The main signs of impairment or lack of consciousness. Impaired consciousness

Consciousness is the ability to perceive oneself and the external world, as well as to report on events occurring in the external world and form one’s own reaction in response to these events.

Consciousness allows you to navigate the environment, time and your own personality. The formation of human consciousness occurs in several stages:

1. Waking consciousness . The presence of such consciousness allows you to choose the most favorable environment for yourself. So, a child under 1 year old understands that he is more comfortable in his mother’s arms than just on the soft surface of the crib;
2. Subject consciousness . Such consciousness is typical for the ages of 1-3 years, it allows the formation of a basic idea of ​​​​objects - “cat”, “dog”, “grandfather”, “grandmother” and others;
3. Individual consciousness . This type of consciousness is formed in the period from 3 to 9 years. The child receives basic ideas about space and time, and, thanks to this, distinguishes himself from the environment;
4. Collective consciousness . In the period from 9 to 16 years, a teenager develops a collective consciousness that combines a basic idea of ​​himself with a basic idea of ​​other people and builds initial interpersonal interactions;
5. Reflective consciousness . This is the most mature form of consciousness, it is formed from 16-22 years old and onwards. Such consciousness allows for introspection and deep analysis of the world around us, establishing complex cause-and-effect relationships and making predictions for the future.

Pathologies of consciousness are a very important branch of neuroscience. Every doctor must be able to determine the degree of lucidity of the patient, because many emergency conditions are very closely related to disturbances of consciousness. Universal criteria that allow one to suspect disorders of consciousness were proposed by the German psychiatrist Karl Jaspers . These criteria are the basic diagnostic tool to this day:

• Detachment from the outside world;
• Disorientation in time, space and self;
• Thinking disorders;
• Amnesia.

Let's look at them separately, this is a fundamentally important point.

Detachment from the outside world means a state in which the patient does not perceive (does not fully perceive) everything that happens around him. It is always difficult to establish contact with such a patient; he does not hear or perceive speech addressed to him, he ignores the gestures and facial expressions of the interlocutor with normally functioning organs of vision and hearing. In order to get an answer from the patient, the doctor has to repeat the question very loudly and several times. Often contact with such patients is generally impossible. Detachment is the main criterion for clouding of consciousness.

Disorientation is a lack of understanding and/or misconception. As you remember, within the framework of our symptom complex, disorientation in time, space and one’s own personality is distinguished. Time disorientation is a condition in which the patient ceases to understand what time of day it is, what day of the week, month or even year. As a rule, the first symptom of clouding of consciousness is disorientation in time.

Disorientation in space is the patient’s lack of understanding of where he is now. A person in a hospital may believe that he is in a store, office center or stadium. Disorientation in space and time is classified as allopsychic disorientation.

The most severe mental disorders are accompanied by disorientation in one's own personality . It is also called “autopsychic disorientation.” During personality disorientation, the patient experiences difficulty in self-identification - he cannot say who he is, what he does and what his name is. Also, such disorientation manifests itself in situations when the patient begins to perceive himself pervertedly - he may consider himself a supernatural being, a demon, an alien from another world, an animal, an inanimate object or phenomenon - a black hole, a magical amulet.

Thinking disorders during disorders of consciousness are manifested by a variety of symptoms. The most common is fragmented thinking, which turns into incoherence. This is expressed, as you remember, in the patient’s speech, which becomes similar to the pronunciation of individual words and interjections that are in no way connected with each other.

Amnesia is a complete loss of memory of any period. In the case of disorders of consciousness, we are talking about loss of memory of the period of the illness itself. If we are talking about a mild disorder, the patient may remember some events that occurred during the illness, but without any details and with a broken sequence.

Impairments of consciousness are also divided into qualitative and quantitative.

Reasons for development

Stupor develops as a result of structural changes in the brain. It is also possible to provoke the abnormal condition with diffuse, functional disorders. Both options are equally dangerous; the first is much more difficult to deal with, since organic changes are noted in the brain tissue, and therefore the chances of recovery and quality restoration are lower. Among the specific reasons.

• A brain tumor

For an abnormal condition to develop, the tumor must reach a certain size. Usually these are large meningiomas or large malignant glial tumors, more than 3-5 cm in diameter. The specific cause of stupor is compression of brain structures, swelling and increased intracranial pressure. For recovery, it is necessary to drain the cranial cavity and get rid of excess cerebrospinal fluid (CSF). Surgical treatment of the tumor is carried out whenever possible, but excision of neoplasia is the key condition for normalizing the condition.

• Brain abscess

In common parlance - an abscess. An accumulation of pus surrounded by a capsule. It develops after an infectious lesion of the central nervous system (for example, after encephalitis, meningitis), as a result of a long course of syphilis; abscesses are often found in HIV-positive patients. There are also spontaneous cases of abscess formation. It is impossible to do without opening and draining the abscess. But the operation itself almost always leads to swelling of the brain, which prevents a clear consciousness.

• Traumatic brain injuries

From simple tissue bruise to concussion. Often, a hematoma, an area of ​​accumulation of blood from destroyed vessels, occurs in parallel. A double negative effect occurs: compression of the brain by cerebrospinal fluid, which actively accumulates after the injury itself, and compression by the hematoma. For recovery, both provoking factors must be eliminated at once. Progression in such a case is rapid, the time is less than in other situations.

• Aneurysm rupture, bleeding into cerebral structures of a different origin

As in the previous case, disturbances of consciousness provoke heavy bleeding and the formation of large hematomas.

• The process is also possible with brain stem infarction

This condition can almost never be corrected. The patient has virtually no chance of survival. The phenomena of respiratory dysfunction and cardiac activity soon increase. The temperature becomes unstable.

• A sharp drop in body temperature

The process leads to a sharp weakening of cerebral blood flow, metabolic processes also become insufficiently intense. Recovery in this case is possible, but the longer the brain is in a state of insufficient trophism and cellular respiration, the less likely it is to return to its original state.

• Infectious lesions

They occur in no more than 3-4% of cases compared to the total number. The main culprits are meningitis and encephalitis. Stupor is an extreme form of impaired consciousness and occurs in advanced forms of the described diseases. With timely treatment, the likelihood of a negative scenario is minimal.

• Metabolic disorders

Hepatic coma, a sharp jump in blood sugar levels in diabetes, hypoglycemia (insufficient concentration of glucose in the blood), and other similar disorders. They are common options, sharing the “palm” only with injuries and endogenous lesions such as stroke.

• Stroke

Acute malnutrition of the brain with death of nerve tissue. Not every form of lesion is accompanied by stupor. The development of the condition requires the involvement of two hemispheres at once. This is possible with extensive damage, usually hemorrhagic, with disruption of the integrity of blood vessels, hemorrhage and the formation of a hematoma. Stupor during a stroke is difficult to correct due to the multiple factors involved.

Stupor also occurs when poisoned by certain toxic substances: barbiturates, alcohols, opioids and others. Often the culprits of the deplorable situation are the patients themselves. Suicidal attempts and drug overdose are the main factors in this group. Accidents are also possible, for example, when children use drugs without intent or overdose as a result of self-medication.

The mechanism is based on one of two possible phenomena: mass effect, that is, compression of brain structures on both sides (as a result of pressure from blood accumulations on nerve tissue). Also direct widespread organic damage to cerebral structures (during injuries, development of large tumors, etc.). This knowledge gives doctors an approximate guideline for urgent diagnosis and reduces the time required to detect the provocateur.

The reasons presented do not exhaust the entire possible list.

Productive disorders

Non-productive disorders are discussed above. And the productive ones include:

• amentia
• twilight stupefaction
• oneiroid
• delirium

Delirium

The main signs (symptoms) of this type of consciousness disorder:

• Perceptual disturbances of various forms:

- sensory synthesis disorders

- hallucinations

- illusions

• tactile illusions of perception
• impairment of remembering what is happening, etc.

As for illusions, patients with delirium mainly experience visual illusions. There may also be hallucinations of the following kind:

• cobweb or threads
• wires
• macro- and micropsychic
• polyopic
• cinematic
• palingnostically
• demonomaniacal
• zoological
• scene-like

With delirium, the patient's thinking is characterized by fragmentation, and false recognitions may occur. The patient remembers this period poorly after regaining consciousness. The orientation on the spot is constantly changing and does not correspond to reality. The same applies to orientation in the current situation, the people around you and time. But a person is almost always aware of who he is.

Another feature of delirium is affective lability. A person can quickly change from curiosity to fear to indignation and vice versa. Mostly emotions are negative. A person in this state has a great desire to move, do and say something. A person can defend himself from his hallucinations, attack imaginary and real people, run away, etc. During the day, the symptoms of delirium appear less.

Oneiroid

This is a clouding of consciousness, which is characterized by fantasies, delusions and dreams. Basically, polymorphic psychopathological symptoms are observed. The person experiences pseudohallucinations and scene-like hallucinations. In most cases, catatonic disorders and affective disorders are observed. Fantastic delusional ideas are typical.

A person’s experiences are subject to one direction, one theme. Painful experiences have a romantic-fantasy theme. When a person regains consciousness, he tells doctors and loved ones that he was on other planets, traveled through time, etc. Many people like what they saw so much that they regret that they returned to a normal, healthy state.

For oneiroids, disturbances in orientation in one’s personality are typical. A person considers himself to be another creature, often not a human. That is, the patient himself takes part in his fantasies as an active person, and not as an outside observer. The somatopsychic sphere is involved. A person may believe that his body has become gaseous or consisting of some fantastic matter. The patient is not oriented completely or to a greater extent in the surrounding world. When the peak of the state in question comes, the person is completely detached from what is happening around him. He completely lives the moment in an imaginary world, where he does not see or feel anything that surrounds him in reality.

It is almost impossible or completely impossible to contact a person in a oneiroid state. It is impossible to understand his hallucinations and illusions by the way a person behaves. When the patient returns to consciousness, he does not remember how he behaved, what happened around him, but he remembers his illusions well.

Oneiric clouding of consciousness is observed during attacks of schizophrenia of the fur-like or periodic type, during intoxication psychoses, exogenous-organic and epileptic psychoses. Oneiroid in many cases occurs before delirium, therefore it is very difficult to distinguish between these two states in psychosis.

Twilight stupefaction

The beginning of the condition is always abrupt, as is the ending. The circle of thoughts and motives narrows significantly. A person comes into a state of extreme excitement, and therefore can pose a threat to others. The behavior may appear planned. The person completely loses orientation, and then he has no memories of what was done. Sometimes a person can orient himself a little in his surroundings and recognize some of the people who surround him.

Kinds:

• delusional
• hallucinatory
• dysphoric
• ambulatory automatism

In the delusional variant, the symptoms correspond to the name of the species. Amnesia is often incomplete. In the hallucinatory form, hallucinations can be visual or auditory. With the dysphoric form of twilight clouding of consciousness, fear, rage, and anger are observed mainly, and at the same time consciousness is not clouded to a large extent. With outpatient automatism, there are no attacks of aggression, no hallucinations or delusions. The patient repeats certain movements, mainly walking back and forth. The cause is often alcohol consumption.

Twilight states can be psychogenic. Then the person “emerges” from reality, transporting himself to a situation that compensates for the currently traumatic experiences. The perception of the situation around is incomplete. Speech and actions can be characterized by demonstrativeness. Memory loss can be partial, and it concerns what happened in real life.

Causes of twilight disturbance of consciousness:

• intoxication psychosis
• vascular psychosis
• TBI
• morbid intoxication
• brain tumors
• epilepsy

Prolonged absence seizure

This is a condition that is similar in appearance to stunning. Main features:

• perseveration
• difficulty comprehending impressions
• problems with perception of reality
• minimal mobility
• apathetic state
• adynamia
• wrong actions in some cases
• sudden start and end
• duration up to 3-4 days
• short periods of normalization of consciousness are typical

Amentia

A person falls into absent-mindedness with symptoms of hypermetamorphosis and bewilderment. The emotions he displays change at a rapid pace. Speech is incoherent, the patient talks a lot. Thinking is incoherent. The condition is also characterized by motor agitation, but rarely leaves the bed in which the patient is located. Often throwing occurs without any coordination.

A person does not understand who he is, what is around him. Next comes complete congrade amnesia. Delirious episodes, depressive affects (or manic), and delusional ideas are typical. When consciousness normalizes, asthenic phenomena are observed. A person can remain in this state for 2-3 weeks or even 3-4 months.

Variants of clouding of consciousness during amentia:

• paranoid
• depressive
• manic
• catatonic
• classical

Main symptoms, unlike other disorders of consciousness

Signs of stupor depend on two factors: the origin of the disorder and its type. There are two forms of the disorder:

1. Hyperkinetic. Accompanied by spontaneous motor activity. The patient makes movements, can speak, but the speech is devoid of logical content. Despite the apparent norm, these are involuntary phenomena and are not controlled by the patient. After a few minutes or more from the beginning, classical phenomena increase.
2. Akinetic. Occurs most often. Associated with a complete lack of motor activity and other functions.

Otherwise, there are no fundamental differences in the options. The concept of stupor includes disturbances in speech, motor and oculomotor reactions. Among the manifestations:

1. Lack of physical activity. Voluntary and involuntary movement. The patient does not change his body position and does not respond to attempts to turn him or bring him to his senses.
2. Deep sleepiness. Stupor is not coma yet, therefore the patient can be returned to partial consciousness; this will require intense stimuli, such as a loud sound, physical, painful impact on the tissue. Restoration of consciousness is short-lived or absent altogether. Instead, the patient reacts to stimuli by changing facial expressions, moving eyelids, and blinking with eyes closed. This is also considered an important differential diagnostic criterion and allows us to distinguish coma from stupor.
3. Lack of speech. The patient does not speak, does not react to words addressed to him, and is not able to show even minimal mental activity, which in such a case is a natural, typical phenomenon.
4. Lack of response to standard stimuli. An attempt to bring him to his senses will not have an effect due to a deep deviation in the regulation of the processes of excitation and inhibition. Strong incentives can play a role, but not always.
5. Symptoms of stupor are complemented by manifestations of the primary condition. Depends on what caused the pathological process. With strokes, convulsions are detected, similar to an epileptic seizure; with brain injuries, a number of reflexes may be absent. Severe disturbances in the structure of the brain lead to problems with respiratory and cardiac activity. There are many options. The underlying disorder needs to be identified as quickly as possible. The patient's life depends on it.

How long does stupor last?

On average, about a few hours. The expected interval is from several minutes to 2-3 days. It is difficult to detect the transition to a complicated form; a coma occurs unnoticed.

Coma, stupor, and stupor are often used in medical literature in a context that is not entirely clear.

What differences exist between these conditions?

Coma and stupor vary in depth. The following manifestations are typical for a comatose state:

• complete absence of voluntary activity,
• complete absence of reactions to stimuli (in some cases, a number of reflexes are preserved, depending on the depth of the coma, which is also heterogeneous in terms of the clinical picture).

Recovery from stupor into clear consciousness with intensive therapy is possible within a few days. It is almost impossible to bring the patient out of a coma. Cases of return to the original state are rare.

The term “stupor” is practically not used in Russian-language sources. But it is found everywhere in English-language literature, used as a synonym for stupor, and stupor as a term refers to milder variants of impaired consciousness.

The difference between stupor and coma and stupor lies in the depth of the disturbance of consciousness. In the case of stupor, there is a semantic double, discrepancies in the interpretation of terms in different medical schools.

The issue of delimitation plays a fundamental role. Therapy depends on the form of the disorder, and doctors also have more opportunities to more accurately predict the outcome.

Types of non-productive disorders of consciousness

Disturbances of consciousness can be productive or unproductive. With the latter, the activity of consciousness is reduced and there are no productive psychopathological symptoms, that is, deceptions of perception and delusions. There are three forms:

• stun
• sopor
• coma

Stun

When a person is deafened, the threshold for perception of external factors and internal impressions increases. Mental activity becomes poor, gradually fading away to an increasing extent. When stunned, only a very intense factor can attract a person's attention. A person does not answer questions immediately, and may not understand complex sentences. He usually answers after a long silence and in short phrases.

When a person is stunned, he is poorly oriented where he is and what places are located relative to the point where he is at the moment. There may be no orientation at all. A person is prone to indifference, akinesia, spontaneity and drowsiness. The voice is quiet, there is no modulation in it, there are no gestures, minimal facial expressions. Perseverations are recorded. The person does not remember that he was in a state of stun for some time. There are no fears.

Nullification

This condition is a mild degree of stunning. At the same time, the person seems uncollected or a little drunk. The meaning of speech (if addressed) is understood after some time. The answers may not correspond to the question, and the actions may also seem incorrect. There may be euphoria and fussiness. At times, for some moments, the person returns to normal consciousness.

An example of nullification: a person was injured in an accident, but does not understand this, and begins to actively remove doctors and try to help his loved ones who also suffered in this situation.

Somnolence

This condition is a form of unconsciousness. The person is very sleepy. If you don’t talk to him or make physical contact, he immediately falls soundly asleep. If you shake him and talk to him, he wakes up. But then he falls asleep again. Somnolence is noted upon recovery from an epileptic coma after seizures. After a seizure, you should not try to wake the person. This is not only difficult, but also dangerous, because it can cause an outbreak of aggression in the patient.

Stun

In its manifestations, stunning is similar to psychoorganic syndrome, but these are not synonyms. Main features:

• memory weakness
• impaired judgment
• aspontaneity
• torpidity

Stunning occurs in patients who are emerging from a coma. After stunning, a coma or a state of stupor can be recorded, which will be discussed in detail below.

Causes of stunning:

• swelling and swelling of brain tissue
• lack of oxygen reaching the brain
• acidosis due to intoxication, skull injury, etc.

Sopor

In this state, a person has only minimal signs of mental activity. If you call his name loudly, the person may turn around. If a person feels pain, he groans or tries to avoid the source of pain. Neurological disorders are also characteristic:

• decreased skin reflexes
• minimizing periosteal reflexes
• weakened tendon reflexes
• decreased muscle tone

Conjunctival and pupillary reflexes, as well as sensitivity, remain normal.

Coma

This condition is characterized by complete depression of mental activity. Main features:

• pelvic disorders
• pathological reflexes
• mydriasis with lack of pupillary response to light
• bulbar disorders
• lack of reflexes
• muscle atony

Transcendent coma is brain death, in which the functioning of internal organs is supported with the help of special devices. The condition is also known as supernumerary coma.

Diagnosis of the pathological process

Neurologists diagnose the pathological process. The task is to urgently assess the condition of the victim and identify the root cause of the negative phenomenon. The second task is solved after partial stabilization of the situation, provision of basic primary medical care, restoration of normal breathing and cardiac activity, because it requires more time.

The main diagnostic measures are based on routine assessment, the neurological status is subject to examination. To make an accurate diagnosis, doctors evaluate reflexes. For an accurate understanding and correlation of clinical findings with theoretical principles, back in the distant 70s, a formal list of criteria for diagnosing stupor and its delimitation from other conditions was developed. This is the so-called Glasgow scale.

In its modern version, it is represented by three main criteria. Each has several options for the patient’s reaction to the stimulus, rated from 6-4 to 1 point.

1. Motor activity (Motor response or simply the letter M). It is presented in six options: from full execution of the movement on command (6 points) to complete absence of reaction to painful stimuli, regardless of intensity (1 point).
2. Speech activity (letter V). Presented in five options. From the ability to accurately answer the question posed to the complete lack of speech. Scored from 5 to 1 point, depending on the results.
3. Oculomotor reaction, eye opening (E). The maximum score is 4 when the eyes are opened voluntarily without any external stimulus. Lack of response to speech stimuli and pain is assessed as 1 point.

As a result, the patient can be given a score from 15 with clear consciousness to 3 with deep coma or brain death. Stupor on the Glasgow scale ranges from 10 to 8 points, which corresponds to a fairly high level of preservation of higher nervous activity and brain activity. The level of consciousness during stupor is impaired, but not yet critically; there is a chance of returning to normal life. Sometimes the term deep stupor is encountered, which corresponds to a moderate coma on the Glasgow scale (7-6 points); this is an imprecise concept; it is not used when describing or compiling an epicrisis. Stupor does not imply the use of clarifying categories.

Further instrumental activities are carried out. As part of basic diagnostics, the following are carried out:

• MRI of the brain, possibly with contrast enhancement (to identify organic disorders, structural changes),
• CT scan of cerebral structures,
• electroencephalography (a method for detecting electrical activity in certain areas of nerve tissue, used as a way to functionally assess the state of the brain).

Stupor is characterized by the presence of functional disorders or organic disorders. Additionally, it is possible to prescribe a blood test for sugar in an express format.

Split

Split consciousness is a definition that has a number of different interpretations and is used differently by various authors.

But, one way or another, splitting refers to a state in which the individual’s consciousness is divided, the perception of reality changes, and the sense of “I” is lost to one degree or another.

Basic interpretations of the definition:

1. Schizophrenia. The very name of this mental illness is translated as “split thinking”, “splitting of the mind” from ancient Greek.
   Therefore, sometimes this phrase can be found in topics about schizophrenia, used as a synonym. It can also be used to describe some schizophrenic symptoms.
2. Thought disorders observed in a number of mental and somatic diseases, for example, dementia. This is confusion of thinking, schizophasia, the desire to continuously produce delusional sayings that seem profound to the patient. However, the definition is used relatively infrequently in this context.
3. Dissociative identity disorder , which is known to most people as “multiple personality disorder.” This is a mental illness in which a person’s personality seems to split into two or more parts, and each of these fragments begins to reflect its own personality, often with individual habits, interests, worldview, which periodically gets the opportunity to express itself.

In modern psychology, the term “split consciousness” is most often applied specifically to dissociative identity disorder: a complex, controversial mental illness.

There have been repeated cases where criminals, trying to avoid punishment, began to talk about the fact that it was not they who committed the crime, but their other evil personality (or personalities).

Therapy

Treatment of stupor involves eliminating the root cause of the deviation; this is the main task. In most cases, intubation is required to ensure breathing when the natural process is disrupted. Changes in blood glucose concentration involve artificial administration of glucose, insulin, or both drugs in combination, depending on the form of the disorder (sugar surge, hypoglycemia).

In case of poisoning, it is necessary to remove toxic components from the digestive tract by rinsing. When a toxic substance is administered parenterally, the nonspecific antidote Naloxone comes to the rescue. The same drug can be administered when poisons are absorbed through the gastrointestinal tract. The concentration is determined locally based on the severity of the condition.

Difficult situations, such as injuries with the formation of a hematoma, a major stroke, require drainage, removal of blood accumulations, and restoration of normal intracranial pressure. Without this, there will be no point in therapeutic activities. With tumors, the issue is even more complicated, because it is necessary to remove the neoplasia, which is the culprit of the mass effect and direct tissue irritation at the site of its localization.

As for the actual measures to stabilize the condition, prevent further development of impaired consciousness, and prevent complications, medications are used:

• thrombolytics (in the first few hours or days): Urokinase, Streptokinisa (dissolve blood clots),
• means for restoring blood volume and fluidity: Reopoliglucin, saline solution as needed,
• cerebrovascular-type drugs that normalize brain nutrition (if there are no contraindications and the process is not provoked by a malignant tumor): Piracetam and others.

If stupor lasts for a long time, it is possible to use antibiotics in short courses to prevent septic, infectious and inflammatory processes. In addition, anticonvulsant medications are prescribed as part of the prevention of spontaneous increases in brain activity in certain areas: Seduxen, Relanium and others.

Patient care plays a big role. From time to time, according to the schedule, it needs to be turned over, the condition of bed and underwear monitored, and hygiene measures carried out. In this case, there are no fundamental differences from caring for comatose patients.

How to give first aid for fainting

According to statistics, about 30% of people lose consciousness at least once in their lives. This condition is called fainting. It can happen for various reasons. Most people panic and therefore cannot react correctly to what is happening. But in some cases, a person’s life may depend on these actions, for this reason it is very important to know how to provide first aid in case of fainting.

Algorithm

To prevent the development of complications, first of all, you should call an ambulance. Qualified doctors will be able to quickly determine the cause of fainting. This information will help reduce the likelihood of losing consciousness in the future.

Usually, before the specialists arrive, the victim is already conscious. It is very important to provide proper first aid and bring a person out of unconsciousness as soon as possible if fainting lasts more than a few tens of seconds. To do this, you need to know the sequence of actions, which will completely depend on where it happened, as well as on weather conditions.

First aid for fainting involves the following measures:

1. The person must be carefully placed on his back. If loss of consciousness occurs in the summer, for example, on the beach, the victim must be moved to the shade. In this case, the head should be slightly tilted to the side and be on a flat surface; you can place a towel under it to slightly raise it.
2. Ensure adequate oxygen access. To do this, clear the upper airways by unbuttoning your shirt collar. You can also loosen the belt on your trousers, if there is one.
3. Check your heartbeat.
4. Raise your legs so that they are above your head. It is best to throw them over a tree or wall. That is, create a right angle with the body. If it is not possible to do this, then you can place a cushion under your feet, which is obtained from a bag or folded clothing.
5. Clothes made from light and natural fabrics can be moistened with water.
6. To quickly bring a person to his senses after fainting, you can wipe his face with a wet handkerchief or simply lightly sprinkle him with water. Wet wipes are also suitable for this.
7. If the person who fainted has long hair, then you can wet it at a distance of no more than 1 cm from the head. Because otherwise, too humid air will form around the head, which will provoke the development of heat stroke.

Most people have a strong association that when they faint, they need to use ammonia. Today there are two opinions about this remedy. If there is no way to bring a person to his senses, and this is the only method left, then ammonia should not be brought too close to the nose. In addition to standard use, it can also be used to rub whiskey.

Features of indoor assistance

The victim should be positioned on a sofa or bed so that his feet are on the armrest, that is, above head level. After this, the belt on his trousers is unfastened, as well as the collar on his shirt. If a man has lost consciousness, then he must loosen his tie to ensure the flow of oxygen. The face can be moistened with water at room temperature.

It is very important to ensure air circulation in the room. To do this, it is recommended to open the window and door. But a patient who has lost consciousness should not be in a draft at this time.

Helping someone who has fainted on the street

First aid for fainting should begin with calling an ambulance. Then the victim must be carefully lifted from the ground and placed on the nearest bench or bench. If any are not observed, then leave them in place without taking off your outerwear.

You just need to loosen the belt and unfasten the collar. If you have a scarf, you need to untie it to allow you to breathe normally.

In this case, the body should take a position so that the legs are higher than the head, which will help ensure the blood circulation in the body necessary for restoration.

After the patient regains consciousness, you can give him warm sweet tea.

How to help with heat and sunstroke?

If the human body is exposed to high temperatures from the environment over a long period, then as a result he may simply lose consciousness.

This occurs due to excessive sweating, which leads to loss of large amounts of fluid and dehydration. At this point, the blood becomes thicker. In addition, there is a violation of the water-salt balance, which causes oxygen starvation of the brain.

Because of this, a malfunction of the heart muscle and blood vessels may occur. The main symptoms of heat stroke are:

• Appearance of lethargy.
• Presence of headaches.
• Nausea.
• Dizziness.
• The picture before your eyes may blur or swim.

First of all, if a person loses consciousness due to heatstroke, it is necessary to quickly eliminate the cause that led to fainting. That is, if exposed to the open sun for a long time, the victim should be immediately moved to the shade or to a well-ventilated room to ensure an influx of fresh air, but drafts should be avoided.

To quickly bring the victim to his senses, a container is placed on his head, in which ice is placed or cold water is poured, while the hands are wrapped in a wet cloth. In parallel with these measures, you need to call an ambulance team, which can accurately determine the patient’s condition and prevent repeated fainting.

Sunstroke can occur in a person as a result of prolonged exposure to the open sun without a hat. Very often it is accompanied by overheating of the body as a whole. Emergency care for fainting from sunstroke has the same order and sequence as measures for the development of heat stroke.

How to help yourself?

Very often there are situations when a person, being alone, begins to feel that he will soon lose consciousness.

In this case, you don’t have to rely on outside help, so you need to know what to do when fainting occurs, or how to prevent it yourself.

The main thing here is not to get confused and quickly react to what is happening. The following points indicate impending fainting:

1. The noise or buzzing in the ears begins to increase.
2. Dark circles and spots appear before your eyes, objects flicker or blur, and the image becomes blurry.
3. It creates the impression of detachment from reality.

If this happens, you must quickly take a sitting or lying position. If this happens in the summer, then you need to find shade and hide there from the scorching rays of the sun.

If you feel dizzy, cross your legs and lean against a tree or the wall of a building. That is, to any vertical object. After this, tense your legs very strongly and squeeze your buttocks. At this moment, blood rushes to the head, which will help to establish proper circulation and avoid fainting.

In addition, oxygen access to the brain should be ensured. To do this you need to take deep breaths. During the first few seconds, it is better to breathe very often and deeply. After the signs that indicate an imminent loss of consciousness have passed, you can regulate your breathing at your discretion. If there is water nearby at such a moment, wash your face and moisten your forehead with it.

One of the most effective ways to avoid fainting is to massage your earlobes. To do this, you need to press and massage the ears with your fingertips.

Usually a person loses consciousness for a few seconds. But even this indicates the appearance of health problems or malfunctions in the body. It is best to call an ambulance or consult a doctor yourself. He will prescribe certain tests, based on the results of which we can draw a conclusion about the state of the body.

If the duration of fainting is about 5 minutes, then this is a serious case that indicates health problems and requires urgent treatment. Under no circumstances should you delay visiting a doctor, otherwise complications may develop that will require long-term treatment.

Source: https://vsepromozg.ru/teoriya/pervaya-pomoshh-pri-obmoroke

Diagnostics

Diagnostic features depend on the general condition of the patient. Most often, psychiatrists and neurologists .

examinations may be prescribed :

• checking reflexes and reactions to external stimuli;
• electroencephalogram;
• computed and magnetic resonance imaging;
• consultation with a specialized specialist (neurologist, psychiatrist).

Of course, the methods for diagnosing coma are significantly different from diagnosing, for example, delirium.

If disturbances of consciousness are associated with any somatic pathology , diagnostic measures are carried out to determine the patient’s condition.

COMATOUS CONDITIONS

Comatose states are among the most severe and dangerous syndromes. The term “coma” (from ancient Greek - deep sleep) denotes the most significant degree of pathological inhibition of the central nervous system, characterized by a deep loss of consciousness, lack of reflexes to external irritations and a disorder in the regulation of vital body functions.

Consciousness is the most important function of the brain, developed in the process of human evolution. The quality of consciousness determines all human activity. It is important to promptly establish the diagnosis of its disorders, the cause and nature of the pathological process. There are many classifications of disorders of consciousness.

DEGREES OF IMPAIRMENT OF CONSCIOUSNESS

Coma refers to quantitative syndromes of disturbance (depression) of consciousness. In 1982, A.I. Konovalov et al. proposed a classification of depression of consciousness, highlighting 7 degrees of assessment of consciousness: clear, moderate stupor, deep stupor, stupor, moderate coma, deep coma, extreme coma.

1. Clear consciousness - its complete preservation, adequate reaction to the environment, full orientation, wakefulness.
2. Moderate stupor - moderate drowsiness, partial disorientation, delayed answers to questions (sometimes they need to be repeated), slow execution of commands.
3. Deep stupor - deep drowsiness, disorientation, almost complete sleepy state, limitation and difficulty of speech contact, monosyllabic answers to repeated questions, execution of only simple commands.
4. Stupor (sound sleep, unconsciousness) - almost complete absence of consciousness, preservation of purposeful defensive coordinated movements, opening of eyes to painful and sound stimuli, occasional monosyllabic answers to repeatedly repeated questions, immobility or automated stereotypical movements, loss of control of pelvic functions.
5. Moderate coma (I) - inability to wake up, chaotic uncoordinated defensive movements to painful stimuli, lack of opening eyes to stimuli, lack of control of pelvic functions, mild respiratory and cardiovascular problems are possible.
6. Deep coma (II) - cannot be awakened, lack of protective movements, impaired muscle tone, lack of swallowing, lack of pupillary reaction to light, involuntary urination and defecation, pathological types of breathing appear, cardiovascular decompensation.
7. Transcendental (terminal) coma (III) - agonal state, atony, areflexia, wide pupils, no reaction to light, pulse in the peripheral arteries is not palpable, vital functions are supported by mechanical ventilation and cardiovascular drugs.

To quantify impairment of consciousness, the coma scale developed in Glasgow is used.

The best result for each of the three characteristics is assessed, the results are added up and entered into the observation chart. A certain amount of points corresponds to the descriptive characteristics of consciousness disorders:

• 15 points - clear consciousness;
• 14-13 points - stunning;
• 12-9 points - stupor;
• 8-4 points - coma;
• 3 points - brain death.

REASONS FOR THE DEVELOPMENT OF COMATOUS CONDITIONS

The reasons for the development of a coma may be:

• metabolic disorders (diabetes mellitus, adrenal insufficiency, hypoxia, uremia, hepatic coma);
• intoxication (alcohol, drugs, barbiturates, ethylene glycol, anticonvulsants, etc.);
• shock of any etiology;
• severe general infections (sepsis, typhoid, malaria, pneumonia, etc.);
• cerebral hypoxia (late resuscitation, drowning, hanging, carbon monoxide poisoning, cyanide poisoning);
• injuries and diseases of the brain (traumatic brain injury, cerebral hemorrhages, brain tumors, brain abscesses, cerebral infarctions due to thrombosis and embolism);
• brain damage due to meningitis and encephalitis;
• hyperthermia and hypothermia;
• epilepsy.

CLINICAL SYMPTOMOCOMPLEXES IN COMA

In comatose states, the most common symptom complexes are:

• respiratory failure of central origin;
• sudden stop of breathing;
• motor agitation and convulsions;
• hyperthermia of central origin;
• cerebral edema;
• increased intracranial pressure;
• circulatory complications (pulmonary edema, sudden circulatory arrest).

PRINCIPLES OF DIAGNOSIS OF COMATOUS STATES

When making a diagnosis and analyzing the clinical picture of coma, it is necessary to pay attention to a number of points.

1. It is necessary to find out at what speed the coma developed, since different comas have their own pace of development.
2. Assess the patient for signs of trauma that may occur both before and during the development of coma.
3. Find out the possibility of exogenous intoxication (use of toxic substances, inhalation of poisons, etc.).
4. It is important to find out what clinical picture preceded the coma (fever, arterial hyper- or hypotension, polyuria and polydipsia, changes in appetite, vomiting, diarrhea, convulsions, repeated loss of consciousness or other neurological symptoms).
5. The patient has any chronic disease (diabetes mellitus, hypertension, kidney disease, liver disease, thyroid disease, epilepsy). At the same time, the existence of a disease does not mean that it led to coma (for example, a long course of diabetes mellitus does not exclude the development of uremia or stroke).
6. They find out what medications, psychotropic and toxic substances (tranquilizers, sleeping pills, narcotics, alcohol) could have been used by the patient. At the same time, it is necessary to take into account that not only the assumption of a possible overdose of any substances (for example, traces of injections on a drug addict), but even direct evidence of the use of the relevant substance (for example, alcohol) does not exclude other causes (for example, injury) .

When providing medical care to patients in a comatose state, there are general, universal measures that do not depend on the causes, pathogenesis and clinical manifestations of coma. Immediate hospitalization in the intensive care unit is required, and in case of head injury or subarachnoid hemorrhage, in the neurosurgical department. In all cases, emergency treatment should be started immediately.

Comatose states serve as a limitation to a number of prescriptions:

• regardless of the depth of cerebral insufficiency, the use of drugs that depress central nervous system: narcotic analgesics, neuroleptics, tranquilizers, since this is fraught with aggravation of the severity of the condition (with the exception of coma with convulsive syndrome, for which diazepam is indicated);
• drugs with a stimulating effect are also contraindicated - psychostimulants, respiratory analeptics (with the exception of the respiratory analeptic bemegride - a specific antidote for barbiturate poisoning);
• nootropic drugs (piracetam) are contraindicated in cases of disturbance of consciousness deeper than superficial stupor;
• At the prehospital stage, insulin therapy is unacceptable;
• An excessive decrease in blood pressure is unacceptable, which aggravates damage to brain tissue.

COMA IN SEVERE BRAIN TRAUMA

Until now, despite the achievements of modern intensive therapy, more than 40% of victims die from cerebral coma, and many of the survivors remain deeply disabled.

The severity of brain damage depends on the nature of the injury itself (impact, gunshot wound, fall from a height, sudden braking while driving a car). Depending on the direction of the blow and other factors, different parts of the brain are damaged to a greater or lesser extent. The severity of the damage is also determined by the occurrence of general reactions of the body to the injury (shock, respiratory failure, infection, etc.).

If the brain is damaged in the area of ​​its trunk, where the centers of respiration and blood circulation are located, the victim usually dies at the scene of the disaster. If even very large areas of the brain are damaged in other parts, recovery can be achieved if the harmful effects of secondary factors are prevented. Brain tissue reacts to injury with circulatory disorders and swelling. This leads to an uneven increase in its parts and the so-called wedging (Fig. 31). When respiratory failure occurs, blood circulation deteriorates and harmful reactions increase many times over, leading to irreversible changes in the brain and its death.

Clinic and diagnosis of traumatic brain injury

Traumatic brain injury can cause concussion, contusion, and hemorrhages into the cranial cavity and directly into the brain tissue. It is these injuries, together with cerebral edema, that determine the clinical picture (greater or lesser degree of loss of consciousness, paralysis, focal symptoms, etc.).

With severe traumatic brain injury, the functions of vital organs are always affected: breathing, blood circulation, hemostatic system, protective mechanisms; Trophic disturbances rapidly increase. Respiratory dysfunction in TBI occurs due to cerebral edema and dislocation of the brain stem, obstruction of the upper respiratory tract due to inhibition of protective reflexes against the background of impaired consciousness. The protective reflexes of the respiratory system include pharyngeal, laryngeal and cough, when suppressed there is a high probability of aspiration (saliva, blood, gastroduodenal contents) with the subsequent development of aspiration pneumonia and/or acute respiratory distress syndrome.

In patients with TBI, ventilation failure occurs due to hypoventilation or pathological breathing rhythms (bradypnea, tachypnea, Kussmaul, Cheyne-Stokes, Biotta), hypoxia and hyper- or hypocapnia. Hypoxia leads to disruption of cerebral hemodynamics and increased intracranial pressure.

In traumatic coma, the diagnosis does not cause much difficulty, since there are signs of traumatic injuries. Loss of consciousness in this case can last from several minutes to 24 hours, and sometimes more. When examining patients in this case, pale skin (especially the face), vomiting, involuntary urination and defecation, and bradycardia are noted. In some types of lesions (traumatic epidural and subdural hematoma), a so-called lucid interval is observed when the patient regains consciousness. Then his condition sharply worsens, anisocoria, increasing hemiparesis are noted, and convulsions may develop. Unfortunately, in approximately half of the cases, the picture of traumatic brain lesions can be erased by concomitant alcohol intoxication. In this case, a traumatic coma can be suspected on the basis of concomitant lesions: wound surfaces, hematomas, bruising in the orbital area may be observed - a “symptom of glasses”, bleeding and leakage of liquor from the ears, nose, mouth. The most severe are open craniocerebral injuries.

Examination of the fundus of the eye (congestive optic disc, radiography of the skull in two projections, electroencephalography and echoencephalography) helps in diagnosis.

Emergency care and treatment for traumatic brain injury

The main task at the scene is to improve breathing and circulation to prevent secondary brain damage. To do this you need:

• free the airways from foreign bodies;
• ensure their free patency throughout transportation to the hospital (ensuring the patency of the upper respiratory tract consists of preventing tongue retraction: positioning the victim on his side, moving the lower jaw, freeing the upper respiratory tract from mucus, blood, vomit, installing an air duct; removable dentures should be removed prostheses);
• in case of ventilation problems, mechanical ventilation is performed using manual or automatic devices, preferably with the addition of oxygen;
• when shock develops, plasma-substituting solutions are administered, but care is taken to ensure that there is no excessive increase in pressure, since the brain with TBI is very sensitive to high blood pressure, which can increase swelling.

We must strive to deliver the victim to a hospital where there is a computed tomograph, angiography equipment and a neurosurgical department. In the hospital, they continue to ensure sufficient gas exchange and maintain the necessary blood circulation; the patient undergoes tracheal intubation while administering atropine and muscle relaxants. Emergency fiberoptic bronchoscopy is indicated for all patients with severe TBI and associated trauma admitted in an unconscious state, for the purpose of early diagnosis of aspiration and sanitation of the tracheobronchial tree.

One of the main methods of treating victims with TBI is mechanical ventilation, which allows normalizing gas exchange and blood flow. In case of severe TBI, there is a need for prolonged mechanical ventilation, which is a reliable way to prevent and treat cerebral edema. Indications for transfer to mechanical ventilation: apnea or hypopnea, tachypnea over 35 per minute, the presence of pathological respiratory rhythms, coma less than 8 points (on the Glasgow scale), persistent intracranial hypertension.

Primary tracheostomy without preliminary intubation is performed for extensive damage to the face, nose, jaws, tongue, obstruction of the lumen of the pharynx and larynx by large foreign bodies.

If necessary, craniotomy is performed to remove intracranial hematomas. After surgery and in those patients who did not need it, intensive therapy is continued, the special objectives of which are to prevent intracranial hypertension and improve cerebral circulation, normalize the supply of oxygen and energy to the brain.

All patients in a coma require the most careful care, as they very quickly develop bedsores, contractures, and infectious complications. Good care ensures the success of intensive care.

COMA WITH DIABETES

Most patients and their relatives usually know a lot about diabetes, what medications are used to treat it, and what diet to follow. But often the normal course of diabetes is interrupted by its decompensation. This manifests itself in two different conditions: an increase in the concentration of sugar in the blood (hyperglycemia) or a decrease in its concentration (hypoglycemia). In both cases, coma may develop.

Hypoglycemic coma

Most often develops with an overdose of drugs used to treat diabetes, primarily insulin. But it can develop with a pancreatic tumor, fasting or drinking alcohol, acute infection, physical or mental stress, liver failure, etc.

Clinic and diagnostics. The lack of glucose entering the brain causes nerve cells to quickly deplete their minimal reserves. Their activity decreases sharply, and irreversible changes quickly occur. Therefore, hypoglycemic coma is more dangerous than hyperglycemic coma. If the decrease in blood glucose levels develops gradually, then at the beginning the patient experiences feelings of hunger, fear, anxiety, and then excitement. The patient may become aggressive. There may be hallucinations. Characteristic external manifestations: pale skin covered with profuse cold sweat, small frequent muscle contractions (fibrillations); Sometimes blood pressure rises. Then comes loss of consciousness, often accompanied by convulsions; narrow pupils, shallow breathing, hypotension and bradycardia.

The diagnosis is confirmed by an urgent urine and blood test for glucose. During hypoglycemia, there is no glucose in the urine, so the indicator strip does not color.

Urgent Care. If the diagnosis is confirmed, 40-60 ml of 40% glucose solution and 100-200 mg of thiamine should be injected into a vein as quickly as possible, and 0.5 ml of 0.1% adrenaline solution should be injected subcutaneously. Then, intravenous drip administration of 10% glucose solution with the addition of glucocorticoid hormones (4-8 mg dexamezatone) is established under the control of blood glucose levels. Measures to combat cerebral edema are started (iv administration of 10 ml of 25% magnesium sulfate solution). After emerging from a comatose state, it is necessary to ingest carbohydrates (drink sweet tea with a bun).

Hyperglycemic ketoacidotic coma

Hyperglycemic ketoacidotic coma is an extreme degree of carbohydrate and lipid metabolism disorder in severe diabetes.

Loss of consciousness develops against the background of hyperglycemia, ketoacidosis (excessive accumulation of ketone bodies) and hyperosmolarity of blood plasma. The latter leads to cellular and general dehydration with loss of potassium, sodium, phosphorus, magnesium, calcium and bicarbonate ions. These disorders cause the development of coma.

Clinic. It usually begins gradually, with general malaise, weakness, depression, headache, loss of appetite, dyspeptic disorders, and increased breathing. Then pain appears in the epigastric region and extremities, deep and prolonged Kussmaul-type breathing with the smell of acetone, drowsiness and apathy, which progress to complete loss of consciousness.

On examination, the skin is dry, cold, the face is hyperemic and haggard. The tongue is dry, coated. Eyeballs are soft. The pulse is rapid, weak, blood pressure is low, muscles are relaxed, tendon reflexes are decreased or absent. On auscultation there may be a pleural friction rub. In the absence of infection, body temperature may be subnormal.

Laboratory studies reveal severe hyperglycemia, hyperketonemia, acidosis, hyperazotemia, leukocytosis, erythrocytosis, and increased hematocrit. High glucosuria and a sharply positive reaction to acetone are noted in the urine.

Urgent Care. Since symptoms of dehydration of the body come to the fore, it is first necessary to administer intravenous saline solutions. Infusion for the first hour, respectively, 1 and 1.5 liters of 0.9% sodium chloride solution. For hyperosmolar coma and long-term ketoacidotic coma, heparin therapy is indicated - up to 10 thousand units intravenously.

Hyperosmolar coma

It is characterized by a particularly high level of hyperglycemia and hyperosmolarity of the blood with its thickening and severe dehydration in the absence of ketoacidosis. Hyperosmolar coma most often develops in patients over 50 years of age who suffer from mild diabetes mellitus when exposed to certain dehydrating factors (vomiting, diarrhea, taking diuretics, insufficient fluid replenishment with high diuresis, renal failure, hemodialysis, extensive burns). The level of glucose in the blood during this coma can increase to 55.5 mmol/l or more.

Clinic. The development of clinical manifestations is similar to those in hyperosmolar ketoacidotic coma (see above). Neurological and neuropsychiatric disorders are characteristic: hallucinations, slurred speech, hemiparesis, convulsions, areflexia, muscle hypertonicity, increased temperature of central origin.

Emergency care and treatment principles are the same as for the treatment of ketoacidotic coma.

Ambulance for unspecified coma is provided on the basis of the order of the Ministry of Health of the Russian Federation dated December 24, 2012 No. 1431n “On approval of the standard of emergency medical care for unspecified coma.”

DIFFERENTIATED THERAPY OF SPECIFIC COMATOUS CONDITIONS

At the prehospital stage, treatment of comatose states should be limited to the necessary minimum. Hunger (alimentary-dystrophic) coma:

• warming the patient;
• infusion of 0.9% sodium chloride solution (with the addition of 40% glucose solution at the rate of 60 ml per 500 ml solution) with an initial rate of 200 ml per 10 minutes under the control of respiratory rate, heart rate, blood pressure and auscultation pattern in lungs;
• fractional administration of vitamins: thiamine (100 mg), pyridoxine (100 mg), cyanocobalamin (up to 200 mg), ascorbic acid (500 mg);
• hydrocortisone 125 mg.

Alcohol coma. To suppress bronchorrhea and as a premedication before tracheal intubation, a bolus injection of 0.5-1.0 ml of 0.1% atropine solution is indicated. Within 4 hours after drinking alcohol, gastric lavage through a tube (after tracheal intubation) to clean rinsing water with 10-12 liters of water at room temperature is indicated, followed by the introduction of enterosorbent. It is necessary to warm the patient. 0.9% sodium chloride solution is administered intravenously at an initial rate of 200 ml per 10 minutes under the control of respiratory rate, heart rate, blood pressure and auscultation of the lungs. In the future, it is possible to switch to Ringer's solution, bolus or drip administration of up to 120 ml of 40% glucose, fractional administration of vitamins: thiamine (100 mg), pyridoxine (100 mg), cyanocobalamine (up to 200 mg), ascorbic acid (500 mg).

Opiate coma. Naloxone 0.4-0.8 mg IV or endotracheally with possible additional administration after 20-30 minutes if the condition worsens again. If tracheal intubation is necessary, premedication with 0.5-1.0 ml of 0.1% atropine is required.

Cerebrovascular coma (stroke). Since differential diagnosis of ischemic and hemorrhagic strokes is absolutely impossible at the prehospital stage, only undifferentiated treatment is carried out:

• correction of hemodynamic disorders;
• stroke is the main indication for the use of glycine, Semax, Mexidol, piracetam (see above);
• to improve brain perfusion - bolus administration of 7 ml of 2.4% aminophylline solution (with blood pressure exceeding 120 mm Hg);
• in severe cases, to reduce capillary permeability, improve microcirculation and hemostasis, a bolus injection of 250 mg of etamsylate is indicated; to suppress proteolytic activity, an infusion of aprotinin (Gordox, Trasylol) at a dose of 300 thousand KIU is indicated.

Eclamptic coma. Bolus administration of 15 ml of 25% magnesium sulfate solution over 15 minutes; if the convulsive syndrome persists, diazepam 5 mg bolus until the seizures stop; infusion of Ringer's solution at a rate of 125-150 ml/hour, rheopolyglucin - 100 ml/hour.

Hyperthermic coma (heatstroke). Cooling, normalization of external respiration (see above), infusion of 0.9% sodium chloride solution at an initial rate of 1-1.5 l/hour, hydrocortisone up to 125 mg.

Hypocorticoid (adrenal) coma. Bolus administration of 40% glucose and thiamine solution (see above), hydrocortisone up to 125 mg; infusion of 0.9% sodium chloride solution (with the addition of 40% glucose solution at the rate of 60 ml per 500 ml solution, taking into account the amount already administered as a bolus) at an initial rate of 1-1.5 l/hour under the control of respiratory rate , heart rate, blood pressure and auscultatory picture of the lungs.

Indications for hospitalization. Coma is an absolute indication for hospitalization, refusal of which is possible only if an agonal state is diagnosed.

Zaryanskaya V. G. Fundamentals of resuscitation and anesthesiology for medical colleges: textbook / V. G. Zaryanskaya. — Ed. 14th. — Rostov n/a: Phoenix, 2020 (Secondary medical education)