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PubMed1994

[An uni-dimensional ordinal coma scale].

With the introduction and wide acceptance of the Glasgow coma scale, some progress was made in 1980s. Various types of coma scale were offered from different centers of the world for assessing coma and impaired consciousness. The existing coma scales may be divided into two main categories: (1) multi-dimensional scale, e.g., Glasgow coma scale (GCS), Glasgow-Liege coma scale (G-LCS), Maryland coma scale (MCS); and (2) uni-dimensional scale, e.g., Edinburgh-2 coma scale (E2CS). There is evidence that the uni-dimensional coma scale is better than the multi-dimensional coma scale. The major drawbacks in the multi-dimensional coma scale is the total figure of coma level must be envisaged stereographially. The sum of scores of three dimensions of GCS, as in a multi-dimensional scale, consists of 13 levels from 3 through 15, but the numbers of simple combination constituting each score are considerable. No. 9 in GCS scale may be made up of 18 combinations. E2CS, as an uni-dimensional scale, seems to be an improvement over GCS. On the basis of comparison between two main categories of coma scale and considering the shortcomings of E2CS, a modified uni-dimensional ordinal coma scale called "Chengdu-1 Coma scale" (C1CS) was proposed and applied for evaluating the depth of coma and for prognosticating the patients' outcome. This study was based on 98 acutely head-injured patients treated in the Neurosurgical department of 1st Affiliated Hospital of WCUMS, from October 1983 through May 1984. The follow-up results showed that a good correlation was observed between the score of C1CS and the outcome scale score (Glasgow outcome scale, GOS) of the patients.

Coma↗
PubMed1993

Glasgow Coma Scale score in the evaluation of outcome in the intensive care unit: findings from the Acute Physiology and Chronic Health Evaluation III study.

OBJECTIVE: To investigate the ability of the Glasgow Coma Scale score to predict hospital mortality rate for adult medical-surgical intensive care unit (ICU) patients without trauma. DESIGN: A prospective cohort analysis of adult medical-surgical patients from a nationally representative sample of 40 U.S. hospitals. PATIENTS: 15,973 consecutive, nontraumatic ICU admissions and a comparison group of 687 head trauma admissions. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients' gender, age, treatment location before ICU admission, comorbidities, admission diagnosis, daily physiologic measurements, Glasgow Coma Scale score, Acute Physiology and Chronic Health Evaluation (APACHE III) score, subsequent hospital mortality rate, and unit-specific sedation practices were noted. Hospital mortality rates were stratified by the first ICU day Glasgow Coma Scale score for all admissions. The relationship between the Glasgow Coma Scale score and outcome for two high mortality medical diagnoses (post-cardiac arrest and sepsis) were also examined and compared to the relationship found in patients with head trauma. The Glasgow Coma Scale score on ICU admission had a highly significant (r2 = .922, p < .0001) but nonlinear relationship with subsequent outcome in ICU patients without trauma. Discrimination of patients into high- or low-risk prognostic groups was good, but discrimination in the intermediate levels (Glasgow Coma Scale score of 7 to 11) was reduced. This relationship varied within the operative and nonoperative groups, and also within different disease categories, various age groups, and certain ranges of the Glasgow Coma Scale score. A reduced initial Glasgow Coma Scale score associated with sepsis was a combination of factors associated with a higher mortality rate than that found in patients with head trauma. The proportion of patients who could not be assigned a Glasgow Coma Scale score because of sedation/paralysis varied widely across ICUs. The overall predictive capability of the APACHE III Prognostic Scoring System was improved by incorporating the Glasgow Coma Scale score. CONCLUSIONS: We demonstrated the prognostic importance of admission levels of consciousness as measured by the Glasgow Coma Scale score on ICU and hospital mortality rates. We concluded that the Glasgow Coma Scale score may be used to stratify and predict mortality risk in general intensive care patients, but lack of sensitivity in the intermediate range of Glasgow Coma Scale Score should be noted. Ideally, the Glasgow Coma Scale score should also be applied in the context of other physiologic information and the patient's specific diagnosis. Variation in the use of sedatives in different ICUs means that imputing or substituting a value other than normal for an unobtainable Glasgow Coma Scale score may introduce a substantial treatment bias into subsequent outcome predictions.

Coma↗
PubMed1999

Prediction of the post-comatose motor function by motor evoked potentials obtained in the acute phase of traumatic and non-traumatic coma.

OBJECTIVE: To define the value of electrically elicited motor evoked potentials (MEP), obtained during the initial phase of the coma, for correct prediction of the post-coma motor status. METHODS: Fifty-two patients were investigated by MEP within 72 hours after onset of the coma. It was the aim to correlate the MEP findings to the motor function two months after coma onset. RESULTS: Three patients with normal MEP showed no post-coma motor deficit. In 21 patients, a bilateral, symmetric prolongation of the central motor conduction time (CMCT) was registered. Eighteen of these 21 patients (86%) showed a normal post-coma motor status. In 28 patients, unilaterally absent evoked potential, or unilaterally prolonged CMCT, or bilaterally prolonged CMCT with significant difference in each hemisphere were observed. A post-coma contralateral paresis was found in 25 of these 28 patients (89%). That paresis was functionally important in 15 patients (54%) and functionally unimportant in 13 patients (46%). CONCLUSION: We identified certain MEP patterns (unilateral extinction of the evoked potential, unilateral, bilateral prolongation of the CMCT with significant "side" difference), which indicated a pyramidal tract lesion and a post-coma motor deficit with an accuracy of 89%. This refers to the motor results, which may not be the final post-coma motor results which are usually assessed six months after the coma onset. The MEP changes did not allow one to predict the severity of the paresis. The accuracy of prediction of a motor deficit increased from the MEP finding of unilaterally prolonged CMCT to the MEP finding of unilateral extinction of the potential. The most common finding, bilateral central motor slowing without significant "side" difference, did not indicate a post-coma paresis in 86%, leading to the assumption, that bilateral, symmetrical prolongation of the CMCT was not caused by lesions of the descending motor pathways, but by the drugs administered for treating the comatose patient. In conclusion, MEP allows one to predict the presence of a post-coma motor deficit with a high degree of accuracy already in the initial phase of coma, but MEP fails to predict the severity of that deficit.

Acute Disease↗
PubMed2001

Vigilance scoring in children with acquired brain injury: Vienna Vigilance Score in comparison with usual coma scales.

An instrument in neurologic rehabilitation for the assessment of a person's clarity of consciousness must fulfill the need to provide the rehabilitation team with some information regarding the structuring of the rehabilitation process. The Vienna Vigilance Score is oriented toward cooperation within the rehabilitation team with the specific advantage of focus on the subject status of the patient on the basis of the dialogue. It does not use painful stimuli and is oriented toward the next developmental step of the rehabilitation process. The first extensive application of the Vienna Vigilance Score was carried out in a 3-year study of 38 children and adolescents. We report the comparison with other coma scales (Glasgow Coma Scale, Children's Coma Score, and Modified Glasgow Coma Scale) on 24 children and adolescents (1.4-16.8 years of age). The results showed satisfying statistical parameters: measuring range comparable with other scales; a Kendall tau correlation of .59 on both the Modified Glasgow Coma Scale and the Children's Coma Scale and of .66 on the Glasgow Coma Scale; a Spearman's rank order correlation of .70 to both the Modified Glasgow Coma Scale and the Children's Coma Scale and of .78 on the Glasgow Coma Scale. By accepting the Glasgow Coma Scale as a gold standard for classification of the level of coma, we can confirm satisfactory measuring qualities for the Vienna Vigilance Score.

Adolescent↗
PubMed1989

Sequence and transcription mapping of Bacillus subtilis competence genes comB and comA, one of which is related to a family of bacterial regulatory determinants.

The complete nucleotide sequences of the comA and comB loci of Bacillus subtilis were determined. The products of these genes are required for the development of competence in B. subtilis and for the expression of late-expressing competence genes. The major 5' termini of both the comA and comB transcripts were determined. The inferred promoters of both comA and comB contained sequences that were similar to those found at the -10 and -35 regions of promoters that are used by sigma A-RNA polymerase, the primary form of this enzyme in vegetative cells. The comB gene was located approximately 3 kilobase pairs upstream of the comA gene and encoded a 409-amino-acid protein with a predicted molecular weight of 46,693. The comA locus contained two open reading frames (ORFs) and comB contained one ORF. The predicted amino acid sequence of the comA ORF1 gene product consisted of 214 amino acids, with an aggregate molecular weight of 24,132. The ORF1 product was required for competence, while ORF2, which was cotranscribed with ORF1 and encoded a predicted protein of 126 amino acids, was not. The predicted protein sequence of the comA ORF1 gene product was found to be similar to that of several members of the effector class of procaryotic signal transducers. The C-terminal portion of the predicted comA sequence contained a possible helix-turn-helix motif, which is characteristic of DNA-binding proteins. comA ORF1 was cloned on a multicopy plasmid and was shown to complement the competence-deficient phenotype caused by the comA124 insertion of Tn917lac. Also, the presence of comA ORF1 in multiple copies interfered with sporulation. Anti-peptide antibodies raised to the predicted product of comA ORF1 reacted strongly with a single protein band of about 24,000 daltons in immunoblots. The possible roles of multiple signal transduction systems in triggering the development of competence are discussed.

Amino Acid Sequence↗
PubMed1983

[Causes and diagnostic criteria of hepatic coma--an analysis of 560 cases].

560 patients with hepatic coma were treated during the years 1958 to 1982 in Homburg and Bad Kissingen . 82 patients had an endogeneous and 478 an exogeneous hepatic coma. Endogeneous hepatic coma was caused most frequently by fulminant virus hepatitis, intoxication, and hepatorenal syndrome accompanying serum hepatitis. Exogeneous hepatic coma in patients with cirrhosis of the liver was caused in most cases by gastrointestinal bleeding, by a diet too high in protein, or by excessive diuresis. Early clinical symptoms are changes in writing tests and ability to concentrate, whereas hepatic foetor occurs in coma stage III and IV. Clinical chemistry findings pointing to imminent hepatic coma are increase of arterial ammonia in exogeneous hepatic coma, and increase of free phenols in endogeneous hepatic coma. The increase of prothrombin time is prognostic for imminent hepatic coma in both types. Prognosis of endogeneous hepatic coma is still rather bad; 87% of the patients suffering from it died; in exogeneous hepatic coma prognosis has improved for stage I and II in the last 23 years, whereas however the total prognosis for all 4 stages is still unchanged, letality being 55%.

Adult↗
PubMed2003

Accumulation of triglycerides in the proximal tubule of the kidney in diabetic coma.

AIMS: The present study was initiated by a very recent histochemical observation of lipid accumulation in the renal cortex of a woman who died in a diabetic coma. Two older reports of lipid accumulation in the kidneys of patients who died, most likely in a state of non-regulated diabetes, supported this observation. We have examined whether lipid accumulation in the renal cortex is characteristic of diabetic coma and, if so, which type of lipid accumulates. METHODS: Three groups were studied. Ten subjects who died in a diabetic coma, eight diabetics who died of known causes unrelated to diabetes, and seven normal control subjects without any diagnosed diabetes who died of known causes. All were subjected to histological examination for lipid accumulation in the renal cortex. Detailed analysis of cortex lipids was performed for two of the subjects who died in a diabetic coma and all diabetic controls as well as non-diabetic control subjects. RESULTS: All subjects who died in a diabetic coma showed vacuolar lesions staining strongly for lipid in the proximal tubules. Neither normal controls nor non-coma diabetics showed these lesions. Compared with normal controls, renal cortex lipid was about tripled in the two analysed diabetic coma subjects due to 60-100-fold increases of triglycerides. The non-coma diabetics did not differ from the other controls with respect to triglycerides or other types of lipid, except that cholesteryl esters were elevated, though still a quantitatively minor component. CONCLUSION: Our findings strongly indicate that vacuolar lesions in the proximal tubules are characteristic of diabetic coma and that they are caused by accumulated triglycerides. Therefore, histological examination of renal cortex using a lipid stain may be a useful forensic tool in establishing diabetic coma as the cause of death.

Adult↗
PubMed1979

Prevalence and prognostic significance of coma after cardiac arrest outside intensive care and coronary units.

In 181 patients resuscitated from cardiac arrest, the prevalence and duration of coma were registered and related to the site of occurrence of cardiac arrest, cardiac rhythm during arrest, age and clinical outcome of the patients. Coma was most frequent after cardiac arrest outside the hospital, as 84% of these patients were comatose for more than 1 h and 56% for more than 24 h; the corresponding values for patients with cardiac arrest in general wards were 63% and 30%, respectively, and for patients with cardiac arrest during ambulance transport, 80% and 44%. Permanent brain damage was extremely rare if the coma lasted less than 6 h (1 out of 62 patients), and relatively rare with a coma duration between 6 and 24 h (5 out of 34 patients). Of the patients, 85 remained comatose for more than 24 h and only 7 of them were discharged alive, all with cerebral impairment of a severity increasing with the duration of the coma. None regained consciousness after more than 7 days' coma, and a total of 80 patients died in coma, 20 with signs of cerebral death. Older patients were more vulnerable to coma than younger ones, but coma as such was not more frequent. We found no differences in coma after asystole and ventricular fibrillation. Problems concerning the selection of patients who have a chance of survival, although comatose after cardiac arrest, are discussed.

Adolescent↗
PubMed2006

The portrayal of coma in contemporary motion pictures.

BACKGROUND: Coma has been a theme of screenplays in motion pictures, but there is no information about its accuracy. METHODS: The authors reviewed 30 movies from 1970 to 2004 with actors depicting prolonged coma. Accurate depiction of comatose patients was defined by appearance, the complexity of care, accurate cause of coma and probability of awakening, and appropriate compassionate discussion between the physician and family members. Twenty-two key scenes from 17 movies were rated for accuracy by a panel of neurointensivists and neuroscience nurses and then were shown to 72 nonmedical viewers. Accuracy of the scenes was assessed using a Likert Scale. RESULTS: Coma was most often caused by motor vehicle accidents or violence (63%). The time in a comatose state varied from days to 10 years. Awakening occurred in 18 of 30 motion pictures (60%). Awakening was sudden with cognition intact, even after prolonged time in a coma. Actors personified "Sleeping Beauty" (eyes closed, beautifully groomed). Physicians appeared as caricatures. Only two movies had a reasonable accurate representation (Dream Life of Angels and Reversal of Fortune). The majority of the surveyed viewers identified inaccuracy of representation of coma, awakenings, and conversations on the experience of being in a coma, except in 8 of the 22 scenes (36%). Twenty-eight of the 72 viewers (39%) could potentially allow these scenes to influence decisions in real life. CONCLUSIONS: Misrepresentation of coma and awakening was common in motion pictures and impacted on the public perception of coma. Neurologic advice regarding prolonged coma is needed.

Adolescent↗
PubMed1978

Brain monoamines in hepatic encephalopathy and other types of metabolic coma.

Tyrosine (Tyr), tyrosine hydroxylase (TH), tryptophan (Trp), serotonin (5-HT), and 5-hydroxyindole acetic acid (5-HIAA) were assayed spectrofluorometrically and radioenzymatically in various regions of post-mortem brains of human patients with hepatic, uremic, and diabetic coma, liver cirrhosis without coma, and hepatic coma treated with parenteral administration of L-valine, a branched-chain amino acid. The results were as follows: In both hepatic and diabetic coma Tyr was increased as compared to non-comatose cirrhosis and controls, while TH acitivity was within normal limits, indicating sufficient oxygen supply of the brain in both types of coma. Brain DA showed a mild decrease in all types of metabolic coma. Brain Trp was not considerably changed in non-comatose cases of liver cirrhosis and after L-valine treatment of hepatic encephalopathy, but was significantly increased in hepatic coma, with highest elevation in the brainstem tegmentum. Both 5-HT and 5-HIAA were not significantly changed in non-comatose cirrhosis, while a general increase with prevalence for the brainstem was obvious in all types of metabolic coma. After L-valine treatment of hepatic coma, 5-HT levels were usually decreased below control values, while 5-HIAA levels were at or below controls. These results in human post-mortem brains confirm previous CSF and brain findings in experimental and human hepatic and uremic encephalopathies, indicating derangement of brain monoamine neurotransmitter metabolism which is attributed to imbalance of aromatic and branched-chain amino acids in plasma and brain. Increased cerebral 5-HT turnover, particularly in the ascending serotonergic brainstem systems, due to derangement of brain uptake of Trp is suggested to represent an important biochemical substrate of disorders of consciousness in hepatic failure and other types of metabolic encephalopathies. Clinical improvement of hepatic encephalopathy and of the underlying neurotransmitter derangements by administration of L-valine and the possible role of this competitive amino acid on intermediary metabolism and ammonia detoxification are discussed.

Aged↗
PubMed1982

Diffuse axonal injury and traumatic coma in the primate.

Traumatic coma was produced in 45 monkeys by accelerating the head without impact in one of three directions. The duration of coma, degree of neurological impairment, and amount of diffuse axonal injury (DAI) in the brain were directly related to the amount of coronal head motion used. Coma of less than 15 minutes (concussion) occurred in 11 of 13 animals subjected to sagittal head motion, in 2 of 6 animals with oblique head motion, and in 2 of 26 animals with full lateral head motion. All 15 concussioned animals had good recovery, and none had DAI. Conversely, coma lasting more than 6 hours occurred in one of the sagittal or oblique injury groups but was present in 20 of the laterally injured animals, all of which were severely disabled afterward. All laterally injured animals had a degree of DAI similar to that found in severe human head injury. Coma lasting 16 minutes to 6 hours occurred in 2 of 13 of the sagittal group, 4 of 6 in the oblique group, and 4 of 26 in the lateral group, these animals had less neurological disability and less DAI than when coma lasted longer than 6 hours. These experimental findings duplicate the spectrum of traumatic coma seen in human beings and include axonal damage identical to that seen in sever head injury in humans. Since the amount of DAI was directly proportional to the severity of injury (duration of coma and quality of outcome), we conclude that axonal damage produced by coronal head acceleration is a major cause of prolonged traumatic coma and its sequelae.

Acceleration↗
PubMed1992

Limitations of the Glasgow Coma Scale in predicting outcome in children with traumatic brain injury.

OBJECTIVE: To study the hypothesis that, in the absence of an ischemic-hypoxic state, children with severe traumatic brain injury and with unfavorable Glasgow Coma Scale scores may have good recovery. DESIGN: Retrospective, observational, cross-sectional study with factorial design. SETTING: Inpatient population in a university hospital. PATIENTS: Seventy-nine children with traumatic brain injury admitted to the intensive care unit. INTERVENTIONS: All patients received close monitoring and strict control of intracranial pressure (less than 20 mm Hg) and cerebral perfusion pressure (greater than 60 mm Hg). MEASUREMENTS AND RESULTS: Admission Glasgow Coma Scale score, survival, need for cardiopulmonary resuscitation, presence of shock, peak intracranial pressure, duration of coma, Glasgow Outcome Scale score, and the results of neuropsychologic tests were analyzed. Of 79 children, 70 (89%) survived. Although the mortality rate was higher among patients with Glasgow Coma Scale scores of 3 to 5, 14 (64%) of 22 of these children survived. Nonsurvivors had a significantly higher incidence of shock and need for cardiopulmonary resuscitation. Except for two patients who had prolonged hypoxemia, all children, including those with Glasgow Coma Scale scores of 3 to 5, had a satisfactory outcome (Glasgow Outcome Scale scores of 4 or 5). Neuropsychologic outcome was not significantly different in the survivors with Glasgow Coma Scale scores of 3 to 5 and those with Glasgow Coma Scale scores of 6 or more. CONCLUSIONS: A low Glasgow Coma Scale score does not always accurately predict the outcome of severe traumatic brain injury; in the absence of hypoxic-ischemic injury, children with traumatic brain injury and Glasgow Coma Scale scores of 3 to 5 can recover independent function.

Adolescent↗
PubMed2005

A reappraisal of rhythmic coma patterns in children.

OBJECTIVE: This study was designed to determine the prevalence of rhythmic coma patterns in comatose children and to ascertain the prognostic significance of reactive rhythmic coma patterns. METHODS: We retrospectively analyzed and classified electroencephalogram (EEGs) in comatose children between two months and 18 years of age during the period 1996 - 2003 according to modified Young's classification. Outcome at one-year was scored according to the Paediatric Cerebral and Overall Performance Category Scale. Outcomes were compared using Fisher's exact test and Mann-Whitney test. RESULTS: Analysis of 63 electroencephalogram (EEG) records in 38 patients showed rhythmic patterns in 19 records (30.2%; 9 alpha, 4 spindle, 4 theta and 2 beta coma patterns, total number of children = 14). Aetiology and outcome of alpha coma patterns and other rhythmic coma patterns were similar. In five children, one type of rhythmic pattern changed to another. Records with reactive rhythmic coma 66.7% (6/9), were associated with favourable outcome. Sixty percent of the records (6/10 records in seven children) with non-reactive pattern were associated with unfavourable outcome. This clinically significant difference did not reach statistical significance (lower Paediatric Cerebral and Overall Performance Category Scale score p= 0.14; favourable outcome p=0. 19). CONCLUSION: Rhythmic coma patterns in comatose children are not uncommon. Aetiology, reactivity and outcome of individual patterns are similar and thus make the rhythmic coma patterns distinct EEG signatures in comatose children. There was a clinically significant better outcome with reactive rhythmic coma patterns.

Adolescent↗
PubMed1988

Patients' recollections of their posttraumatic coma.

Patients' recollections of posttraumatic coma as viewed retrospectively were explored in this descriptive study. Fifteen patients from two urban north Texas hospitals who incurred traumatic head injury and associated coma (Glasgow Coma Scale score of 8 or less for at least six hours) were interviewed. A set of open-ended questions was developed and utilized in a semi-structured interview with each subject. Data such as age, sex, type of injury, how injury occurred, Glasgow Coma Scale score, and duration of coma were collected. Responses elicited during the interviews were analyzed qualitatively. In this investigation seven subjects reported no recollections of being comatose. Eight were able to relate experiences with three prevailing themes: imprisonment, sensory experiences, and death-like experiences. Four subjects recalled actions perceived as helpful and not helpful while in coma. Recollections of unconsciousness appeared to have been affected by the length of coma but not by the Glasgow Coma Scale score or the type of head injury sustained. These findings reveal patients in coma from a traumatic head injury have a limited degree of awareness of the environment. That awareness should be incorporated into nursing management of the comatose patient in acute and chronic care settings.

Adolescent↗
PubMedDate not supplied

[Alpha coma: clinical, electroencephalographic and aetiological correlation in childhood].

INTRODUCTION: Alpha coma is defined as the appearance, in an unconscious patient, of EEG activity in the alpha frequency band (8-13Hz). OBJECTIVE: To determine, in our setting, the incidence, aetiology, clinical significance and course of alpha coma in paediatric patients and review the literature. PATIENTS AND METHODS: We did a retrospective study of the patients admitted to a paediatric intensive care unit who had alpha activity recorded whilst in coma. RESULTS: Only two patients, aged 5 and 12 years, were found. Both had complex congenital cardiopathy and cardio-respiratory arrest one and twelve days postoperatively, respectively. Several EEGs were done whilst they were in coma. Barbiturate coma was not used. Both had clinical mid-brain involvement during alpha recording. The pattern was bilateral, arreactive and preceded by a theta pattern, appeared two days after the arrest, was maintained for two and three days in the two cases and was followed by delta pattern. The second case finally showed a 'burst-suppression'. The CAT was normal. The patients died 4 and 11 days after the appearance of alpha coma. CONCLUSIONS: Alpha coma is rare in childhood. Both the aetiology and the bad prognosis are similar to that of adults. Alpha coma is a transient EEG pattern occurring during the evolution of coma. We consider it to be due probably to mid-brain involvement.

Adult↗
PubMed1985

Coma at the onset of young insulin-dependent diabetes in Japan. The results of a nationwide survey. Japan and Pittsburgh Childhood Diabetes Research Groups.

The descriptive epidemiology of diabetic coma at onset was investigated in a nationwide survey of insulin-dependent diabetic (IDDM) children (age at onset less than 18 yr) throughout Japan for the years 1970-81. Of the 1172 cases, 148 (12.6%) were unconscious at onset. Diabetic coma was highly associated with abnormalities in the biochemical variables. There was no sex difference in the frequency of coma; however, there was an inverse association with age wherein children under 5 yr of age were approximately two times more likely to present in coma than older children. There was a strong association with reported infections wherein patients with coma were more than twice as likely to report infection than patients without coma. It seemed that the frequency of coma did not decline during the study period. The risk of dying at onset was very high; diabetic children in coma (4.7%) were 12 times more likely to die than patients without coma.

Adolescent↗
PubMed1993

[Myxedema coma as a rare postoperative complication].

Myxedema coma is characterized by severe lack of thyroid hormones, unconsciousness and serious restriction of vital functions. The mortality rate still ranges between 50 and 80%. In patients with inapparent hypothyroidism myxedema coma occasionally follows surgery, anesthesia or severe infection. A case of myxedema coma following surgery is reported. CASE REPORT. A 46-year-old woman was anesthesized for hip replacement. The intraoperative cardiovascular situation was characterized by hypotension and tachycardia. On the first postoperative day, unexpectedly a cardiac arrest occurred. Resuscitation with high doses of epinephrine was successful. There was no evidence of myocardial infarction, hypoxia and pulmonary embolism as causative factors for cardiac arrest. A pulmonary artery catheter was inserted and showed low cardiac output. Catecholamines and intravascular fluids were administered without hemodynamic improvement. In the next 5 days pneumonia was followed by ARDS and acute renal failure. After successful treatment of these complications the patient remained in deep coma. An intracerebral disease could be excluded by computerized tomography. Evaluation showed low thyroid hormones (T3; T4) and elevated TSH. The diagnosis of a myxedema coma was assumed. After failure of oral therapy with L-thyroxine (0.025-0.05 mg/day) for 10 days, intravenous therapy with 0.5 mg L-thyroxine was performed. Thirty-six hours later the patient regained consciousness, without cardiac complications. The patient progressed uneventfully under oral therapy with 0.1 mg L-thyroxine and was discharged from the hospital 6 weeks later. DISCUSSION. Pathophysiology and symptomatology of a case of postoperative myxedema coma are described (Tables 1-4). In this patient, the following symptoms occurred: low thyroid hormones (T3; T4), elevated TSH, deep coma, decreased ventilatory response to CO2, diminished myocardial contractility under catecholamine stimulation, impaired renal water excretion. After failure of oral substitution of L-thyroxine, intravenous therapy had to be performed in spite of the high risk of further cardiac complications in this patient. This led to complete recovery with normal neuropsychological and cardiopulmonary parameters. CONCLUSION. Myxedema coma is a rare complication in postoperative care, but in cases of inexplicable unconsciousness thyroid failure should be excluded. If myxedema coma is evident, intravenous therapy with L-thyroxine should be performed under the conditions of extended monitoring.

Coma↗
PubMed1977

[Hepatic coma--causes, recognition, treatment].

The name of the disease coma hepaticum is a collective notion for etiologically, pathologo-anatomically and biochemically different kinds of a failure of the function of the liver. A demarcation of different forms of the liver coma is necessary above all for prognostic and therapeutic reasons: hepatic disintegration coma, coma in hepatic failure, mixed coma, false hepatic coma, ferment block coma. Despite certain progress the therapeutic possibilities in hepatic coma cannot satisfy in recent years. Also the use of different, partly very expensive methods of the so-called liver substitute (exchange function and plasmapheresis, heterologous and homologous extracorporal liver perfusion, parasymbiotic crossed circulation, haemoperfusion with encapsulated activated charcoal, liver transplantation) up to now did not lead to a decisive improvement of the nearly infaust prognosis of the hepatic disintegration coma. Therefore preventing measures and careful control of endangered patients deserve particular attention.

Anti-Bacterial Agents↗