Algorithm of cerebral edema
Edema and swelling of the brain in infections. Mechanisms of cerebral edema
One of the most common causes of emergencies for infectious diseases are disorders of central nervous functionsystem. Various forms of manifestations of these disorders are often combined with the clinical concept of "peyrotoxicosis," emphasizing the toxic-infectious origin of functional and organic changes in the central nervous system. Due to the emergence of neurotoxicosis, two main groups should be distinguished.
To the 1st group include neurotoxic phenomena,caused mainly by general metabolic disorders resulting from intoxication: the so-called hypertoxic forms of various infections and severe changes in the central nervous system associated with the adverse course of many infectious diseases occurring with shock, severe tissue hypoxia, renal or hepatic insufficiency.
2nd group includes a more limited range of infections,toxins or pathogens of which have a tropism to the central nervous system and thereby determine a specific clinical picture of the disease, the so-called neuroinfections. Despite the considerable conventionality of such a separation, it is dictated by the practice of different management of patients with neurotoxicosis.
Nonspecific, polyethological character changes in the central nervous system in the first group of neurotoxicosis is combined withfeatures of various diseases (influenza, dysentery, salmonellosis, typhoid fever, malaria, viral hepatitis, etc.) and is not an obligatory attribute of this infection, but rather an exception, a sign of atypical flow. In the second group, changes in the central nervous system are specific for this disease and determine its clinical picture (rabies, tick-borne encephalitis, meningococcal meningitis, botulism, tetanus, etc.).
NK Permyakov indicates that the acute swelling of the brain substance is often accompanied by convulsive contractions of skeletal muscles, especially the gastrocnemius muscles, and is accompanied by a sharp extension of the feet ("ballerina's foot").
It is appropriate to recall here words of N. N. Burdenko. "Whoever has the skill to prevent and treat cerebral edema, he owns the key to the life and death of the patient."
For hypertoxic neurotoxicosis characterized by rapid development, the overall picturesevere intoxication. Pathognomonic symptoms of infection can be slightly expressed, recede into the background or appear with delay. Typical sudden onset of the disease with an increase in temperature to 40 ° C and above, chills, tachycardia, shortness of breath, growing headache, agitation, hyperreflexia, sweating and hyperemia of the skin, vomiting, not associated with eating. The phenomena of hyperthermia, cortical and sympathicotonic stimulation are characteristic for the beginning edema-swelling of the brain. Arterial pressure is often increased to 18.7-21.3 / 12.0-14.7 kPa (140-160 / 90-110 mm Hg).
Sometimes already in the first hours disease signs of cerebral hypertension are revealed -rigidity of the occipital muscles, positive symptoms of Kernig - Brudzinsky, general hyperesthesia. In more severe cases, convulsions or hypertension of the muscles occur early, impairment of consciousness up to coma, psychomotor agitation, symptoms of diffuse or focal encephalitis. Some of the listed signs may fall out or be most pronounced. This pattern is often defined as a meningeal or meningoencephalitic syndrome, toxic meningoencephalitis, toxic encephalopathy. To determine the intoxication character of these changes, rapid development, absence of inflammatory changes in cerebrospinal fluid, diffuse character of encephalitic symptoms and their rapidly passing character with effective pathogenetic therapy are important.
Of great importance is revealing "Small" signs of the disease, indicatingthe possible etiology of the emergency condition (for example, mild abdominal pain and stool disruption in dysentery and salmonellosis, the presence of rash and muscle pains with hemorrhagic fevers and leptospirosis, characteristic changes in the pharynx of influenza and other respiratory viral infections, mild coughing and hard breathing in pneumonia, initial signs of erysipelas, etc.). It is necessary to take into account epidemiological information about influenza, malaria, leptospirosis, hemorrhagic fevers, intestinal infections in this area, as well as indications of head injury, alcohol abuse.
We repeatedly had to observe patients dysentery. predominantly young men with developmenthyperthermia, general intoxication and mild meningeal phenomena with an increase in cerebrospinal pressure with an unchanged composition of the cerebral fluid, and 8-20 hours and even on the 2nd day after the development of neurotoxicosis, they developed dysentery hemocolitic phenomena. Often the neurotoxic syndrome develops in the midst of the underlying disease (influenza, pneumonia, sepsis, typhus and typhoid fever, etc.).