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PubMed1992

Effect of iron chelation therapy on recovery from deep coma in children with cerebral malaria.

BACKGROUND: Cerebral malaria is a severe complication of Plasmodium falciparum infection in children, with a mortality rate of 15 to 50 percent despite antimalarial therapy. METHODS: To determine whether combining iron chelation with quinine therapy speeds the recovery of consciousness, we conducted a randomized, double-blind, placebo-controlled trial of the iron chelator deferoxamine in 83 Zambian children with cerebral malaria. To be enrolled, patients had to be less than six years old, have P. falciparum parasitemia, have normal cerebrospinal fluid without evidence of bacterial infection, and be in a coma from which they could not be aroused. Deferoxamine (100 mg per kilogram of body weight per day, infused intravenously for 72 hours) or placebo was added to standard therapy with quinine and sulfadoxine-pyrimethamine. The time to the recovery of full consciousness, time to parasite clearance, and mortality were examined with Cox proportional-hazards regression analysis. RESULTS: The rate of recovery of full consciousness among the 42 patients given deferoxamine was 1.3 times that among the 41 given placebo (95 percent confidence interval, 0.7 to 2.3); the median time to recovery was 20.2 hours in the deferoxamine group and 43.1 hours in the placebo group (P = 0.38). Among 50 patients with deep coma, the rate of recovery of full consciousness was increased 2.2-fold with deferoxamine (95 percent confidence interval, 1.1 to 4.7), decreasing the median recovery time from 68.2 to 24.1 hours (P = 0.03). Among 69 patients for whom data on parasite clearance were available, the rate of clearance with deferoxamine was 2.0 times that with placebo (95 percent confidence interval, 1.2 to 3.6). Among all 83 patients, mortality was 17 percent in the deferoxamine group and 22 percent in the placebo group (P = 0.52). CONCLUSIONS: Iron chelation therapy may hasten the clearance of parasitemia and enhance recovery from deep coma in cerebral malaria.

Child, Preschool↗

PubMed1998

Assessment of brain perfusion in coma and comparison between SPECT and CT scan data: preliminary report.

In this study we submitted 24 comatose patients (Glasgow Coma Score <8) to Single Photon Emission Tomography (SPECT) during the clinical course of coma to verify its utility and the relationship between SPECT and CT scan data. SPECT was recorded following i.v. injection of Xe-133 in 17 patients and of Tc-99m-HMPAO or Tc-99m-ECD in the remaining 7. SPECT data recorded during the acute phase of coma did not show a clear correlation between cerebral blood flow (CBF) and outcome. SPECT and CT scan detected abnormalities in the same areas in 6 cases (25%); 6 patients (25%) with focal CT-scan lesions showed no focal CBF alterations in the same regions; conversely, in the remaining 12 cases (50%) SPECT disclosed severe perfusion abnormalities where no lesions were detectable on CT-scan. SPECT allowed us to recognize different regional flow patterns, such as absolute or relative hyperemia or oligoemia, which could not be checked with other means, thus improving patient's management. Apart from cerebral ischemia, there was no relationship between lesions on CT-scan and flow pattern. Our preliminary results suggest that SPECT can improve both the knowledge of patient's neurological conditions and management in comparison to the use of only CT scan.

Adolescent↗

PubMed1995

The Apache II scoring system in neurosurgical patients: a comparison with simple Glasgow coma scoring.

In order to compare the predictive value of the Apache II, the Glasgow Coma Scale and Revised Trauma Scoring systems in relation to outcome in a neurosurgical department high dependency unit (HDU), all 109 patients entering the unit under the care of one consultant were studied. All patients in the HDU were self-ventilating, so that motor responses were not suppressed by muscle relaxants or sedation. Initial Minimum and Maximum Glasgow Coma Scale Scores, Revised Trauma Score, Apache II and the Apache minus neurological weighting (Apache-NW) scores, were compared as predictors of outcome (as assessed by the Glasgow Outcome Score at 6 months). Twenty-eight patients had a bad outcome, i.e. Glasgow Outcome Scores 1-3, and 72 individuals a good outcome, i.e. scores 4 or 5. Statistical analysis was by the Spearman Ranked Correlation Test, and comparison of Receiver Operational Characteristics Curves. Data were complete on 100 patients (91.7%) and show the Maximum Glasgow Coma Score, followed by the Apache II score, as the best predictors of outcome analysed. This was also true if all patients except those with head injury were analysed as a group. All scoring systems were significantly better predictors of outcome in the head injured patient. For this group, Apache II had an outcome predictive value of 97% compared with 93% for initial and 95% for minimum GCS. Removing the neurological weighting from Apache II weakened its predictive ability in all patients, emphasizing that it is the neurological status of the patient which best predicts overall functional outcome. Apache II data are also much more time-consuming to collect than GCS data.(ABSTRACT TRUNCATED AT 250 WORDS)

Brain Injuries↗

PubMed2001

A new complication of hypothyroid coma: neurogenic dysphagia: presentation, diagnosis, and treatment.

We report the case of a patient with severe hypothyroid coma in whom hypothyroid-related neurogenic oropharyngeal dysphagia was suspected, videoscopically confirmed, and successfully treated. This complication has not previously been described, and may have contributed to the historically high mortality associated with severe cases of hypothyroid coma. In the future, the early detection and aggressive treatment of this complication and its sequelae should ensure a further reduction in mortality from hypothyroid coma.

Aged↗

PubMed1993

Histopathology of cutaneous changes in drug-induced coma.

Present knowledge of the histopathology of cutaneous changes seen in drug-induced coma is very incomplete: Only 1 of the 11 papers on this subject mentions follicular or sebaceous gland damage, with very little attention focused on vascular changes. We made a careful study of serial sections from eight cutaneous biopsy specimens from seven patients who suffered drug-induced coma with the following findings: (a) The secretory portion of the eccrine sweat coil is the epithelium most susceptible to necrosis. It is followed by, ex aequo, eccrine sweat duct, hair follicle, and sebaceous gland, and, lastly, the epidermis. (b) In the eccrine sweat duct, the outer root sheath of the hair follicle, and the epidermis, necrosis does not usually appear first in the outermost (basal cell) layer. (c) Necrosis of the outer root sheath of the telogen "club" follicle is usually more advanced than that of the secondary hair germ, and, at times, a spared anagen bulb can be seen in closest proximity. (d) Vascular changes correlate proportionately with epidermal damage and consist of a largely neutrophilic inflammatory infiltrate and blood vessel wall damage, mainly involving arterioles. Our findings contradict the widely accepted hypothesis that pressure is the main cause of the cutaneous changes in drug-induced coma.

Adult↗

PubMed1984

Coma scale for use in brain-injured children.

The association between admission coma score and eventual outcome was assessed using a coma scale developed for children with a variety of central nervous system injuries. As opposed to the Glasgow coma scale, this scale does not demand assessment of verbalization, and thus can be applied to the preverbal or previously intubated child. Cortical function is graded from 6 (purposeful, spontaneous movements) to 0 (flaccid), and brainstem function is graded from 3 (intact) to 0 (absent and apneic). Maximum total score is 9. In 91 children treated for intracranial hypertension, the association was moderately good. The scale was better in predicting the outcome of patients with hypoxic encephalopathy and head trauma than that of patients with Reye's syndrome, meningitis, or encephalitis. No child with a score of less than 3 survived in spite of intensive therapy. Most of these children were flaccid with depressed or absent brainstem reflexes. No child with flaccidity on admission survived.

Brain Injuries↗

PubMed2000

Coma prognosis in children. Part I: definitional and methodological challenges.

Prediction of outcome from coma is a frequent and important task of neurologists. It is difficult enough in adult patients and even more difficult in children. Part I of this review considers some of the methodological problems and caveats besetting clinical research in this field: the very definition of coma, definition of the study population and outcome variables, study design, the fallacy of self-fulfilling prophecy, early death rate from nonneurologic causes resulting in low statistical power, and invalid attempts to compensate for that by combining outcome categories, lumping together age groups, short and inhomogeneous follow-up, and failure to provide confidence intervals. Part II reviews the clinical pediatric coma-prognosis literature, first according to etiology and then according to electrodiagnostic tests.

Child↗

PubMed1999

Prognosis in presumptive hypoxic-ischemic coma in nonneurologic trauma.

BACKGROUND: The neurologic outcome of comatose patients has a wide variation from complete reawakening to death. Methods of predicting the outcome of coma caused by either head injury or cardiac arrest have been the subject of much discussion in the literature. However, prediction of neurologic prognosis in comatose trauma patients without head injury has rarely been discussed. We reviewed our experience in treating patients with presumptive hypoxic-ischemic coma after trauma and tried to identify factors relating to their neurologic outcomes. METHODS: Thirty-six patients with normal brain computed tomographic scans, who remained comatose 10 minutes after stabilization of their hemodynamic status, were studied. Serial motor response, verbal response, pupillary light reflex, presence of spontaneous breathing and seizure, and blood glucose level were recorded to evaluate their roles in predicting neurologic outcomes. RESULTS: There were five deaths (mortality rate, 14%) and 11 patients (31%) with neurologic deficits. An absence of spontaneous breathing, a blood glucose level greater than 300 mg/dL during resuscitation, and a presence of seizure signified a poor prognosis. Initial neurologic evaluation at 10 minutes after stabilization of hemodynamic status was not accurate in predicting outcome. A motor response worse than withdrawal from painful stimuli at 24 hours after injury and an absence of pupillary light reflex at 48 hours after injury predicted a poor neurologic outcome, with a 100% accuracy rate. CONCLUSION: Hypoxic-ischemic coma in patients sustaining major trauma yielded a significantly better survival and neurologic outcome than that induced by cardiac arrest or head injury. Decision-making in the first 24 hours after injury should not be affected by the patient's neurologic status at that time. A motor response worse than withdrawal at 24 hours after injury and an absence of pupillary light reflex at 48 hours after injury predicted a poor neurologic outcome.

Adolescent↗

PubMed2003

Outcome of coma in children.

Coma following a hypoxic-ischemic event is a serious condition and common reason for admission to the pediatric intensive care unit. Because coma has a high rate of mortality and morbidity in children, and the clinician may be unsure of the outcome very early in the course, it is important to have strategies to define prognosis. Although most studies have been conducted in adults, we review factors predicting outcome from coma of nontraumatic causes in infants and children. We consider the relation between physical findings, commonly accessible laboratory tools, and outcome, and comment on some newer techniques that may become more available for clinical purposes.

Adolescent↗

PubMed2000

Management of unexplained coma in children.

Coma in children is uncommon and can pose difficulties in diagnosis and management. Resuscitation should concentrate on management of the airway, breathing and circulation and on rapid exclusion of easily correctable conditions, e.g. hypoglycaemia. Common causes of coma are considered and the diagnostic evaluation of these children is discussed. A case of a toddler in coma is discussed from the perspective of the accident and emergency department to illustrate the management of these challenging but uncommon patients.

Anticonvulsants↗

PubMed2005

The interpretation of the EEG in stupor and coma.

This review discusses a variety of causes of stupor and coma and associated electroencephalographic (EEG) findings. These include metabolic disturbances such as hepatic or renal dysfunction, which are often characterized by slowing of background rhythms and triphasic waves. Hypoxia and drug intoxications can produce a number of abnormal EEG patterns such as burst suppression, alpha coma, and spindle coma. Structural lesions, either supra- or infratentorial, are reviewed. EEGs in the former may show focal disturbances such as delta and theta activity, epileptiform abnormalities, and attenuation of faster frequencies. In infratentorial lesions, the EEG may appear normal, particularly with a pontine lesion. Some patients may be encephalopathic because of ongoing epileptic activity with minimal or no motor movements. This entity, nonconvulsive status epilepticus (NCSE), is difficult to diagnose in obtunded/comatose patients, and an EEG is required to verify the diagnosis and to monitor treatment. Several EEG patterns and their interpretation in suspected cases of NCSE such as periodic lateralized epileptiform discharges (PLEDs), bilateral independent periodic lateralized epileptiform discharges (BIPLEDs), generalized periodic epileptiform discharges (GPEDs), and triphasic waves are reviewed. Other entities discussed include the locked-in syndrome, neocortical death, persistent vegetative state, brainstem death, and brain death.

Animals↗

PubMed1995

Quantifying nursing care in barbiturate-induced coma with the therapeutic intervention scoring system.

The use of pentobarbital-induced coma to manage intractable increased intracranial pressure remains a viable option in the acutely brain-injured patient. In a retrospective review of 15 patients with a variety of neurological injuries at our institution, it was found that aggressive management of respiratory, hemodynamic, metabolic and neurological status was required with the use of pentobarbital coma. A scoring system to determine the amount of interventions and nursing care required was used in the review. The Therapeutic Intervention Scoring System (TISS) demonstrated that with the acuity of illness, there were predictably increased interventions. As a method for quantifying the amount of care in this group of individuals, scoring of the interventions before, during, and after barbiturate coma was assessed. The findings demonstrated a significant difference in the scoring. Mean scores were: pre-treatment = 31.8, s.d. = 7.5; during = 41.7, s.d. = 2.0; post-treatment = 36.4, s.d. = 5.2, p < 0.01. Further modifications of the TISS to include current neuroscience therapies, such as the monitoring of cerebral oxygen extraction by jugular bulb catheterization, may increase the utility of the TISS.

Adult↗

PubMed1991

A case of cervical carcinoma of the uterus presenting with hyperosmolar non-ketotic coma as a manifestation of ectopic adrenocorticotropic hormone syndrome.

A case of advanced cervical carcinoma of the uterus with ectopic adrenocorticotrophic hormone (ACTH) syndrome is described. The patient was seen for general malaise 21 months after surgical treatment of the primary lesion whose histology was undifferentiated small cell carcinoma of the uterine cervix. She had extensive metastases in the liver and the abdominal wall. In addition to the typical clinical manifestations of Cushing's syndrome such as moon face, central obesity and acne vulgaris, hyperglycemia was so severe that she was in a hyperosmolar non-ketotic coma. Endocrinological examinations revealed elevated plasma ACTH and cortisol, and urinary excretion of 17-hydroxycorticosteroids and 17-ketosteroids, which were not suppressed by high-dose dexamethasone administration. Based on these clinical and laboratory findings, a diagnosis of ectopic ACTH syndrome was made. Among the results of other endocrinological examinations conducted to find the etiological cause of the hyperglycemic coma, which seemed to be unusual for ectopic ACTH syndrome, the plasma somatostatin level was abnormally high. Metastatic tumors in the liver obtained at the time of autopsy contained large amounts of both ACTH and somatostatin, and gel filtration studies revealed that the peptides produced by the tumor had the molecular sizes of the biologically active forms of the respective peptides. These observations suggest possible involvement of the somatostatin in deteriorating glucose intolerance to develop hyperglycemic hyperosmolar non-ketotic coma as a drastic disturbance of metabolism.

Adrenocorticotropic Hormone↗

PubMed1980

The two survival cases of alpha-pattern coma caused by large amounts of hypnotica and neuroleptica.

The EEGs of two men (42 and 63 years old) in coma who took large amounts of hypnotica and neuroleptica for intended suicides were occupied by an alpha pattern, and the patients were diagnosed as alpha-pattern coma. The prominent pattern in their EEGs changed from an alpha pattern to a theta pattern, and subsequently into an alpha pattern of low amplitude. The patients recovered without any residual neurological symptoms. It has been confirmed by our two cases, as well as by other reported cases, that the outcome of the alpha-pattern coma caused by drug poisoning is favorable. It is concluded that a longitudinal EEG recording should be performed as early as possible when the patient is in a comatose state.

Adult↗

PubMed1980

Pediatric coma: prognosis and outcome.

A review of 40 previously comatose children identified significant degrees of disability 10 months after the insult. Of all the antecedent factors assessed, duration of coma correlated most highly with outcome, especially in relation to language and intellectual spheres. The literature reveals heterogeneous approaches to the study of sequelae of pediatric coma, and thus disparate results: a more uniform approach is needed to the study of the nature and prognosis of pediatric coma.

Activities of Daily Living↗

PubMed1986

Thiopentone induced coma after severe birth asphyxia.

The aim of this study was to determine the feasibility of inducing a prolonged coma in severely asphyxiated newborn babies by the infusion of high dose thiopentone. In six severely asphyxiated babies the electroencephalograph (EEG) and blood pressure were monitored continuously. Thiopentone was infused at a rate sufficient to suppress completely the EEG providing the mean blood pressure remained above 35 mm Hg; it was continued until there was no evidence of cerebral oedema for 24 hours. In two the infusion was stopped prematurely because of hypotension that was unresponsive to treatment. In the other four a deep coma was maintained for a median duration of 127 hours. All developed pharmacodynamic tolerance to the thiopentone and showed non-linear elimination kinetics. Three babies died; the three survivors have moderate to severe handicap. It was concluded that with full intensive care it is possible to induce a deep coma; the outcome does not seem to be improved, however, and the incidence of complications was high.

Asphyxia Neonatorum↗

PubMed1979

Value of emergency toxicological investigations in differential diagnosis of coma.

Out of 208 cases of coma of unknown aetiology referred to the poisons unit of this hospital during 1978 for emergency toxicological investigations, 108 were found to be due to self-poisoning medical conditions, mainly neurological, accounted for coma in 90 patients; the cause was not ascertained in the remaining 10 cases. More than one preparation had been ingested by 58 (54%) of the poisoned patients, although barbiturates were the drugs most commonly encountered in the severe cases. Toxicological investigations should be considered in the differential diagnosis of coma when history, physical examination, and emergency biochemical measurements yield little diagnostic information.

Acute Disease↗

PubMed2001

Cutaneous eruptions in coma patients with nontraumatic rhabdomyolysis.

BACKGROUND: Rhabdomyolysis has been described most commonly after muscle injury but may also result from coma due to alcohol intake or drug abuse. Its clinical findings usually occur as muscular pain and swelling, but these symptoms are also seen in as many as 60% of patients with nontraumatic rhabdomyolysis. The diagnosis of slight nontraumatic rhabdomyolysis is often difficult to establish clinically. Few previous studies have reported cutaneous symptoms in nontraumatic rhabdomyolysis. OBJECTIVE: We attempted to elucidate a relationship between nontraumatic rhabdomyolysis and cutaneous eruption. METHODS: We studied 7 patients who were diagnosed as having massive to slight nontraumatic rhabdomyolysis with a cutaneous eruption in pressure areas at the first visit to our hospital between March 28, 1988, and June 27, 1998. RESULTS: They revealed wine-red-colored urine and elevated serum myogenic enzyme. Two patients complained of muscle pain. In all patients, cutaneous eruptions including well-demarcated erythema, bullae and deep ulcers were observed in areas of pressure. The pathological findings of 5 cutaneous eruptions revealed necrosis of sweat ducts and glands in the dermis. CONCLUSIONS: The pathogenesis of nontraumatic rhabdomyolysis and the cutaneous eruptions in coma patients has not been elucidated, but these conditions are due to similar factors; pressure and hypoxia are considered to be important causative factors for both. Cutaneous eruptions in the coma patient may be an important clinical symptom of nontraumatic rhabdomyolysis.

Adolescent↗