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PubMed2002

[Traumatic brain injuries in adults: from coma to wakefulness. Neurophysiological data].

OBJECTIVE: To analyse relevant literature and to express an expert point of view concerning the interest of electroencephalography and evoked potentials recordings in the evaluation of severe head trauma in adults in the context of a consensus conference. MATERIAL AND METHODS: Scientific databases have been checked on the Internet using key-words. The summaries of 340 papers have checked out. Consequently 94 papers have been thoroughly analysed. Fifty-nine of them are cited in the text of this paper. RESULTS: Electroencephalography (EEG) and evoked potentials (Eps) evaluate the functional status of the brain. They augment the clinical examination. They are non invasive and easy to perform at patient's bedside. The EEG evaluate globally the functional status of the brain but it is very sensitive to sedative and anaesthetic drugs. It can disclose subclinical or electroclinical epileptic seizures. When reactivity to sensory stimulations can be elicited, this can be considered a prognostic indicator for a good outcome. Evoked potentials are less influenced by sedative drugs. There are several types of evoked potentials, each one with a different localizing value. Brainstem auditory evoked potentials (or short-latency Eps) evaluate the auditory nerve and brainstem. When normal they have no specificity. When abnormal they are an indicator of a poor or bad outcome. Somatosensory and auditory middle-latency Eps evaluate the primary cortex. In coma due to traumatic brain injury the presence of primary cortex components is an indicator of a good outcome and its absence is an indicator of a poor outcome at least when there is no focal brain lesion as to have the primary cortex component to be absent. Event-related potentials evaluate associative brain areas. When they are present in a comatose patient they favor the idea that some cognitive processes are active and they have a high positive predictive value for a return to consciousness. The electrophysiological evaluation can help to identify atypical situations and pathologies close to coma, disclose nonconvulsive seizures and localize certain complications or dysfunctions in atypical cases.

Adult↗
PubMed2001

Does wave VI of BAEP pertain to the prognosis of coma?

OBJECTIVES: The significance of brainstem auditory evoked potential (BAEP) wave VI for the outcome of comatose patients was assessed and compared to the prognostic impact of median nerve evoked somatosensory potential (MSEP) recording. PATIENTS AND METHODS: One hundred sixteen patients in a comatose state due to traumatic brain injury (n = 57) and to intracerebral hemorrhage or tumours (n = 59) were investigated prospectively. Outcome was assessed 3 months after the onset of coma using Glasgow Outcome Score (GOS). Standard BAEP and MSEP recordings were obtained within 24 h after coma onset. The frequency of findings was correlated with outcome by means of non-parametric statistical analysis. Additionally, 27 healthy volunteers were studied to confirm the constant presence of wave VI in normal BAEP. RESULTS: In healthy controls, wave VI was present in 53/54 ears stimulated. Outcome correlation analysis revealed a significantly (p < 0.01) higher frequency of abnormal wave VI in patients with unfavourable outcome (GOS 1-3) irrespective of the underlying pathology. Similarly, abnormal MSEP findings were significantly more frequent in this outcome group. Diagnostic sensitivity for an unfavourable outcome was low for both parameters, whereas specificity and positive predictive value of abnormal wave VI as well as of abnormal MSEP were equally high. CONCLUSION: Abnormal BAEP wave VI bears prognostic information in comatose patients.

Adolescent↗
PubMed1983

Plasma amino acid levels in hyperosmolar nonketotic diabetic coma.

The plasma amino acid levels in five patients with hyperosmolar nonketotic diabetic coma and in seven normal subjects were analysed. In the patients with hyperosmolar nonketotic diabetic coma, total amino acids were generally low, especially, the concentrations and the molar ratios of arginine, taurine and serine were significantly low, and ornithine decreased only at the concentration. The level of phenylalanine increased both at the concentration and the molar ratio, and tyrosine did only at the molar ratio. The significance of such changes in the plasma is discussed in relation to diabetic ketoacidosis or lactic acidosis.

Amino Acids↗
PubMed1981

[Myoglobinuric renal failure in hyperosmolar diabetic coma (author's transl)].

Acute rhabdomyolysis with myoglobinuric renal failure occurred in a 66-year-old woman who was in hyperosmolar non-ketotic diabetic coma. No previous description of such a case has been found. The clinical picture was characterized by the typical findings of hyperosmolar coma, in addition to excessive serum creatine kinase and myoglobin levels and massive myoglobinuria with acute renal failure. The rhabdomyolysis became fully manifest only under insulin treatment, possibly the result of insulin-induced hypophosphataemia, which seems to be of importance in the causation of the rhabdomyolysis.

Acute Kidney Injury↗
PubMed2003

Late-onset presentation of ornithine transcarbamylase deficiency in a young woman with hyperammonemic coma.

Ornithine transcarbamylase deficiency (OTCD) is an X-linked inherited disease and the most common inborn error in urea synthesis in human patients. In adult heterozygous patients, OTCD can be responsible for life-threatening hyperammonemic coma. We report the case of a 32-year-old woman admitted to our hospital with seizures after a recent high protein load. Her parents related a history of recurrent episodes of vomiting, meat refusal, lethargy, and convulsions since childhood, and measurement of plasma ammonemia levels was the key to early diagnosis of OTCD. We report the pathophysiologic characteristics, clinical features, clinical course, and differential diagnosis of OTCD and discuss the therapeutic options, including continuous venovenous hemodiafiltration and pharmacologic therapy for reduction of plasma ammonemia levels. A diagnosis of OTCD should be considered in adult nonhepatic patients with hyperammonemic coma, particularly if they have a history of protein avoidance and neurologic symptoms. Early recognition and appropriate treatment are critical to avoid severe brain damage and death.

Adult↗
PubMed1979

Hyperglycemia and diabetic coma: possible relationship to diuretic-propranolol therapy.

Two patients developed diabetic coma when taking a combination of a thiazide diuretic and propranolol. On subsequent follow-up one patient is taking no insulin and has been maintained on hydrochlorothiazide; the other patient required insulin on two occasions when challenged with a propranolol-thiazide combination, but not when the thiazide was discontinued or replaced with furosemide. These reports suggest the possibility that the risk of developing hyperglycemia and diabetic coma with this combination may be greater than when taking diuretics alone. The mechanism is probably multifactorial.

Diabetic Coma↗
PubMed1990

Comparison of intramuscular glucagon and intravenous dextrose in the treatment of hypoglycaemic coma in an accident and emergency department.

Hypoglycaemia remains a serious and much feared complication of insulin therapy. In this study, patients attending an accident and emergency department in hypoglycaemic coma were randomized to treatment with either intravenous dextrose (25g) or intramuscular glucagon (1mg), administered into the right thigh. Restoration of normal conscious level was slower after glucagon than dextrose (9.0 vs 3.0 min, P less than 0.01), although the average duration of hypoglycaemic coma was 120 min. Two patients in the glucagon-treated group, who failed to show satisfactory recovery after 15 min, required additional treatment with intravenous dextrose. On questioning following recovery, all except two patients reported loss of awareness of the onset of hypoglycaemia Intramuscular glucagon is valuable in the treatment of severe hypoglycaemia outwith hospital and, although the slightly slower and less predictable recovery may appear to make it a less attractive option than intravenous dextrose in the accident and emergency department, this must be balanced against the advantages of ease of administration and a lower incidence of serious adverse effects.

Diabetes Mellitus, Type 1↗
PubMedDate not supplied

Hyperglycemic hyperosmolar nonketotic coma following diazoxide, anesthesia and operation.

Unsuspected hyperglycemia caused prolonged postanesthetic coma in a nondiabetic patient treated with IV diazoxide and furosemide. The combined effect of these drugs with general anesthesia and surgical stress was postulated as the cause of the hyperglycemia. Blood glucose should be measured during and after general anesthesia in patients who are potential candidates for hyperglycemic hyperosmolar nonketotic coma.

Aged↗
PubMed1992

Severe head injury in children: experience of the Traumatic Coma Data Bank.

The outcome at discharge, 6 months, and 1 year after they had sustained severe head injuries was investigated in children (0-15 yr old at injury) who were admitted to the neurosurgery service at one of four centers participating in the Traumatic Coma Data Bank. Of 103 eligible children, the quality of recovery was assessed by the Glasgow Outcome Scale (GOS) at 6 months after injury in 92 patients (86% of series) and at 1 year in 82 patients (73% of series). The lowest post-resuscitation Glasgow Coma Scale score and pupillary reactivity were predictive of the 6-month GOS as were their interaction. Analysis of the first computed tomographic scan disclosed that bilateral swelling with/without midline shift was related to a poor outcome as was the presence of mass lesions. Comparison of age-defined subgroups of patients revealed that outcome was poorest in the 0- to 4-year-old patients, as reflected by their mortality, which increased to 62% by 1 year. Distinctive features of the injuries in the 0- to 4-year-olds included evacuated subdural hematomas (20% of patients) and hypotension (32% of patients). The most favorable outcome was attained by 5- to 10-year-olds (2/3 had a good recovery by 1 yr), whereas the GOS distribution of adolescents was intermediate between the children and adults. In summary, the GOS data reflect heterogeneity in the quality of outcome after severe head injury depending on age, neurological indices, and computed tomographic scan diagnostic category.

Adolescent↗
PubMed1992

Significance of different levels of the Edinburgh 2 coma scale calculated from the outcome of neurosurgical patients.

In the management of patients with acute cerebral disturbances, it is essential to determine precisely the degree of impaired consciousness. In order to secure the accuracy of observations, one must use a reliable coma scale. We have evaluated the Edinburgh 2 coma scale (E2CS) and explored the relationship between levels of the E2CS and the final outcome. Case notes and observation charts of the past 7 years were reviewed, covering neurosurgical operations on 406 patients, in each of whom the postoperative course was evaluated periodically by the E2CS and the outcome was determined by the Glasgow outcome scale. By matching the outcome with each level of impaired consciousness, about 22,000 pairs of data were obtained. In order to quantify the morbidity rate, different stages of the Glasgow outcome scale were rated from 100 through 0, arbitrarily. It was proved that levels of the E2CS were arranged in the correct order in respect to both mortality and morbidity rates. It was shown at the same time that each level has different prognostic significance and that the distance between each level is not identical. The recommendation is made to separate the levels on a chart not by an ordinal number but by the distance calculated on the basis of either mortality or morbidity rates. This will make it possible to get a rough estimate of the patients' prognoses by simply looking at a daily clinical chart.

Adolescent↗
PubMed1994

Auditory evoked potentials at 40 Hz (SSR40Hz) in post-trauma coma patients.

The authors evaluated auditory evoked steady state rest potentials at 40 Hz (SSR40Hz) in 21 post-trauma coma patients and compared their predictive value for prognosis of survival and quality of life with the results of the electroencephalogram (EEG), the computed tomography (CT) scan, and the Glasgow Coma Scale. SSR40Hz potentials recorded immediately after trauma had a maximum (100%) sensibility and specificity for a fetal prognosis and a high value for life prognosis. Consequently they appear to be a useful parameter for deciding on organ explant procedures. The EEG was more reliable in predicting a quality of life prognosis.

Adult↗
PubMed1990

Prompt recovery of plasma arginine vasopressin in diabetic coma after intravenous infusion of a small dose of insulin and a large amount of fluid.

We studied the changes in plasma arginine vasopressin in 5 patients with diabetic ketoacidosis and one patient with non-ketotic hyperosmolar coma who had marked hyperglycemia (36.6 +/- 4.6 mmol/l, mean +/- SEM) and dehydration. Plasma osmolality (Posm) was 342.2 +/- 11.4 mOsm/kg H2O, and hematocrit, serum protein, and blood urea nitrogen were also elevated at hospitalization. Circulating blood volume was decreased by approximately 21% as compared with that on day 7. Plasma AVP level was increased to 8.5 +/- 1.6 pmol/l at hospitalization. When hyperglycemia was improved by iv infusion of a small dose of insulin plus fluid administration, plasma AVP level promptly decreased to 2.4 +/- 0.4 pmol/l within six hours. When plasma AVP level had normalized, Posm was still as high as 305 mOsm/kg H2O, but the loss of circulating blood volume was only 4.2% of the control state. Plasma AVP level was positively correlated with change in hematocrit (plasma AVP = 3.58 + 0.45.hematocrit, r = 0.468, p less than 0.01), serum protein (r = 0.487, p less than 0.01), Posm (r = 0.388, p less than 0.01), and blood glucose (r = 0.582, p less than 0.01). Plasma AVP level was negatively correlated with the change in circulating blood volume (plasma AVP = 3.6 - 0.14.change in circulating blood volume, r = -0.469, p less than 0.01). These results indicate that both non-osmotic and osmotic stimuli are involved in the mechanism for AVP release in patients with diabetic coma, and that the non-osmotic control of AVP may contribute to circulating homeostasis, protecting against severe blood volume depletion in diabetic patients suffering from hyperglycemia and dehydration.

Adult↗
PubMedDate not supplied

Post-coma disturbance and post-traumatic amnesia as nonlinear predictors of cognitive outcome following severe closed head injury: findings from the Westmead Head Injury Project.

This study sought to identify combinations of early neurological variables which best predict cognitive outcome 12 months after severe head injury. At the time of admission patients were assessed on seven neurological indices. Twelve months later a battery of neuropsychological tests examining recent memory functioning and speed of information processing was administered. Recent memory functioning was best predicted by a combination of post-coma disturbance (PCD; i.e. the duration of post-traumatic amnesia, PTA, minus the duration of coma) and presence of subarachnoid haemorrhage (multiple r = 0.54, p < 0.001). Speed of information processing was best predicted by the duration of PTA (r = 0.35, p < 0.01). However, these conclusions were based on square root transformation of PCD and PTA variables. The success of this transformation in assisting prediction confirms suggestions that the relationship between PTA and cognitive outcome is nonlinear.

Adolescent↗
PubMed1978

[Low doses of insulin--comparison between hyperosmolar nonketotic coma and diabetic ketoacidosis (author's transl)].

The authors present a comparison between the results achieved in the treatment of 11 cases of nonketotic hyperosmolar "coma" and 13 cases of diabetic ketoacidosis using low doses of intramuscular insulin hourly. Surprisingly both, larger amounts of insulin and longer periods were needed to compensate the metabolic disturbance of the nonketotic hyperosmolar "coma" cases when compared to the ketoacidosis ones. The data obtained in this study suggest a possible direct relationship between the initial urea levels and the total amount of insulin needed to reduce the initial glycemia to a normal glycemic level.

Adult↗
PubMed2002

Rehabilitation outcome in a patient awakened from prolonged coma.

BACKGROUND: This article describes the rehabilitation of a patient recovering from a prolonged coma (defined as lasting longer than 4 weeks). The case is noteworthy because it exemplifies the possibilities and difficulties entailed in treating these patients, who are often regarded as too severely impaired to justify intensive rehabilitation efforts. CASE REPORT: The patient is a 28-year old Polish male, unmarried, who suffered serious closed head injuries in an automobile accident in April of 1999. He was in a comatose state for more than two months, with a GCS score of 5. When admitted for rehabilitation he was bedridden, with global aphasia, agraphia, limb apraxia, and executive dysfunction. The rehabilitation program developed for him is described in detail. RESULTS: Over the course of rehabilitation, which began in December 1999 and continues to this writing, the patient has regained locomotion capabilities (though with impairments), and his speech has improved considerably. The apraxia has largely resolved, and he is able to write his name and copy words. He is now capable of performing many activities of daily living. CONCLUSIONS: A comprehensive program of rehabilitation characterized by a strategic, heuristic approach is capable of achieving a good outcome even in very difficult cases, such as prolonged coma.

Accidents, Traffic↗
PubMed1977

[Hyperosmolar nonketotic diabetic coma in children].

Nonketotic hyperosmolar diabetic coma is a rare manifestation of juvenile diabetes, in contrast to adult onset diabetes. To date only 20 cases have been published, the majority of them infants and toddlers. This type of diabetic coma is seen with unusual frequency in children with Down's syndrome and psychomotor retardation. The clinical picture is characterised by severe dehydration, hyperglycemia with often extremely high blood sugar levels, hyperosmolarity and glucosuria without ketonuria. Mortality in children has been high (24%). This paper reports the case of a 14-month-old girl with Down's syndrome. Clinical and therapeutic as well as pathogenetic aspects are discussed.

Diabetic Coma↗
PubMed2006

Status epilepticus caused by a myxoedema coma.

The case of a 63-year-old woman who presented with status epilepticus, coma and hypoventilation is reported. A primary neurological cause was considered. Hypothermia led to further investigations and a diagnosis of severe hypothyroidism. The neurological complications of hyperthyriodism include alteration in mental status with slowness, decreased concentration and lethargy, headache, cranial nerve palsies, dysarthria, hoarseness, myopathy, neuropathy, reflex changes, ataxia, and psychotic episodes. Our patient suffered from a rare consequence of severe hypothyroidism presenting with status epilepticus and she died despite treatment. To our knowledge this is the second patient to be reported with myxoedema coma with this kind of presentation. Despite therapeutic options, there is a high mortality rate.

Atrophy↗
PubMed2006

Clinical scales for comatose patients: the Glasgow Coma Scale in historical context and the new FOUR Score.

The Glasgow Coma Scale (GCS) has been the gold standard for assessing the level of consciousness in patients with significant brain injury. Prior efforts to modify or replace this scale have been unsuccessful because no scale could improve on its simplicity and practical usefulness. This review provides a historical perspective on coma scales and introduces a new and simple, but more comprehensive, scale: the Full Outline of UnResponsiveness (FOUR) Score, which has been recently validated. The FOUR Score has 4 components with "4" as a maximal score for each item. The individual components are eye responses (eye opening and eye tracking), motor responses (responses to pain and following simple hand commands), brainstem reflexes (pupil, cornea, and cough reflexes), and respiration (breathing rhythm and respiratory drive in ventilated patients). The FOUR Score is a further improvement on previous scales for classifying and communicating impaired consciousness.

Brain Injuries↗