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In eclampsia neurological complications carry a high maternal mortality and morbidity. The case of an unbooked 15-year-old primiparous teenager who presented in shock, unconscious, quadriplegic and transiently blind one day after home delivery is reported. Co-operative inter-departmental management was undertaken and the patient was discharged, satisfactorily recovered.
Acute H2S (hydrogen sulfide) poisoning can cause permanent damage to the nervous system. We describe two patients with such damage. Both reported nausea, feeling unwell and irritation of the eyes during work, and have developed persistent memory problems and neurasthenic symptoms. Neither of them had been unconscious. The first patient was exposed during one and a half hours welding of a sewage pump. The second patient worked for three weeks in a laboratory where hydrogen sulfide leaked from faulty equipment. The cases demonstrate the need for thorough work and symptom anamnesis together with neuropsychological testing in order to achieve a correct diagnosis of encephalopathy caused by hydrogen sulfide exposure.
We describe a novel mouth-cup device for sampling breath from unconscious subjects and analysis with a hand-held breath-alcohol instrument, the "Alcolmeter SD-2." This equipment was evaluated in healthy volunteers after they drank a moderate dose of alcohol. Three kinds of breath were analyzed: (a) end-expired air from a conventional mouth-tube, (b) breath sampled from the mouth-cup, and (c) air from a nasal tube supplied with the breath analyzer. The ethanol concentration in breath from the mouth-cup was slightly less than in end-expired air but significantly greater than in nasal air. Results with mouth-tube and mouth-cup correlated highly with blood-ethanol concentration as determined by gas chromatography; nasal-tube air correlated less well. The Alcolmeter responded not only to ethanol but also to methanol, 1-propanol, and 2-propanol, whereas ethylene glycol gave no response. The time-response curve for methanol was different, and this might permit differential diagnosis of methanol poisoning.
Report on observations from the last ten years with covert administration of drugs (ketamine, lorazepam, temazepam) as well as other anesthetics (chloroform) in which the subsequent clouding of consciousness or unconsciousness was exploited for criminal acts. These were sexual abuse and robbery; in one case, the anesthesized person was the victim of a flat fire, and in the other case forced breathing of chloroform led to fatal intoxication. The examples show that without routine chemical and toxicological investigations in unclear circumstances of death, but also when the cause of death ist apparently certain, the underlying cause may easily be overlooked. Furthermore, covert administration of anesthetics in alcoholic drinks and subsequent robbery is still to be reckoned with in the appropriate milieu.
The detection of cerebral lesions by chemical laboratory studies has not as yet been possible. Tests were carried out to determine whether there was an increase in plasma concentration of the neurotransmitter gamma-aminobutyric acid (GABA) in 12 unconscious patients: 6 with severe craniocerebral trauma (CCT) and 6 with spontaneous intracranial hemorrhage. Normal plasma concentrations were detected in the central venous blood of patients with severe CCT (normal range 366 +/- 123 pmol/ml); in patients with intracranial hemorrhage the values were partially elevated. Maximal values in arterial blood were around 613 pmol/ml (patients with CCT) and 1723 pmol/ml (patients with spontaneous intracranial hemorrhage). The influence of fluid turnover on plasma GABA concentrations is discussed.
Coma in children is an overwhelming process. The article discusses the probable etiological factors that may lead to coma condition, the physical examination, laboratory diagnosis and therapeutic management of the unconscious patient. Emphasis is being given to the emergency treatment of associated cardiac arrest and reference to the medicolegal problem arising from the prolonged use and discontinuance of mechanical life-supporting devices.
Anticipating to get some new informations about the cerebral circulations of the comatous patients, two kinds of radioisotopic techniques were combined and applied to twelve unconscious patients of various etiologies. The first step was the conventional gas clearance method using xenon 133 as the indicator. Regional cerebral blood flows were measured at the six areas over each hemisphere. Immediately following this procedure, about 150 muCi of I-131 MAA (I-31 macroaggregated human serum albumin) were injected into internal carotid artery via the same catheter inserted already for the first procedure. Radioactivities of the head and lungs were measured and the relative shunt flow was calculated based on the formula already described elsewhere. Profil scanning of the whole body of the patient was also performed after the intracarotid injection of I-131 MAA. Consciousness states of the ten patients were all severely damaged and causes of the disturbed consciousness were various, including 5 of subdural hematoma, 2 of occlusive cerebrovascular disease, 2 of brain tumor and 1 of ruptured intracranial aneurysm. This investigation revealed the following results; 1) In all patients, regional cerebral blood flows were shown decreased over all areas detected. The regional cerebral blood flows could not be increased by 5% carbon dioxide inhalation, suggesting angioparalysis in these areas. 2) Graphical analysis of the clearance curves revealed triphasic flow pattern in rCBF in four cases. In three cases among the four, the intracarotid injection of I-131 MAA showed the radioisotope labelled particles were captured not only in the brain, but also in the lungs and the relative shunt flow calculated increased up to twice as much as normal controls. It indicates that some of the particles larger than the cerebral capillary size passed through the brain and were captured by the capillary net work of the lungs. From the above described data, it might be concluded that the initial rapid component of triphasic flow pattern in rCBF measurement does not represent the hyperemia of luxury perfusion of metabolic origin, but arteriovenous shunting blood flow, probably, through the precapillary thoroughfare channels which have been anatomically demonstrated by Hasegawa et al.
Health care team members, including the dietitian, must set patient-centered treatment goals that are handled individually and that respect the unique values and personal decision of the patient. The patient's expressed desire is the primary guide for determining the extent of nutrition and hydration once the patient is diagnosed as being in a PVS. Within the extent of the law, the family should share decision making when the patient's preference is not stated and the family is in agreement about medical care. The health care team will need to discuss with the family as needed the issues of ethics, values, religious guidelines, and pastoral advice. If the patient's choice is feeding, the dietitian will ensure that the composition of the feeding promotes nutritional health. If the patient's choice is cessation of feeding, the dietitian should explain what is known about the duration of time between cessation of feeding and death. Sensitivity to the family's needs and responsiveness to their questions are imperative in both scenarios. Within institutions, the ethics committee should help establish and implement defined written guidelines for care of the permanently unconscious. The dietitian should be required to be a member of or consultant to such a committee and should serve an integral role in development of institutional policy. The dietitian must provide education about nutrition and hydration issues, serve as a patient advocate, and participate in the legal and ethical issues regarding feeding. The dietetics community is involved in the legislative arena at the state and local level to promote the use of advanced directives and to affect legislative and societal changes that result in appropriate care for patients in a PVS.
A 75-year-old female with a history of cerebral infarction fell into sudden hypotension (mean blood pressure of around 46 mmHg) and severe anemia (hematocrit < or = 10%; minimum hemoglobin concentration of 2.0 g.dl-1) of approximately one hour due to massive hemorrhage during surgical removal of pheochromocytoma originated in the right adrenal gland. Nevertheless, she recovered from the unconsciousness after over 9 hours postoperatively. It is suggested that major reasons for her escaping from the brain damage, in spite of the low cerebral perfusion pressure, might be the decreased cerebral oxygen consumption due to the intraoperative mild hypothermia (31.5 degrees C) and the avoidance due to hemodilution of the extremely low cerebral blood flow.
PURPOSE: We report here our experience in using intravenous methohexital (MHX), an ultrashort-acting barbiturate, for brief unconscious sedation of pediatric oncology outpatients undergoing painful, invasive procedures. METHODS: Following published monitoring guidelines for deep pediatric sedation, 1.0 mg/kg MHX was administered immediately before the procedure, 1% xylocaine was given locally, and MHX was additionally titrated to maintain minimal response to pain during the procedure. Clinical data reported here were gathered retrospectively from permanent medical records. RESULTS: Data reported here represent 132 evaluable consecutive procedures in 33 patients ranging in age from 1.6 to 20.5 years. Patients underwent an average of 4 +/- 3 procedures and received a mean total MHX dose per procedure of 5.8 +/- 2.1 mg/kg. The mean length of time from start of sedation to full arousability was 30 +/- 12 min. Twenty-three (17.4%) procedures were associated with clinically insignificant decreases in diastolic blood pressure or heart rate below resting normal ranges for age. Eight (6.1%) procedures in six patients were associated with minor complications requiring no intervention, such as transient behavioral changes, transient myoclonus, and minimal stridor. Five procedures (3.8%) in five patients required simple suctioning to manage secretions. Only two procedures (1.5%) in two patients required brief bag-mask ventilation plus suctioning for suspected laryngospasm. None required intubation. No differences in clinical features or MHX doses were noted for patients with, as compared to those without, complications. All procedures were completed with a satisfactory level of sedation. CONCLUSIONS: Our experience indicates that MHX, with appropriate monitoring as described here, is a safe and effective agent for use in pediatric oncology outpatient sedation programs.
This study of some psychological themes in a classical philosophical work, Plato's Republic, is an exercise in applied psychoanalysis that attempts to formulate an integrated psychoanalytic and philosophical understanding of certain ideas to be found in that work. It contains an interpretative study of a legend introduced by Plato at a crucial point in the development of the philosophical argument of the Republic. It is hypothesized that his use of this legend can be traced to an unconscious conflict in Plato, which when identified and interpreted can broaden our understanding and appreciation of the humanity of this work.
First, after a short introduction, the author goes into the threatened identity in adoptive families and the role sexuality hereby plays. This is demonstrated with a case example. Then the unconscious fantasies and dealing with the incest prohibition are described, followed by thoughts about therapy and the problem of the right time to tell the child about his adoption.
Drug addiction is considered in terms of an addiction syndrome, and a theory for its motivation is proposed, based on the treatment of several drug addicts in psychoanalysis and psychotherapy. It is suggested that the main cause of the addiction syndrome is the unconscious need to entertain and to enact various kinds of homosexual and perverse fantasies, and at the same time to avoid taking responsibility for this. It is hypothesised that specific drugs facilitate specific fantasies and using drugs is considered to be a displacement from, and a concomitant of, the compulsion to masturbate while entertaining homosexual and perverse fantasies. The addiction syndrome is also hypothesised to be associated with life trajectories that have occurred within the context of traumatogenic processes, the phases of which include social, cultural and political factors, encapsulation, traumatophilia, and masturbation as a form of self-soothing. This hypothesis about the traumatic origins of the addiction syndrome is illustrated with data from the psychoanalyses of addicts.
Traumatic twilight state on the one and amnestic episode (transient global amnesia) on the other side are as a rule easy to differentiate from the patient's age, his behavior during the acute state of disease and the kind of its improving. Contrary to other authors' opinion, differentiation is not just possible by diagnosing an injury or its absence. In minor skull traumata preceding the traumatic twilight states injuries are often not manifest and otherwise amnestic episodes occasionnally occur after minor traumata. In a 64 years old woman an obviously typical amnestic episode appeared in direct connection with a probable fall on the back of the head. A 28 years old man underwent a five-hour amnestic episode whereas the EEG showed normal curves. The episode occurred 15 minutes after striking hard upon the ground with the back of the head during a ground roll without following unconsciousness. In both cases traumatic twilight states were not involved. In account of the interval of 15 minutes the trauma of the second case seems not be be the direct cause for the manifestation of amnestic episode. It also shows that the aspect of the disease in the rare occurrence in younger or middle-aged persons is on principle not different from that in old ones. Since a special medical examination during the acute state is only possible as exception the patient's amnestically seizable behaviour obtains greatest importance in differential diagnosis. For the rare coincidence the trauma is given no pathogenetic relevance in amnestic episodes.
BACKGROUND: Many anesthetic drugs have been shown to disrupt conscious recall (explicit memory) in volunteers. However, unconscious processing (implicit memory) of intraoperative auditory material may occur during general anesthesia and may provide an opportunity for intraoperative therapeutic intervention. In this study, we examined patients undergoing elective cardiac surgery for evidence of intraoperative implicit and explicit memory. METHODS AND RESULTS: Twenty-five subjects provided written informed consent and underwent general anesthesia and cardiopulmonary bypass for cardiac surgery. During the operation, patients were randomized to receive 1 of 2 different audiotapes of associated word pairs. Postoperatively, a blinded observer conducted a standardized interview to determine the extent of intraoperative implicit and explicit memory. With the use of free association, significant intraoperative implicit memory was found. In contrast, no patient had spontaneous or directed recall of intraoperative events, and we did not find evidence of intraoperative explicit memory with a recognition task. CONCLUSIONS: Patients undergoing general anesthesia for cardiac surgery were reliably able to reinforce associations between word pairs solely on the basis of their intraoperative presentation. This provides further evidence that patients are capable of processing intraoperative auditory information.
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