First aid for coma

Occurs due to acute or chronic renal failure, which is a complication or stage of development of almost any kidney disease. According to statistics, uremia ranks 11th among the causes of mortality of the population after cardiovascular diseases, tumors, diabetes, cirrhosis of the liver, etc. In order of decreasing frequency, the causes of uremic com are: chronic pyelonephritis, chronic glomerulonephritis, diabetic glomerulosclerosis, nephrosclerosis, polycystic and amyloidosis of the kidneys, collagenous nephropathy, intoxication, dielectrolyte nephropathy, metabolic nephropathy, vascular anomalies of the kidneys, etc. Pathogenesis. In the chronic process, uremia develops if 80–90% of the glomeruli are affected. A rough idea of ​​the size of the lesions give indicators of glomerular filtration, the level of creatinine in the blood. Along with the death of the structural subunits of the kidney during inflammatory processes, perifocal infiltrations, edema of the renal parenchyma, and allergic reactions play a definite role in the development of renal failure. In urodynamic disorders, urostasis, a series of ascending reflexes disrupts blood circulation and lymph circulation in the kidneys, which contributes to a further decrease in their functions. Water-electrolyte shifts — dehydration, hypovolemia, dielectrolytemia, and acid-base imbalance — play a significant role in the disorders occurring in uremic coma disorders. In chronic renal failure, which passes into the uremic coma, the "contamination" of the blood increases with protein, acid slags, the compensatory and adaptive capabilities of the body are depleted. The blood increases the content of urea, creatinine, indole products - primarily phenols, methylguanidine, guanidine-succinic acid. Polypeptides with an average molecular weight (from 300 to 1500), so-called medium molecules, accumulate in the blood. The concentration of calcium increases due to increased production of parathyroid hormone, magnesium ions, various changes in sodium levels in plasma and tissues occur. Clinical picture. Uremic coma develops gradually either after an acute renal lesion with anuria, or as a result of the evolution of a severe renal disease under the influence of an adverse factor. Initially, there is a sharp weakness, headache, nausea, itching, insomnia, the appearance of "veil", "mist" before the eyes. Patients become restless, rarely aggressive, later - indifference, drowsiness, which go into a spoor and coma. There are frequent skin, gingival, nasal, uterine, gastrointestinal bleeding (uremic hemorrhagic diathesis). Inspection. The patient's appearance is noteworthy: puffy, pale face, most often yellowish-pale due to urochromes accumulating in the skin (ocherdermia). The skin is dry, peeling with traces of scratching, arising (sometimes long before a coma) due to itching of the skin. On the latter, urats can be seen. Fibrillary twitching of facial muscles, convulsive twitching of the muscles of the limbs, abdominal wall are observed. Pupils are narrowed. Exhaled sick air with the smell of urine. Vomit have the smell of ammonia.

In the clinic of the preceding coma of the period and during the coma, gastric, anemic, non-electrolytemic, and neuropsychiatric syndromes are distinguished, the combination of which determines the disease. Due to the fact that the pressor function of the kidneys is preserved, and the depressive one falls, the majority of patients show elevated numbers of blood pressure. There are other signs of damage to the cardiovascular system, for example, dry uremic pericarditis, myocardial dystrophy (to which hypertension, anemia, intoxication lead), deafness of heart tones, functional noise, heart failure. Patients may experience toxic diarrhea, often stomatitis.

Additional research methods. Changes in urine analysis (decrease in specific gravity, appearance of protein, formed elements) indicate the presence of kidneys, as well as an increase in the content of residual nitrogen in the blood, urea, creatinine. Signs of dielectrolytemia are identified, anemia and leukocytosis appear.

Treatment for uremic coma It is aimed at detoxifying the body, combating the resulting acidosis, and replacing kidney function. Achieving these goals is especially difficult in cases of slowly developing coma in severe chronic kidney disease. The most effective treatment for this type of coma is hemodialysis and peritoneal dialysis. Both methods have the same indications, but different contraindications. In cases where hemodialysis or peritoneal dialysis is not possible to carry out, it is necessary to carry out therapeutic measures aimed at achieving the goals set by other means. With the purpose of detoxification - bloodletting in the amount of 200-400 ml or exchange blood transfusion (4-5 liters) for several days (5-7 times). Introduction of 5% glucose solution, 10-20% mannitol solution, 4% sodium bicarbonate solution in amounts calculated by diuresis, hemodez, gastric lavage with alkaline solutions (for example, soda solution) 2-3 times a day. It is best to wash the stomach with a probe 2-3% solution of soda in the amount of 4-5 liters. For washing the intestines using siphon enemas with soda solution in the amount of 6-8 liters and the so-called intestinal lavage. Intestinal and gastric washes help clean the blood from toxins. With vomiting, 10 ml of a 10% solution of sodium chloride is administered intravenously, 0.5 ml of a 0.1% solution of atropine subcutaneously. When excited, chloral hydrate is prescribed (50 ml of a 3-5% solution in an enema), phenobarbital, wet wraps, with skin itch, help wash the skin with cologne, salicylic or camphor alcohol. In case of anemia and hematocrit drop below 20%, red blood cell transfusions are shown (200 - 300 ml). Antihypertensive therapy is carried out with the aim of gradually and moderately lowering blood pressure. To reduce protein catabolism, enhance reparative processes in the kidneys, anabolic steroids are prescribed (nerobol, methandrostenolone 5 mg 1-2 times a day for 15-20 days). An important section in the treatment of precomatose uremia is the appointment of a diet to the patient, containing the minimum amount of protein, which sharply limits salt intake. Recommended diet N7a, developed by the Institute of Nutrition, Academy of Medical Sciences of the USSR. It contains 20 grams of protein per day, which is provided by full animal protein (boiled meat — 26.5, egg protein), protein-free chloride chloride bread, dishes and side dishes made from vegetables, greens, milk and dairy products, fruits, sugar, vitamin berry broths. The appointment of a low-protein diet with advanced renal failure contributes to the disappearance of uremic symptoms and a decrease in the level of nitrogenous slags (urea, residual nitrogen). However, prolonged use of this diet causes hunger and weight loss in patients, therefore, as the symptoms of uremia are eliminated, a less strict diet should be applied.

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Causes of Uremic Coma

In most cases, uremic coma is a consequence of chronic forms of glomerulonephritis or pyelonephritis. In the body, toxic metabolic products are formed in excess, which is why the amount of excreted daily urine is sharply reduced and coma develops.

The extrarenal reasons for the development of uremic coma include: poisoning with drugs (sulfanilamide series, salicylates, antibiotics), poisoning with industrial poisons (methyl alcohol, dichloroethane, ethylene glycol), shock states, indomitable diarrhea and vomiting, transfusion of incompatible blood.

In case of pathological conditions of the body, a violation occurs in the blood circulation system of the kidneys, as a result of which oliguria develops (the amount of excreted urine is about 500 ml per day), and then anuria (the amount of urine is up to 100 ml per day). The concentration of urea, creatinine and uric acid is gradually increasing, which leads to symptoms of uremia. Due to an acid-base imbalance, metabolic acidosis develops (a condition in which the body contains too many acidic foods).

Symptoms of uremic coma

The clinical picture of uremic coma develops gradually, slowly. It is characterized by pronounced asthenic syndrome: apathy, increasing general weakness, fatigue, headache, daytime sleepiness and sleep disturbance at night.

Dyspeptic syndrome is manifested by loss of appetite, often before anorexia (refusal to eat). The patient has dry and bitter taste in the mouth, there is a smell of ammonia from the mouth, increased thirst. Often join stomatitis, gastritis, enterocolitis.

Patients with increasing uremic coma have a characteristic appearance - the face looks puffy, the skin is pale, dry to the touch, traces of scratching are visible due to intolerable itching. Sometimes on the skin you can observe the deposition of uric acid crystals, similar to powder. Hematomas and hemorrhages, pastoznost (pallor and a decrease in the elasticity of the skin of the face on the background of small edema), edema in the lumbar region and lower extremities are visible.

Hemorrhagic syndrome manifests uterine, nasal, gastrointestinal bleeding. On the part of the respiratory system, his disorder is observed, the patient is worried about paroxysmal dyspnea. Blood pressure drops, especially diastolic.

The increase in intoxication leads to severe pathology of the central nervous system. The patient's reaction decreases, he falls into a state of stupor, which ends with a coma. At the same time there may be periods of sudden psychomotor agitation, accompanied by delusions and hallucinations. With an increase in coma, involuntary twitching of individual muscle groups is permissible, pupils constrict, tendon reflexes increase.

Pathogenesis of uremic coma

The first important pathogenetic and diagnostic sign of the onset of uremic coma is azotemia. In this state, residual nitrogen, urea and creatinine are always increased, their indicators determine the severity of renal failure.

Azotemia causes such clinical manifestations as disorders of the digestive system, encephalopathy, pericarditis, anemia, skin symptoms.

The second most important pathogenetic feature is a shift in water and electrolyte balance. In the early stages, there is a violation of the ability of the kidneys to concentrate urine, which is manifested by polyuria. In end-stage renal failure, oliguria and then anuria develop.

The progression of the disease leads to the fact that the kidneys lose the ability to retain sodium and this leads to salt depletion of the body - hyponatremia. Clinically, this is manifested by weakness, low blood pressure, skin turgor, increased heart rate, blood clots.

In the early polyuric stages of development of uraemia, hypokalemia is observed, which is expressed by a decrease in muscle tone, shortness of breath, and often spasms.

At the terminal stage, hyperkalemia develops, characterized by a decrease in blood pressure, heart rate, nausea, vomiting, and pain in the mouth and abdomen. Hypocalcemia and hyperphosphatemia are the causes of paresthesias, seizures, vomiting, bone pain, and osteoporosis.

The third most important link in the development of uremia is a violation of the acidic state of the blood and tissue fluid. At the same time, metabolic acidosis develops, accompanied by shortness of breath and hyperventilation.

Expert Editor: Pavel Alexandrovich Mochalov | D.M.N. general practitioner

Education: Moscow Medical Institute. I. M. Sechenov, specialty - “Medicine” in 1991, in 1993 “Occupational diseases”, in 1996 “Therapy”.

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Etiology and pathogenesis

Uremia literally denotes the monochrome. When it occurs, the body is poisoned with those products that are retained in the blood and tissues due to impaired renal function. Uremia develops in the final stages of chronic nephritis, nephrosclerosis, hydronephrosis and in such rare diseases as bilateral kidney damage by tuberculosis and their cystic degeneration. Ultimately, in these diseases, the glomeruli are replaced by scar tissue and the so-called shriveled kidney develops.

There are cases of development of uremia in prostatic hypertrophy in men and in malignant tumors (cancer) of the uterus in women causing prolonged urinary retention in the first case and compression of the ureters in the second.

Long before uremic coma develops, i.e., the patient falls into an unconscious state, he has a number of signs of kidney failure. These symptoms develop gradually, sometimes over many years. The patient can pay attention to the fact that he began to allocate a large amount of light urine, and at night more than during the day (a healthy person releases most of the urine during the day). When examining such urine, its specific weight is low. At the same time, the excretion of slag exchange by the kidneys is disturbed. This entails a delay in the body of the patient products of nitrogen metabolism - increases the content of residual nitrogen in the blood.

In addition, renal failure is accompanied by a number of other biochemical changes in the body. Thus, the alkaline-acid balance is disturbed, a large amount of acidic products (the acidosis develops) is retained in the blood and tissues. The accumulation of residual nitrogen and acidic products leads to a slow but progressive poisoning of the body. The patient appears weak, headache, insomnia, reduced performance. Blood pressure is usually elevated. Urine changes that indicate kidney disease are noticeable.

With the accumulation of nitrogenous toxins in the body, they begin to be secreted by the mucous membrane of the stomach (according to MP Konchalovsky's apt expression, “the stomach begins to urinate”), with the result that the patient develops so-called excretory gastritis. This leads to a sharp decrease in appetite, nausea, and vomiting. For far advanced disease, vomiting is characteristic in the morning on an empty stomach. However, it also happens after eating (it should be noted that nausea and vomiting in uremia are often a manifestation of central nervous system intoxication). In addition to gastritis, in the terminal stage of uremia, excretory colitis may occur, since nitrogenous wastes are secreted by the intestines, diarrhea appears. The stool is liquid, watery, then with mucus and blood, which may be the reason for the erroneous assumption of dysentery.

Sharp dry mouth is also caused by the release of urea with saliva. Urea is also excreted through the sweat glands and causes itchy skin. On the pale skin of the patient there are numerous scratches and traces of them. In the final stage of uremia, small crystals of urea can be seen on the skin, especially on the face near the wings of the nose. During this period, the smell of urea in the exhaled breath of the patient draws attention.

When uremia develops quite early emaciation, which is steadily progressing and reaches the degree of cachexia. The depletion of the patient is caused not only by a drop in nutrition, but also by the breakdown of muscle and other body tissues.

Inherent sign of uraemia is anemia. It is not caused by hematuria, which may be insignificant, but by the suppression of the function of blood formation as a result of the effect of residual nitrogen on the bone marrow. Intoxication of the bone marrow also explains leukocytosis, reaching 20,000–30,000 in the terminal period of uremia. Together with anemia, the patient develops hemorrhagic diathesis caused by a decrease in the number of platelets, as well as a malfunction of the vascular walls. Hemorrhages appear on the skin, hemorrhagic stomatitis, sometimes nasal bleeding, hemorrhagic gastritis.

One of the main symptoms of azotemic uremia is damage to the central nervous system. We have already indicated the early signs of central nervous system intoxication - headache, insomnia, general weakness, decreased performance. Later, drowsiness and indifference to the environment develop. Apathy is the result of depression of the patient’s consciousness, which is not completely lost. In some cases, there is mental arousal, hallucinations, which can lead to an incorrect diagnosis of acute psychosis.

As a manifestation of uremic intoxication, short-term muscle twitching is observed, in the terminal period - seizures.

As a result of central nervous system intoxication, respiratory distress occurs, and noisy deep breathing develops (Kussmaul's big breathing), which gives the impression that the patient is sleeping. Another type of breathing is less characteristic - cheyne-stosovo (fast-growing and aggravated breathing with pauses). These pathological forms of respiration indicate deep lesions of the central nervous system with impaired function of the respiratory center.

One of the signs of uremia is constriction of the pupils and visual impairment, manifested by a narrowing of the visual field, sometimes significant. Often, with the first complaints of blurred vision, patients with uremia turn to oculists. Based on the characteristic changes in the fundus of the eye, the optometrist establishes kidney disease.

Shortly before the death of a patient suffering from uremia, when listening to the heart, a pericardial rub is determined, called "death knell". Fibrinous pleurisy may also develop. Sometimes with uremia, an attack of cardiac asthma and pulmonary edema are observed as a result of heart failure.

Terminal signs of uremic poisoning also include a decrease in temperature. In the last days of life, it falls to 35 ° and even lower. In such patients, terminal pneumonia often occurs at normal temperature.

Thus, the development of uremic coma is preceded by a long period of the disease, characterized by a slowly progressive development of azotemia. We have already pointed to the phenomena of central nervous system intoxication, in some cases leading to confusion, mental agitation and hallucinations, in others to drowsiness and complete apathy. These symptoms are characteristic of the precomatose state.

With developed forms of uremic coma, the consciousness of patients is completely disturbed. They do not answer questions, do not react to various irritations. On examination, the patient draws attention to the dramatic exhaustion, sallow-pale skin. In the exhaled air there is a smell of urine (ammonia), deep, noisy breathing like Kussmaul. Pupils are sharply narrowed, react poorly to light (in the late stage, the comas do not react to light at all). The skin is dry with traces of scratching.

The diagnosis of uremic coma is not difficult if the patient has been under the supervision of a doctor or medical assistant for kidney disease for a long time. If a doctor (paramedic) first sees a patient who is in a comatose state, it is possible to establish azotemic uremia on the basis of information received from relatives. The above characteristic clinical signs and symptoms such as high blood pressure, pericardial friction noise, etc. should be considered.

At statement of the diagnosis difficulties are possible. Thus, psychic arousal for uraemia sometimes leads to an incorrect assumption of mental illness. Uremic colitis can be mistaken for dysentery, uremic coma in the terminal phase - for cerebral stroke. When the patient is observed only in the period of coma, it may be necessary to have a differential diagnosis with diabetic coma. Below we give a comparative description of uremic and diabetic coma.

Radical treatment can be possible only in cases where uremia is caused by urinary retention due to obstruction of the ureter with a stone, compression of the ureter by a tumor, retention of urine during prostate hypertrophy. However, uremia on the basis of these diseases is extremely rare. As a rule, it develops with bilateral chronic kidney disease, leading to irreversible sclerotic changes in them.

When treating a patient with uremia should: 1) to contribute to the preservation of the remaining functional capacity of the kidneys, 2) to prevent and reduce the effects of intoxication caused by the accumulation of nitrogen metabolism toxins, 3) to conduct symptomatic therapy of complications caused by uremia. These measures are to some extent preventive in relation to the development of uremic coma.

For the implementation of the first task it is necessary to provide the patient with favorable conditions of life (warm, well-ventilated room) and food. Clear and specific instructions on diet and diet are given. A vegetarian diet is prescribed. The required amount of protein is provided by the consumption of yogurt or kefir, as well as fresh cottage cheese. It is necessary to emphasize the expediency of consuming large quantities of fresh vegetables and fruits. Vegetables and fruits have a positive effect on the alkaline-acid balance of the body, they act alkalizingly. Grapes, watermelons, melons are useful for these patients.

In food it is necessary to limit the salt content. However, it would be wrong to assign a strict salt-free regimen to a patient with uremia. Prolonged deprivation of salt leads to a decrease in the chlorides in the blood, and this in turn contributes to the breakdown of body tissues and an increase in the residual nitrogen of the blood. In some cases, with uremia, hypertonic sodium chloride solution is even administered intravenously. This has to be done if the patient has been on a salt-free diet for a long time. A decrease in blood chlorides in uremia is noted when the kidneys excrete a lot of urine (polyuria), and with it a significant amount of common salt. In these cases, intravenous administration of a hypertonic solution of table salt gives a noticeable therapeutic effect: the patients feel better, the effects of intoxication are reduced, the level of residual nitrogen in the blood decreases.

The depletion of the body with sodium chloride occurs with frequently repeated vomiting, which causes dehydration and loss of chlorides. Therefore, if a patient with uremia has vomiting, a physiological solution (0.85% sodium chloride solution) should be administered to him in the form of drip enemas or subcutaneously.

Of the drugs used for uremia, glucose is one of the first places. It plays the role of a neutralizing agent for intoxication and, moreover, is a high-calorie nutritious product. Glucose can be administered orally with ascorbic acid. More often, it is injected parenterally - intravenously, subcutaneously, in the form of drip enemas. Large amounts (40–80 ml) of 40% glucose solution are infused 1-2 times a day intravenously. For subcutaneous administration, 5% glucose solution is used in an amount up to 1 l 1-2 times a day. For nutritional drip enemas used 0.5-1 l of 5% glucose solution. The introduction of large amounts of fluid is dictated by the fact that patients, as we have said, with frequent vomiting, lose a lot of water.

Bloodletting, by means of which a certain amount of toxic products can be removed from the body, is rarely used for uremia due to the presence of anemia.

For severe anemia, vitamin B12, campolone, iron supplements, and fractional red blood cell mass or whole blood transfusions are prescribed.

A large number of nitrogenous toxins can be removed from the body by washing the stomach. Systematically washing the stomach, you can alleviate the patient’s condition for a while. With the same purpose, sometimes resort to siphon enemas.

With persistent vomiting, in addition to washing the stomach and injecting hypertonic sodium chloride into the vein, chloroform water, anesthesin, novocaine are given inwards.

Rp. Aq. Chloroformii 200.0 (1.0: 200.0)
DS. 1 tablespoon 2-3 times a day
Rp. Anesthesini 0.25
D. t. d. N. 12
S. 1 powder 3 times a day
Rp. Sol. Novocaini 0.25% 100.0
DS. 1 tablespoon 2 times a day

If uremia is accompanied by cardiac insufficiency and circulatory disorders, it is necessary to prescribe heart remedies. When uremia often develops acute heart failure of the left ventricular type. In such cases, it is best to apply strophanthin (intravenously) in a 0.05% solution in an amount of 0.5-1 ml in 20 ml of 40% glucose solution. Introduce strophanthin intravenously must be very slowly - within 3-5 minutes.

For collapse, as well as for violations of the respiratory center (breathing type Kussmaul, Cheyne-Stokes) required subcutaneous injections of caffeine and camphor. A more drastic measure can be intravenous infusion of 1 ml of 10% caffeine solution (Sol. Coffeini natrio-benzoici), which must be done very carefully and very slowly. Even better, following the same precautions, administer intravenously euphylline.

Rp. Sol. Euphyllini 2.4% 10.0
D. t. d. N. 3 in amp
S. 5-10 ml of the contents of the ampoule diluted in 20 ml of 40% glucose solution. Inject into a vein (very slowly!)

Intravenous infusion of these funds is recommended in a hospital setting.

Recently, euphylline has been used successfully in enemas: 0.3 g of aminophylline per 40-50 ml of water warmed to body temperature.

In addition, it is necessary to carry out symptomatic treatment. For headaches, pyramid and other painkillers or mustard plasters are applied to the occipital region. In the absence of significant anemia, leeches are assigned that can be placed on the region of the mastoid processes (behind the ears) or on the sacrococcygeal region. If the patient is agitated, he is given bromine, luminal, chloral hydrate and other sedatives.

Itching can be alleviated by the use of bromine, luminal. Bromine can be administered intravenously (Sol. Natrii bromati 10% 10.0). It is advisable to wipe the skin with cologne, lemon slices. Chloral hydrate (in enemas), pantopon is also used.

In uremic acidosis, which is manifested by noisy breathing, the appointment of alkalis is shown (Borjom, Essentuki No. 20 and No. 4). In addition, you should enter in drip enemas or subcutaneously alkali-saline solutions:

Rp. Sol. Natrii bicarbonici 5%
Sol. Natrii chlorati 0,85% aa 250,0 Sterilisl
MDS. For subcutaneous and intravenous administration

Spasms, muscle twitching can sometimes be stopped by the introduction of calcium chloride or sodium chloride.

Epidemiology

The most common infectious and inflammatory pathology of the urinary organs, as evidenced by medical statistics, pyelonephritis. According to postmortem studies, this disease is detected in at least 6% of those who have undergone an autopsy. The maximum pyelonephritis was found, according to different authors, in 18-30% of autopsies. It is believed that half of the patients who died in a state of uremic coma, it was caused by this pathology.

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Complications and consequences

Acute uremia with adequately carried out treatment (hemodialysis) is in most cases curable, patients are fully restored in about a year, sometimes in half a year. However, the failure to provide emergency care and the absence of dialysis in almost all cases is fatal.

The course of chronic pathology can be calculated for years, while the patient's condition will be quite satisfactory. The most innocuous, however, unpleasant consequence is the smell of ammonia from the body and exhaled air. Constant intoxication does not pass without a trace for the body. The liver, heart, nervous system and bone marrow are gradually disrupted. Calcium loss leads to osteoporosis, anemia and thrombocytopenia lead to bleeding, the organs of the senses are disturbed - sight, smell, taste. Sometimes the circulation of toxins in the blood leads to cerebrovascular diseases. The most terrible complication of uremia is deep coma and patient death.

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Diagnosis of uremic coma

This condition is diagnosed by symptomatology, test results, data from instrumental diagnostics, taking into account the patient’s history and interviews of close relatives.

The main in the diagnosis of uremic coma are blood tests. Her biochemical study gives an idea of ​​the content of ammonia and ammonia compounds, creatinine, whose indices will exceed the norm. The analysis also determines the level of concentration of the main electrolytes (Na, K, Mg, Ca).

The degree of impairment of the metabolism of organic substances is determined by the proteinogram (a blood test for the level of protein and protein fractions), a blood test for the lipid spectrum and the level of glucose.

Urinalysis is not specific for uremic coma and indicates the presence of a common chronic renal pathology. In the urine can be determined proteins, traces of blood, cylinders, talking about the acidic environment. Urine has a low density in polyuria, and high - in oliguria.

Instrumental diagnostics prescribed by the doctor if necessary. This is, above all, an ultrasound of the kidneys. To diagnose the condition of other organs, electrocardiography, radiography, magnetic resonance and computed tomography, ultrasound of the abdominal organs, etc. can be prescribed.

According to research and laboratory tests, differential diagnosis is carried out with other conditions: hepatic, ketoacidotic coma and severe renal impairment.

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Treatment of uremic coma

This condition requires the use of emergency measures to prevent the death of the patient. Emergency care for uremic coma consists of the following therapeutic measures. The patient’s condition is assessed on the Glasgow scale. Then, first of all, perform the resuscitation of the heart and lungs, restoring their work, try to keep what has been achieved (use, if necessary, oxygenation and mechanical ventilation, heart massage). Regularly monitor vital signs - pulse rate, the presence of respiration, blood pressure. Make a cardiogram, conduct emergency diagnostic procedures. Periodically in the process of resuscitation measures assess the state of consciousness.

The gastrointestinal tract is washed with 2% sodium bicarbonate solution, saline laxatives are prescribed.

In case of salt deficiency, intramuscular injections of 0.25l isotonic saline are prescribed. Excess sodium is neutralized. Spironolactone a diuretic agent that does not remove potassium and magnesium ions, but increases the excretion of sodium and chlorine ions, as well as water. Shows selectively at elevated pressure the ability to reduce it, reduces the acidity of urine. Contraindicated in anuria, liver failure, an excess of potassium and magnesium, sodium deficiency. May cause side effects from the digestive organs, central nervous system and metabolic processes.Assign a daily dose of 75 to 300mg.

To lower blood pressure, antihypertensive drugs are prescribed, for example, Kapoten inhibits the enzymatic activity of the catalyst for the synthesis of angiotensin II (a hormone produced by the kidneys). It promotes relaxation of blood vessels, reduces blood pressure in them and the load on the heart. Arteries expand under the influence of the drug to a greater extent than the veins. Improves blood flow to the heart and kidneys. Provides a decrease in the concentration of sodium ions in the blood. A daily dose of 50mg medication reduces the vascular permeability of the microvasculature and slows down the development of chronic renal dysfunction. The hypotensive effect is not accompanied by a reflex increase in the pulse and reduces the oxygen demand of the heart muscle. Dosing individual, depending on the severity of hypertension. Side effects - increased levels of protein, urea and creatinine, as well as - potassium ions in the blood, acidification of blood.

To eliminate acidosis, intravenous injections are prescribed. Trisamine, activating the functions of the blood system, supporting its normal acid-base balance. The drug is injected slowly at a rate of 120 drops / min. The largest daily volume of the injected substance should not be greater than the calculated one - 50 ml per kilogram of the patient's body weight. The use can lead to inhibition of respiratory function, overdosing - to alkalization, vomiting, decrease in the level of glucose, arterial pressure. The drug for renal failure is used carefully.

Rehydration is stopped by infusion solutions: isotonic glucose in a volume of 0.3-0.5 l and sodium bicarbonate (4%) in a volume of 0.4 l. It is desirable to take into account both the individual sensitivity of the patient and undesirable effects:

  • glucose solution - in cases of diabetes,
  • sodium bicarbonate - with a deficiency of calcium and chlorine, anuria, oliguria, swelling and hypertension.

Normalization of protein metabolism is carried out using Retabolil. It is administered intramuscularly in a dose of 1 ml of 5% solution. The drug effectively activates protein synthesis, eliminates depletion, compensates for the lack of nutrition of bone tissue, however, has a moderate androgenic effect. Caution should be exercised in case of renal and hepatic dysfunction.

Potassium deficiency is compensated Panangin It is believed that the active ingredients (potassium asparaginate and magnesium asparaginate), entering the cells due to asparginata, flow into metabolic processes. Normalizes the heart rhythm, compensates for the deficiency of potassium. When the patient complains of dizziness - reduce the dose of the drug. A slow intravenous infusion of a solution is prescribed: one or two Panangin ampoules - ¼ or ½ liter of isotonic sodium chloride or glucose solution (5%).

The increased content of potassium in the blood is arrested: 0.7 l of sodium bicarbonate solution (3%) and glucose (20%).

Persistent vomiting is stopped by intramuscular injections. Cerucala 2 ml, which has a normalizing effect on the muscle tone of the upper digestive tract. The antiemetic effect of the drug does not apply to vomiting of the vestibular and psychogenic genesis.

An obligatory procedure to cleanse the body of accumulated toxic metabolic products, excess water and salts is the use of an artificial kidney apparatus (extracorporeal hemodialysis). The essence of the method is that arterial blood is passed through a system of filters (artificial semi-permeable membranes) and returned to the vein. In the opposite direction, bypassing the filter system, a solution flows, similar in composition to the blood in a healthy organism. The device controls the transfer of necessary substances into the patient's blood and harmful - into dialysate. When the normal composition of the blood is restored, the procedure is considered complete. This method has been used for a long time and has proven to be very effective in the treatment of acute or chronic uremia, caused both by a malfunction of the kidneys in case of their insufficiency and in cases of acute exogenous intoxication.

In the presence of an infectious process, individual antibacterial therapy is prescribed.

Since the development of uremic coma occurs with increasing intoxication, anemia and oxygen starvation of tissues, the body needs vitamins. Ascorbic acid is usually prescribed, against the background of which immunity increases, vitamin D, which prevents the development of osteoporosis, vitamins A and E, useful for overdried, itchy and losing skin elasticity, B vitamins necessary for hemopoiesis. Of these, pyridoxine (vitamin B6) is particularly useful. Its deficiency contributes to the rapid accumulation of urea in the blood. Its level decreases very quickly with a daily intake of 200mg of this vitamin. Recommended daily intake of vitamins: B1 - at least 30 mg, E - 600 units, natural vitamin A - 25 thousand units.

In addition, it is desirable to take lecithin (from three to six tablespoons), as well as choline - four times a day: three - before meals and once before going to bed at 250 mg (one gram per day).

Nutrition also plays a positive role. You must consume at least 40g of protein daily, otherwise the accumulation of urea is rapidly. Moreover, preference should be given to plant proteins (beans, peas, lentils, bran). They do not contribute to the accumulation of sodium, as opposed to animals. To normalize the intestinal microflora is recommended to drink sour milk drinks.

Physiotherapy treatment can be used for prophylactic purposes and during the period of rehabilitation treatment. Applied magnetic, laser, microwave and ultrasound therapy. Methods of treatment are selected individually, taking into account the history, tolerance, associated diseases. Physical procedures improve blood circulation, have a thermal, physical and chemical effect on body tissues, stimulate immune function, help relieve pain, inflammation, slow down dystrophic processes.

Folk treatment

Alternative prophylactic treatment methods can slow down the development of uremic coma and shorten the rehabilitation period.

In case of exacerbation of uremia and the inability to immediately call the ambulance team at home, the following urgent procedures can be performed:

  • prepare a hot bath (42 ° C) and lower the patient there for 15 minutes,
  • then do an enema with water and salt and vinegar (not essences),
  • after the enema has acted, give a laxative, for example, senna.

Assisting, it is necessary to periodically water the patient with water or serum. Alkaline mineral water helps in such cases. Put a cold compress or ice on your head. With nausea, as well as - vomiting, you can give pieces of ice to swallow or drink iced tea.

Traditional medicine recommends wrapping the patient in a cold wet sheet, arguing that such an action helped save more than one life. If there is really no way to get medical care, then it is done this way: a warm blanket is spread on the bed, a sheet soaked in cold water and well wrung out on top of the bed. Lay on it the patient, wrapped in a sheet, then a warm blanket. From above too cover with a warm plaid, especially try to keep feet of the patient warm. Convulsions must pass, and having warmed up, the patient falls asleep for several hours. Do not wake him. If on awakening the convulsions in the patient begin again, it is recommended to repeat the wrapping.

Prepare a mixture of powdered seven parts of peppermint seed, three parts of white pepper and two parts of the stone-cutted femur root. To accept a powder, washing down with its broth of a dogrose, three or four times in a day. This tool is considered a useful component of complex treatment of patients even on hemodialysis.

Prevention of blood concentrations of nitrogenous compounds and other toxins is considered to be the daily use of parsley and dill, celery, lovage, lettuce and onion in summertime, as well as radish and radish, cucumbers and tomatoes. It is good to eat cabbage, carrots and beets in the raw state, to cook dishes from these vegetables as well. It is useful to use dishes from potatoes, pumpkins and zucchini. Fresh berries have a cleansing effect:

  • forest - cranberries, strawberries, blueberries, cranberries, blackberries,
  • garden - strawberries, raspberries, gooseberries, plums, black chokeberry and red grapes.

Watermelons and melons will be useful. In spring you can drink birch sap without restrictions. In the autumn-winter period, they use the already mentioned vegetables and apples, oranges, and grapefruits.

The recipe for the normalization of the water-salt balance: the unrefined grains of oats are poured with water, brought to a boil and roasted, not allowing boiling, on a small fire for three to four hours. Then another hot oat is rubbed through a colander. The resulting kissel should be eaten immediately, it is allowed to add some honey.

With uremia, urolithiasis, herbal therapy is applied. It is recommended to drink nettle infusion, which is prepared in a ratio of: 200 ml of boiling water - a tablespoon of crushed dried nettle leaves. At first, a quarter of an hour is insisted on a water bath, then ¾ hour at room temperature. Filter and drink one third of a glass before each meal (three or four times a day).

For chronic disorders of the kidneys, kidney disease and uremia, it is recommended to pour two teaspoons of the golden button grass with a glass of cold boiled water and leave for four hours in a closed jar. Then drain and squeeze the juice from the lemon to taste. Drink a quarter cup a month four times a day before meals.

We grind and mix 15g of roots of bull grass and parsley, hips and juniper, add 20g of black currant leaves and heather flowers to them. Brew a dessert spoon of vegetable mixture with boiling water (200ml) for five minutes and strain. Drink three times a day for a month. Contraindicated in acute renal pathologies, ulcerative lesions of the gastrointestinal tract, pregnant women.

We grind and mix 30g of smooth gryzhnik grass and horsetail grass, birch leaves and bearberry. A tablespoon of vegetable mixture is poured into enamelware and poured with a glass of water. With the lid closed, simmer on low heat for about three minutes. Broth insist for another five minutes. Filter, cool to a warm state and take three times a day for a month. For acute cystitis, take with caution.

Summer recipe - an infusion of fresh leaves of lilac: chop the leaves of lilac, take two tablespoons, brew boiling water in a volume of 200 ml, bring to a boil and leave to heat for two to three hours. Drain, squeeze lemon juice in infusion to taste. Take one tablespoon in front of four main meals. The course of treatment is two weeks, then after two weeks you can repeat. This treatment is recommended for all summer, while there are fresh leaves of lilac. In the fall - be examined.

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Homeopathy

Homeopathic medicines can help prevent uremic coma, as well as help to restore health quickly and qualitatively and eliminate its consequences.

Ammonium causticum is recommended as a powerful stimulator of cardiac activity in uremia, when blood traces, proteins and hyaline cylinders are observed in the urine. A characteristic symptom of its use are bleeding from the natural orifices of the body, a deep syncope.

Hydrocyanic acid (Acidum Hydrocyanicum) is also a first aid drug in agony for uremic coma. However, the problem is that usually these drugs are not at hand.

In inflammatory diseases of the kidneys, in particular, pyelonephritis or glomerulonephritis (which, when chronic, can lead to the development, ultimately, of uremic coma), drugs of choice are Snake venom (Lachesis) and Gold (Aurum). However, if kidney inflammation was preceded by tonsillitis, chronic tonsillitis has developed, then Sulfuric Liver (Hepar sulfuris) or Mercury preparations will be more effective. Therefore, in order for homeopathic treatment to help, you need to consult a qualified specialist.

For prophylactic purposes in chronic uraemia, a complex homeopathic remedy is recommended. Beberis Homemaord. It consists of three plant components in different homeopathic dilutions.

Berberis vulgaris (Berberis vulgaris) - enhances the drainage function of the urinary organs, has an analgesic, anti-inflammatory effect, helps to eliminate excess salts, remove calculous deposits and prevent their deposition.

Bitter gourd (Citrullus colocynthis) - activates the blood supply to the peritoneal organs, relieves spasms, has a neutralizing and diuretic effect, eliminates renal colic.

White Camelite (Veratrum album) - has a tonic and antiseptic activity, has a beneficial effect on the central nervous system, restores depleted organism.

Appointed as a drainage agent, with pathologies of the urinary organs, joints, liver, digestive tract and dermatological diseases.

Drops are patients over 12 years old. Pour 10 drops into a container containing 5-15 ml of water and drink, trying to hold it longer in the mouth. The drug is taken three times a day for a quarter of an hour before meals or one hour after.

The daily portion can be diluted in 200 ml of water and taken in small sips throughout the day.

For the relief of acute conditions, a single dose of 10 drops is taken every quarter of an hour, however, not more than two hours.

Side effects and interactions with other drugs have not been identified.

Complex homeopathic drops Galium Heel have an effect on the cellular level. This is one of the main drainage means of the parenchyma of the lungs, heart muscle, kidneys and liver. Appointed for detoxification of the body, with dyspeptic symptoms, impaired renal function, kidney disease, as a diuretic, with bleeding, exhaustion, cerebral, cardiovascular and respiratory pathologies. Contains 15 components. Side effects are not fixed. Contraindicated in individual sensitization.

It is applied at any age. For children 0–1 years old, the recommended dose is five drops, 2–6 years old — eight drops, older than six, and adults 10. For relief of acute symptoms, a single dose is taken every quarter or half hour for one or two days. The highest daily dosage is 150-200 drops. Duration of reception is one or two months.

The specificity of this homeopathic remedy implies its use at the initial stage of treatment as monotherapy (or in combination with Lymphomyosot - a preparation for cleaning the lymphatic system). It is recommended to administer the main drugs that affect the functioning of the organs after a ten to fourteen-day period from the start of drainage treatment. If it is impossible to postpone taking an organotropic drug, it is allowed to take Galium-Heel at the same time. This drug is recommended to start taking in the initial phase of the disease, when there are no marked clinical symptoms and minor complaints, because by draining the tissues, it provides training for effective exposure to organotropic drugs, both homeopathic and allopathic. As a result, the effectiveness of treatment increases.

Lymphomyosot homeopathic medicine, contains 16 components. Strengthens lymphatic drainage, relieves intoxication, edema and inflammation, reduces exudation, activating cellular and humoral immunity.Available in drops and solution for injection. It is contraindicated in case of hypersensitivity to ingredients. Use caution in thyroid pathologies. In rare cases, skin allergic reactions may occur.

Drops are dissolved in water (10 ml) and held in the mouth for suction as long as possible, taking is carried out three times a day before meals for half an hour or one hour after. Patients 12 years and older drop 10 drops, babies one or two, from one to three years - three, from three to six - five, from six to 12 - seven.

For the relief of acute conditions, a single dose is taken every quarter of an hour, however, no more than 10 times. Then go to the usual reception.

With increased thyroid function, take half the dosage corresponding to the age, increasing it daily by one drop and bringing it to the age norm.

In severe cases, prescribed injection. A single dosage is one ampoule and is used from the age of six. Injections are given two or three times a week intramuscularly, subcutaneously and intracutaneously, intravenously and at acupuncture points.

Oral administration of the solution from the ampoule is also possible; for this, its contents are diluted in cup of water and drunk throughout the day at regular intervals, retaining the liquid in the mouth.

Echinacea Compositum CH - A comprehensive homeopathic medicine containing 24 components.

It is shown in infectious and inflammatory processes of various origins, including pyelitis, cystitis, glomerulonephritis, a fall in immunity and intoxication. Contraindicated in active tuberculosis, cancer of the blood, HIV infection. Sensitization reactions are possible (skin rashes and hypersalivation). It is administered intramuscularly in one ampoule from one to three injections per week. In rare cases, there may be an increase in body temperature as a result of stimulation of immunity, which does not require discontinuation of the drug.

Ubiquinone compositum, a multicomponent homeopathic drug that normalizes metabolic processes, is prescribed for hypoxia, enzymatic and vitamin-mineral deficiency, intoxication, exhaustion, tissue degeneration. The action is based on the activation of immune protection and restoration of the functioning of the internal organs due to the components contained in the preparation. Available in ampoules for intramuscular injection similar to the previous tool.

Solidago compositum Cit is prescribed for acute and chronic pathologies of the urinary organs (pyelonephritis, glomerulonephritis, prostatitis), as well as for stimulation of urine excretion. Relieves inflammation and spasms, boosts immunity, promotes recovery, and also has a diuretic and disinfecting effect, which is based on the activation of its own immunity. Available in ampoules for intramuscular injection similar to the previous tool.

In violation of the assimilation of vitamins, for the regulation of redox processes, detoxification and restoration of normal metabolism is used Coenzyme compositum. Available in ampoules for intramuscular administration, the principle of its action and use is similar to previous means.

Surgery

With irreversible changes in the renal tissue, in order to avoid death, there is only one way out - kidney transplantation. Modern medicine is practicing organ transplantation from another person.

This is a rather complicated and expensive operation, however, it has already been performed repeatedly and successfully. The indication for transplanting this organ is the terminal stage of chronic renal dysfunction, when the organ is no longer possible, and the patient will die.

Patients are on chronic hemodialysis to save life while waiting for a transplant.

There are no single contraindications for transplantation, their list may differ in different clinics. An absolute contraindication is a cross-immunological reaction with donor lymphocytes.

Virtually all clinics will not take to operate an HIV-infected patient.

The operation is not carried out in the presence of cancer tumors, however, after their radical treatment, in most cases it is possible to perform transplantation after two years, with some types of tumors - almost immediately, with others - this period is extended.

The presence of active infections is a relative contraindication. After the treatment of tuberculosis during the year, the patient is under the supervision of doctors, and in the absence of relapse, he will undergo an operation. Chronic inactive forms of hepatitis B and C are not considered a contraindication to surgical intervention.

Decompensated extrarenal pathologies are relative contraindications.

The lack of discipline of the patient at the preparatory stage can be the reason for the refusal of organ transplantation. Also, mental illness that will not allow you to perform strict medical prescriptions are contraindications to transplantation.

In diabetes mellitus, which leads to terminal kidney dysfunction, transplantation is performed and more and more successfully.

The optimal age for this operation is 15-45 years. In patients older than 45 years, the likelihood of complications increases, mainly vascular emboli and diabetes.

Prevention

The main preventive measure is a healthy lifestyle, avoiding, if possible, injuries and poisoning, serious infectious diseases, as well as their thorough treatment. Persons with congenital and chronic pathologies of the urinary system, diabetes mellitus are recommended timely diagnosis and therapy for the prevention of exacerbations. All of this will help avoid serious renal dysfunctions.

An important place in preventive measures to prevent the development of uremic coma is the prevention of congenital renal pathologies, the search for markers of heredity and prenatal diagnosis, especially in high-risk married couples.

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Uremic coma, developing as a result of acute cessation of kidney function, is characterized by rapid progression and a high percentage of reversibility (from 65 to 95% of cases of survival). The majority of patients after the rehabilitation period regained their ability to work and returned to normal life. Exceptions (death) are particularly severe degree of damage and the lack of extrarenal cleansing.

With prolonged anuria from five days to a week, potassium surplus, excess water, and acidosis can be the cause of death. Significantly complicate the clinical course and call into question the favorable prognosis of uncontrolled arterial hypertension, circulatory disorders and other pathologies of the cardiovascular system.

Extend the patient’s life in the terminal stage of uremic coma can only be done using an artificial kidney machine. Regular hemodialysis procedures increase the life expectancy of patients with chronic uremia for up to 20 years or more (the known maximum was 22 years).

An organ transplant is performed in critical cases when renal replacement therapy is not effective and there are no other options for saving life. It allows you to increase life expectancy by 10-15 years. During this entire period, recipients must carefully follow the medical recommendations and take immunosuppressants that have a lot of side effects. Kidney transplantation is a priority in the treatment of children, since hemodialysis negatively affects their development.

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183. The role of the study of the system of hla-antigens in the diagnosis of internal diseases.

MHC (Major Histocompatibility Complex - the main histocompatibility complex, in humans it’s also HLA - Human Leukocyte Antigen - human leukocyte antigen) - transplant (tissue) hypertension, performing a number of functions:

1) participate in intercellular interactions in the implementation of the immune response, that is, with the help of HLA molecules

Alien AG is presented for further recognition by T-cell antigen recognition receptor

2) determine the immunological reactivity of the organism as a whole - due to the existence in the HLA-region of a special immune response gene (Ir-gene), the presence of which determines the ability of the organism to develop an immune response to a particular hypertension, this same function of the HLA-region is associated with a predisposition to a number of diseases .

Designation of HLA-specificity includes three components: 1) the abbreviation of the entire system, 2) the locus containing this specificity, 3) the antigen number (for example, HLA-B12). In the case when the genetic position of the antigen is still not clear enough or not sufficiently clarified, put the symbol "w" (workshop) before its sequence number.

HLA system genes are located on the short arm of chromosome 6 and are divided into three groups: class I, class II and class III, and the molecules (antigens) that are controlled by these genes are also grouped.

AG interconnectionHLAwith a predisposition to a number of diseases.

In the process of studying the hypertension of the HLA system a significant relationship between the development of diseases and loci A, BHLA-1 andDRHLA-2.

To explain the mechanisms of inclusion of the products of the HLA-complex in the pathogenesis of diseases several hypotheses were put forward:

a) receptor hypothesis - certain HLA AG systems are receptors for viruses that facilitate

their fixation and cell penetration

b) the hypothesis of molecular "mimicry" - some microorganisms carry surface specificities,

identical to HLA-structures of the host macroorganism, therefore, tolerance to these microorganisms develops, their recognition by the immune system does not occur and the disease develops

C) the hypothesis of modification (change) of its own hypertension - Modified autologous AG is recognized by the immune system as foreign, which leads to a breakdown of tolerance

d) hypothesis about the effect of a hypothetical Ir-gene on susceptibility to diseases - leads to a violation of the selection of antigenic determinants, the presence of "holes" in the repertoire of T-lymphocytes, a violation of T-lymphocyte-mediated suppression

e) hypothesis about the influence of "non-classical" HLA genes mapped withinMHC - HSP genes, C4a and C2 deficiency associated with SLE and pyogenic infection, etc.

A number of rheumatic diseases (Bechterew's disease, Reiter’s syndrome, RA) have a common genetic marker- HLA-B27, a number of autoimmune lesions associated with HLA DR2, DR3, DR4 alleles (Goodpasture’s syndrome, celiac disease, Hashimoto's goiter, multiple sclerosis, severe myasthenia, vulgar piavma , SLE, vitiligo, dermatitis herpetiformis, common pemphigus, etc.), etc.

The cell membrane of the body contains the gene products of all loci located on both strands of the 6th chromosome. In humans, there are two haplotypes and each cell of the body carries the diploid set of HLA AGs, one of which is encoded by the mother’s HLA genes and the other by the father (the sex cells are the exception, they contain only one haplotype).

HLA-phenotype - Histocompatibility hypertension detected on the cells of a particular person. Determination of the HLA phenotype allows you to establish a predisposition to a number of diseases.

As a rule, peripheral blood lymphocytes are phenotyped. Because in this case, it is not known which HLA-AG, which of the two haplotypes of the parents are encoded, the parents are typed, the haplotypes of the subject are determined, and then the HLA phenotype is recorded, following the numerical order of the HLA antigens (for example, HLA-phenotype A 1,2, B5.12, DR2.5, DQ3.4, etc.)

For phenotyping use lymphocytotoxic test - based on the ability of anti-HLA-AT in the presence of complement to destroy lymphocytes carrying relevant antigenic determinants, cell death is demonstrated by adding trypan blue, dead cells are stained and are considered or modified by microscope microphocytotoxic test (currently replaces lymphocytotoxic test). You can also use the methods of DNA hybridization, PCR (more often in scientific research).

Watch the video: Science for Kids - Helping Someone Who is Unconscious. First Aid. Operation Ouch (October 2019).

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