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At least 289 records · Page 16Linked to original sources
PubMed1999

Successful use of alternate waste nitrogen agents and hemodialysis in a patient with hyperammonemic coma after heart-lung transplantation.

BACKGROUND: Lethal hyperammonemic coma has been reported in 2 adults after lung transplantation. It was associated with a massive elevation of brain glutamine levels, while plasma glutamine levels were normal or only slightly elevated. In liver tissue, glutamine synthetase activity was markedly reduced, and the histologic findings resembled those of Reye syndrome. The adequacy of therapy commonly used for inherited disorders of the urea cycle has not been adequately evaluated in patients with this form of secondary hyperammonemia. OBJECTIVE: To determine whether hemodialysis, in conjunction with intravenous sodium phenylacetate, sodium benzoate, and arginine hydrochloride therapy, would be efficacious in a patient with hyperammonemic coma after solid-organ transplantation. DESIGN: Case report. SETTING: A children's hospital. PATIENT: A 41-year-old woman with congenital heart disease developed a hyperammonemic coma with brain edema 19 days after undergoing a combined heart and lung transplantation. METHODS: Ammonium was measured in plasma. Amino acids were quantitated in plasma and cerebrospinal fluid by column chromatography. The effectiveness of therapy was assessed by measuring plasma ammonium levels and intracranial pressure and performing sequential neurological examinations. RESULTS: The patient had the anomalous combination of increased cerebrospinal fluid and decreased plasma glutamine levels. To our knowledge, she is the first patient with this complication after solid-organ transplantation to survive after combined therapy with sodium phenylacetate, sodium benzoate, arginine hydrochloride, and hemodialysis. Complications of the acute coma included focal motor seizures, which were controlled with carbamazepine, and difficulty with short-term memory. CONCLUSIONS: The aggressive use of hemodialysis in conjunction with intravenous sodium phenylacetate, sodium benzoate, and arginine hydrochloride therapy may allow survival in patients after solid-organ transplantation. An acute acquired derangement in extra-central nervous system glutamine metabolism may play a role in the production of hyperammonemia in this illness that resembles Reye syndrome, and, as in other hyperammonemic disorders, the duration and degree of elevation of brain glutamine levels may be the important determining factors in responsiveness to therapy.

Adult↗
PubMed2005

Initial Glasgow Coma Scale score predicts outcome following thrombolysis for posterior circulation stroke.

BACKGROUND: Randomized trials of thrombolytic stroke treatment have either excluded patients with posterior circulation ischemia or used inclusion criteria making enrollment of these patients less likely. Consequently, there is less published information on thrombolytic therapy for posterior circulation stroke. OBJECTIVE: To determine effective thrombolytic treatment times for posterior circulation stroke and factors that might help predict clinical outcome. DESIGN: We describe our experience treating 21 consecutive patients with either intravenous or intra-arterial thrombolytic therapy for posterior circulation ischemic stroke between October 9, 1993, and February 19, 2001. MAIN OUTCOME MEASURES: National Institutes of Health Stroke Scale, Glasgow Coma Scale, and modified Rankin Scale scores were evaluated at baseline, and the modified Rankin Scale was measured 3 months after stroke, with a good outcome being a modified Rankin Scale score of 2 or less. RESULTS: Nine patients received intravenous therapy; 12 patients received intra-arterial therapy. The median National Institutes of Health Stroke Scale score at onset was 20 (range, 2-39), and the median Glasgow Coma Scale score was 9 (range, 3-15). Twelve patients were treated within 8 hours of symptom onset (range, 1 1/2 hours to 16 days). Nine patients (43%) had a modified Rankin Scale score of 2 or less at 3 months. The initial Glasgow Coma Scale score and treatment within 8 hours of symptom onset were each associated with good outcome, but the initial National Institutes of Health Stroke Scale score was not predictive. CONCLUSIONS: Thrombolytic therapy for posterior circulation stroke may be beneficial even when initiated 8 hours after symptom onset. Level of consciousness, as measured by Glasgow Coma Scale score, seems to be a more important predictor of outcome than the initial National Institutes of Health Stroke Scale score.

Adult↗
PubMed2001

Delayed cerebral edema and fatal coma after minor head trauma: role of the CACNA1A calcium channel subunit gene and relationship with familial hemiplegic migraine.

Trivial head trauma may be complicated by severe, sometimes even fatal, cerebral edema and coma occurring after a lucid interval ("delayed cerebral edema"). Attacks of familial hemiplegic migraine (FHM) can be triggered by minor head trauma and are sometimes accompanied by coma. Mutations in the CACNA1A calcium channel subunit gene on chromosome 19 are associated with a wide spectrum of mutation-specific episodic and chronic neurological disorders, including FHM with or without coma. We investigated the role of the CACNA1A gene in three subjects with delayed cerebral edema. Two subjects originated from a family with extreme FHM, and one subject was the previously asymptomatic daughter of a sporadic patient with hemiplegic migraine attacks. In all three subjects with delayed severe edema, we found a C-to-T substitution resulting in the substitution of serine for lysine at codon 218 (S218L) in the CACNA1A gene. The mutation was absent in nonaffected family members and 152 control individuals. Haplotype analysis excluded a common founder for both families. Neuropathological examination in one subject showed Purkinje cell loss with relative preservation of granule cells and sparing of the dentate and inferior olivary nuclei. We conclude that the novel S218L mutation in the CACNA1A calcium channel subunit gene is involved in FHM and delayed fatal cerebral edema and coma after minor head trauma. This finding may have important implications for the understanding and treatment of this dramatic syndrome.

Adolescent↗
PubMed2003

Electrical treatment of coma via the median nerve.

The median nerve is a portal to interact with the injured comatose brain. Peripheral nerve electrical stimulation has a central nervous system effect. Two to three weeks of right median nerve stimulation (RMNS) can hasten awakening from deep coma by increasing the dopamine levels. Three cases of electrically treated GCS-4 teenagers with acute diffuse brain injuries from motor vehicle crashes are presented by video. Pilot studies of RMNS for acute post-traumatic coma states have been done over the last ten years at East Carolina University and the University of Virginia. The neurophysiological effects of RMNS have been well documented at several neurosurgical centers in Japan using neuroimaging and spinal fluid assays. RMNS is a safe, inexpensive, non-invasive therapy for neuro-resuscitation of coma patients. When employed early in the coma, the time in the ICU may be shortened and the quality of the final outcome may be enhanced.

Adolescent↗
PubMed1984

Classifications of coma.

Coma classifications have been a matter of debate for over 35 years. The Glasgow Coma Scale is now widely accepted but its indiscriminate application has often led to misuse. The various methods that have been devised can be divided into two types, coma scales and coma scoring systems. In this critique the origins and values of these methods are analysed.

Coma↗
PubMed1995

Problems of the Glasgow Coma Scale with early intubated patients.

The Glasgow Coma Scale is probably the most common grading scale in neurotraumatology all over the world. Its validity concerning severity and prognosis of the injury has been established in the Anglo-American literature. Data derived from the German rescue system, however is different from the Anglo-American in some respects. The analysis of a well-defined group of German trauma patients with moderate and severe head injuries (n = 299) shows that low Glasgow Coma Scores (GCS 3-6) established during the first two posttraumatic days must not correspond directly to the outcome after one year. Especially for the best Glasgow Coma Score during the day after the injury, GCS 4 had a poorer collective long-term prognosis than GCS 3. Therefore, German data from head injury studies based on the Glasgow Coma Scoring are difficult to compare to those cited in the Anglo-American literature. Any statistical analysis of a so called "ranking scale" which does not satisfy its own claims under special conditions is difficult.

Brain Injuries↗
PubMed1975

Course and prognosis of 86 episodes of diabetic coma. A five year experience with a uniform schedule of treatment.

The admission data and the course of 58 episodes of severe diabetic ketoacidotic coma and of 28 episodes of non-ketotic coma are compared. The non-ketotic patients were older; initial blood glucose, osmolarity, blood urea and serum sodium concentration were higher than in the ketotic patients. Treatment in the first 24 hrs consisted of similar amounts of insulin in both coma forms, the presence of acidaemia did not increase the insulin needs. Acidaemia was corrected only when pH was below 7.20. The disadvantages of alkali therapy are emphasized. A comparison of the age groups of survivors and those patients who died within 72 hrs showed an increase in mortality with age. However, the mortality rates from ketotic and non-ketotic coma were similar in the age groups above 50 years. On admission, blood glucose, osmolarity and blood urea were higher in the fatal cases. Blood urea was the most important indicator of a fatal outcome. The response of blood glucose to insulin was impaired in the subsequently fatal cases. Insulin was given in "moderate" doses by constant infusion. The use of "small" doses is discussed. Early mortality was 14% in the ketotic and 29% in the non-ketotic cases. The most frequent causes of death were circulatory failure of undetermined origin, infections and thromboembolic complications.

Adult↗
PubMed1977

Brain monoamines in metabolic (endotoxic) coma. A preliminary biochemical study in human postmortem material.

Spectrofluorometric assays of DA, 5-HT and 5-HIAA were performed in different areas of postmortem brains of humans who died in hepatic and uremic coma. Brain DA showed a mild general decrease, the average reduction being 20 to 30 percent of the controls. By contrast, 5-HT and 5-HIAA were markedly increased in most brain areas, most significantly in the reticular and raphé nuclei of the brainstem and in some parts of the limbic system. Despite individual and regional differences, the monoamine changes had similar patterns in both hepatic and uremic coma. These data in human brain which confirm previous clinical and experimental studies in hepatic encephalopathy suggest some common disorders of central monoamine metabolism in endotoxic coma of different origin. Brain edema, a constant feature in toxic coma, is probably due to increased 5-HT content in the brain, the pathophysiologic effect of 5-HT on the blood-brain barrier being well established. The prominent changes of indoleamine metabolism in the reticular brainstem and limbic systems may be related to disorders of consciousness.

Aged↗
PubMed1976

Assessment and prognosis of coma after head injury.

The Glasgow Coma Scale, based upon eye opening, verbal and motor responses has proved a practical and consistent means of monitoring the state of head injured patients. Observations made in the early stages after injury define the depth and duration of coma and, when combined with clinical features such as a patient's age and brain stem function, have been used to predict outcome. Series of cases in comparable depths of coma in Glasgow and the Netherlands showed remarkably similar outcomes at 3 months. Based upon observations made in the first 24 hours of coma after injury, data from 255 previous cases reliably predicted outcome in the majority of 92 new patients. The exceptions were patients with potential to recover who later developed complications: no patient did significantly better than predicted.

Brain Injuries↗
PubMed1990

Use of flumazenil in intoxicated patients with coma. A double-blind placebo-controlled study in ICU.

In a double-blind placebo-controlled prospective clinical trial we studied the efficacy and safety of the benzodiazepine antagonist, flumazenil. In 23 patients admitted to the Intensive Care Unit with coma due to overdose with benzodiazepines or other sedatives, flumazenil i.v. (up to 2 mg or placebo) was given. In 13 patients given flumazenil the Glasgow Coma Scale (GCS) increased significantly from 4.9 to 7.8 (p less than 0.05). Six of these 13 patients, including mainly benzodiazepine mono-intoxications, needed only one series of injections (up to 1.0 mg flumazenil); the GCS increased thereby from 4.5 to 10.7 within a maximum of 5 min (p less than 0.01). In the remaining 7 patients, needing two series of injections of flumazenil (up to 2.0 mg), GCS did not rise significantly and coma was related to intoxications with nonbenzodiazepine sedatives, flunitrazepam and in one patient, encephalitis. In the 10 patients receiving placebo, the GCS did not change. A significant increase in the GCS from 5.5 to 10.8 (p less than 0.001) was, however, observed when flumazenil (up to 1.0 mg) was given after placebo. In patients with EEG monitoring the changes in waveform pattern paralleled the clinical response. Effects could be detected within 1-2 min after flumazenil injection and lasted up to 45 min. There were no adverse reactions or benzodiazepine withdrawal symptoms. We conclude that flumazenil is an effective and safe drug in the treatment of benzodiazepine overdose. The use of flumazenil is of diagnostic value in mixed-drug intoxications or coma of unknown origin and is of therapeutic importance for reversal of benzodiazepine intoxications.

Adolescent↗
PubMed1983

Prognostic value of CT in head-injury coma.

The brain CT findings in 54 patients in coma 1-5 (Bozza-Marrubini scale) following craniocerebral trauma are analysed retrospectively. Attention is focused on those of the CT features that constitute indirect signs of brainstem involvement: obliteration of the suprasellar cisterns, distortion of the perimesencephalic and quadrigeminal cisterns, dilatation of the temporal horn and widening of the cerebellopontine angle cistern on the lesion side, considered anatomically and clinically responsible for coma. The patients fell into three groups: 7 with negative CT, 31 with intracranial lesions not affecting the brainstem and 16 with CT evidence of descending transtentorial herniation. The CT signs correlated significantly with coma level and survival. These CT signs can be used alongside the clinical and other instrumental data -- EEG, VEP and intracranial pressure -- as a further criterion of severity in head-injury coma.

Adolescent↗
PubMedDate not supplied

Coma in the pediatric patient: evaluation and management.

Coma in the pediatric patient is a medical emergency and must be dealt with in a rapid, organized way. Basic life support needs, evaluation of history, and physical examination are all of paramount importance and evaluation of these three critical areas must proceed simultaneously. Specific diagnoses must be treated appropriately, but there are key general principals to coma management that must be dealt with sequentially. The outcome in childhood coma is substantially better than adult coma, and in many cases is determined by speed and appropriateness of intervention.

Child↗
PubMed2004

Thyroid storm as precipitating factor in onset of coma in an elderly woman: case report and literature review.

Thyroid storm is an uncommon but life-threatening manifestation of hyperthyroidism which, unless appropriately treated by combined therapy, causes 30-60% of deaths in hospitalized patients. Mental deterioration leading to apathy and eventually coma is a rare clinical presentation of this pathology, frequently observed in the elderly. We present the case of a 77-year-old hypertensive woman who was hospitalized for fast onset of coma, probably due to the unusual combination of a hypernatremic hyperosmolar state and an unexpected thyroid storm (TS). Although not definitely ascertained, the possible etiology was the hyperthyroid phase of chronic autoimmune thyreopathy (Hashitoxicosis). Notably, the significant adjunctive role of thyroid hyperfunction in the pathogenesis of coma was confirmed by the fact that, although metabolic abnormalities were overcome, complete and satisfactory recovery of the patient's mental and physical condition occurred only with normalization of thyroid hormones by antithyroid treatment. Our case highlights the importance of properly evaluating thyroid function in elderly patients who show a sudden progressive impairment in their mental condition, for early detection of potentially fatal conditions such as thyroid storm or myxedematous coma.

Aged↗
PubMed2004

[Glasgow Coma Scale in traumatic brain injury].

Even 30 years after its first publication the Glasgow Coma Scale (GCS) is still used worldwide to describe and assess coma. The GCS consists of three components, the ocular, motor and verbal response to standardized stimulation, and is used as a severity of illness indicator for coma of various origins. The GCS facilitates information transfer and monitoring changes in coma. In addition, it is used as a triage tool in patients with traumatic brain injury. Its prognostic value regarding the outcome after a traumatic brain injury still lacks evidence. One of the main problems is the evaluation of the GCS in sedated, paralysed and/or intubated patients. A multitude of pseudoscores exists but a universal definition has yet to be defined.

Brain Injuries↗
PubMed1998

Differentiation of autonomic nervous activity in different stages of coma displayed by power spectrum analysis of heart rate variability.

The analysis of heart rate (HR) variability offers a noninvasive method to investigate autonomic nervous system activity in comatose patients. We analyzed three components of the HR variability in a group of comatose patients: the low-frequency band (LF), representing mainly sympathetic influence, the mid-frequency band (MF), representing sympathetic and parasympathetic influence, and the high-frequency band (HF), representing the parasympathetic influence. A value for sympathovagal balance was defined as LF/HF and MF/HF ratio. Moreover, the skin conductance level (SCL) and the skin conductance resistance (SCR) variability were recorded. The patient group consisted of 22 patients with traumatic brain injuries. Coma depth was assessed by the Glacow Coma Scale and artifact-free HR, SCL, and SCR were measured 75 times in the patient group. The results documented a significant gain in sympathetic nervous system activity corresponding with the state of emerging from coma. This gain was most pronounced in the HF component of the HR and in the sympathovagal balance between LF/HF. The findings in SCL and SCR variability endorsed this result. It is concluded that emerging from coma is accompanied by an increasing influence of the sympathetic nervous system on HR control. This leads to a change in the sympathovagal balance, i.e., a reintegration of parasympathetic and sympathetic activity.

Adolescent↗
PubMed1997

The prognostic significance of coma-rating, duration of anoxia and cardiopulmonary resuscitation in out-of-hospital cardiac arrest.

Early determination of outcome after successful prehospital cardiopulmonary resuscitation (CPR) is a common problem with great ethical, economic, social, and legal consequences. We prospectively investigated 112 adult patients who had been resuscitated after out-of-hospital cardiac arrest (CA). The aim of our study was to determine whether coma rating by the mobile intensive care unit (MICU) is a useful tool for outcome prediction. For neurological assessment the Innsbruck Coma Scale (ICS) was used initially and after return of spontaneous circulation (ROSC) or 20-30 min after the start of CPR, before any sedating drugs were given. The duration of anoxia and CPR were determined with the automatically recorded emergency call protocol of the dispatch centre and the protocol of the MICU. For estimation of cerebral outcome at the time of discharge from hospital we used the Glasgow-Pittsburgh Cerebral Performance Categories (CPC). Restoration of spontaneous circulation was achieved in 42 patients (37%), and 15 (13%) were discharged from hospital. The first coma rating performed immediately at the time of arrival on scene had no significant prognostic value for prediction of neurological outcome (P = 0.204) and survival (P = 0.103). The second coma rating (performed after ROSC or 20-30 min after the start of CPR), however, demonstrated a significant correlation with neurological outcome (P = 0.0000) and survival (P = 0.0000), a correlation which was comparable to both duration of anoxia and duration of CPR. In patients with out-of-hospital cardiac arrest prognostic information could be obtained with the ICS as early as 20-30 min after the start of cardiopulmonary resuscitation.

Adolescent↗
PubMed2002

Coma blisters, peripheral neuropathy, and amitriptyline overdose: a brief report.

BACKGROUND: Coma blisters are most commonly associated with barbiturate and benzodiazepine overdose; however, they have also been described in association with many other substances, including amitriptyline. OBJECTIVE: To review the literature on the clinical manifestations of coma blisters in the setting of amitriptyline overdose. METHODS: Case report and literature review. RESULTS: Coma blisters in association with amitriptyline overdose have rarely been documented in the literature. Of the few reported cases, peripheral neuropathy has been present two (including our case report) out of four times. CONCLUSION: Amitriptyline is known to impair endothelial cell tight junction integrity. Thus, individuals with amitriptyline overdose may be predisposed to microvascular damage during the compression imposed from a comatose state. This may help to explain the tendency for patients to present with the interesting triad of coma, blisters, and neuropathy.

Adult↗
PubMed1994

Alpha, theta and alpha-theta coma: a clinical outcome study utilizing serial recordings.

Alpha coma (AC), theta coma (TC) and alpha-theta coma (ATC) are transient clinical-electroencephalographic phenomena which do not differ from each other in etiology or outcome and are indicative of a severe disturbance in thalamo-cortical physiology. Although most patients do poorly, these patterns are not reliably predictive of outcome, regardless of etiology. We found that AC, TC or ATC usually change to a more definitive pattern by 5 days from coma onset. EEG reactivity in subsequent patterns is relatively favorable, while a burst-suppression pattern without reactivity is unfavorable in anoxic-ischemic encephalopathy.

Alpha Rhythm↗