Diagnostic and Diagnostic and emergency help for life-emergency help for life-

threatening lesions of the threatening lesions of the central nervous systemcentral nervous system

Prepared by:Prepared by:C.M.S., assistant professor C.M.S., assistant professor

of outpatient therapy of outpatient therapy and emergency medical and emergency medical

emergency KSMUemergency KSMUA.R. AlpyssovaA.R. Alpyssova

The purpose of the lectureThe purpose of the lecture

After completing the lecture, students After completing the lecture, students should focus on issues of diagnosis should focus on issues of diagnosis and emergency treatment for life-and emergency treatment for life-threatening central nervous system lesions in threatening central nervous system lesions in the amount of the first medical care the amount of the first medical care (doctor's line crews), and depending on the (doctor's line crews), and depending on the patient - in the amount ofpatient - in the amount of specialized specialized care (intensive care team, brigades of care (intensive care team, brigades of intensive therapy)intensive therapy)

ССomaoma Coma - a condition characterized by lack Coma - a condition characterized by lack

of reaction to external stimulus.of reaction to external stimulus.

CausesCauses

Coma develops:Coma develops: In diffuse defeats the lesions of the cerebral In diffuse defeats the lesions of the cerebral

cortexcortex      (eg, in metabolic encephalopathy)      (eg, in metabolic encephalopathy)      brainstem (eg, space-occupying lesions in the       brainstem (eg, space-occupying lesions in the posterior fossa).posterior fossa).

Unilateral lesion of the cortex: a stroke Unilateral lesion of the cortex: a stroke or tumor, in case they cause compression of or tumor, in case they cause compression of the opposite hemisphere or brain stem.the opposite hemisphere or brain stem.

Diagnosis and treatmentDiagnosis and treatment are carried  are carried out quickly, in a clear sequence given below. The out quickly, in a clear sequence given below. The main task - to find out the cause of the coma main task - to find out the cause of the coma and to determine whether surgical intervention.and to determine whether surgical intervention.

Brain damage in coma at any moment could Brain damage in coma at any moment could become irreversible, so treatment become irreversible, so treatment starts immediately, without waiting starts immediately, without waiting for completion of the survey.for completion of the survey.

A. Maintenance of vital functions.A. Maintenance of vital functions. Provide  Provide a clear airway, give oxygen, if a clear airway, give oxygen, if necessary, start artificial ventilation. To necessary, start artificial ventilation. To enter, monitoring heart rate, blood enter, monitoring heart rate, blood pressure, body temperature, ECG and saO2.pressure, body temperature, ECG and saO2.

B. Immobilization of the spine.B. Immobilization of the spine. If the injury is  If the injury is not excluded, in this way until the spine X-not excluded, in this way until the spine X-rays provide its complete immobility, to the neck rays provide its complete immobility, to the neck clothed collar splint.clothed collar splint.

C.C.  Venous access.Venous access. Establish venous catheter,  Establish venous catheter, takes blood samples  (overall analysis, arterial takes blood samples  (overall analysis, arterial blood gases, seeding, glucose, electrolytes, urea blood gases, seeding, glucose, electrolytes, urea nitrogen, ammonia, liver enzymes, blood group, nitrogen, ammonia, liver enzymes, blood group, Rh-factor, the toxicological study) and urine Rh-factor, the toxicological study) and urine (overall analysis, toxicology study).(overall analysis, toxicology study).

D. Intravenously injected D. Intravenously injected the following drugs.the following drugs. 1.1. Thiamine,Thiamine, 100 mg. 100 mg. 2.2. Glucose, Glucose, 1 g / kg (in 1 vial 50% glucose  1 g / kg (in 1 vial 50% glucose 

containing  25 g of glucose).containing  25 g of glucose). 3.3. Naloxone Naloxone ( antagonist of narcotic analgesics), ( antagonist of narcotic analgesics),

0.01 mg / kg.0.01 mg / kg. 4.4. FlumazenilFlumazenil (benzodiazepine receptor blocker),  (benzodiazepine receptor blocker),

0.2 mg. The drug can be injected repeatedly at 0.2 mg. The drug can be injected repeatedly at intervals of 1 min, total dose should not exceed 1 intervals of 1 min, total dose should not exceed 1 mg (sometimes causing seizures).mg (sometimes causing seizures).

E. The total surveyE. The total survey 1.1.History.History. Payed attention to injury, seizures,  Payed attention to injury, seizures,

taking drugs, alcohol, diabetes and other taking drugs, alcohol, diabetes and other diseases.diseases.

2. Examination2. Examination often gives a clue to the  often gives a clue to the diagnosis: it may be, for diagnosis: it may be, for example, arteriovenous shunt in a patient CRFexample, arteriovenous shunt in a patient CRF ((ХПНХПН)), the nature rash of meningococcal , the nature rash of meningococcal disease or symptoms of traumatic brain injury disease or symptoms of traumatic brain injury (wounds, bruises around the eyes and in (wounds, bruises around the eyes and in the mastoid process, the accumulation of blood in the mastoid process, the accumulation of blood in the tympanic cavity).the tympanic cavity).

3. 3. Neurological examination. Neurological examination. Main attention Main attention given to hearth symptoms and signs of given to hearth symptoms and signs of focal herniation. In order to not to miss the focal herniation. In order to not to miss the deterioration, the survey is repeated periodically.deterioration, the survey is repeated periodically.

F. Focal herniation F. Focal herniation requires an immediate break-requires an immediate break-reducing intracranial pressure, at the same time reducing intracranial pressure, at the same time carried out a consultation in neurosurgeon.carried out a consultation in neurosurgeon.

1.1.  Ventilator in a mode Ventilator in a mode of hyperventilation.of hyperventilation. Reducing paCO2 until 25- Reducing paCO2 until 25-30mm Hg. causes a narrowing of cerebral vessels and 30mm Hg. causes a narrowing of cerebral vessels and fast, within minutes, reducing the intracranial fast, within minutes, reducing the intracranial pressure. Further reduction paCO2 inappropriate - it can pressure. Further reduction paCO2 inappropriate - it can lead to a significant decrease in cerebral blood flow.lead to a significant decrease in cerebral blood flow.

2.2. MannitolMannitol (1-2 g / kg intravenously min at 10-20) -  (1-2 g / kg intravenously min at 10-20) - osmotic agent, which reduces brain swelling. The osmotic agent, which reduces brain swelling. The maximum effect after 90 minutes.maximum effect after 90 minutes.

3.3.DDexamethasoneexamethasone (10 mg / intravenously then  (10 mg / intravenously then 4 mg intravenously every 6 hours) reduces 4 mg intravenously every 6 hours) reduces the perifocal edema in the tumor or abscess.the perifocal edema in the tumor or abscess.

G. CT of the headG. CT of the head is carried out immediately, as  is carried out immediately, as soon as the patient's condition. The study makes it soon as the patient's condition. The study makes it possible to distinguish lesions that require surgical possible to distinguish lesions that require surgical intervention (eg, hematoma of the cerebellum) intervention (eg, hematoma of the cerebellum) from those under which it is not shown (eg, from those under which it is not shown (eg, bleeding in the bridge).bleeding in the bridge).

H. Lumbar punctureH. Lumbar puncture performed if the  performed if the previous studies did not reveal the cause previous studies did not reveal the cause of coma. (If the CT scan revealed volume of coma. (If the CT scan revealed volume formation or displacement of midline formation or displacement of midline structures, lumbar puncture is not performed, in structures, lumbar puncture is not performed, in this case of suspected meningitis, broad-this case of suspected meningitis, broad-spectrum antibiotics is spectrum antibiotics is prescribed without bacteriological confirmation of prescribed without bacteriological confirmation of diagnosis)  The SBLdiagnosis)  The SBL((  СМЖСМЖ)) investigates to cytosis, investigates to cytosis, protein, glucose, protein, glucose, cryptococcal antigen, performed sowing on mushrcryptococcal antigen, performed sowing on mushrooms and ooms and bacteria, stain microscopy by Gram, Ziehl-bacteria, stain microscopy by Gram, Ziehl-Neelsen and with contrasting ink. If antibiotic Neelsen and with contrasting ink. If antibiotic therapy has begun, the bacteria usually do not therapy has begun, the bacteria usually do not show up - in these cases, the SBL show up - in these cases, the SBL is sometimes tested for bacterial antigens. One is sometimes tested for bacterial antigens. One tube of SBL were frozen in case you tube of SBL were frozen in case you needed further investigations.needed further investigations.

I. EEGI. EEG was performed if and after a lumbar  was performed if and after a lumbar puncture diagnosis remains unclear. Study to puncture diagnosis remains unclear. Study to diagnose unseizure status diagnose unseizure status epilepticus. Characteristic, although epilepticus. Characteristic, although not pathognomonic, EEG changes in not pathognomonic, EEG changes in hepatic encephalopathy, herpes encephalitis, poisoninhepatic encephalopathy, herpes encephalitis, poisoning by barbiturates and certain other conditions.g by barbiturates and certain other conditions.

J. Emergency correction of hemostasis J. Emergency correction of hemostasis (blood (blood transfusion of fresh frozen plasma, transfusion of fresh frozen plasma, cryoprecipitatecryoprecipitate, platelets) is shown in a brain , platelets) is shown in a brain haemorrhage and the haemorrhage and the upcoming neurosurgical operations.upcoming neurosurgical operations.

A. Monitoring.A. Monitoring. If the diagnosis remains  If the diagnosis remains unclear, leaving the patient under close unclear, leaving the patient under close observation and continued evaluation. In such observation and continued evaluation. In such cases, the most likely cause of the coma - metabolic cases, the most likely cause of the coma - metabolic disorders, poisoning, or brainstem strokes.disorders, poisoning, or brainstem strokes.

III. Neurological examinationIII. Neurological examination A Glasgow Coma ScaleA Glasgow Coma Scale allows you to quantify the severity  allows you to quantify the severity

of the state and monitor its evolution. The scale consists of of the state and monitor its evolution. The scale consists of three sections, assessment for each section summarize, the three sections, assessment for each section summarize, the total score can range from 3 (severe coma) to 15 (normal) total score can range from 3 (severe coma) to 15 (normal) points.points.

B. The rhythm of breathingB. The rhythm of breathing 1. Cheyne Stokes respiration1. Cheyne Stokes respiration (breathing  (breathing

rate undulating fluctuation of tachypnea to apnea) rate undulating fluctuation of tachypnea to apnea) occurs in the metabolic encephalopathy, occurs in the metabolic encephalopathy, supratentorial lesions, as well as cardiac and pulmonary supratentorial lesions, as well as cardiac and pulmonary disease.disease.

2. Tachypnea2. Tachypnea usually occurs in  usually occurs in metabolic acidosis, hypoxemia and lung disease such metabolic acidosis, hypoxemia and lung disease such as pneumonia - but can also be caused by lesions of the as pneumonia - but can also be caused by lesions of the upper brain stem.upper brain stem.

3. Agonal breathing 3. Agonal breathing (occasional deep breaths, a series of (occasional deep breaths, a series of frequent respiratory movements, alternating with periods frequent respiratory movements, alternating with periods of apnea, irregular breathing movements) indicates a lesion of apnea, irregular breathing movements) indicates a lesion of the brain stem and is preceded by respiratory arrest.of the brain stem and is preceded by respiratory arrest.

C. PupilsC. Pupils 1. Wide pupil does not react to light1. Wide pupil does not react to light - a sign  - a sign

of temporomandibulartentorial herniation on the side of temporomandibulartentorial herniation on the side of expanding the pupil (similar picture can give of expanding the pupil (similar picture can give and midriatiki such asand midriatiki such as  scopolaminescopolamine andand atropine atropine).).

2. Narrow pupils that react to light, 2. Narrow pupils that react to light, are observed with are observed with an overdose of narcotic an overdose of narcotic analgesics, metabolic encephalopathy, lesions of the analgesics, metabolic encephalopathy, lesions of the bridge and the thalamus.bridge and the thalamus.

3. 3. Pupils of average size, not reacting to lightPupils of average size, not reacting to light - a  - a sign of the midbrain lesions, usually with a sign of the midbrain lesions, usually with a central herniation.central herniation.

4. Ample pupils not reacting to light4. Ample pupils not reacting to light - a sign  - a sign of severe hypoxic encephalopathy or of severe hypoxic encephalopathy or intoxication intoxication scopolaminescopolamine, , atropineatropine, , Glutethimide Glutethimide and methanol.and methanol.

G. Position of the eye.G. Position of the eye. With the defeat of the cortex of  With the defeat of the cortex of a cerebral eyes are turned away from a cerebral eyes are turned away from the hemiparesis, ie in the direction of destruction. When the hemiparesis, ie in the direction of destruction. When unilateral lesions of the bridge's eyes turned to the unilateral lesions of the bridge's eyes turned to the side hemiparesis that is opposite to the lesion. If not side hemiparesis that is opposite to the lesion. If not detected hemiparesis, cortical lesion and the bridge can detected hemiparesis, cortical lesion and the bridge can be distinguished by restriction of the horizontal mobility of be distinguished by restriction of the horizontal mobility of the eye.the eye.

D. Eye movements D. Eye movements in coma assessed by vestibulo-ocular in coma assessed by vestibulo-ocular reflex. If the excludedreflex. If the excluded injury of the cervical injury of the cervical spine, causing reflex, the patient turning his head up and spine, causing reflex, the patient turning his head up and down and from side to side (sample doll eyes). When a down and from side to side (sample doll eyes). When a saved vestibulo-ocular reflex eyesaved vestibulo-ocular reflex eye move in the direction move in the direction opposite the movement of the head, so that the gaze isopposite the movement of the head, so that the gaze is directed at one point. If cervical spine injury is not directed at one point. If cervical spine injury is not excluded or breakdown doll eyeexcluded or breakdown doll eye reflex cause you can not, reflex cause you can not, apply cold test. The head of the bed lift up to 30 ° and apply cold test. The head of the bed lift up to 30 ° and poured into the ear of 10-50 ml of ice water (the ear poured into the ear of 10-50 ml of ice water (the ear canal must be going through, and the tympanic canal must be going through, and the tympanic membrane intact), and both eyes should deviate in the membrane intact), and both eyes should deviate in the direction of stimulation. To cause vertical movement of the direction of stimulation. To cause vertical movement of the eyes, the water pouredeyes, the water poured simultaneously into both ears.simultaneously into both ears.

1. Immobility in both eyes1. Immobility in both eyes indicates bilateral  indicates bilateral involvement of the bridge or poisoninginvolvement of the bridge or poisoning by barbiturates, by barbiturates, phenytoin, or tricyclic antidepressants.phenytoin, or tricyclic antidepressants.

2. The immobility of one eye - 2. The immobility of one eye - a sign a sign of unilateral lesions of the brain stem.of unilateral lesions of the brain stem.

3. 3. Limitation of eye movements in the Limitation of eye movements in the horizontalhorizontal allows us to distinguish unilaterallesion of  allows us to distinguish unilaterallesion of the cortex and the bridge - the state, which is the cortex and the bridge - the state, which is characterized by the standard deviation of eyes: in the characterized by the standard deviation of eyes: in the direction of the hearth with lesions of the cortexand in direction of the hearth with lesions of the cortexand in the opposite direction with the defeat of the bridge. If the opposite direction with the defeat of the bridge. If the eyes are turning, crossing the center the eyes are turning, crossing the center line - struck the bark, and if only to reach the middle line - struck the bark, and if only to reach the middle line - the bridge. If you can identify the hemiparesis, line - the bridge. If you can identify the hemiparesis, the differential diagnosis is simplified:the differential diagnosis is simplified: eye deviation to eye deviation to the side hemiparesis said of the defeat of the the side hemiparesis said of the defeat of the bridge to the opposite side - the defeat of the cortex.bridge to the opposite side - the defeat of the cortex.

4. Limitation of eye movements in the 4. Limitation of eye movements in the verticalvertical occurs in lesions of the midbrain, occurs in lesions of the midbrain, central herniation and acute hydrocephalus.central herniation and acute hydrocephalus.

E. Movement of the limbs.E. Movement of the limbs.Evaluate Evaluate the symmetry and direction of movement - both the symmetry and direction of movement - both spontaneous and in response to pain.spontaneous and in response to pain.

1. The asymmetry of movements 1. The asymmetry of movements - a sign - a sign of hemiparesis.of hemiparesis.

Decorticational Decorticational and decerebrate rigidity, in contrast and decerebrate rigidity, in contrast to the asymmetry of movements does not indicate to the asymmetry of movements does not indicate a focal disease, it happens, a focal disease, it happens, in particular, metaboliccoma.in particular, metaboliccoma.

3. Outside leg rotation3. Outside leg rotation is possible  is possible with hemiparesis, hip fractures and dislocationswith hemiparesis, hip fractures and dislocations

IV. BreakIV. Break-occurs when the pressure differential created -occurs when the pressure differential created by the volume form, part of the brain pushes through a by the volume form, part of the brain pushes through a particular hole in the neighboring department of the particular hole in the neighboring department of the cranial cavity. This is a deadly condition that cranial cavity. This is a deadly condition that requires emergency neurosurgical intervention. In requires emergency neurosurgical intervention. In anticipation of surgery is anticipation of surgery is performed reducing intracranial pressure.performed reducing intracranial pressure.

A. Symptoms of increasing intracranial A. Symptoms of increasing intracranial pressurepressure occur with any kind of herniation, these  occur with any kind of herniation, these include: headache, nausea, vomiting, hypertension, include: headache, nausea, vomiting, hypertension, bradycardia, papilledema, abducens lesion, blurred bradycardia, papilledema, abducens lesion, blurred vision, loss of consciousness.vision, loss of consciousness.

B. Temporomandibular -tentorial break-B. Temporomandibular -tentorial break-in occurs unilaterally raising the pressure above in occurs unilaterally raising the pressure above the snaring of the cerebellum. Parahippocampal gyrus the snaring of the cerebellum. Parahippocampal gyrus and a hook adjacent sections of the temporal lobe are and a hook adjacent sections of the temporal lobe are moved under the gallop, squeezing the midbrain. moved under the gallop, squeezing the midbrain. Symptoms can grow rapidly. The first symptom - the Symptoms can grow rapidly. The first symptom - the expansion of the pupil on the affected side, then expansion of the pupil on the affected side, then developed hemiparesis on the affected developed hemiparesis on the affected side, tetraparesis and coma.side, tetraparesis and coma.

C. The central break C. The central break - develops as a result of - develops as a result of bilateral pressure increase over the snaring of the bilateral pressure increase over the snaring of the cerebellum. In the gallop, along cerebellum. In the gallop, along with cutting portions of the temporal with cutting portions of the temporal lobes and diencephalon is pressed. Characterized lobes and diencephalon is pressed. Characterized by progressive depression of by progressive depression of consciousness, decerebrate rigidity and decorticationaconsciousness, decerebrate rigidity and decorticational; breath initially normal or type of Cheyne-Stokes will l; breath initially normal or type of Cheyne-Stokes will develop tachypnea, pupils of average size, the light develop tachypnea, pupils of average size, the light did not respond.did not respond.

D. Cerebellar break-inD. Cerebellar break-in is under increasing  is under increasing pressure cerebellar snaring. Cerebellar tonsils are pressure cerebellar snaring. Cerebellar tonsils are wedged into the foramen magnum, compressing the wedged into the foramen magnum, compressing the medulla oblongata. Characterized by depression of medulla oblongata. Characterized by depression of consciousness, respiratory rhythm disturbances consciousness, respiratory rhythm disturbances and sleep apnea.and sleep apnea.

ConfusionConfusion V. Confusion characterized V. Confusion characterized

by disorientation, memory impairment, speech, by disorientation, memory impairment, speech, attention and concentration, hallucinations attention and concentration, hallucinations and excitation.and excitation.

VI. The reasonsVI. The reasons are manifold confusion - alcohol  are manifold confusion - alcohol and alcoholic abstinence, drugs and and alcoholic abstinence, drugs and narcotics, avitaminosis B1, sepsis, infections of the narcotics, avitaminosis B1, sepsis, infections of the CNS, liver and kidney failure, hypoxia, hypoglycemia, CNS, liver and kidney failure, hypoxia, hypoglycemia, electrolyte disturbances, acute intermittent electrolyte disturbances, acute intermittent porphyria, lupus, migraine aura. Confusion often occurporphyria, lupus, migraine aura. Confusion often occurs following an epileptic seizure, she meets and the s following an epileptic seizure, she meets and the organic CNS lesions (subarachnoid hemorrhage, organic CNS lesions (subarachnoid hemorrhage, subdural hematoma, stroke). In the elderly with subdural hematoma, stroke). In the elderly with dementia and confusion can be caused by even dementia and confusion can be caused by even a relatively mild illness.a relatively mild illness.

VII. Diagnosis and treatmentVII. Diagnosis and treatment A. Case history.A. Case history. Pay attention to injury, seizures,  Pay attention to injury, seizures,

taking of drugs, alcohol, diabetes and other taking of drugs, alcohol, diabetes and other diseases. Analyze laboratory data and information about diseases. Analyze laboratory data and information about the medication.the medication.

B. Survey. B. Survey. Symptoms Symptoms of physical (pneumonia) or neurologic (neck stiffness, of physical (pneumonia) or neurologic (neck stiffness, paralysis) of the disease may indicate the cause paralysis) of the disease may indicate the cause of confusion.of confusion.

C. Airway, breathing and circulationC. Airway, breathing and circulation should be  should be provided in the first place. At the same time establish provided in the first place. At the same time establish a venous catheter, take blood samples (arterial blood a venous catheter, take blood samples (arterial blood gases, glucose, electrolytes, BUN, calcium, magnesium, gases, glucose, electrolytes, BUN, calcium, magnesium, ammonia, TTG, seeding, and toxicological ammonia, TTG, seeding, and toxicological studies) and urine (overall analysis studies) and urine (overall analysis and toxicology research.)and toxicology research.)

D.D. CT CT can identify these organic lesions as intracranial can identify these organic lesions as intracranial hematoma, stroke, subarachnoid hemorrhage, and hematoma, stroke, subarachnoid hemorrhage, and abscess.abscess.

E. Lumbar punctureE. Lumbar puncture is indicated  is indicated for suspected meningitis and encephalitis. Sometimes it for suspected meningitis and encephalitis. Sometimes it is uses also for suspected subarachnoid haemorrhage - if is uses also for suspected subarachnoid haemorrhage - if the diagnosis could not be confirmed with CT and the diagnosis could not be confirmed with CT and MRT. Bulk of education, especially with the MRT. Bulk of education, especially with the displacement of medial structures, increase the risk displacement of medial structures, increase the risk of herniation, so if you have symptoms of focal pre-of herniation, so if you have symptoms of focal pre-perform CT scans. For suspected bacterial meningitis perform CT scans. For suspected bacterial meningitis before the introduction of antibiotics just beginning, and before the introduction of antibiotics just beginning, and then underwent CT, and only then - if not detected volume then underwent CT, and only then - if not detected volume formation - a lumbar puncture.formation - a lumbar puncture.

F. Cross-cutting activities.F. Cross-cutting activities. Enter Enter thiamine thiamine (100 mg /  (100 mg / intravenously), then glucose (50 ml 50% intravenously), then glucose (50 ml 50% solution intravenously ). Tranquilizers better not to solution intravenously ). Tranquilizers better not to appoint, if necessary, giveappoint, if necessary, give lorazepam lorazepam (1mg  (1mg inside) or inside) or chlordiazepoxidechlordiazepoxide (25 mg inside). The patient  (25 mg inside). The patient should be in quiet bright house under close observation. If should be in quiet bright house under close observation. If the patient safety requires fixing, it is used, but the patient safety requires fixing, it is used, but possibly not for long.possibly not for long.

Alcohol withdrawal syndromeAlcohol withdrawal syndrome Alcohol withdrawal syndrome occurs with cessation of Alcohol withdrawal syndrome occurs with cessation of

alcohol often occurs during hospitalization.alcohol often occurs during hospitalization. VIII. Easy withdrawal syndromeVIII. Easy withdrawal syndrome characterized  characterized

by tremor, irritability, lack of appetite by tremor, irritability, lack of appetite and nausea. Symptoms usually appear and nausea. Symptoms usually appear within several hours after drinking alcohol and going within several hours after drinking alcohol and going through 2 days. Treatment - a well-lit room, a quiet through 2 days. Treatment - a well-lit room, a quiet environment, tranquilizers, environment, tranquilizers, and vitamins. Assign and vitamins. Assign chlordiazepoxide chlordiazepoxide (25-100 mg (25-100 mg inside every 6 hours) or inside every 6 hours) or diazepam diazepam (5-20 mg (5-20 mg inside every 6 hours), inside every 6 hours), thiaminethiamine (100 mg /  (100 mg / intramuscularly, then 100mg / day inside) and a intramuscularly, then 100mg / day inside) and a multivitamin with multivitamin with folic acidfolic acid. It is important not to miss . It is important not to miss the more severe manifestations of abstinence, and the more severe manifestations of abstinence, and if the house to monitor the patients no if the house to monitor the patients no one, hospitalization is shown.one, hospitalization is shown.

IX. Abstinent seizuresIX. Abstinent seizures - usually brief,  - usually brief, generalized, or re - occur within 12-48 hours after generalized, or re - occur within 12-48 hours after stopping alcohol. Anti / convulsive means does not stopping alcohol. Anti / convulsive means does not shown. Necessarily rule out(especially in severe shown. Necessarily rule out(especially in severe cases) other causes of seizures - brain cases) other causes of seizures - brain injury, intracranial hematoma, meningitis, injury, intracranial hematoma, meningitis, and metabolic disorders: they are often found in and metabolic disorders: they are often found in abstinence.abstinence.

X. Delirium tremensX. Delirium tremens (delirium tremens) develops  (delirium tremens) develops in 5-10% of cases of withdrawal symptoms. Clinical in 5-10% of cases of withdrawal symptoms. Clinical manifestations - tremors, hallucinations, agitation, manifestations - tremors, hallucinations, agitation, confusion, disorientation, and autonomic confusion, disorientation, and autonomic disorders (fever, tachycardia, sweating). Deliriumdisorders (fever, tachycardia, sweating). Delirium develops over 3-4 days after cessation of alcohol develops over 3-4 days after cessation of alcohol ingestion and lasts 3-5 days.ingestion and lasts 3-5 days. Lethality reached Lethality reached 15%. We must look for other causes of confusion.15%. We must look for other causes of confusion.

A.ControlA.Control of dehydration and electrolyte disturbances.of dehydration and electrolyte disturbances. Patients with severe alcohol withdrawal Patients with severe alcohol withdrawal syndrome often develops hypomagnesemia, syndrome often develops hypomagnesemia, hypokalemia andhypokalemia and hypoglycemia. Fever, excess hypoglycemia. Fever, excess sweating and vomiting leading to severe dehydration.sweating and vomiting leading to severe dehydration.

B.B.  ChlordiazepoxideChlordiazepoxide. Initial dose - 100 mg / . Initial dose - 100 mg / intravenously or inside, then - 100 mg every 2-6 intravenously or inside, then - 100 mg every 2-6 hours, but no more than 500 mg in the first hours, but no more than 500 mg in the first 24 hours The next day the dose is reduced by 24 hours The next day the dose is reduced by half, then it is reduced by 25-50 mg / day. When liver half, then it is reduced by 25-50 mg / day. When liver damage is used instead damage is used instead of of chlordiazepoxidechlordiazepoxide,, oxazepam oxazepam (15-30 mg inside every  (15-30 mg inside every 6-8 hours), it appears mainly by the kidneys.6-8 hours), it appears mainly by the kidneys.

Brain injuryBrain injury XI. Urgent actionsXI. Urgent actions A clear airway, breathing and blood A clear airway, breathing and blood

circulationcirculation was evaluated in the first place. Patients  was evaluated in the first place. Patients with severe traumatic brain injury, as a rule, with severe traumatic brain injury, as a rule, develop hypoventilation, which leads to develop hypoventilation, which leads to increased intracranial increased intracranial pressure, hypotension and contributes to brain pressure, hypotension and contributes to brain ischemia. Fractures of the facial skull ischemia. Fractures of the facial skull naso tracheal  intubation is not applicable. The naso tracheal  intubation is not applicable. The continuous registration of heart rate, blood continuous registration of heart rate, blood pressure, ECG and pulse - oximetry.pressure, ECG and pulse - oximetry.

B. Immobilization of the cervical spine B. Immobilization of the cervical spine of collar bus. If the X-ray examination fractures and of collar bus. If the X-ray examination fractures and dislocations of the cervical vertebrae are excluded, the dislocations of the cervical vertebrae are excluded, the tire is removed.tire is removed.

СС. Medical History.. Medical History. Find out the time of  Find out the time of occurrence of all symptoms, especially lossoccurrence of all symptoms, especially loss of of consciousness, whether there was lucid consciousness, whether there was lucid interval (a sign of growing hematoma)and interval (a sign of growing hematoma)and whether amnesia (a sign of whack).whether amnesia (a sign of whack).

D. Inspection.D. Inspection. Pay attention  Pay attention to penetrating wounds and other injuries.to penetrating wounds and other injuries.

E. Neurological examination.E. Neurological examination. The  The first estimate for the severity of injury Glasgow first estimate for the severity of injury Glasgow Coma Scale, looking for focal symptoms and signs Coma Scale, looking for focal symptoms and signs of herniation. Not to miss the deterioration, the of herniation. Not to miss the deterioration, the survey is repeated periodically.survey is repeated periodically.

XII. TreatmentXII. Treatment A minor injuries.A minor injuries. The patient is conscious, there is  The patient is conscious, there is

no focal neurological symptoms, a history - short-no focal neurological symptoms, a history - short-term loss or confusion, term loss or confusion, agitation and amnesia. Carried out X-rays of skull agitation and amnesia. Carried out X-rays of skull and cervical spine. On the first day neurological and cervical spine. On the first day neurological examination was repeated every examination was repeated every hour. Sometimes observation can be hour. Sometimes observation can be charged home; they should clearly explain the cases charged home; they should clearly explain the cases in which the patient must be taken to hospital.in which the patient must be taken to hospital.

B. Moderate injuryB. Moderate injury, or focal neurological , or focal neurological symptoms. Spend X-ray of the cervical spine and symptoms. Spend X-ray of the cervical spine and CT of the head. On the first day neurological CT of the head. On the first day neurological examination was repeated every hour. When an examination was repeated every hour. When an intracranial hematoma, skull fractures and cervical intracranial hematoma, skull fractures and cervical spine shows a consulting neurosurgeon.spine shows a consulting neurosurgeon.

C. Severe traumaC. Severe trauma. Require immediate consultation of a . Require immediate consultation of a neurosurgeon.neurosurgeon.  IntubateIntubate trachea, begin artificial trachea, begin artificial ventilation, establish venous catheter. At the same time ventilation, establish venous catheter. At the same time carry out pre-operative laboratory tests, diagnose carry out pre-operative laboratory tests, diagnose and treat the injuries of other organs. Before CT and X-and treat the injuries of other organs. Before CT and X-ray of skull and cervical ray of skull and cervical spine shows moderate hyperventilation(paCO2 about spine shows moderate hyperventilation(paCO2 about 35 mmHg. Cent.) And fluid 35 mmHg. Cent.) And fluid restriction hypoosmalial solutions do not enter). The head restriction hypoosmalial solutions do not enter). The head should be raised to 30 ° and placed on the midline. should be raised to 30 ° and placed on the midline. Corticosteroids are not used. Break-requires immediate Corticosteroids are not used. Break-requires immediate treatment.treatment.

D. Penetrating head injuryD. Penetrating head injury, even in the absence , even in the absence of focal neurological symptoms, CT of focal neurological symptoms, CT and requires consultation of a neurosurgeon. Do not try and requires consultation of a neurosurgeon. Do not try to remove a foreign body from the wound (eg, knife).to remove a foreign body from the wound (eg, knife).

E. Increase of neurological symptomsE. Increase of neurological symptoms, regardless of , regardless of the severity of the injury requires immediate CT scan of the severity of the injury requires immediate CT scan of the head to avoid bruising, even if CT scans on the head to avoid bruising, even if CT scans on admission did not reveal any changes.admission did not reveal any changes.

F. Intracranial hematomasF. Intracranial hematomas 11. Epidural hematoma. Epidural hematoma usually occurs in fractures  usually occurs in fractures

of the skull with damage to the of the skull with damage to the meningeal artery. Characteristic of lucid interval, meningeal artery. Characteristic of lucid interval, followed by deterioration and the development of the followed by deterioration and the development of the classical picture of tentorial-classical picture of tentorial-herniation emporomandibular(drowsiness, then coma, diherniation emporomandibular(drowsiness, then coma, dilatation of the pupil on the affected side and latation of the pupil on the affected side and hemiparesis on the opposite side). Can only save the life hemiparesis on the opposite side). Can only save the life of an emergency removal of a hematoma.of an emergency removal of a hematoma.

2. Acute subdural hematoma2. Acute subdural hematoma on the clinical picture is  on the clinical picture is similar to an epidural. Lethality reaches 20-similar to an epidural. Lethality reaches 20-50%. Displaying an emergency surgical treatment.50%. Displaying an emergency surgical treatment.

3. Chronic subdural hematoma3. Chronic subdural hematoma occurs mainly  occurs mainly in elderly and debilitated patients with alcoholism and in in elderly and debilitated patients with alcoholism and in patients receiving anticoagulants, may develop after a patients receiving anticoagulants, may develop after a minor injury. Clinical manifestations - headache, minor injury. Clinical manifestations - headache, confusion, drowsiness. Surgical treatment is indicated in confusion, drowsiness. Surgical treatment is indicated in severe neurological symptoms and large size hematomasevere neurological symptoms and large size hematoma

4. Intracerebral hematoma 4. Intracerebral hematoma can occur both in the can occur both in the time of injury, and some time later. The need for time of injury, and some time later. The need for surgery is determined by the severity of the condition, surgery is determined by the severity of the condition, size and location of hematoma.size and location of hematoma.

J. J. Fractures of the skull Fractures of the skull increases the risk of increases the risk of epidural hematoma and infection. About the turn epidural hematoma and infection. About the turn of the skull shows outflow of of the skull shows outflow of СМЖ СМЖ  from the  from the nose or ear, accumulation of blood in the tympanic nose or ear, accumulation of blood in the tympanic cavity, a symptom score, a hematoma in the area of  cavity, a symptom score, a hematoma in the area of  the mastoid process. Diagnosis is confirmed by CT the mastoid process. Diagnosis is confirmed by CT scan. Shows the consultation of a neurosurgeon.scan. Shows the consultation of a neurosurgeon.

Acute spinal cordAcute spinal cord Common symptom of spinal cord injuries - the presence Common symptom of spinal cord injuries - the presence

of the level below which features been violated of the level below which features been violated and above - are stored. Disease outcome is often and above - are stored. Disease outcome is often determined by the speed of recognition and treatment.determined by the speed of recognition and treatment.

XIII. Spinal cord compressionXIII. Spinal cord compression manifested the  manifested the growing weakness in the legs, loss of sensitivity, urinary growing weakness in the legs, loss of sensitivity, urinary retention, retention, alternated ischuria paradoxical, and sometimes back alternated ischuria paradoxical, and sometimes back pain. The cause of compression may be the primary pain. The cause of compression may be the primary and metastatic tumors, herniated discs, epidural abscess, and metastatic tumors, herniated discs, epidural abscess, hematoma, and vascular malformations. A similar hematoma, and vascular malformations. A similar picture given transverse myelitis and picture given transverse myelitis and transverse myelopathy. The causes transverse transverse myelopathy. The causes transverse myelitis - enterovirus virus, varicella-zoster, tuberculosis myelitis - enterovirus virus, varicella-zoster, tuberculosis and other granulomatous, syphilis, and other granulomatous, syphilis, СКВСКВ..

   Transverse myelopathyTransverse myelopathy occurs when the spinal cord  occurs when the spinal cord infarctions and multiple sclerosis.infarctions and multiple sclerosis.

A. InspectionA. Inspection, tended to establish the level of damage , tended to establish the level of damage (remember that there may be several). Shooting pain, (remember that there may be several). Shooting pain, paresthesia, numbness, paresis, decreased muscle tone paresthesia, numbness, paresis, decreased muscle tone and reflexes in the area of innervation of the spine showed and reflexes in the area of innervation of the spine showed it inflammation or compression. For cross-spinal cord area it inflammation or compression. For cross-spinal cord area is characterized by segmental sensory disturbances at the is characterized by segmental sensory disturbances at the level of damage below which there is a bilateral level of damage below which there is a bilateral conductive loss of sensitivity and paralysis. In acute flaccid conductive loss of sensitivity and paralysis. In acute flaccid paralysis injury (weakening of muscle tone and reflexes), paralysis injury (weakening of muscle tone and reflexes), with the gradual development of the disease - spastic with the gradual development of the disease - spastic (increased muscle tone, increased reflexes, Babinski (increased muscle tone, increased reflexes, Babinski reflex). Spinal cord compression is often accompanied by reflex). Spinal cord compression is often accompanied by urinary retention. With the defeat of half the diameter of urinary retention. With the defeat of half the diameter of the spinal cord develops symptoms of Brown-Sekara: the spinal cord develops symptoms of Brown-Sekara: paresis and loss of proprioceptive and vibration sensitivity paresis and loss of proprioceptive and vibration sensitivity on the affected side, loss of pain and temperature on the affected side, loss of pain and temperature sensitivity on the opposite side. Compression of the lower sensitivity on the opposite side. Compression of the lower lumbar and sacral root causes loss of sensation in the legs lumbar and sacral root causes loss of sensation in the legs and crotch, legs flaccid paralysis, urinary and fecal and crotch, legs flaccid paralysis, urinary and fecal incontinence.incontinence.

B. X-ray of the spine.B. X-ray of the spine. X-ray of the  X-ray of the spine reveals metastases, osteomyelitis, intervertebral spine reveals metastases, osteomyelitis, intervertebral disc lesions, fractures and dislocations of the disc lesions, fractures and dislocations of the vertebrae. To refine the size and location of the vertebrae. To refine the size and location of the lesion performed MRI or myelography combined lesion performed MRI or myelography combined with CT. Examine all parts of the with CT. Examine all parts of the spine. When compression of the spinal spine. When compression of the spinal cord myelographycan cord myelographycan cause sudden deterioration requiring emergency decocause sudden deterioration requiring emergency decompression laminectomy, so consult a mpression laminectomy, so consult a neurosurgeon performed before and not after the neurosurgeon performed before and not after the study. The same goes for a lumbar puncture, which is study. The same goes for a lumbar puncture, which is used in the diagnosis of infectious, inflammatory and used in the diagnosis of infectious, inflammatory and neoplastic lesions.neoplastic lesions.

C. Treatment. C. Treatment. Maintain breathing and circulation. At Maintain breathing and circulation. At the same time carry out the pre-the same time carry out the pre-operative examination.operative examination.

1. Infections1. Infections are treated with antibiotics and antiviral agents. are treated with antibiotics and antiviral agents. 2.2. Dexamethasone Dexamethasone  (10 mg / intravenously, then (10 mg / intravenously, then

4 mg /intravenously every 6 h) is often prescribed for spinal 4 mg /intravenously every 6 h) is often prescribed for spinal cord compression, and sometimes with transverse cord compression, and sometimes with transverse myelitis and spinal cordinfarction, although the benefit of it is myelitis and spinal cordinfarction, although the benefit of it is not proven.not proven.

3. Consultation of a neurosurgeon3. Consultation of a neurosurgeon should be held as soon as  should be held as soon as possible.possible.

4. Emergency radiation therapy4. Emergency radiation therapy in combination with  in combination with corticosteroids is indicated for compression of the spinal corticosteroids is indicated for compression of the spinal cord malignancy. The diagnosis of the tumor must be cord malignancy. The diagnosis of the tumor must be confirmed morphologically.confirmed morphologically.

5. Care5. Care plays a pivotal role in the acute phase and in the  plays a pivotal role in the acute phase and in the future. Monitor airway, identify pulmonary and future. Monitor airway, identify pulmonary and urinary infections, pressure ulcers on HIV prevention and urinary infections, pressure ulcers on HIV prevention and contractures. Need regular emptying of the bladder and contractures. Need regular emptying of the bladder and intestines. Retention of urine may be accompanied intestines. Retention of urine may be accompanied by autonomic disturbances - headache, tachycardia, by autonomic disturbances - headache, tachycardia, sweating and hypertension. In such cases, shows sweating and hypertension. In such cases, shows the immediate bladder catheterization.the immediate bladder catheterization.

XIV. Spinal cord injuryXIV. Spinal cord injury is usually easily  is usually easily diagnosed according to the examination and medical diagnosed according to the examination and medical history, but you can omit if patient is unconscious history, but you can omit if patient is unconscious or drunk. Surgical treatment is indicated in or drunk. Surgical treatment is indicated in penetrating wounds, foreign bodies, fractures, penetrating wounds, foreign bodies, fractures, comminuted, displaced vertebrae and bruises. Spinal comminuted, displaced vertebrae and bruises. Spinal cord concussion usually resolves in a few hours or days.cord concussion usually resolves in a few hours or days.

A. Immediate actionA. Immediate action. Prior to X-ray studies provide a . Prior to X-ray studies provide a complete immobilization of the spine, especially the complete immobilization of the spine, especially the cervical spine. Consult a neurosurgeon. Monitor heart cervical spine. Consult a neurosurgeon. Monitor heart rate, blood pressure, identify signs of hypoxia. Because rate, blood pressure, identify signs of hypoxia. Because of autonomic instability in heart rate and blood of autonomic instability in heart rate and blood pressure can change rapidly. In severe hypotension pressure can change rapidly. In severe hypotension administered administered dopaminedopamine (5-15 mcg / kg /  (5-15 mcg / kg / min) or min) or dobutaminedobutamine (3-20 mcg / kg /  (3-20 mcg / kg / min).Alfa adrenostimulyatory better not to use, because min).Alfa adrenostimulyatory better not to use, because they cause vasoconstriction, which is fraught with spinal they cause vasoconstriction, which is fraught with spinal cord ischemia. Infusion therapy may be complicated by cord ischemia. Infusion therapy may be complicated by pulmonary edema. Mechanical ventilation is necessary in pulmonary edema. Mechanical ventilation is necessary in trauma of the cervical spine, to shift in trauma of the cervical spine, to shift in this neck impossible. Spend mask ventilation, intubation this neck impossible. Spend mask ventilation, intubation naso tracheal blind or tracheostomy.naso tracheal blind or tracheostomy.

B. Examination B. Examination reveals local tenderness, radicular reveals local tenderness, radicular pain, paresis, sensory disturbances, decreased muscle pain, paresis, sensory disturbances, decreased muscle tone, reflexes, absence, urine, and injuries of other tone, reflexes, absence, urine, and injuries of other organs. To clarify the nature and extent organs. To clarify the nature and extent of lesions underwent CT or MRT.of lesions underwent CT or MRT.

C. Introduction of C. Introduction of methylprednisolonemethylprednisolone  in the first in the first 8 hours after injury (30 mg / 8 hours after injury (30 mg / kg /bolus, then infusion at 5.4 mg / kg / h for kg /bolus, then infusion at 5.4 mg / kg / h for 23 h) enhances the rehabilitation (N Engl J Med 23 h) enhances the rehabilitation (N Engl J Med 322:1405, 1990).322:1405, 1990).

Cerebrovascular accidentCerebrovascular accidentXV. Ischemic stroke XV. Ischemic stroke is characterized is characterized

by acute development of focal neurological by acute development of focal neurological symptoms corresponding to the pool one way or symptoms corresponding to the pool one way or

another artery. The localization of another artery. The localization of stroke set by neurological examination, CT stroke set by neurological examination, CT

and MRT. Brain damage in stroke is and MRT. Brain damage in stroke is irreversible, but can recover lost functions. In irreversible, but can recover lost functions. In

the transient cerebral ischemia(transient the transient cerebral ischemia(transient ischemic attack), it occurs within 24 hours, with a ischemic attack), it occurs within 24 hours, with a

small stroke - within 1 week. The encouraging results of small stroke - within 1 week. The encouraging results of the application of recombinant the application of recombinant alteplazaalteplaza - drug that  - drug that can improve the outcome of ischemic stroke - have can improve the outcome of ischemic stroke - have changed the traditional approach to diagnosis and changed the traditional approach to diagnosis and treatment of stroke. To the fore now come fast and treatment of stroke. To the fore now come fast and

accurate diagnostic tools to help apply accurate diagnostic tools to help apply the medication with the greatest success. the medication with the greatest success.

AlteplazaAlteplaza  not safe, it is used only in strict accordance not safe, it is used only in strict accordance with the instructions of the American Academy of with the instructions of the American Academy of

Neurology and the American Heart Neurology and the American Heart Association (Neurology 47:835, 1996).Association (Neurology 47:835, 1996).

A. Case historyA. Case history. Specify the time of onset of . Specify the time of onset of symptoms, identify triggers (head symptoms, identify triggers (head trauma, seizures). Transient cerebral trauma, seizures). Transient cerebral ischemia (transient aphasia, dysarthria, blurred ischemia (transient aphasia, dysarthria, blurred vision in one eye, paresis or disorders of sensation) - a vision in one eye, paresis or disorders of sensation) - a sign of atherosclerosis, the most common cause sign of atherosclerosis, the most common cause of ischemic stroke. Trauma, even minor, can lead to of ischemic stroke. Trauma, even minor, can lead to separation of carotid and vertebral arteries. Other separation of carotid and vertebral arteries. Other causes of stroke -atrial fibrillation, heart causes of stroke -atrial fibrillation, heart disease, collagen disease, sickle cell anemia. By a disease, collagen disease, sickle cell anemia. By a stroke predisposes hypertension, diabetes, smoking, stroke predisposes hypertension, diabetes, smoking, recent childbirth, drug addiction and a number of recent childbirth, drug addiction and a number of drugs such as oral contraceptives. Classic migraine - a drugs such as oral contraceptives. Classic migraine - a risk factor for ischemic stroke and at the same risk factor for ischemic stroke and at the same time the disease with which it is sometimes time the disease with which it is sometimes confused. Transient paralysis of the case confused. Transient paralysis of the case after partial seizures (Todd's postikal paralys).after partial seizures (Todd's postikal paralys).

B. Physical examinationB. Physical examination often reveals the cause  often reveals the cause of stroke. Approximately 20% of this cardiac embolism. Look of stroke. Approximately 20% of this cardiac embolism. Look for signs of aortic or mitral stenosis, arterial for signs of aortic or mitral stenosis, arterial embolism, fundus, the conjunctiva, embolism, fundus, the conjunctiva, nail boxes, leather palms and fingers, and kidneys. Fever may nail boxes, leather palms and fingers, and kidneys. Fever may indicate infective endocarditis, in which case the stroke is indicate infective endocarditis, in which case the stroke is caused by septic emboli. On examination, it is easy caused by septic emboli. On examination, it is easy to detect diseases such asneurofibromatosis and tuberous to detect diseases such asneurofibromatosis and tuberous sclerosis, which also may be complicated by stroke. Other sclerosis, which also may be complicated by stroke. Other causes of stroke, revealed during the inspection - vasculitis causes of stroke, revealed during the inspection - vasculitis and SLE.and SLE.

C. Neurological examinationC. Neurological examination allows us to establish the  allows us to establish the localization of stroke. For stroke in the basin of the internal localization of stroke. For stroke in the basin of the internal carotid artery and its branches is characterized carotid artery and its branches is characterized byaphasia, contralateral hemiparesis and unilateral byaphasia, contralateral hemiparesis and unilateral anesthesia. Stroke in the pool basilar and vertebral anesthesia. Stroke in the pool basilar and vertebral arteries causes a one-or two-sided motor and sensory arteries causes a one-or two-sided motor and sensory disorders, often in combination with symptomatic lesions of the disorders, often in combination with symptomatic lesions of the brain stem and cranial nerve palsy. Horner's syndrome (ptosis, brain stem and cranial nerve palsy. Horner's syndrome (ptosis, miosis, anhidrosis on the face) with hemiparesis on the miosis, anhidrosis on the face) with hemiparesis on the opposite side - a sign of carotid artery dissection.opposite side - a sign of carotid artery dissection.

D. Principles of diagnosis and treatmentD. Principles of diagnosis and treatment 1. 1. Supporting theraphy. Supporting theraphy. Adjust permanent puls-oximetria, Adjust permanent puls-oximetria,

monitoring FHSh, arterial pressure and ECGmonitoring FHSh, arterial pressure and ECGНН ( pay to ( pay to attention, is there flinkle aritmia). Give O2, set vein cateter, attention, is there flinkle aritmia). Give O2, set vein cateter, determine the degree of glucose in blood. Other labour determine the degree of glucose in blood. Other labour researches: general analyses of blood including formula of researches: general analyses of blood including formula of leicotcit and account of trombocits electrolits and createen. leicotcit and account of trombocits electrolits and createen. Lead X-ray of chest cell. Lead X-ray of chest cell.

2.2. CT will adjust, depending on the condition or decease of CT will adjust, depending on the condition or decease of sick, after the examination at receiving department at once if it sick, after the examination at receiving department at once if it possible. The investigation reveal all hemorragic insults and possible. The investigation reveal all hemorragic insults and majority ishemic insults, except those which are in initial stage majority ishemic insults, except those which are in initial stage and small, especially which are set in barrel of brain ( they are and small, especially which are set in barrel of brain ( they are visible by MRT). Also, CT help to reveal vast education about visible by MRT). Also, CT help to reveal vast education about head brain and also estimate antitestimony to lumbal punction. head brain and also estimate antitestimony to lumbal punction.

3. 3. Alteplaza.Alteplaza. If we exclude hemorrhagic  If we exclude hemorrhagic stroke, meningitis and encephalitis, stroke, meningitis and encephalitis, injected recombinant injected recombinant alteplazaalteplaza. Treatment may be . Treatment may be complicated by the extremely complicated by the extremely dangerous bleeding in ischemic focus, so you need dangerous bleeding in ischemic focus, so you need to adhere strictly to theto adhere strictly to the instructions on the drug.instructions on the drug. Among the numerous contraindications Among the numerous contraindications to to alteplaza alteplaza - stroke prescription more than - stroke prescription more than 3 hours, recent surgery, head trauma, 3 hours, recent surgery, head trauma, gastrointestinal bleeding, hematuria, muscle gastrointestinal bleeding, hematuria, muscle cramps at the beginning of a stroke, blood clotting, cramps at the beginning of a stroke, blood clotting, severe hypertension (systolic BP> 185 mm Hg., severe hypertension (systolic BP> 185 mm Hg., diastolic blood pressure> 120 mm Hg.) Dose of 0.9 mg diastolic blood pressure> 120 mm Hg.) Dose of 0.9 mg / kg (maximum 90 mg), 10% of the dose (no more / kg (maximum 90 mg), 10% of the dose (no more than 9 mg) injected intravenously  for 1 min, and the than 9 mg) injected intravenously  for 1 min, and the rest - for one hourrest - for one hour infusion pump. infusion pump. AspirinAspirin, , heparinheparin and  and warfarinwarfarin in the first day of stroke onset is not  in the first day of stroke onset is not appointed. Arterial hypertension after appointed. Arterial hypertension after administration administration alteplaza alteplaza can lead to hemorrhage in can lead to hemorrhage in the ischemic focus.the ischemic focus.

E. Additional studiesE. Additional studies 1. MRI1. MRI allows more accurate than CT scan to establish  allows more accurate than CT scan to establish

the nature of brain damage. It can be used for the the nature of brain damage. It can be used for the study of major cerebral vessels.study of major cerebral vessels.

2. Doppler study2. Doppler study - non-invasive diagnostic carotid  - non-invasive diagnostic carotid artery stenosis. Cerebral artery stenosis. Cerebral angiography demonstrated to detect aneurysms of angiography demonstrated to detect aneurysms of cerebral vessels, vasculitis, and before CEA.cerebral vessels, vasculitis, and before CEA.

3.3.  Echocardiography Echocardiography can can detect intracardiac thrombi detect intracardiac thrombi and valve changes(vegetation, and valve changes(vegetation, stenosis or insufficiency), blood clots in the left stenosis or insufficiency), blood clots in the left atrial transesophageal atrial transesophageal echocardiography reveals better. Atrial septal echocardiography reveals better. Atrial septal defect and patent foramen ovale (paradoxical defect and patent foramen ovale (paradoxical embolism causes) reveal at echocardiography with embolism causes) reveal at echocardiography with contrast of the right heart.contrast of the right heart.

4. Lumbar puncture4. Lumbar puncture allows a cytological,  allows a cytological, microbiological and serological test and microbiological and serological test and diagnose malignancy and infection.diagnose malignancy and infection.

5. Laboratory studies. 5. Laboratory studies. Depending on Depending on the presumptive diagnosis determine the the presumptive diagnosis determine the sedimentation rate, anticardiolipin antibodies, sedimentation rate, anticardiolipin antibodies, antinuclear antibodies, lipid profile, antinuclear antibodies, lipid profile, hemoglobin electrophoresis is carried out by other hemoglobin electrophoresis is carried out by other studies.studies.

F. F. Treatment of ischemic stroke, atherosclerosisTreatment of ischemic stroke, atherosclerosis 1. 1. Aspirin Aspirin (1300 mg / day), according to the controlled (1300 mg / day), according to the controlled

trials, reduces the likelihood of ischemic stroke, also trials, reduces the likelihood of ischemic stroke, also including repeating. When failure or intolerance toincluding repeating. When failure or intolerance to aspirin aspirin, it , it can be replacedcan be replaced ticlopidine ticlopidine, 250 mg 2 times a day (N Engl J , 250 mg 2 times a day (N Engl J Med 321:501, 1989).Med 321:501, 1989).

2. Carotid endarterectomy.2. Carotid endarterectomy. Controlled trials have  Controlled trials have shown that patients with severe(70-99%) stenosis of shown that patients with severe(70-99%) stenosis of the carotid artery, recently had a stroke and lightweight, the carotid artery, recently had a stroke and lightweight, endarterectomy reduces the risk of recurrent stroke (N Engl endarterectomy reduces the risk of recurrent stroke (N Engl J Med 325:445, 1991).We also show that the therapy with J Med 325:445, 1991).We also show that the therapy with aspirinaspirin in patients with severe (>  in patients with severe (> 60%)asymptomatic carotid 60%)asymptomatic carotid artery stenosis endarterectomy reduces stroke risk by half artery stenosis endarterectomy reduces stroke risk by half the price of a relatively small number of perioperative the price of a relatively small number of perioperative complications (JAMA 273:1421, 1995).complications (JAMA 273:1421, 1995).

3. Anticoagulants3. Anticoagulants can  can prevent stroke, including repeated, but at the same time prevent stroke, including repeated, but at the same time increase the risk of bleeding complications. That outweighs increase the risk of bleeding complications. That outweighs the - benefit or harm is not yet clear. The appointment of the - benefit or harm is not yet clear. The appointment of anticoagulants decide based on the characteristics of each anticoagulants decide based on the characteristics of each case.case.

G. Prevention G. Prevention of cardiogenic embolismof cardiogenic embolism. Showing anticoagula. Showing anticoagulants,  nts,  heparinheparin begin with, then move on  begin with, then move on warfarinwarfarin, , maintaining an maintaining an МНО МНО  in the range 2-3 (with  in the range 2-3 (with mechanical prostheses - about mechanical prostheses - about 3.5). Hypertension - a relative contraindication to 3.5). Hypertension - a relative contraindication to anticoagulants (possible hemorrhagic stroke).anticoagulants (possible hemorrhagic stroke).

3. Elimination of risk factors.3. Elimination of risk factors. Normalization of  Normalization of blood pressure, diabetes compensation, blood pressure, diabetes compensation, smoking and drug use, losing weight reduces smoking and drug use, losing weight reduces the risk of stroke. For women may be useful the risk of stroke. For women may be useful to stop taking oral contraceptives.to stop taking oral contraceptives.

XVI. Hemorrhagic strokeXVI. Hemorrhagic stroke A. Intracerebral hemorrhage.A. Intracerebral hemorrhage. The acute development  The acute development

of focal neurological symptoms, which depends on the of focal neurological symptoms, which depends on the size and location of the fire. With extensive size and location of the fire. With extensive haemorrhage there are signs of increasing intracranial haemorrhage there are signs of increasing intracranial pressure - headache, vomiting and impaired pressure - headache, vomiting and impaired consciousness. Possible break-and death. For the consciousness. Possible break-and death. For the differential diagnosis of ischemic stroke underwent CT.differential diagnosis of ischemic stroke underwent CT.

1. Etiology. 1. Etiology. The most common cause - The most common cause - arterial hypertension, with bleeding most often arterial hypertension, with bleeding most often occurs in the shell, and thalamus (70%), at least - in occurs in the shell, and thalamus (70%), at least - in the bridge (10%), cerebellum (10%), hemispheric white the bridge (10%), cerebellum (10%), hemispheric white matter (10%). Other causes - head trauma, matter (10%). Other causes - head trauma, anticoagulants, saccular aneurysm, anticoagulants, saccular aneurysm, arteriovenous malformation, tumor, coagulation arteriovenous malformation, tumor, coagulation disorders, amyloid angiopathy, and vasculitis.disorders, amyloid angiopathy, and vasculitis.

2. Treatment. 2. Treatment. Plays a fundamental role to Plays a fundamental role to maintain vital functions.maintain vital functions.

a.a.  Blood pressure reduction  Blood pressure reduction is carried  is carried out slowly and carefully. In patients with out slowly and carefully. In patients with hypertension impaired regulation of vascular hypertension impaired regulation of vascular tone, and a sharp decline in blood pressure can lead tone, and a sharp decline in blood pressure can lead to brain ischemia. BP reduced within a few days, to brain ischemia. BP reduced within a few days, watching the neurological symptoms: its growth may watching the neurological symptoms: its growth may be indicative of ischemia.be indicative of ischemia.

b. Consultation of a b. Consultation of a neurosurgeon.neurosurgeon. Emergency surgery is  Emergency surgery is indicated for hemorrhagein the cerebellum: indicated for hemorrhagein the cerebellum: it threatens to brain stem compression and it threatens to brain stem compression and death. At other sites of hemorrhage surgery is death. At other sites of hemorrhage surgery is indicated in case of herniation.indicated in case of herniation.

B. Subarachnoid hemorrhageB. Subarachnoid hemorrhage begins with  begins with a sudden severe headache, can join impaired a sudden severe headache, can join impaired consciousness, fever and back pain. On consciousness, fever and back pain. On examination reveals focal neurological symptoms, stiff examination reveals focal neurological symptoms, stiff neck and bleeding in the retina. There may be neck and bleeding in the retina. There may be relapses and complications - an ischemic stroke, relapses and complications - an ischemic stroke, hydrocephalus, seizures, hyponatremia.hydrocephalus, seizures, hyponatremia.

1. Etiology. 1. Etiology. The most common cause - rupture The most common cause - rupture of saccular aneurysms, formed by of saccular aneurysms, formed by the medial defect and the internal elastic the medial defect and the internal elastic membrane walls of large arteries. Can rupture and membrane walls of large arteries. Can rupture and other aneurysms - spindle (presumably the origin other aneurysms - spindle (presumably the origin of atherosclerosis)and septic (in infective of atherosclerosis)and septic (in infective endocarditis). Other endocarditis). Other causes: hypertension, arteriovenous malformations, causes: hypertension, arteriovenous malformations, blood disorders, head trauma, blood disorders, head trauma, tumors, cocaine and amphetamines.tumors, cocaine and amphetamines.

2. Survey. 2. Survey. CT detects blood in the subarachnoid CT detects blood in the subarachnoid space in 90% of cases. If the CT scan did not confirm space in 90% of cases. If the CT scan did not confirm the diagnosis, carry out a lumbar the diagnosis, carry out a lumbar puncture. If detected in the SBL of blood, it is puncture. If detected in the SBL of blood, it is important to make sure that she did not get there with important to make sure that she did not get there with the most puncture. SBL is collected in a number the most puncture. SBL is collected in a number of tubes in small quantities, if blood from test tubes to of tubes in small quantities, if blood from test tubes to the tube becomes smaller, the source of bleeding - the the tube becomes smaller, the source of bleeding - the puncture site. The collected SBL was centrifuged: puncture site. The collected SBL was centrifuged: the supernatant subarachnoid hemorrhage will the supernatant subarachnoid hemorrhage will be yellow, while bleeding from the puncture be yellow, while bleeding from the puncture site - bright. Aneurysms and other site - bright. Aneurysms and other vascular anomalies can be detected by vascular anomalies can be detected by CT and MRT with contrast, but the CT and MRT with contrast, but the diagnosis requires angiography - especially if you diagnosis requires angiography - especially if you plan an operation.plan an operation.

3. Treatment.3. Treatment. In the saccular aneurysm surgery is  In the saccular aneurysm surgery is shown. If the operation is not shown. If the operation is not possible or delayed, appoint bed rest, sedatives, possible or delayed, appoint bed rest, sedatives, analgesics, and laxatives - these measures are analgesics, and laxatives - these measures are necessary to prevent the increase in necessary to prevent the increase in ICP. Hypotension is ICP. Hypotension is alsounacceptable. Antihypertensives may be alsounacceptable. Antihypertensives may be used only at very high arterial hypertension (diastolic used only at very high arterial hypertension (diastolic blood pressure> 130 mm Hg. Art.) Blood blood pressure> 130 mm Hg. Art.) Blood pressure in these cases, lower slowly and pressure in these cases, lower slowly and carefully, always taking care of carefully, always taking care of neurological symptoms. Calcium neurological symptoms. Calcium antagonist nimodipine (60 mg orally every 4 hours for antagonist nimodipine (60 mg orally every 4 hours for 3 weeks) improves the outcome of 3 weeks) improves the outcome of subarachnoid hemorrhage, and reduces the risk subarachnoid hemorrhage, and reduces the risk of ischemic stroke side effect is negligible. In of ischemic stroke side effect is negligible. In the spasm of cerebral vessels used infusion therapy, the spasm of cerebral vessels used infusion therapy, means that increase blood pressure, and balloon means that increase blood pressure, and balloon angioplasty.angioplasty.

Convulsive status epilepticusConvulsive status epilepticus XVII. Determination of convulsive status XVII. Determination of convulsive status

epilepticus. epilepticus. Convulsive status epilepticusis characterized Convulsive status epilepticusis characterized by unconsciousness and convulsions (permanent or by unconsciousness and convulsions (permanent or short breaks)of more than 30 minutes. This condition short breaks)of more than 30 minutes. This condition is very dangerous, are treated without waiting is very dangerous, are treated without waiting for completion of the survey. In gathering medical for completion of the survey. In gathering medical history is necessary to pay attention to past illnesses, history is necessary to pay attention to past illnesses, intake of medicines and allergies.intake of medicines and allergies.

XVIII. XVIII. TreatmentTreatment. . A. Supporting measuresA. Supporting measures. Establish a . Establish a

permanent monitoring of vital signs, including pulse-permanent monitoring of vital signs, including pulse-oximetry and ECG. Enter the nasal or oral airway, oximetry and ECG. Enter the nasal or oral airway, give oxygen. If you need ventilation, it is better to give oxygen. If you need ventilation, it is better to start right away with bag and mask rather than trying to start right away with bag and mask rather than trying to intubate the trachea (in the background fits this would intubate the trachea (in the background fits this would not be without miorelaxation).Establish venous catheter of not be without miorelaxation).Establish venous catheter of large diameter, preferably two: one for glucose and one large diameter, preferably two: one for glucose and one for saline solution to enter for saline solution to enter phenytoinphenytoin. Enter. Enter thiamine thiamine, , 100 mg itravenously, then 50 ml50% glucose / 100 mg itravenously, then 50 ml50% glucose / intravenously. Sharp corners of bed tax with linen.intravenously. Sharp corners of bed tax with linen.

Take blood for general and biochemical analysis (determine Take blood for general and biochemical analysis (determine the levels of glucose, potassium, sodium, calcium, the levels of glucose, potassium, sodium, calcium, magnesium, BUN, creatinine, and if necessary -magnesium, BUN, creatinine, and if necessary -anticonvulsants), take a urine test. May be needed, in anticonvulsants), take a urine test. May be needed, in addition, the toxicological study of blood and urine.addition, the toxicological study of blood and urine.

B. TreatmentB. Treatment. Below is the regimen recommended by the . Below is the regimen recommended by the American working group on status epilepticus (JAMA American working group on status epilepticus (JAMA 270:854, 1993). When status epilepticus drugs areinjected 270:854, 1993). When status epilepticus drugs areinjected into the I / O, but as soon as the patient's condition, go to into the I / O, but as soon as the patient's condition, go to the reception inside, which is much less dangerous .the reception inside, which is much less dangerous .

1. Benzodiazepines1. Benzodiazepines can quickly arrest the seizures and  can quickly arrest the seizures and thus gain time for other procedures. Enterthus gain time for other procedures. Enter lorazepam  lorazepam (0.1 (0.1 mg / kg / intravenously at a rate of 2 mg / min, maximum mg / kg / intravenously at a rate of 2 mg / min, maximum dose - 4 mg) ordose - 4 mg) or diazepam  diazepam (0.2 mg / kg at 5 mg / min, (0.2 mg / kg at 5 mg / min, maximum dose - 10 mg). The effect of these drugs of short maximum dose - 10 mg). The effect of these drugs of short duration, thus simultaneously administeredduration, thus simultaneously administered phenytoinor phenytoinor oth other long-acting. Benzodiazepines depress respiration: may er long-acting. Benzodiazepines depress respiration: may require intubation and mechanical ventilation.require intubation and mechanical ventilation.

2. Phenytoin2. Phenytoin (20 mg / kg, if necessary - up to 30 mg /  (20 mg / kg, if necessary - up to 30 mg / kg) - the best way to relieve convulsive status kg) - the best way to relieve convulsive status epilepticus. The drug is administered through an epilepticus. The drug is administered through an  syringe with saline solution (with  syringe with saline solution (with glucose glucose phenytoinphenytoin precipitates) as close as  precipitates) as close as possible to the vein, the rate of introduction - no more possible to the vein, the rate of introduction - no more than 50 mg / min. The continuous registration of blood than 50 mg / min. The continuous registration of blood pressure and electrocardiogram: there may pressure and electrocardiogram: there may be hypotension and AB- block (with a decrease be hypotension and AB- block (with a decrease in infusion rate, they usually are). If you have an in infusion rate, they usually are). If you have an existing AB- block phenytoin contraindicated. Easier existing AB- block phenytoin contraindicated. Easier and safer to use and safer to use fosfenitoinfosfenitoin - a new  - a new drug recently approved by the FDA. In the body it is drug recently approved by the FDA. In the body it is converted to an equimolar amount of converted to an equimolar amount of phenytoinphenytoin and  and dosed indosed in fenitoinov’s fenitoinov’s units: 1  units: 1 fenitoinov’sfenitoinov’s unit unit corresponds 1 mg of corresponds 1 mg of phenytoinphenytoin (usual  (usual dose fdose fosfenitoinaosfenitoina - 20  - 20 fenitoinovyhfenitoinovyh units  units /kg). /kg). FosfenitoinFosfenitoin can be administered more  can be administered more quickly thanquickly than phenytoin phenytoin (up to 150 units of  (up to 150 units of fenitoin /fenitoin / min), it is less irritating to veins, in  min), it is less irritating to veins, in addition, it is suitable for the intramuscularly addition, it is suitable for the intramuscularly administration.administration.

3. 3. PPhenobarbitalhenobarbital is used in the insufficiency  is used in the insufficiency phenytoinphenytoin. The . The drug administered at 5 mg / kg with time to 50 mg / min every drug administered at 5 mg / kg with time to 50 mg / min every 20 min until the termination of seizures, usually it takes about 20 min until the termination of seizures, usually it takes about 1 hour, serum levels of the drug at the same time is about 20 mg / 1 hour, serum levels of the drug at the same time is about 20 mg / ml. ml. PhenobarbitalPhenobarbital further enhances the respiratory  further enhances the respiratory depression caused bybenzodiazepines, and in most depression caused bybenzodiazepines, and in most cases required intubation and mechanical ventilation. As cases required intubation and mechanical ventilation. As with with phenytoinphenytoin, requires continuous recording of blood pressure , requires continuous recording of blood pressure and ECG and ECG phenobarbitalphenobarbital causes arrhythmias and hypotension. causes arrhythmias and hypotension.

4. Long-term infusion4. Long-term infusion of benzodiazepines is sometimes  of benzodiazepines is sometimes used instead of used instead of phenytoinphenytoin and  and phenobarbitalphenobarbital..

5. Barbiturate coma or general 5. Barbiturate coma or general anesthesiaanesthesia with miorelaxation used in inefficient TI other  with miorelaxation used in inefficient TI other measures, doctors spend their intensive care unit.measures, doctors spend their intensive care unit.

B. Transfer to the reception of anticonvulsants in prep-B. Transfer to the reception of anticonvulsants in prep-inside.inside. After the convulsions stopped, and rose- After the convulsions stopped, and rose-c, consciousness, and before the patient can return to their c, consciousness, and before the patient can return to their usual anticonvulsant therapy, supportive therapy is carried usual anticonvulsant therapy, supportive therapy is carried out. Her scheme and lasting is determined out. Her scheme and lasting is determined individually, usually using phenytoin, 4-7 mg / kg / day, and individually, usually using phenytoin, 4-7 mg / kg / day, and phenobarbital, 1-5 mg / kg / day / in or inside. Benzodiazepines do phenobarbital, 1-5 mg / kg / day / in or inside. Benzodiazepines do not apply.not apply.

XIX. The survey XIX. The survey aims to establish the cause. If-tion had aims to establish the cause. If-tion had not previously suffered from epilepsy, performed a lumbar not previously suffered from epilepsy, performed a lumbar puncture, CT or MRI of the head. Applied to EEG diag-puncture, CT or MRI of the head. Applied to EEG diag-kyo and the selection of the treatment of epilepsy, status kyo and the selection of the treatment of epilepsy, status epilepticus in unconvulsive, however, with a epilepticus in unconvulsive, however, with a convulsive - not Spanish the upgrade. Common causes of convulsive - not Spanish the upgrade. Common causes of status epilepticus following:status epilepticus following:

A. Organic CNS: A. Organic CNS: tumors (primary and metastatic), tumors (primary and metastatic), infection (bacterial meningitis, herpes encephalitis), SLE, infection (bacterial meningitis, herpes encephalitis), SLE, ischemic stroke, hematoma, traumatic brain injury.ischemic stroke, hematoma, traumatic brain injury.

B. Metabolic disorders: B. Metabolic disorders: hypoglycemia, electrolyte hypoglycemia, electrolyte disturbances (hyponatremia, hypocalcemia), uremia, disturbances (hyponatremia, hypocalcemia), uremia, hypoxia, discontinuation of drugs hypoxia, discontinuation of drugs (benzodiazepines,barbiturates and (benzodiazepines,barbiturates and other anticonvulsant drugs), other anticonvulsant drugs), theophyllinetheophylline overdose, cocain overdose, cocaine.e.

C. Reducing the dose of anticonvulsantsC. Reducing the dose of anticonvulsants - a common  - a common cause epilept second status in patients cause epilept second status in patients with epilepsy. Reception Teacher-in may prevent acute with epilepsy. Reception Teacher-in may prevent acute infection-edisease, the absence of the drug at the infection-edisease, the absence of the drug at the pharmacy s, carelessness and forgetfulness. To reduce the pharmacy s, carelessness and forgetfulness. To reduce the actual dose leads and concomitant medications that actual dose leads and concomitant medications that the effect of  weaken effect of under convulsive means.the effect of  weaken effect of under convulsive means.

HeadacheHeadache Headache - one of the most Headache - one of the most

frequent complaints. If it is severe or is accompanied frequent complaints. If it is severe or is accompanied by neurological symptoms, you need an by neurological symptoms, you need an urgent examination.urgent examination.

XX. Etiology. XX. Etiology. Distinguish primary and Distinguish primary and secondary (symptomatic) headache. To include a secondary (symptomatic) headache. To include a primary headache, primary headache, psychogenic headache and hortonovskaya. psychogenic headache and hortonovskaya. Headache physical stress, Headache physical stress, posttraumatic, cough and cold headache - if not found posttraumatic, cough and cold headache - if not found the organic CNS - is also considered to the organic CNS - is also considered to be primary. Causes of primary headaches are be primary. Causes of primary headaches are unknown, the recent violations of the essential role of unknown, the recent violations of the essential role of serotonergic transmission withdrawn.serotonergic transmission withdrawn.

A. Primary headacheA. Primary headache 1. Migraine. Characterized by attacks 1. Migraine. Characterized by attacks

of unilateral throbbing headache, usually with nausea, of unilateral throbbing headache, usually with nausea, vomiting, dislike of bright lights and loud noises. The vomiting, dislike of bright lights and loud noises. The duration of an attack - from 4 to 72 h, longer bout of duration of an attack - from 4 to 72 h, longer bout of migraine called status. In classic migraine attack migraine called status. In classic migraine attack before or simultaneously with it there is an aura - a before or simultaneously with it there is an aura - a short-term visual, motor, sensory and mental short-term visual, motor, sensory and mental functions. Contribute to the emergence of an attack functions. Contribute to the emergence of an attack of mental and physical stress, hunger, fatigue, of mental and physical stress, hunger, fatigue, limitation or excess of sleep, bright lights, limitation or excess of sleep, bright lights, alcohol, menstruation, oral contraceptives, alcohol, menstruation, oral contraceptives, pregnancy, certain foods (cheese, chocolate) and food pregnancy, certain foods (cheese, chocolate) and food additives (monosodium glutamate, nitrites), additives (monosodium glutamate, nitrites), nitroglycerinnitroglycerin. Migraine affects 18% of women and 6% . Migraine affects 18% of women and 6% of men, the disease begins before 30 years.of men, the disease begins before 30 years.

2. Psychogenic headache 2. Psychogenic headache is usually a long, double-is usually a long, double-sided, compressed, not throbbing, is accompanied sided, compressed, not throbbing, is accompanied by tension in neck, usually occurs in the afternoon, by tension in neck, usually occurs in the afternoon, with heavy emotions and anxiety. The clinical with heavy emotions and anxiety. The clinical picture psychogenic headache may resemble a picture psychogenic headache may resemble a migraine, often these diseases combined.migraine, often these diseases combined.

3. Hortonovskaya headache3. Hortonovskaya headache - very strong,  - very strong, unilateral, localized in the orbital, periorbital, unilateral, localized in the orbital, periorbital, or temporal region, accompanied by autonomic or temporal region, accompanied by autonomic disturbances(lacrimation, ptosis, miosis, nasal disturbances(lacrimation, ptosis, miosis, nasal congestion, conjunctival injection) with the congestion, conjunctival injection) with the samehand, lasts from 30 minutes to 2 hours The samehand, lasts from 30 minutes to 2 hours The attack can be caused by alcohol and attack can be caused by alcohol and nitroglycerinnitroglycerin. During the attack the patient from . During the attack the patient from pain rushes through the room - in contrast to migraine pain rushes through the room - in contrast to migraine patients, which extinguishes the light and tries to patients, which extinguishes the light and tries to sleep. Men suffer from up to 6 times more often than sleep. Men suffer from up to 6 times more often than women. Very characteristic frequency of attacks - they women. Very characteristic frequency of attacks - they occur in the same hour for several days or weeks occur in the same hour for several days or weeks and then stopped for a few months or years.and then stopped for a few months or years.

B. Secondary headacheB. Secondary headache. The nature . The nature of secondary headache depends on the underlying of secondary headache depends on the underlying disease. So, for subarachnoid hemorrhage is disease. So, for subarachnoid hemorrhage is characterized by an instant arose a characterized by an instant arose a sharp headache, brain tumors are not sharp headache, brain tumors are not as intense pain, more or less constant, as intense pain, more or less constant, and gradually growing, sometimes associated with the and gradually growing, sometimes associated with the position of the body. In the diagnosis can help to age position of the body. In the diagnosis can help to age at onset of disease, such as giant cell arteritis usually at onset of disease, such as giant cell arteritis usually develops after 50, and migraine - up to 30 years. A develops after 50, and migraine - up to 30 years. A characteristic feature of secondary headache - characteristic feature of secondary headache - save focal neurological symptoms between save focal neurological symptoms between attacks (if it occurs before the attack and ends at the attacks (if it occurs before the attack and ends at the same time with him or earlier, is more likely a same time with him or earlier, is more likely a migraine). Headache may occur when the extra-migraine). Headache may occur when the extra-and intracranial lesions of the head, systemic and intracranial lesions of the head, systemic diseases and metabolic disorders, and depressiondiseases and metabolic disorders, and depression

1. Intracranial lesions:1. Intracranial lesions: hemorrhage  hemorrhage (intracerebral, subarachnoid, subdural), arteriovenous (intracerebral, subarachnoid, subdural), arteriovenous malformations, brain abscess, meningitis, malformations, brain abscess, meningitis, encephalitis, vasculitis, obstructive hydrocephalus, encephalitis, vasculitis, obstructive hydrocephalus, ischemic stroke. Headaches often occur after lumbar ischemic stroke. Headaches often occur after lumbar puncture.puncture.

2. Extracranial lesions of the 2. Extracranial lesions of the head: head: sinus syndrome, TMJ, giant cell arteritis, sinus syndrome, TMJ, giant cell arteritis, glaucoma, optic neuritis, caries lesions in the cervical glaucoma, optic neuritis, caries lesions in the cervical spine.spine.

3. Systemic diseases and metabolic disorders3. Systemic diseases and metabolic disorders, , such as fever, viral infection, hypoxia, hypercapnia, such as fever, viral infection, hypoxia, hypercapnia, hypertension, allergies, hypertension, allergies, anemia, caffeine withdrawal, nitrites, and carbon anemia, caffeine withdrawal, nitrites, and carbon monoxide.monoxide.

4. Depression 4. Depression - a common cause of long-term, non-- a common cause of long-term, non-treatment of headache. Keep in mind that in atypical treatment of headache. Keep in mind that in atypical depression to the forefront violations of the chair, depression to the forefront violations of the chair, sleep and appetite.sleep and appetite.

XXII.XXII. TreatmentTreatment A. Non-narcotic analgesicsA. Non-narcotic analgesics are used  are used

for migraine and psychogenic headache. Use for migraine and psychogenic headache. Use of of aspirinaspirin, , acetaminophenacetaminophen (combined  (combined with their good andwith their good and izometeptenom  izometeptenom butalbitalbutalbital),), ketorolac ketorolac (30-60 mg / l),  (30-60 mg / l), naproxennaproxen (550 mg 2-3 times a  (550 mg 2-3 times a day orally)and day orally)and flurbiprofenflurbiprofen (100 mg orally 2 times a  (100 mg orally 2 times a day) . When hortonov’s headache day) . When hortonov’s headache helpshelps indomethacin indomethacin (50 mg orally or rectally 2-3 times  (50 mg orally or rectally 2-3 times a day).a day).

B. B. Prochlorperazine Prochlorperazine (5-10 mg / in) used in migraine: it (5-10 mg / in) used in migraine: it reduces nausea and sometimes can cut short the reduces nausea and sometimes can cut short the attack. May cause acute dystonia and hypotension.attack. May cause acute dystonia and hypotension.

C. C. Ergotamine Ergotamine - vasoconstrictor drug used for migraine and in - vasoconstrictor drug used for migraine and in hortonovs’ . Ergotamine best help if it is taken immediately after hortonovs’ . Ergotamine best help if it is taken immediately after the attack at the high dose (but not enough to induce the attack at the high dose (but not enough to induce vomiting). Typically, the initial dose - 2-3 mg orally. If the vomiting). Typically, the initial dose - 2-3 mg orally. If the attack continues, repeat the reception (1-2 mg every attack continues, repeat the reception (1-2 mg every 30 min until a total dose of 8-10 mg), but at least it 30 min until a total dose of 8-10 mg), but at least it helps. If ingestion causes vomiting, you can try rectal helps. If ingestion causes vomiting, you can try rectal administration. At a dose of 16 mg / week increases the risk administration. At a dose of 16 mg / week increases the risk of side effects such as angina, intermittent claudication, and of side effects such as angina, intermittent claudication, and headache, can be addictive.headache, can be addictive.

D.D.  Dihydroergotamine Dihydroergotamine for action similar for action similar to to ergotamineergotamine, but introduced parenterally.Relative , but introduced parenterally.Relative contraindications - coronary artery disease and age over 60 contraindications - coronary artery disease and age over 60 years. If the attack has just begun, administered 1.2 mg under years. If the attack has just begun, administered 1.2 mg under skin or intramuscularly the midst of an attack is skin or intramuscularly the midst of an attack is administered 0.75 mg / intravenous, so as not to induce administered 0.75 mg / intravenous, so as not to induce vomiting, for 3 minutes before it is vomiting, for 3 minutes before it is administered administered prochlorperazineprochlorperazine, 5-10 mg / intravenous. After 30 , 5-10 mg / intravenous. After 30 minutes, you can still add 0.5 mg minutes, you can still add 0.5 mg of of dihydroergotaminedihydroergotamine. When migraine with . When migraine with 

dihydroergotamine dihydroergotamine status of status of prochlorperazineprochlorperazine administered every 8 hours. administered every 8 hours.

E.E. Sumatriptan  Sumatriptan for parenteral administration can for parenteral administration can cut even a migraine attack, which began several weeks cut even a migraine attack, which began several weeks ago. Initial dose - 6 mg under skin, in an hour, you can ago. Initial dose - 6 mg under skin, in an hour, you can repeat the introduction. During the day about a third of repeat the introduction. During the day about a third of patients resumed the attack. patients resumed the attack. SumatriptanSumatriptan into effect is  into effect is weaker and only at the beginning of the attack. Initial weaker and only at the beginning of the attack. Initial dose - 25-100 mg, if necessary, receive repeated dose - 25-100 mg, if necessary, receive repeated every 2 h up to a total dose of300 every 2 h up to a total dose of300 mg. mg. SumatriptanSumatriptan should not be used within 24 hours  should not be used within 24 hours after taking after taking ergotamine. ergotamine. In IDH (Ischemic disease of In IDH (Ischemic disease of heart) heart) sumatriptan sumatriptan relatively contraindicated.relatively contraindicated.

F.F.  Narcotic analgesicsNarcotic analgesics may have to appoint to  may have to appoint to the severe headache. Long-term use can not be due to the severe headache. Long-term use can not be due to the risk of dependency.the risk of dependency.

G. G. CaffeineCaffeine - an important adjunct for the treatment  - an important adjunct for the treatment of migraine, it is available in tablets of migraine, it is available in tablets (also good tea or coffee) and is part of the combined (also good tea or coffee) and is part of the combined drugs.drugs.

3. General measures.3. General measures. The patient must lie in a  The patient must lie in a quiet dark room. If we can get to quiet dark room. If we can get to sleep, migraine often goes away.sleep, migraine often goes away.

XXIII. PreventionXXIII. Prevention is carried out, if  is carried out, if seizures recur frequently, and nausea they can be seizures recur frequently, and nausea they can be difficult. When psychogenic headache used tricyclic difficult. When psychogenic headache used tricyclic antidepressants. Migraine using tricyclic antidepressants. Migraine using tricyclic antidepressants, beta-blockers, and at their neeff-STI -antidepressants, beta-blockers, and at their neeff-STI -methysergidemethysergide. This drug is known for his way-. This drug is known for his way-Tew cause retroperitoneal fibrosis, pleural and heart Tew cause retroperitoneal fibrosis, pleural and heart valve, but this complication is reversible and is rare (1 valve, but this complication is reversible and is rare (1 in 5000).When hortonov’s headaches use of beta-in 5000).When hortonov’s headaches use of beta-blockers,blockers, methysergide methysergide, but probably the best , but probably the best remedy in this case -remedy in this case - prednisone prednisone. With the in . With the in effectiveness of these tools are also effectiveness of these tools are also used: migraine - used: migraine - phenelzine phenelzine (MAO inhibitor),(MAO inhibitor), valproic  valproic acidacid, calcium antagonists, with hortonov’s headache , calcium antagonists, with hortonov’s headache -- indomethacin indomethacin, , verapamiverapamil and l and lithiumlithium..

Muscular weaknessMuscular weakness To muscle weakness cause muscle diseases, neuromuscular To muscle weakness cause muscle diseases, neuromuscular

synapses, peripheral nerves and central nervous synapses, peripheral nerves and central nervous system. Here we consider a disease that most system. Here we consider a disease that most oftenrequire emergency treatment.oftenrequire emergency treatment.

XXIV. Guillain-Barre syndromeXXIV. Guillain-Barre syndrome (acute inflammatory  (acute inflammatory demyelinating poliradikuloneyropatiya). The etiology is demyelinating poliradikuloneyropatiya). The etiology is unknown, and sometimes the disease is preceded unknown, and sometimes the disease is preceded by infection (cytomegalovirus, Epstein-Barr virus, by infection (cytomegalovirus, Epstein-Barr virus, Campylobacter jejuni),surgery and vaccinations.Campylobacter jejuni),surgery and vaccinations.

A. Clinical picture. A. Clinical picture. The main manifestations - rapidly The main manifestations - rapidly progressive symmetric ascending paralysis, progressive symmetric ascending paralysis, paresthesia and pain, loss of sensitivity is usually not. May paresthesia and pain, loss of sensitivity is usually not. May result in cranial nerves, especially facial. Reflexes are result in cranial nerves, especially facial. Reflexes are reduced. reduced.  СМЖ СМЖ protein level was increased, no pleocytosis, protein level was increased, no pleocytosis, the number of lymphocytes is typically less than 20 ml-1. The the number of lymphocytes is typically less than 20 ml-1. The differential diagnosis is carried out with arsenic poisoning, differential diagnosis is carried out with arsenic poisoning, acute porphyria, tick-borne encephalitis, botulism, acute porphyria, tick-borne encephalitis, botulism, and diphtheria polyneuropathy.and diphtheria polyneuropathy.

B. Treatment. B. Treatment. In severe cases, apply equally In severe cases, apply equally well to plasmapheresis and well to plasmapheresis and immunoglobulin / in the immunoglobulin / in the introductionintroduction, beginning as early as possible. Treatment of , beginning as early as possible. Treatment of mild to be developed. Effective Capacity-corticosteroids, mild to be developed. Effective Capacity-corticosteroids, immunosuppressants, and others in prospect is not immunosuppressants, and others in prospect is not proven. Existing role played a supportive therapy.proven. Existing role played a supportive therapy.

1. Respiratory function 1. Respiratory function requires close monitoring, requires close monitoring, preferably in the intensive care unit, so if preferably in the intensive care unit, so if necessary, immediately begin artificial ventilation.necessary, immediately begin artificial ventilation.

2. autonomic neuropathy2. autonomic neuropathy a. Fluctuations in blood pressurea. Fluctuations in blood pressure. In the short-x increase . In the short-x increase

blood pressureapprox-UT antihypertensives short blood pressureapprox-UT antihypertensives short action. Hypotension may develop due to the decrease in action. Hypotension may develop due to the decrease in venous return, which further venous return, which further enhances ventilation. Applied fluid therapy, enhances ventilation. Applied fluid therapy, and sometimes - vasoconstrictors.and sometimes - vasoconstrictors.

b. Disturbances of heart rhythmb. Disturbances of heart rhythm - one of the most  - one of the most common causes of death in Guillain-Barre common causes of death in Guillain-Barre syndrome. Continuous registration of ECG. There are as syndrome. Continuous registration of ECG. There are as bradyarrhythmias (sinus node stop, complete AV block) bradyarrhythmias (sinus node stop, complete AV block) and tachyarrhythmias. Heart and tachyarrhythmias. Heart rhythm disturbances contribute to hypoxia and electrolyte rhythm disturbances contribute to hypoxia and electrolyte disturbances.disturbances.

XXV. Myasthenia gravisXXV. Myasthenia gravis - an autoimmune disease  - an autoimmune disease that affects the cholinergic neuromuscular synapses, that affects the cholinergic neuromuscular synapses, often develops when tumors of the thymus. Get sick often develops when tumors of the thymus. Get sick more often women and men 20-30 years old 50-more often women and men 20-30 years old 50-70 years old. The main symptoms- muscle weakness, 70 years old. The main symptoms- muscle weakness, ptosis, dysarthria, dysphagia, respiratory ptosis, dysarthria, dysphagia, respiratory failure. Weakness, usually increases after failure. Weakness, usually increases after exercise, but may exercise, but may be permanent. Distinguish eye (light) and be permanent. Distinguish eye (light) and generalized forms, the latter may be accompanied by generalized forms, the latter may be accompanied by acute bulbar and respiratory disorders that acute bulbar and respiratory disorders that require emergency treatment. Variants of the require emergency treatment. Variants of the course varied. Typically, the disease progresses in the course varied. Typically, the disease progresses in the early years, then stabilize, but meets and fluctuating early years, then stabilize, but meets and fluctuating course with exacerbations and remissions. The course with exacerbations and remissions. The differential diagnosis is carried out with differential diagnosis is carried out with botulism and Eaton-Lambert syndrome.botulism and Eaton-Lambert syndrome.

A. DiagnosisA. Diagnosis 1. Test with 1. Test with edrofoniemedrofoniem. Introduction . Introduction edrofoniyaedrofoniya patients  patients

with myasthenia gravis causes a decrease in short-with myasthenia gravis causes a decrease in short-term weakness. The sample gives a lot of false positives.term weakness. The sample gives a lot of false positives.

2. Antibodies to choline receptor 2. Antibodies to choline receptor - the best way to - the best way to diagnose, both sensitive and specific.diagnose, both sensitive and specific.

3. Chest CT scan 3. Chest CT scan reveals timomu.reveals timomu. 4. EMG4. EMG with high frequency stimulation allows  with high frequency stimulation allows

a differential diagnosis with Eaton-a differential diagnosis with Eaton-Lambert syndrome and botulism. Eaton syndrome LambLambert syndrome and botulism. Eaton syndrome Lambert-amplitude response increases several times, ert-amplitude response increases several times, and after cessation of stimulation falls below the initial and after cessation of stimulation falls below the initial level. Myasthenia amplitude increases only by 30-level. Myasthenia amplitude increases only by 30-40% and may begin to decline against the background 40% and may begin to decline against the background of stimulation, but after cessation of of stimulation, but after cessation of stimulation increases again. For botulism is stimulation increases again. For botulism is characterized by preservation of high amplitude for characterized by preservation of high amplitude for several minutes after cessation of stimulation.several minutes after cessation of stimulation.

B. Treatment.B. Treatment. Single schema does not exist. The choice of  Single schema does not exist. The choice of method depends on the special-Taylor case. Rapid increase method depends on the special-Taylor case. Rapid increase in breathing and swallowing disorders requires emergency in breathing and swallowing disorders requires emergency treatment, especially maintenance (mechanical treatment, especially maintenance (mechanical ventilation),and eliminate provoke 's factors (infection, ventilation),and eliminate provoke 's factors (infection, thyroid disease).thyroid disease).

1. 1. AChEAChE inhibitors  inhibitors are used in all forms of myasthenia are used in all forms of myasthenia gravis. Usually prescribed gravis. Usually prescribed pyridostigminepyridostigmine, an initial dose , an initial dose of 30-60 mg orally 3-4 times a day, later changing it, of 30-60 mg orally 3-4 times a day, later changing it, focusing on the well-being. Sometimes, the drug must be focusing on the well-being. Sometimes, the drug must be taken every 2-3 hours. When unperturbed TI oral Spanish-taken every 2-3 hours. When unperturbed TI oral Spanish-UT continuous in / UT continuous in / neostigmineneostigmine infusion, the  infusion, the initial sutoch. dose is 1 / 45 of a daily dose initial sutoch. dose is 1 / 45 of a daily dose of of pyridostigmine.pyridostigmine.

2. Thymectomy2. Thymectomy in all forms  in all forms of myasthenia almost always leads to remission. The of myasthenia almost always leads to remission. The operation was carried out in generalized myasthenia operation was carried out in generalized myasthenia gravis and severe ocular myasthenia options, gravis and severe ocular myasthenia options, especially after failure of medical treatment, possibly in the especially after failure of medical treatment, possibly in the early stages of the disease. In milder cases early stages of the disease. In milder cases of ocular myasthenia gravis in people over 60 of ocular myasthenia gravis in people over 60 and children expediency operations is and children expediency operations is questionable. Thymoma - an absolute indication questionable. Thymoma - an absolute indication for thymectomy at any age.for thymectomy at any age.

3. Immunosuppressants.3. Immunosuppressants. With lack of  With lack of effectiveness of inhibitors ofeffectiveness of inhibitors of AChE  AChE to addto add prednisoneprednisone therapy. If you start with high doses (60- therapy. If you start with high doses (60-80 mg / day), improvement comes quickly, but at the 80 mg / day), improvement comes quickly, but at the beginning of the weakness of sharply increasing, so beginning of the weakness of sharply increasing, so the treatment is carried out in hospital. After 1-the treatment is carried out in hospital. After 1-2 weeks of moving to the alternating pattern and a 2 weeks of moving to the alternating pattern and a few months to a maintenance dose is reduced. If few months to a maintenance dose is reduced. If you start with low-dose of an alternating pattern, you start with low-dose of an alternating pattern, the deterioration in the beginning of reception does the deterioration in the beginning of reception does not occur, but the improvement not occur, but the improvement comes later. When failure or intolerance to comes later. When failure or intolerance to corticosteroids to change to corticosteroids to change to azathioprineazathioprine (1-2 mg /  (1-2 mg / kg / day orally). The effect is not earlier than 2 kg / day orally). The effect is not earlier than 2 months. Side effects - leukopenia, months. Side effects - leukopenia, pancytopenia, infectious pancytopenia, infectious complications, gastrointestinal disorders, liver complications, gastrointestinal disorders, liver damage. Recently, controlled trial ofdamage. Recently, controlled trial of cyclosporine cyclosporine has  has been shown to be effective (Ann NY Acad Sci been shown to be effective (Ann NY Acad Sci 681:539,1993). It was also reported on the successful 681:539,1993). It was also reported on the successful use of use of cyclophosphamidecyclophosphamide and and immuneimmune globulin for / globulin for / intravenous the introduction.intravenous the introduction.

4. Plasmapheresis 4. Plasmapheresis provides a temporary effect, it is provides a temporary effect, it is

mainly used in severe cases, the ineffectiveness mainly used in severe cases, the ineffectiveness

of medical treatment; accurate readings are not of medical treatment; accurate readings are not

installed.installed.

5. Aggravating factors5. Aggravating factors include infections,  include infections,

pregnancy, thyroid disease. Although pregnancy, thyroid disease. Although

many drugs increase weakness in many drugs increase weakness in

myasthenia absolutely contraindicated only muscle myasthenia absolutely contraindicated only muscle

relaxants.relaxants.

B. Myasthenic crisis B. Myasthenic crisis - a sharp increase in muscle - a sharp increase in muscle weakness, it can be triggered byinfections and weakness, it can be triggered byinfections and operations, including thymectomy. The greatest operations, including thymectomy. The greatest danger, especially in patients with bulbar impairment danger, especially in patients with bulbar impairment and weakness of respiratory muscles, is respiratory and weakness of respiratory muscles, is respiratory failure. There should be continuous monitoring failure. There should be continuous monitoring of respiratory function, with the first signs of respiratory function, with the first signs of deterioration begin to mechanical ventilation.of deterioration begin to mechanical ventilation.

Cholinergic crisis Cholinergic crisis - the result of an overdose - the result of an overdose of of AChEAChE inhibitors. Clinically, it can bedistinguished  inhibitors. Clinically, it can bedistinguished from myasthenic, so when you transfer the patient to from myasthenic, so when you transfer the patient to the ventilator the ventilator AChEAChE inhibitors abolish (in this case is  inhibitors abolish (in this case is eliminated and the stimulation of bronchial eliminated and the stimulation of bronchial secretions). Used as corticosteroids, secretions). Used as corticosteroids, immunoglobulins fimmunoglobulins for / in the introductionor / in the introduction and  and plasmapheresis. Thymectomy in plasmapheresis. Thymectomy in the myasthenic Stroke does not hold.the myasthenic Stroke does not hold.

XXVI. BotulismXXVI. Botulism poisoning develops  poisoning develops when exotoxin Clostridium botulinum, blocks when exotoxin Clostridium botulinum, blocks the release of acetylcholine from presynaptic the release of acetylcholine from presynaptic terminals. Symptoms appear 12-36hours after terminals. Symptoms appear 12-36hours after consuming contaminated products, characterized consuming contaminated products, characterized by autonomic disorders (dry mouth, blurred by autonomic disorders (dry mouth, blurred vision, constipation, urinary retention), lesions of vision, constipation, urinary retention), lesions of cranial nerves and muscular cranial nerves and muscular weakness. Apply serum weakness. Apply serum anti botulinum types A, B, E anti botulinum types A, B, E (after intracutaneous test administered 1 vial / (after intracutaneous test administered 1 vial / intravenous and 1 bottle / intramuscularly). To intravenous and 1 bottle / intramuscularly). To remove not grown deep exotoxin, give a remove not grown deep exotoxin, give a laxative. Plays an important role to maintain vital laxative. Plays an important role to maintain vital functions.functions.

XXVII. RhabdomyolysisXXVII. Rhabdomyolysis can cause serious physical  can cause serious physical activity, metabolic disorders activity, metabolic disorders and intoxications (eg alcohol). Characterized by rapid and intoxications (eg alcohol). Characterized by rapid development of muscle weakness and development of muscle weakness and myalgia. Rhabdomyolysis leading myalgia. Rhabdomyolysis leading to hyperkalemia, myoglobinuria and acute renal to hyperkalemia, myoglobinuria and acute renal failure.failure.

XXVIII. Toxic and metabolic myopathiesXXVIII. Toxic and metabolic myopathies occur  occur in intoxications and metabolic in intoxications and metabolic disorders, particularly with disorders, particularly with alcohol, corticosteroids, lipid-lowering drugs, alcohol, corticosteroids, lipid-lowering drugs, hypothyroidism. The main display - the hypothyroidism. The main display - the increasing weakness of the proximal increasing weakness of the proximal extremities. Can myalgia, in such cases differential extremities. Can myalgia, in such cases differential diagnosis with myositis and dermatomyositis.diagnosis with myositis and dermatomyositis.

Increased muscle toneIncreased muscle tone XXIX. Neuroleptic malignant syndrome XXIX. Neuroleptic malignant syndrome is caused is caused

by by haloperidolhaloperidol, phenothiazine , phenothiazine derivatives and rderivatives and reserpineeserpine. The main . The main manifestations - hyperthermia, impaired manifestations - hyperthermia, impaired consciousness, muscle rigidity, elevated consciousness, muscle rigidity, elevated  КФК КФК  and  and myoglobinuria. In severe cases develop cardiac myoglobinuria. In severe cases develop cardiac arrhythmias, shock, hyperkalemia, acidosis, and renal arrhythmias, shock, hyperkalemia, acidosis, and renal failure. Treatment consists in the abolition of all failure. Treatment consists in the abolition of all suspected drugs, cooling the body, maintaining the suspected drugs, cooling the body, maintaining the vital functions and control of the vital functions and control of the individual manifestations. In severe cases, individual manifestations. In severe cases, appoint appoint dantrolenedantrolene (2 mg / kg / intravenous, if  (2 mg / kg / intravenous, if necessary, repeated at intervals of 5 min, total dose necessary, repeated at intervals of 5 min, total dose should not exceed 10 mg / kg) in the lungs should not exceed 10 mg / kg) in the lungs -- bromocriptine bromocriptine inside. inside.

XXX. Malignant hyperthermia XXX. Malignant hyperthermia is caused by is caused by the inhaled anesthetics in humans with a the inhaled anesthetics in humans with a genetic defect in calcium channels sarcoplasmic genetic defect in calcium channels sarcoplasmic reticulum. It often occurs when the disease of the reticulum. It often occurs when the disease of the central core myopathy and Duchenne. The classic central core myopathy and Duchenne. The classic triad of symptoms - hyperthermia, triad of symptoms - hyperthermia, stupor and muscular rigidity. CK activity increased. stupor and muscular rigidity. CK activity increased. Possible kidney failure due Possible kidney failure due to myoglobinuria, and arrhythmia due to electrolyte to myoglobinuria, and arrhythmia due to electrolyte imbalance. Decisive for the outcome is rapid imbalance. Decisive for the outcome is rapid diagnosis. Anesthesia is stopped, hold ventilation, diagnosis. Anesthesia is stopped, hold ventilation, eliminate acid-base and electrolyte eliminate acid-base and electrolyte disturbances, administered disturbances, administered dantrolenedantrolene (0,8-10 mg / kg  (0,8-10 mg / kg / intravenous)./ intravenous).

XXXI. Tetanus XXXI. Tetanus appears stiff and painful tonic appears stiff and painful tonic spasms. The causative agent (Clostridium tetani) can spasms. The causative agent (Clostridium tetani) can enter the body in wounds, burns and under skin injection enter the body in wounds, burns and under skin injection of drugs. The incubation period of 2-54 days, in most of drugs. The incubation period of 2-54 days, in most cases - 2 weeks. 50-60% fatality rate. Ill mostly not been cases - 2 weeks. 50-60% fatality rate. Ill mostly not been vaccinated against tetanus, and persons with vaccinated against tetanus, and persons with immunodeficiency. When injury is important as early as immunodeficiency. When injury is important as early as possible to enter the possible to enter the adsorbed tetanus adsorbed tetanus toxoidtoxoid. Treatment: debridement; . Treatment: debridement; antitetanus antitetanus iimmunoglobulinmmunoglobulin i / m in some places proximal to the i / m in some places proximal to the wound, wound, benzylpenicillinbenzylpenicillin, 2 million units w / every 6 hours , 2 million units w / every 6 hours for 10 days (if you are allergic to penicillin it is replaced for 10 days (if you are allergic to penicillin it is replaced with with tetracyclinetetracycline, 2 g / day orally, or , 2 g / day orally, or erythromycinerythromycin, 2 g / , 2 g / day orally). The patient was placed in a separate quiet day orally). The patient was placed in a separate quiet room. Provide a clear airway (tracheostomy performed at room. Provide a clear airway (tracheostomy performed at laryngospasm), struggling with seizures of laryngospasm), struggling with seizures of benzodiazepines, barbiturates, analgesics, muscle benzodiazepines, barbiturates, analgesics, muscle relaxants, and sometimes, the dose should be sufficient, relaxants, and sometimes, the dose should be sufficient, the patient was kept in a state of shallow sleep. After the patient was kept in a state of shallow sleep. After recovery, have been active immunization.recovery, have been active immunization.

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