When most or all of the cerebral functions fail, but the functions of the brainstem, diencephalon, and spinal cord remain, the condition is called persistent vegetative state (PVS). The patient appears awake, although he probably has no consciousness. A waking coma should be distinguished from the minimally conscious state (MCS) and locked-in syndrome, although the transitions here are fluid.
What is a waking coma?
A waking coma or appalic syndrome is defined by a holistic loss of consciousness as well as the ability to communicate. Furthermore, there is bowel and urinary bladder incontinence. Sleep and wake rhythms are disturbed, but basal vital functions such as circulation, respiration, and digestion still function. Patients can also sleep and respond sporadically to stimuli. To outsiders, sufferers appear awake, but this impression is largely deceptive. The pathways between the cerebrum and the brain stem are severely damaged. While the brain stem still functions, cerebral function shows a pronounced disturbance. Some patients eventually wake up, while others never regain a normal state of consciousness. Consequently, persistent vegetative state or appalic syndrome is a complex and very severe clinical picture that is treated in a hospital’s intensive care unit.
Causes
Waking coma is always a result of very severe damage to the brain. The damage is often triggered by a traumatic brain injury or a lack of oxygen caused by circulatory arrest. Other causes of these neurological disorders include stroke, meningitis and brain tumors. Neurodegenerative diseases, which include Parkinson’s syndrome, for example, can also cause apallic syndrome. In addition, there are cases in which extreme persistent hypoglycemia can lead to the condition of wakeful coma. Whatever the trigger, there is severe damage to the cerebrum. Often, other important brain regions are also permanently damaged, causing a waking coma or apallic syndrome.
Symptoms, complaints, and signs
The so-called waking coma or apallic syndrome is characterized by an extensive standstill of communication possibilities. The patient usually requires intensive medical treatment when diagnosed. He has often survived an accident with severe brain injuries or has fallen into a waking coma due to other circumstances. Initially, he must be artificially ventilated and fed intravenously. The onset of the vegetative state is usually sudden. Only in certain neurodegenerative disease patterns can the symptoms develop insidiously. A typical symptom is that the affected person appears awake. They have their eyes open, but they are looking into space. Obviously, they do not perceive what is happening around them. Whether there is no perceptual ability at all is debatable. Often, caregivers experience that increased blood pressure or other signals indicate some level of responsiveness. Other symptoms include aphasia, incontinence, spasticity, or involuntary movement patterns. Reflexes and respiratory reflexes typically remain. In a later stage of apallic syndrome, muscle shortening, muscle twitching, palpitations, sweating or hypertension may occur. These symptoms are considered signs of an autonomic nervous system that is no longer functioning normally. Only in a few cases do patients wake up after years of being in a coma. In most cases, pressure sores develop as a result of prolonged lying down. Prolonged ventilation can cause pneumonia, which can lead to death.
Diagnosis and course
Diagnosis of persistent vegetative state is clinical and usually takes several weeks or months. Severe neurologic defect syndromes must be detected. For this purpose, apparative diagnostics are used, which include magnetic resonance imaging, electroencephalogram, and evoked potentials. They are used in combination, since none of these examination methods alone is suitable for a diagnosis. A distinction must be made from other clinical pictures such as locked-in syndrome and coma. If a coma has been diagnosed, the relatives must be prepared for a treatment success rate of less than 50%.A better prognosis is given if the vegetative state is just beginning, the patient is young, and there is traumatic brain injury. Improvement of the vegetative state or apallic syndrome is unlikely if, for example, brainstem reflexes are absent for more than 24 hours, there has been no pupillary response for three days, or there is massive brain edema on CT.
Complications
Patients who fall into a persistent vegetative state suffer from both acute complications and late complications that often become apparent after awakening. Typical problems include incontinence and bedriddenness, usually associated with other sequelae such as inflammation, sores, and circulatory problems. After awakening, the patient usually suffers from delirium, which may persist for several days to weeks. If the waking coma is prolonged, permanent mental symptoms are also possible. A prolonged coma often also affects the patient’s psyche. Depressive moods, changes in personality or severe dissociative disorders then occur. Anxiety disorders can also occur in the context of an apallic syndrome. An existing vegetative state leads in the course to a decrease in brain activity and can be fatal as a result of the complications. Improvement of the vegetative state becomes increasingly unlikely as the disease progresses. If a feeding tube is placed in the patient, there are possible risks of injury to the stomach, small intestine, or esophagus. In isolated cases, the feeding tube is placed in the trachea instead of the esophagus, which can cause serious injury and infection. The medications administered may cause unforeseen side effects in some cases.
When should you see a doctor?
A doctor is needed as soon as the affected person becomes unresponsive, making it impossible to communicate with him or her. An ambulance must be alerted because intensive medical care becomes necessary. Until the arrival of the physician, it is imperative to follow the telephone instructions of the emergency medical team. Otherwise, there is a risk of sudden death of the person concerned. If the symptoms occur after an accident, a fall or the application of force, it is necessary to act as quickly as possible. Due to the nature of the condition, the person in a coma cannot undertake any activities to seek help. Therefore, persons present are required to react immediately. First aid measures must be applied to ensure the survival of the affected person. Involuntary movements, irregularities of the heart rhythm or a twitching of various muscles on the body of the affected person indicate an existing disorder. A lack of breathing, a pale appearance and a blank look are also to be interpreted as warning signals of the organism. If the ability to react remains absent despite all efforts, the body also does not respond to the natural reflexes and sudden changes occur within a few minutes, the emergency physician should be called. In some cases, the development of health impairments is gradual. Nevertheless, in the case of a waking coma, the help of persons present is mandatory.
Treatment and therapy
Treatment of apallic syndrome is based on the developmental phases of early neurologic rehabilitation. Acute treatment is the focus of therapy. In this phase, a tracheotomy is usually performed and a feeding tube is placed through the abdominal wall. In most cases, a urine drain is also placed through the abdominal wall. This ensures vital functions and allows the patient to receive the best possible nursing care. In addition, applications by physiotherapists and speech therapists should already be carried out in this phase. After the acute treatment has been completed, the next phase follows. Here, the therapy is extended by neuropsychological measures and occupational therapy. For some patients, music therapy is also used. The aim of these treatment methods is to improve mental, motor and psychological functions. In this phase, which can last from one month to one year, the further course of the patient’s state of health is decided. If there is a noticeable improvement in mental and physical performance, further measures can be taken. If the patient remains in an unconscious state, so-called “activating treatment care” is initiated.Always the therapy of an awake coma or an apallic syndrome takes place under medical guidance, since this is demanded also by the insurance companies as well as is checked.
Prevention
Waking coma cannot be prevented directly. However, any severe damage to the head and brain should be avoided, as this could have an impact on brain functions. If the coma vigil or apallic syndrome is already present, specific therapeutic measures can occasionally improve the condition of the affected person a little.
Aftercare
After a persistent vegetative state, follow-up care plays an exceedingly important role. For example, patients continue to require care after they are discharged from the hospital, depending on the extent of their activity limitations. This also applies to patients who have regained their independence. Rehabilitation aftercare takes place on an outpatient basis and extends over a longer period of time, the duration of which cannot always be determined. Possible aftercare treatments include 24-hour nursing care, out-of-hospital intensive care that includes ventilation, and a residential community that provides outpatient care. In mild cases, assisted living can also be implemented. Some affected individuals are even able to work in a special workshop for disabled people. On the other hand, other affected persons require permanent care in a day care center, a practice for outpatient neurorehabilitation or in a vigil coma house. Numerous patients can still recover from apallic syndrome years later in their familiar surroundings. Consultations are available through long-term care insurance companies. For example, they have the task of providing individual advice to those affected on care within their own homes. Special care support points are also available in numerous regions. An important component of aftercare is early rehabilitation. It continues the acute treatment from the hospital and includes therapeutic nursing, physiotherapeutic measures, speech and swallowing therapy, occupational therapy and neuropsychological treatments. The aim is to improve the patient’s state of consciousness.
Here’s what you can do yourself
In a persistent vegetative state, the patient naturally cannot initiate self-help measures. In this state of health, the affected person appears as if he is awake. In fact, however, his state of consciousness is minimal or nonexistent. In this situation, the patient is completely dependent on the support and help of the medical team providing care as well as the relatives. Normally, the affected person is in an inpatient stay. Here, the necessary care measures are automatically carried out by medical staff. It is helpful and advisable for the relatives to work closely with the nurses or assistants on the ward where the patient is being treated. Daily checks should be made at regular intervals to ensure that the points of support on the patient’s body do not develop pressure sores or wounds. Therefore, the patient’s body should be repeatedly moved or its position changed. Continuous application of cream to the points of contact has also proved helpful. The patient’s environment should be provided with fresh air several times a day. The oxygen supply supports the organism in the healing process. At the same time, care must be taken to ensure that the patient does not freeze or become exposed to an increased risk of infection. Although there is insufficient statistical evidence, patients consistently report after the fact that communication from family members to the patient has a positive impact in the recovery process.
