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Could I have a statement, please? What do you like doing in your spare time? Could I take your name and number, please? Anche la presenza di una divergenza orizzontale o verticale dei bulbi è indizio di una lesione a carico del tronco encefalico, mentre il nistagmo o un movimento ondulatorio spontaneo di va e vieni dei due globi oculari sono indizio di uno stato di coma superficiale, talvolta presente anche in corso di stati di intossicazione acuta alcoolica. Le pupille fisse e dilatate che si hanno in seguito ad una diffusa anossia-ischemia, hanno una cattiva prognosi.
La postura del paziente con compromissione della coscienza è un altro indizio di patologia cerebrale emisferica o del tronco e va osservata attentamente e più spesso indotta dallo stimolo doloroso. Le posture in flessione implicano, in genere, una lesione più alta e, pertanto, una migliore prognosi rispetto a quelle in estensione.
Con la sofferenza della porzione inferiore del tronco encefalico, si arriva alla non responsività motoria associata a flaccidità. Il tal caso valutate la presenza del rigor nucalis piegando passivamente la testa con il mento spostato in direzione dello sterno. Con la rigidità nucale si potrà identificare quello che i neurologi chiamano segno di Brudzinski che consiste nella flessione delle ginocchia e delle anche per ridurre la tensione meningea indotta dalla flessione del collo.
Dopo aver effettuato la visita ed una corretta anamnesi siete in grado di valutare la gravità dello stato di coma ed ipotizzarne eventualmente le cause. Questi divengono particolarmente pressanti quando, come frequentemente accade, rimane coinvolto un bambino. Riteniamo pertanto utile esporre i principali criteri che possono orientare il Medico nella gestione di questi particolari pazienti. Esistono due possibili situazioni: a Crisi isolata in un paziente, che non ha sofferto di fenomeni analoghi.
La crisi isolata impone in ognuno di questi casi il ricovero a scopo diagnostico e terapeutico. In questo caso il ricovero non è in genere indispensabile, ma la decisione andrà soppesata in considerazione ad una serie di fattori. Se ricorre una di queste situazioni, è corretto ricoverare il paziente epilettico.
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Consigliamo tuttavia di decidere in relazione al contesto, dati il rischio di depressione respiratoria e la necessità di eseguire un monitoraggio delle funzioni vitali. La crisi di Grande Male è spesso seguita da ipotonia ed areflessia generalizzata, midriasi, rilasciamento sfinterico Attenzione: di fronte a questi pazienti non affrettatevi a fare diagnosi di decesso, vi potrebbero essere imbarazzanti resurrezioni. È disidratato?