Post-Coma | Fondazione Santa Lucia

Post-Coma

Characteristics and Causes

The coma is the loss of consciousness due to brain damage and is accompanied by a loss of vigilance and consciousness. Patients are unable to open their eyes, speak in an understandable way or answer or respond to any external stimulus. Among the most common causes that lead to coma are head trauma, ischemia, hemorrhage, cerebral hypoxia, infections of the central nervous system (meningitis and encephalitis). 70 percent of patients overcome the acute phase (neurosurgical intervention or reanimation). Upon the gradual recovery of consciousness opens up a range of post resuscitation intensive rehabilitation specialty therapies.

 

Vegetative and Minimally Conscious

After being treated in the acute phase in units of hospitals such as Intensive Care, Neurosurgery, Neurology, Stroke Unit and Cardiac Surgery, patients may be admitted to the Santa Lucia Foundation in vegetative or minimally conscious state. In the first case, patient has open eyes but no communication skills and relationship with those nearby. In a minimally conscious state, he shows moments of relationship with the environment (e.g. He turns his gaze to those who speak or perform in a manner not consistent some command). The transition from the vegetative to the minimally conscious state often has its first manifestations with their families rather than with health and medical professionals.

Multidisciplinary Treatment

The neurorehabilitation plan is multidisciplinary and utilizes internal and external collaborations to manage the complex treatment required by this type of patient. Resuscitation skills, internal medicine, cardiology, pulmonology, otolaryngology and phoniatrics, infectiology, neurosurgery, plastic surgery, thoracic surgery, digestive endoscopy, endocrinology, maxillofacial, as well as neurological and neuropsychological physiatrics, are crucial in the first stages of the rehabilitation process. In the initial phase, special attention is paid to the stabilization of the patient who is at risk of complications such as respiratory failure, cardiac problems, recurrent infections, septicemia, deep vein thrombosis, pulmonary embolism, autonomic crisis with significant changes in blood pressure and heart rate. Drug treatment and neuropsychological conditions of psychomotor agitation or absolute inertia are critical to the progress of the rehabilitation.

 

Nursing

Nursing staff play an important role, from the early stages of treatment, in hygienic care (with suitable baths), in the management of the tracheostomy tube and nutrition (with a dedicated dietetic service), in controlling the correct positioning of the patient in bed and in custom wheelchairs, in the prevention and treatment of bedsores or in the recovery of the sitting position, given the availability of suitable lifting equipment.

 

Breathing and Swallowing

In case of swallowing or compromised respiratory function, it is required to manage the tracheal canal and the naso-gastric tube or PEG (feeding tube for nutrition and hydration), with specific gradual decannulation protocols and swallowing training, for the recovery of eating and functional and verbal communication, wherever possible. Upon assessment, respiratory physiotherapy employs specialists and specific aids (insufflator or cough machine).

 

Passive Physiotherapy

Critical is the prompt approach of the physiotherapist to the patient, even when he is not able to respond to commands and perform voluntary movements. The patient is stimulated to improve responsiveness and is helped to recover muscle tone, compromised by a long period of immobility (passive rehabilitation, i.e. without the patient's ability to perform exercises on the advice of the physiotherapist), gradual static standing and robot assisted simulating walking (erect).

 

Activate Physiotherapy

The neuromotor rehabilitation then aims for active recovery of the movement in progressive stages, such as the active movement-assisted limbs and gradually standing and ambulatory training, even on the treadmill, with relief of body weight. Among rehabilitation techniques are used more traditional methods such as Bobath Kabat, cognitive therapy practice (Perfetti) and more innovative methods like Tecar therapy, Gait Trainer, biofeedback and hydrokinetic therapy.

 

Cognitive-Behavioral Rehabilitation

When the patient is not responsive or is not able to communicate even in gestures, evoking potentials and augmentative and alternative systems of communication are used. Evoking potentials are sensory stimuli combined with monitoring of brain activity, allowing to identify the areas of the brain that remain active, including those that manage sensory perception, such as hearing and sight. Even advanced neuroimaging techniques, such as functional magnetic resonance imaging, can provide useful information on remaining brain function. When the patient is responsive, interviews, direct observations, and standardized tests are utilized in order to create a neuropsychological evaluation that indicates any lack of concentration, memory, attention, language, reasoning, knowledge, behavior and space-time orientation of the patient. The goal is to improve cognitive skills and to recover compromised executive functions, such as the ability to plan praxis, relate to others and perform actions of daily life. This activity is supported by the Occupational Therapy Unit and can also involve the family of the patient.

 

Psychological Support Service

Psychological support is available for the family of the post-comatose inpatient with severe brain injury outcomes. This service is also assured to Santa Lucia Foundation patients and families admitted on day hospital basis. In fact, a severe brain injury represents a traumatic event not only for the patient, but also for those who live next to him. The Service provides family members (and caregivers) psychological support, theoretical knowledge and practical skills, which are useful to provide effective assistance to the patient. In this way, the caregiver is able to work in harmony with the objectives and practices foreseen by the protocols of rehabilitation, providing in turn to psychologists important relevant information about the patient's family, environment and the developments throughout the period of rehabilitation.

 

Patient Discharge

Once the patient's discharge from hospital ward is certain, the patient and family receive the support of Social Workers. The procedure involves the activation of the network of regional health facilities, which are required to ensure the availability of equipment and practical aids if they return home (CAD = Center for Home Care) or in receive additional treatment in Extensive Rehabilitation Centers or Health Care Residences (RSAs). Patient discharge at the end of highly specialized treatment creates a situation of new incentives to the patient, who must face the return to the rhythms, commitments and social relations of everyday life. Subsequent treatment in the day hospital or on an outpatient basis at the Foundation can ensure continuity to the rehabilitation project.