If the majority or all of the cerebrum functions fail, but the functions of the brainstem, diencephalon and spinal cord remain, this is referred to as a vegetative state or apallic syndrome (Persistent Vegetative State, PVS). The patient appears awake, although he is probably unconscious. A vegetative state is to be distinguished from the minimal state of consciousness (MCS) and locked-in syndrome, even if the transitions here are fluid.
What is a vegetative state?
A vegetative state or Appalian syndrome is defined by a holistic loss of consciousness and the ability to communicate. For definitions of feces, please visit lawfaqs.net.
There is also bowel and bladder incontinence. Sleeping and waking rhythms are disturbed, but the basic life functions such as circulation, breathing and digestion still work. The patients can also sleep and sometimes react to stimuli. To outsiders, those affected appear awake, but this impression is largely deceptive.
The pathways between the cerebrum and the brainstem are badly damaged. While the brainstem is still functioning, the cerebrum is clearly dysfunctional. Some patients eventually wake up, while others never regain a normal state of consciousness.
The vegetative state or the Appalian syndrome is therefore a complex and very serious clinical picture, which is treated in the intensive care unit of a hospital.
The vegetative state is always a consequence of very severe damage to the brain. The damage is often triggered by a craniocerebral trauma or a lack of oxygen caused by a circulatory arrest.
Other causes of these neurological diseases are stroke, meningitis and brain tumors. Neurodegenerative diseases, such as Parkinson’s syndrome, can also trigger apallic syndrome. There are also cases in which extreme prolonged hypoglycaemia can lead to a coma state.
Whatever the trigger, severe damage to the cerebrum occurs. Other important brain regions are often also permanently damaged, causing a vegetative state or apallic syndrome.
Symptoms, Ailments & Signs
The so-called vegetative state or apallic syndrome is characterized by an extensive standstill of the communication possibilities. When the diagnosis is made, the patient usually requires intensive care treatment. He has often survived an accident with severe brain injuries or has fallen into a vegetative state due to other circumstances. Initially he had to be artificially ventilated and fed intravenously.
Coma usually occurs suddenly. Only with certain neurodegenerative diseases can the symptoms gradually appear. A typical symptom is that the affected person appears awake. His eyes are open, but they look into emptiness. Apparently they are not aware of what is happening around them. Whether there is no perception at all is debatable. Caregivers often find that elevated blood pressure or other signals indicate a certain ability to react.
Other symptoms include aphasia, incontinence, spasticity, or involuntary movement patterns. Reflexes and breathing reflexes are typically preserved. In a later stage of the apallic syndrome, muscle shortening, muscle twitching, tachycardia, sweating or high blood pressure can occur.
These symptoms are interpreted as a sign of a vegetative nervous system that is no longer functioning normally. Only in a few cases do patients wake up again after years of a coma. In most cases, a decubitus develops as a result of lying down for a long time. Long-term ventilation can lead to pneumonia and death.
Diagnosis & History
The diagnosis of a vegetative state is clinical and usually lasts several weeks or months. Severe neurological defect syndromes must be uncovered. For this purpose, diagnostic equipment is used, which includes magnetic resonance imaging, the electroencephalogram and evoked potentials.
They are used in combination because none of these examination methods alone is suitable for a diagnosis. It must be differentiated from other clinical pictures such as locked-in syndrome and coma. If a vegetative state has been determined, the relatives must be prepared for a treatment success that is less than 50%. A better prognosis is given when the coma is just beginning, the patient is young and there is traumatic brain damage.
An improvement in the coma or the apallic syndrome is unlikely if, for example, the brainstem reflexes have been absent for more than 24 hours, there has been no pupil reaction for three days, or there is massive cerebral edema on the CT.
Patients who fall into a vegetative state suffer from both acute complications and late effects, which often only become noticeable after waking up. Typical problems include incontinence and being bedridden, usually with other consequences such as inflammation, sore spots and circulatory disorders. After waking up, the patient usually suffers from delirium, which can persist for several days to weeks.
If the coma lasts longer, permanent mental problems are also possible. A prolonged coma often has an impact on the patient’s psyche. Depressive moods, personality changes or severe dissociative disorders then occur.
Anxiety disorders can also occur as part of an apallic syndrome. An existing vegetative state leads to a decrease in brain activity over time and can be fatal as a result of the complications. An improvement in the coma becomes more and more unlikely as the disease progresses.
If the patient is given a nasogastric tube, there are possible risks of injuring the stomach, small intestine or esophagus. In some cases, the feeding tube is placed in the trachea instead of the esophagus, which can lead to serious injuries and infections. The drugs administered can in some cases cause unforeseen side effects.
When should you go to the doctor?
A doctor is needed as soon as the person concerned can no longer be contacted and there is therefore no possibility of communication with him or her. An ambulance must be alerted because intensive medical care is required. Until the doctor arrives, the telephone instructions of the emergency medical team must be followed. Otherwise, there is a risk of the person concerned dying suddenly. If the symptoms occur after an accident, a fall or a force, it is necessary to act as quickly as possible. In the case of a vegetative state, the person affected is naturally unable to undertake any activities to seek help. Therefore, persons present are requested to react immediately.
First aid measures must be applied to ensure the survival of the person concerned. Involuntary movements, irregularities in the heart rhythm, or twitching of various muscles on the affected person’s body indicate an existing disorder. A lack of breathing, a pale appearance and an empty look are also to be interpreted as warning signals from the organism. If, despite all efforts, the ability to react fails, if the body also does not react to the natural reflexes and if sudden changes occur within a few minutes, the emergency doctor is calledto call. In some cases, the development of health impairments can be observed gradually. Nevertheless, in the case of a vegetative state, the help of persons present is absolutely necessary.
Treatment & Therapy
The treatment of the apallic syndrome is based on the developmental phases of early neurological rehabilitation. Acute treatment is the focus of therapy. In this phase, an incision is usually made in the trachea and a feeding tube is inserted through the abdominal wall.
In most cases, a urine diversion is also placed through the abdominal wall. This secures vital functions and allows the patient to receive the best possible nursing care. Physiotherapists and speech therapists should already be used in this phase. After the acute treatment has been completed, the next phase follows. The therapy is extended by neuropsychological measures and ergotherapy.
Music therapy is also used for some patients. The aim of these treatment methods is to improve mental, motor and psychological functions. In this phase, which can last from a month to a year, the further course of the patient’s state of health is decided. If there is a noticeable improvement in mental and physical performance, further measures can be taken.
If the person concerned remains unconscious, the so-called “activating treatment care” is initiated. The therapy of a vegetative state or an apallic syndrome always takes place under medical supervision, as this is also required and verified by the insurance companies.
The vegetative state cannot be directly prevented. However, any severe damage to the head and brain should be avoided, as this could affect brain functions. If the vegetative state or the apallic syndrome is already present, the condition of the person affected can occasionally be improved a little through targeted therapy measures.
After a vegetative state, aftercare plays an extremely important role. Depending on the extent of their activity limitations, patients continue to require care even after they are discharged from the hospital. This also applies to regained independence. The rehabilitative aftercare takes place on an outpatient basis and extends over a longer period of time, the duration of which cannot always be determined.
Possible aftercare treatments include 24-hour care, out-of-hospital intensive care that includes ventilation, and a shared apartment that provides outpatient care. In mild cases, assisted living can also be provided. Some of those affected are even able to work in a special workshop for disabled people.
Other sufferers, on the other hand, need permanent care in a day care center, a practice for outpatient neurorehabilitation or in a coma house. Many patients can recover from apallic syndrome years later in their familiar surroundings. Consultations are possible through the care insurance companies.
They have the task of advising those affected individually on how to get care within their own homes. Special care support centers are also available in numerous regions. An important part of aftercare is early rehabilitation. It continues the acute treatment from the hospital and includes therapeutic care, physiotherapeutic measures, speech and swallowing therapy, occupational therapy and neuropsychological treatments. The aim is to improve the patient’s state of consciousness.
You can do that yourself
In the case of a vegetative state, the patient naturally cannot initiate any self-help measures. In this state of health, the sufferer appears to be awake. In fact, however, his state of consciousness is minimal or non-existent. In this situation, he is completely dependent on the support and help of the medical team providing care and his relatives.
Normally, the person concerned is in an inpatient stay. Here, the necessary care measures are carried out automatically by medical staff. The close cooperation of the relatives with the nurses or helpers of the treating ward is helpful and recommendable. It should be checked daily at regular intervals that the contact points of the patient’s body are not developing pressure points or wounds. Therefore, the victim’s body has to be repeatedly moved or repositioned. Continuous creaming of the contact points has also proven to be helpful. The area around the patient should be supplied with fresh air several times a day. The oxygen supply supports the organism in the healing process. At the same time, care must be taken to
Although there is insufficient statistical evidence to support this, patients consistently report afterwards that communication from family members to the patient has a positive impact on the recovery process.