot Sanli points to promote awakening. Immediately give oxygen or mouth-to-mouth artificial respiration to those with apnea.
4. Pay attention to keeping warm and move the patient as little as possible.
5.Establish effective intravenous access as soon as possible, and pay attention to anti-shock if the blood pressure is low.
6. Call the first aid station or send to hospital for emergency treatment as soon as possible.
(B) Identify and treat
Coma is one of the common critical illnesses in clinical practice. It is often caused by heat, phlegm, dampness, blood stasis, epidemic toxin blocking the clear orifices and disrupting the mind, resulting in confusion or unconsciousness. A variety of acute diseases, such as typhoid fever, warm diseases, stroke, syncope, epilepsy, etc., can appear this evidence, treatment should be examined and treated to open the orifice and wake up the mind first. In the process of resuscitation of coma, it is crucial to pay attention to the identification of evidence and treatment, and to grasp the deficiency and urgency of the symptoms.
1.Stasis of blood blocking the orifice
(1) Symptoms: demented, confused, or even coma, tingling pain in the head, or prolonged pain, dizziness, dizziness, forgetfulness and insomnia, or purple lips, dark tongue or spots, and astringent pulse.
(2) Treatment: Invigorate blood circulation, resolve blood stasis, open and close the orifices.
(3) Formulation: Tongkang and invigorate blood circulation.
(4) Drug: Musk (punch) 0.3g Red peony 10g Peach kernel 10g Safflower 10g Chuanxiong 10g Old onion 15g Ginger 10g Red jujube 6, decocted in water to extract juice, 100ml each time, with appropriate amount of yellow wine for nasal feeding, 3-4 times/day.
(5) Addition and reduction: 15g of calamus and 30g of yujin can be added to regulate qi and open the orifice.
2, hyperactivity of liver yang
(1) Symptoms: sudden coma, unconsciousness, flushed face, hemiplegia, snoring, vomiting, incontinence of urine and stool, red and dry tongue, smooth and numbered pulse.
(2) Treatment: Calming the liver and quenching the wind, submerging the Yang and opening the orifice.
(3)Formulation: Antelope and hooked vine soup or Liver quenching wind soup with addition and reduction.
(4) Drug: Hooked vine 15g, raw dragon and peony 30g, raw earth 10g, dandruff 10g, Xia Ku Cao 15g, stone cassia 10g, antelope horn 5g, white peony 10g, maidenhair 10g, decoction nasally, 100ml each time, 3-4 times/day.
(5) Add and subtract: add Citrus aurantium 10g, Biliary South Star 5g, Yun Fu Ling 15g, Semen 10g, etc. if phlegm is prevalent.
3.Deficiency of qi and blood, yin and yang want to get rid of
(1) Symptoms: Sudden fainting, pale face, lipless, weak respiration, sweating and cold skin, pale tongue with thin white fur, sunken and feeble pulse.
(2) Treatment: Tonifying Qi and nourishing Blood, restoring Yang and fixing detachment.
(3) Formulas: Returning Yang to save the body, Ren Shen Yang Ying Tang plus or minus.
(4) Drugs: Ginseng (separately stewed) 10g Astragalus membranaceus 30g Radix Angelicae Sinensis 10g Radix Rehmanniae 15g Radix Aconiti (first decoction) 10g Radix Paeoniae Alba 15g Rhizoma Atractylodis Macrocephalae 10g, decoction juice nasal feeding, 100ml each time, 3-4 times/day.
(5) Add and subtract: for those who are sweating profusely and whose yin and yang want to get rid of, reuse Ginseng to 30g, Radix et Rhizoma Polygonati to 30g, add Wu Wei Zi 15g and Calcined Long Mu 30g each.
4.Stasis-Heat interruption
(1) Symptoms: Fainting without knowing the person, delirium like madness, fullness and sharp pain in the abdomen, strong heat at night, blue and purple lips and nails, vivid or purple tongue, sunken and astringent pulse.
(2) Treatment: Clearing heat and clearing stasis, awakening the mind and opening the orifices.
(3) Formula: Rhizoma Dihuang Tang plus or minus.
(4) Drugs: Rhinoceros horn (Buffalo horn substitute) 10g Radix et Rhizoma 15g Dangpi 10g Radix Paeoniae 10g Forsythia 30g Peach kernel 10g Amber 5g Calamus 15g, decoction of juice nasal feeding, 3-4 times / day .
(5) Add and subtract: for hyperthermia, add gypsum 30g, Radix et Rhizoma Ginseng 30g, Scutellaria Baicalensis 10g; for thick sputum, add Zhaoyu 30g, Radix et Rhizoma Semen 10g, Fritillariae 30g.
5.Dampness and heat disturbs the mind
(1) Symptoms: Delirium or coma with yellow body, yellow eyes, yellow urine, epistaxis, abdominal distension like a drum, fishy taste in the mouth, yellow and greasy tongue coating and string pulse.
(2) Treatment: Clearing heat and dampness, awakening the mind and opening the orifices.
(3) Formula: Yin Chen Artemisia Tang with addition and reduction.
(4) Drugs: Yin Chen 30g, Gardenia 10g, Water hyacinth 10g, Rhubarb 10g, Radix et Rhizoma 10g, Salviae Miltiorrhizae 10g, Xuan Shen 30g, Acorus calamus 15g, Dendrobium 10g, Coix lacrymae 30g, Tiger’s stick 30g, Big belly skin 15g, Yun Ling 15g, decoction intranasally, 100ml each time, 3 to 4 times/day.
(5) Add and subtract: Add 15g of Comfrey and 15g of Cyperus in case of epistaxis, 15g of Patchouli and 15g of Pelargonium in case of thick and greasy tongue.
6.Heat trapped in the pericardium
(1) Symptoms: unconsciousness, delirium with high fever, irritability, convulsions or epistaxis with blood rash, red and vivid tongue, smooth pulse.
(2) Treatment: clear the heart and open the orifices.
(3) Formula: Qing Gong Tang with addition and reduction.
(4) Drug: Xuan Shen Xin 10g Lotus Seed Heart 15g Bamboo Leaf Coiled Heart 10g Rhinoceros Horn (Buffalo Horn Substitute) 10g Forsythia Heart 10g Mai Dong 10g, decoction of 100ml of juice each time nasally, 3 to 4 times/day.
(5) add or subtract: if phlegm-heat is prevalent, add Chuan Calamus 15g, Zhe Bei 30g, Zhu Li 10g, Bile Nan Xing 5g; with blood stasis, add Tao Ren 10g, Safflower 10g, Dan Shen 30g; irritability is very, convulsions, add Zixue Dan nasal feeding; skin rash, delirium, add Angong Niuhuang Wan nasal feeding; deeper dizziness, add to the treasure Dan nasal feeding.
7.Shortness of breath and phlegm
(1) Symptoms: The mind seems to be clear but not clear, wheezing and coughing, phlegm and saliva congestion, sitting and breathing, body heat, high or not high body temperature. The tongue is greasy and cloudy, and the pulse is moist or slippery.
(2) Treatment: resolving phlegm and opening the orifice.
(3) Formulation: Calamus Yujin Tang with flavour.
(4) Drugs: Acorus calamus 15g Yujin 30g fried gardenia 10g forsythia 15g bamboo leaf 5g bamboo lei 10g ginger hemp 10g cloud poria 15g white mustard seed 10g suzy 10g lycopodium 10g, decoction of juice nasal feeding, 100ml / time, 3-4 times / day.
(5) Add and subtract: If there is a lot of phlegm, add 5g of Bile Nanxing and 10g of Tianzhu Huang; if there is high fever, add 10g of Scutellaria baicalensis and 30g of Fritillaria fritillaria; if the dampness is more serious, add Suhexiang Pill; if the wind is also moving and convulsing, add Spasm Stopping San; if the fever is very serious, add Zhi Bao Dan.
8.Yangming internal organs
(1) Symptoms: delirium, restlessness, feeling the bed with clothes, hot flashes in day and night, abdominal fullness and pain, dry stools or foul odor, deep red tongue, yellow dry coating, or even full of mangoes, and sunken and strong pulse.
(2) Treatment: Attacking the accumulation and clearing the lower part of the body, awakening the mind and opening the orifice.
(3) Formulation: Da Cheng Qi Tang.
(4) Drug: Rhubarb 10g, Mangosteen 10g, Citrus aurantium 10g, Huperzine 10g, with Zixue Dan nasal feeding, 3-4 times/day.
(5) Add and subtract: if Yangming internal organs are real and the heart is closed, change to Niuhuang Chengqi Tang; for hyperthermia, add Gypsum 30g, Xuan Shen 30g, Scutellaria 10g; for hyperthermia and faintness, change to Baihu Chengqi Tang; for thick phlegm, add Zhe Bei Mu 30g, Han Xia 10g, Guadua 15g; for gastrointestinal bleeding, add Bai He 15g; for stroke and Yang closure, add Tian Ma 10g, Shi Zhengming 10g, Hooked Vine 10g, Chuan Calamus 15 g; if heat is injurious to yin and fluid is withered and knotted, use Zengliang Chengqi Tang instead.
9.Dampness and heat in the stomach and intestines, internal trapping of epidemic toxins, disturbing the mind
(1) Symptoms: rapid onset, dizziness, high fever, dysentery with red, white, pus and blood, severe abdominal pain, shortness of breath, headache and irritability, red and vivid tongue, yellow and dry coating, slippery pulse.
(2) Treatment: Clearing heat and cooling the blood, detoxifying and opening the orifice.
(3) Formula: Bai Tou Weng Tang with addition and reduction.
(4) Drug: Bai Tou Weng 30g Huang Lian 10g Huang Bai 10g Qin Pi 10g Scutellaria 10g Yin Hua 20g Red Peony 10g Dan Pi 10g Di Yu 15g Antelope’s horn 10g Sheng Di 10g Guan Zong 15g, decoction of juice nasally, 100ml each time, 3-4 times/day.
(5) Addition and subtraction: for those with a lot of pus and blood, add 30g of Amaranthus, 30g of Red Vine and 30g of Tiger Balm; for those with food stagnation, add 15g of Jiao Shanzha and 10g of Citrus aurantium.
(C) Chinese medicine injection
1.Waking Brain Jing Injection: It has the functions of aromatic enlightenment, waking up the mind, relieving pain, resolving phlegm and blood stasis, clearing heat and detoxifying.
2.Qingkailing injection: it has the function of clearing heat and detoxifying, resolving phlegm and clearing the ligaments, waking up the mind and opening the orifices.
3.Phlegm-heat Qing Injection: It has the function of clearing heat, detoxifying and resolving phlegm, and is suitable for those whose coma is caused by phlegm-heat.
4.Bu Chang Dan Hong Injection: It has the function of activating blood circulation and removing blood stasis, promoting blood circulation and relieving collaterals, and is suitable for those with blood stasis and blockage in coma.
5.Chuanxiongzin Injection: For coma caused by occlusive cerebrovascular diseases such as cerebral blood supply insufficiency, cerebral thrombosis, cerebral embolism, etc. It is contraindicated in cerebral hemorrhage and those with bleeding tendency.
6.Growing pulse san injection: It has the function of benefiting qi and nourishing yin, restoring pulse and fixing off, and is suitable for those whose coma is caused by deficiency of qi and yin and pulse deficiency.
7.Sensui Injection: It has good function of benefiting Qi and fixing off, returning Yang and saving rebellion, and has been widely used in clinical emergency, especially suitable for those who are in coma and have Yin and Yang desire to get rid of.
(IV) Chinese patent medicine
1.The Three Treasures of First Aid
An Gong Niu Huang Wan, Zhi Bao Dan and Zi Xue Dan, known as the “Three Treasures of First Aid”, are quick-acting drugs for the treatment of febrile critical illnesses in Chinese medicine, mainly for infectious and contagious diseases. All three are representative drugs for clearing heat and opening the orifices, so they are also known as the “Three Treasures of Warm Diseases”. They are mainly used clinically in cases where the heat and toxicity of the warming evil is so strong that the heart is trapped in the pericardium, or where there is a sudden sensation of obscene qi, or where there is a stroke and the phlegm and heat are internally closed. However, the three medicines are different in nature, with Angong Niuhuang Pill being the coolest, followed by Zixue Dan and then Zhibao Dan. The An Gong Niu Huang Wan is suitable for patients whose fever does not subside, who are delirious and “confused”; Zi Xue Dan is suitable for patients with convulsions, irritability, twitching of hands and feet, who often make loud noises; Zhi Bao Dan is more suitable for patients who are in a coma with fever, who are delirious and silent, as the saying goes, “Ping pang pang Zi Xue Dan As the saying goes, “Ping ping zixue dan, no sound to treasure dan, confused niuhuang pill”.
2.Bu Chang Brain and Heart Capsule: It has the function of benefiting Qi and activating blood, resolving stasis and opening up the channels, which is suitable for patients with stroke caused by Qi deficiency and blood stagnation and stagnation of veins and channels.
3, Suhexiang pill: this formula collects all the aromatic herbs to open the cold and close the door, for the stroke door to seize the door to switch the general. Indications: ① stroke, gas or feel the miasma of the time, resulting in sudden fainting and incoherence, teeth closed, unconscious; ② cold gas closed, sudden pain in the heart and abdomen, want to vomit and diarrhea, and even fainting; ③ pediatric convulsions, coma; ④ angina pectoris of coronary heart disease. Especially suitable for coma evidence of yin closed.
4.Niuhuang Qingxin Pill: It is good at clearing the heart and resolving phlegm, and calming the shock and dispelling the wind. It is used for treating all kinds of wind, slow and longitudinal disorder, speech and heart, forgetfulness and trance, dizziness, panic and grief, or frenzy, confusion, sometimes waking up, epilepsy and wind, phlegm and saliva, phlegm confusion, phlegm fire and phlegm syncope, etc.
5.Rhinoceros horn powder: for stroke, angular arch, disturbed mind, silent mouth.
6.Hong Ling Dan: It is used for treating typhoid fever, heatstroke, cholera and swelling, poisoning by mid-evil, children’s acute fright, five nomas, plague, phlegm nucleus and phlegm blisters.
7. Tongguan San: It has the function of opening the orifices through the passages, and is used for the treatment of sudden fainting, fainting with closed teeth and unconsciousness. Use a little each time, blow the nose to get sneeze.
8.Yushu Dan: formerly known as Taiyi Zijin Dan, has the function of resolving phlegm and opening the orifice, removing filth and detoxification, relieving swelling and pain. Treatments: ① Heatstroke and epidemic. Pain, nausea and vomiting, diarrhea, and phlegm syndrome in children. Externally applied to furuncles and boils, insect bites, nameless swellings, mumps, dancers, throat wind, etc.
(E) Acupuncture
1.Body acupuncture
(1) Acupuncture points: commonly used points: Baihui, Shuigou, Twelve Wells, Shen Que. Alternate points: Dazhi, Chengjiao, Sishencong, Fengchi, Guangyuan.
(2)Treatment
Usually take the commonly used points, and if the effect is not good, choose the alternate points as appropriate. The twelve wells are pierced with trigeminal needles, the Baihui and Shenqui are moxibustion with moxa rolls and moxibustion with salt, and Guangyuan is moxibustion after needling. The number of moxibustion with salt should be sufficient to wake up. Moxibustion with moxa rolls can be placed on the acupuncture points at 3-5 mm, and moxibustion with the bird pecking method until the skin of the acupuncture point area is red and even small blisters are formed. For the rest of the acupuncture points, the diarrhea method is used without leaving needles. Depending on the severity of the disease and improvement, moxibustion can be performed 2 to 4 times a day.
2.Electro-acupuncture
(1) acupuncture points: commonly used points, the brain, Dadun.
(2)Treatment
Brain point downward oblique stab into the needle 5 minutes ~ 1 inch; Dadun acupuncture point needle 5 minutes, with strong stimulation, twisting method, continuous stimulation for 10 minutes. And through the electric needle line strong stimulation. Twice daily, 4-5 days as a course of treatment. At the same time apply conventional western medicine treatment drugs.
3.Skin acupuncture
(1) acupuncture points: commonly used points: Baihui, Fengchi, Fengfu, Yin Tang, Dazhi. Alternate points: Tanzhong, Hatou, Liver Yu, Head Wei.
(2) Treatment
Commonly used acupuncture points are the main points, with additional alternate points as appropriate. With the right thumb and middle finger holding the shank of the seven-star needle, the index finger is fixed, and the wrist is used to move up and down with a light, fine, and even technique, repeatedly performing with the acupuncture area as a range. Rate of 240 times per minute, after the prick will be pricked on the pinch, squeeze out a little blood. If the effect is not obvious, you can increase the technique and extend the time of percussion. The day can be stabbed 3 to 4 times.
(F) Chinese medicine retention enema therapy
Comatose patients are confused and cannot cooperate with oral administration of drugs, and most of the patients are suffering from internal heat, resulting in internal Qi obstruction. The use of Chinese herbal enema with the effect of opening the phlegm and clearing heat and internal organs can make the evil draining from the lower part of the body, which can make the comatose patient conscious, reduce complications, decrease mortality and improve the quality of life of the patient. Chinese medicine enema is simple, safe, painless, no side effects, the longer the enema time, the better the effect of Chinese medicine retention time, the better the effect of smooth stool. Commonly used drugs are raw rhubarb, mannitol, whole guavas, calamus, hyssop, etc., which can be decocted and set aside. Each time you take 100-150ml, add warmth to about 39-41 ℃, the anal tube is moderately thick and thin, insert the depth of 20-30cm is appropriate, slowly drip.
(VII) Calling therapy
Comatose patients have various sensory deprivation due to long-term bed rest, which hinders the process of brain recovery and inhibits central nervous function. Call therapy is a treatment method to increase the patient’s response by stimulation of various senses, which not only enables comatose patients to maintain various normal sensory inputs, but also facilitates the enhancement of bioelectric activity in the brain, adjusts the potential capacity of the cerebral cortex, and promotes the recovery of consciousness.
1.Auditory call
(1) Verbal call by medical personnel: treat the patient as a normal person and tell the patient to cooperate with every thing he does.
(2) Affectionate call: record the patient’s voice that feels affectionate as well as the nickname of the relative to the patient, encouraging words to the patient or memorable events and things to the patient.
(3) Music call: Let the patient listen to more familiar music or listen to various radio broadcasts.
2. Visual appeal
In a darker environment, wrap a flashlight with various colored paper and shine it on the side and front of the patient’s head and face to stimulate the retina and cerebral cortex through the constantly changing colored light. Provide a good visual stimulation environment at the bedside, such as colorful and familiar objects, family photos, and TV programs for 10 to 15 minutes at a time.
3. Gustatory call
In combination with swallowing function training, apply various tastes such as sour, sweet, bitter and spicy for stimulation. Observing the changes in the patient’s facial expression is an indicator to determine whether the stimulation is effective, and pay attention to safety when having tracheal intubation.
4.Sniffing call
The patient can be allowed to smell various substances with stimulating odor, such as perfume, aromatic odor Chinese medicine, etc.
5.Tactile call
In a quieter environment, let family members stroke the patient’s head and body surface and give verbal soothing by the ear; use objects of different temperatures, such as metal spoons dipped in hot or cold water for 30 seconds; passively move the limb joints and painfully stimulate the skin and mucous membranes, etc.
6.Electrical stimulation call
Treatment with cerebral circulation function therapy instrument, 30 minutes per day, 10 days as a course of treatment; low frequency cranial therapy instrument is used to stimulate the median nerve, the intensity of which is sufficient to observe a slight contraction of the patient’s fingers.
(H) Lamp fire therapy
Lamp fire therapy is the use of lantern grass dipped in sesame oil, ignited and cauterized selected points or sites to treat disease a method, due to the bursting sound occurs during the cauterization, also known as explosive lamp fire therapy. This method is mainly through the stimulation of the meridian points or around the affected area, so that the meridian is smooth, the flow of qi and blood, to get rid of evil out. It is suitable for children’s fright, coma, convulsions (twitching), tampering vision, etc. In the case of children who are frightened, if the child is on his back, burn the fontanelle and the upper and lower part of the two eyebrows with a lamp; if the eyes are turned up and down, burn the upper and lower part of the umbilicus; if the child is unconscious, burn the heart of the hands and feet and the chest; if the child is clasping his hands and turning his eyes up, burn the fontanelle and the heart of the two hands; if the child is foaming at the mouth, burn the mouth and the heart of the hands and feet. For head wind and swelling pain, burn the forehead at the solar plexus.
(ix) simple experimental formula
1, fever and coma: a bowl of raw groundnut juice to pour down. If you are thirsty for more than drinking water, then use raw groundnut root, raw mint leaves and other points pounded, squeezed juice, add a little musk, cold water transfer. Feel the heart suddenly cool, that is, no longer take medicine.
2, unconsciousness, but the pulse has not stopped: the use of the hundred grass cream and water irrigation. At the same time, acupuncture Baihui and the side of the middle toenail of the big toe.
V. Western medical treatment
(A) emergency treatment
1, first aid principles: first save life, then identify the disease.
2.Clean the respiratory tract, keep the airway open, tilt the head to the side to prevent asphyxia due to vomiting.
3, oxygen, application of respiratory stimulants, if necessary, tracheal intubation or tracheotomy for artificial assisted ventilation.
4.Quickly establish two or more effective intravenous channels to maintain effective blood circulation and correct shock.
5.Give cardiac monitoring and monitor vital signs.
6.Conduct relevant examinations as soon as possible, such as three major routine, blood biochemistry, blood gas analysis, blood and urine amylase, electrocardiogram, etc. If necessary, CT, MRI, lumbar puncture, etc. in order to clarify the diagnosis.
(B) Symptomatic treatment
1.Reducing intracranial hypertension: mannitol, tachypnea, glycerol fructose, etc., and lateral ventricular puncture and drainage if necessary.
2, control hyperthermia: physical cooling can be used warm water or alcohol bath, placing ice bags, using electronic ice cap ice blanket, etc.; drug cooling can be used Lepirin, aspirin, or analgesic, etc., the heavy case can be used dormant combination intravenous drip.
3, anti-epilepsy: can be intravenous push Valium or phenobarbital, etc.
4.Anti-infection: Cephalosporin III or fluoroquinolones can be given according to experience, and blood culture should be sent for drug sensitivity test as soon as possible.
5, control hypertension: micro-pump can be used to pump sodium nitroprusside, nitroglycerin or uradil and other drugs, and gradually reduce the amount and transition to oral medication after the blood pressure is stable.
6, correct shock: fully expand the volume, if necessary, use cardiac stimulation such as cetiran, apply dobutamine and other vasoactive drugs; severe hemorrhagic anemia as soon as possible to transfuse component blood.
7, correction of abnormal blood glucose: original diabetes or stress increased blood glucose, can apply ordinary insulin 4 ~ 6u/h continuous pumping, every two hours to monitor blood glucose and adjust the amount of drugs; hypoglycemic coma as soon as possible with 50% glucose 40 ~ 60ml intravenous injection, followed by 10% glucose intravenous drip maintenance 12 ~ 24 hours.
8.Wound treatment: If there is an open wound, hemostasis, debridement, suturing and bandaging should be done in time, and attention should be paid to whether there is cranial, spinal and visceral injury.
9, poisoning treatment: drug poisoning should be explored as soon as possible and gastric lavage, followed by catheterization, diuresis, etc. to promote the excretion of toxic substances; clean up the residual toxic substances attached to hair, skin and clothing; apply detoxification treatment.
(C) Etiological treatment
Once the cause is clear, carry out etiological treatment immediately. For example, apply atropine and dephosphoridine for organophosphorus poisoning, hyperbaric oxygen therapy for carbon monoxide poisoning, naloxone therapy for alcohol poisoning, etc.