Résumé
La prise en charge initiale du patient comateux a pour objectif d’assurer le maintien de ses fonctions vitales et de déterminer la cause du coma afin d’administrer, le cas échéant, tout traitement étiologique requis. Cette prise en charge est pluridisciplinaire et l’équipe soignante joue de manière précoce un rôle important dans la prévention et le traitement des complications consécutives au séjour en réanimation, qu’elles soient cutanées, ostéoarticulaires, musculaires, pulmonaires, thromboemboliques ou vasculaires. Ces complications liées au décubitus et à l’immobilisation surviennent rapidement chez les patients hospitalisés pour coma et nécessitent un programme de rééducation dès les premiers jours en réanimation. Une bonne connaissance par le kinésithérapeute des différentes étiologies des comas et de leur sémiologie propre est donc essentielle en phase aiguë, surtout en cas d’hypertension intracrânienne où l’éducation du personnel soignant quant au bon positionnement du patient est cruciale. Le kinésithérapeute doit donc, en plus de sa prise en charge habituelle, prendre en compte la spécificité de chaque patient comateux, être capable d’évaluer la profondeur de son coma et proposer différentes techniques pouvant contribuer à son éveil.
Abstract
Initial management of comatose patients aims at maintaining vital functions to assess the etiology of coma and administer any specific treatments if required. Management is multidisciplinary. Caregivers play an important role to prevent and treat intensive care unit (ICU)-acquired complications including skin, bone and joint, muscle, lung, thromboembolic and vascular complications. Prolonged immobilization-related complications may rapidly occur in the comatose patients, requiring a rehabilitation program in the first days of ICU stay. The physiotherapist should be aware of the different etiologies of coma as well as their specific features during the acute phase, especially in case of intracranial hypertension since education of caregivers regarding patient’s specific positioning is mandatory. Additionally, the physiotherapist should adapt treatments to each comatose patient’s specificities, be able to assess consciousness level and develop all the different techniques contributing to the patient’s awakening. Early rehabilitation is mandatory to improve the physical and functional outcome of ICU patients as well as their final quality of life.
Article PDF
Références
Rigaux P, Kiefer C (2003) [Indications, effectiveness and tolerance of the rehabilitation techniques aimed at improving recovery of awareness following a traumatic brain injury]. Ann Readapt Med Phys 46:219–226
Giacino JT, Zasler ND, Katz DI, et al (1997) Development of practice guidelines for assessment and management of the vegetative and minimally conscious states. J Head Trauma Rehabil 12:79–89
Laureys S, Owen AM, Schiff ND (2004) Brain function in coma, vegetative state, and related disorders. Lancet Neurol 3:537–546
Weiss N, Galanaud D, Carpentier A, et al (2007) Clinical review: Prognostic value of magnetic resonance imaging in acute brain injury and coma. Crit Care 11:230
Plum F, Posner JB (1966) The diagnosis of stupor and coma. F.A. Davis. Philadelphia, Pennsylvania, USA 197 pp.
No authors listed] (1994) Medical aspects of the persistent vegetative state (1). The Multi-Society Task Force on PVS. N Engl J Med 330:1499–1508
No authors listed] (1994) Medical aspects of the persistent vegetative state (2). The Multi-Society Task Force on PVS. N Engl J Med 330:1572–1579
Vanhaudenhuyse A, Schnakers C, Brédart S, Laureys S (2008) Assessment of visual pursuit in post-comatose state: use a mirror. J Neurol Neurosurg Psychiatry 79:223
Wijdicks EF, Bamlet WR, Maramattom BV, et al (2005) Validation of a new coma scale: The FOUR score. Ann Neurol 58: 585–593
Giacino JT, Kalmar K, Whyte J (2004) The JFK Coma Recovery Scale-Revised: measurement characteristics and diagnostic utility. Arch Phys Med Rehabil 85:2020–2029
Durward QJ, Amacher AL, Del Maestro RF, Sibbald WJ (1983) Cerebral and cardiovascular responses to changes in head elevation in patients with intracranial hypertension. J Neurosurg 59:938–944
Moraine JJ, Berré J, Mélot C (2000) Is cerebral perfusion pressure a major determinant of cerebral blood flow during head elevation in comatose patients with severe intracranial lesions? J Neurosurg 92:606–614
Bloomfield GL, Ridings PC, Blocher CR, et al (1996) Effects of increased intra-abdominal pressure upon intracranial and cerebral perfusion pressure before and after volume expansion. J Trauma 40:936–941
Bonnier F, Moraine JJ, Berré J, Mélot C (2003) Mechanism of change in intracranial pressure with head elevation in patients with brain injury. Intensive care Med 29:S199
Wojner-Alexander AW, Garami Z, Chernyshev OY, Alexandrov AV (2005) Flat positioning improves blood flow velocity in acute ischemic stroke. Neurology 64:1354–1357
Schwarz S, Georgiadis D, Aschoff A, Schwab S (2002) Effects of Body Position on Intracranial Pressure and Cerebral Perfusion in Patients With Large Hemispheric Stroke. Stroke 33:497–501
Meixensberger J, Baunach S, Amschler J, et al (1997) Influence of body position on tissue-pO2, cerebral perfusion pressure and intracranial pressure in patients with acute brain injury. Neurol Res 19:249–253
Blissitt PA, Mitchell PH, Newell DW, et al (2006) Cerebrovascular dynamics with head-of-bed elevation in patients with mild or moderate vasospasm after aneurysmal subarachnoid hemorrhage. Am J Crit Care 15:206–216
Winkelman C (2000) Effect of backrest position on intracranial and cerebral perfusion pressures in traumatically brain-injured adults. Am J Crit Care 9:373–380
Mavrocordatos P, Bissonnette B, Ravussin P (2000) Effects of neck position and head elevation on intracranial pressure in anaesthetized neurosurgical patients: preliminary results. J Neurosurg Anesthesiol 12:10–14
Ledwith MB, Bloom S, Maloney-Wilensky E (2010) Effect of body position on cerebral oxygenation and physiologic parameters in patients with acute neurological conditions. J Neurosci Nurs 42:280–287
Brain Trauma Foundation “Guidelines for the Management of Severe Traumatic Brain Injury 3rd Edition”, 2007 Website: www.braintrauma.org
Rosner MJ, Coley IB (1986) Cerebral perfusion pressure, intracranial pressure, and head elevation. J Neurosurg 65:636–641
Thelandersson A, Cider A, Nellgård B (2006) Prone position in mechanically ventilated patients with reduced intracranial compliance. Acta Anaesthesiol Scand 50:937–941
Li X, von Holst H, Kleiven S (2011) Influence of gravity for optimal head positions in the treatment of head injury patients. Acta Neurochir (Wien) 153:2057–2064
Imholz BP, Settels JJ, van der Meiracker AH 1990) Non-invasive continuous finger blood pressure measurement during orthostatic stress compared to intra-arterial pressure. Cardiovasc Res 24:214–221
Van Saene HK, Stoutenbeeck CP, Zandstra DF (1990) Pathophysiology of nosocomial pneumonia in intensive care units. Réan Soins Intens Med Urg 6:100–102
Chi JH, Knudson MM, Vassar MJ (2006) Prehospital hypoxia affects outcome in patients with traumatic brain injury: a prospective multicenter study. J Trauma 61:1134–1141
Salemi C, Morgan J, Padilla S, Morrissey R (1995) Association between severity of illness and mortality from nosocomial infection. Am J Infect Control 23:188–193
Hilker R, Poetter C, Findeisen N (2003) Nosocomial pneumonia after acute stroke: Implications for neurological intensive care medicine. Stroke 34:975–981
Hillier B, Wilson C, Chamberlain D (2013) Preventing ventilatorassociated pneumonia through oral care, product selection, and application method: a literature review. AACN Adv Crit Care 24:38–58
Robichaud A (1990) Alteration in gase exchange related to body position. Crit Care Nurse 10:56–59
Gosselink R, Bott J, Johnson M, et al (2008) Physiotherapy for adult patients with critical illness: Recommendations of the European Society and European Society of Intensive Care Medecine Task Force on physiotherapy for critically ill patients. Intensive Care Med 34:1188–1199
Reychler G, Roeseler J, Delguste P (2007) Kinésithérapie respiratoire. Elsevier 115–120
Berney S, Denehy L (2002) A comparison of the effects of manual and ventilator hyperinflation on static lung compliance and sputum production in intubated ventilated intensive care patient. Physiother Res Int 7:100–108
Paratz J, Burns Y (1993) The effect of respiratory physiotherapy on intracranial pressure, mean arterial pressure, cerebral perfusion pressure and end tidal carbon dioxide in ventilated neurosurgical patients. Physiother Theory Pract 9:3–11
Bolton, CF (2005) Neuromuscular manifestations of critical illness. Muscle Nerve 32:140–163
Demirbag D, Ozdemir F, Kokino S, Berkarda S (2005) The relationship between bone mineral density and immobilization duration in hemiplegic limbs. Ann Nucl Med 19:695–700
Bloomfield SA (1997) Changes in musculoskeletal structure and function with prolonged bed rest. Med Sci Sports Exerc 29:197–206
Kocan MJ, Lietz H (2013) Special considerations for mobilizing patients in the neurointensive care unit Crit Care Nurs Q 36:50–55
Bai Y, Hu Y, Wu Y, et al (2012) A prospective, randomized, single-blinded trial on the effect of early rehabilitation on daily activities and motor function of patients with hemorrhagic stroke. J Clin Neurosci 19:1376–1379
Hanekom S, Gosselink R, Dean E, et al (2011) The development of a clinical management algorithm for early physical activity and mobilization of critically ill patients: synthesis of evidence and expert opinion and its translation into practice. Clin Rehabil 25:771–787
De Patro C, Bastin MH, Preiser JC (2009) Prise en charge de la sarcopénie en reanimation, Nutr Clin Metabol 23:220–225
Gerovasili V, Stefanidis K, Vitzilaios K, et al (2010) Electrical muscle stimulation preserves the muscle mass of critically ill patients: a randomized parallel intervention trial. Crit Care 14: R74
Geerts WH, Heit JA, Clagett GP, et al (2001) Prevention of venous thromboembolism. Chest 119:132S–175S
Vignon P, Dequin PF, Renault A, et al (2013) Intermittent pneumatic compression to prevent venous thromboembolism in patients with high risk of bleeding hospitalized in intensive care units: the CIREA1 randomized trial. Intensive Care Med 39:872–880
Gosselink R, Bott J, Johnson M, et al (2008) Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory Society and European Society of Intensive Care Medecine Task Force on Physiotherapy for Critically Ill Patients. Intensive Care Med 34:1188–1199
Roseler J, Sottiaux T, Lemiale V, Lesny M pour le groupe d’experts (2013) Prise en charge de la mobilisation précoce en réanimation adulte et pédiatrique (électrostimulation inclus). Recommandations formalisées d’experts sous l’égide de la SRLF, SKR, SOFMER et du GFRUP [in press]
Dlouhy BJ, Rao RC (2012) Amantadine for Severe Traumatic Brain Injury. N Engl J Med 366:2427–2428
Lehmkuhl LD, Krawzick L (1993) Physical therapy management of the minimally responsive patient following traumatic brain injury: coma stimulation. Neurology Rep 17:10–17
Lombardi F, Taricco M, De Tanti A, et al (2002) Sensory stimulation of brain-injured individuals in coma or vegetative state: results of a Cochrane systematic review. Clin Rehabil 16:464–472
Gerber CS (2005) Understanding and managing coma stimulation. Are we doing everything we can? Crit Care Nurs Q 28:94–108
Teasdale G, Jennett B (1974) Assessment of coma and impaired consciousness. A practical scale. Lancet 2:81–84
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Koube, I., Devroey, M., Norrenberg, M. et al. Kinésithérapie chez le patient présentant une altération de l’état de conscience. Réanimation 22, 648–655 (2013). https://doi.org/10.1007/s13546-013-0724-5
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s13546-013-0724-5