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PubMed1995

Comparison of APACHE III, II and the Glasgow Coma Scale for prediction of mortality in a neurosurgical intensive care unit.

OBJECTIVES: This study examined the efficacy of predicting power for hospital mortality of three different scoring systems in a neurosurgical intensive care unit (NICU). SETTING: An eight-bed NICU in a 1,270-bed medical centre (Taichung Veterans General Hospital). SUBJECTS: Two hundred patients with head injury, brain tumour, hypertensive intracerebral haemorrhage, rupture of aneurysm or arteriovenous malformation, or other categories were included in our study in a consecutive period of 14 months. Patients less than 14 years old were not included. DESIGN: On the first day of admission, data were collected from each patient to compute the Acute Physiology and Chronic Health (APACHE) II and III, and Glasgow Coma Scale (GCS) scores. Hospital mortality was defined as when death occurred before discharge from hospital. INTERVENTIONS: none. MEASUREMENTS: Sensitivity, specificity and correct prediction outcomes were measured by logistic regression in three scoring systems. The Youden index was also obtained. The best cutoff point in each scoring system was determined by logistic regression or by the Youden index. Data obtained by logistic regression were compared by McNemar's test. The differences in Youden index were calculated by the Student's t-test. The area under the Receiver Operating Characteristic (ROC) curve was computed and the area of each scoring system was then compared by the Wilcoxon Mann-Whitney test. MAIN RESULTS: The correct prediction of outcome was 85.5% in APACHE III, 77.5% in APACHE II and 75.0% in GCS. The area under the Receiver Operating Characteristic (ROC) curve was 0.892 in APACHE III, 0.826 in APACHE II and 0.868 in GCS. For the prediction of dead patients at the best cutoff point, APACHE III and GCS were better than APACHE II, (both p < 0.01 respectively). For the prediction of alive patients at the best cutoff point, APACHE III was better than GCS and APACHE II (p < 0.01 respectively). CONCLUSION: The APACHE III system seems to be the most reliable. The results reveal that the APACHE III system is better in predicting power for hospital mortality than either the GCS or APACHE II systems in our NICU patients.

APACHE↗
PubMed1975

[The EEG during post-traumatic coma (author's transl)].

With traumatic coma, the underlying pathomorphology may vary and it may not always be possible to establish it. Possible organic lesions are contusions of brain, oedema, intracranial haematoma, fat embolism, or an open brain injury. On the other hand there may be no organic lesions, as for instance in concussion. In every case, the leading clinical symptom is alteration of consciousness. This arises through interference, at some point, with the reticulo-thalamocortical system which is responsible for the regulation of consciousness. Concurrently with the alteration of consciousness, the EEG also shows changes. At the same time, the EEG is affected by the other effects of trauma upon the brain. Becuase of this, this EEG is not exclusively determined by the degree of unconsciousness. The possible causes of traumatic unconsciousness, and of the pathological waves seen in such cases, cannot always be established in clinical medicine, and experimental studies particularly with regard to neurophysiology are required to explain them....

Adult↗
PubMedDate not supplied

The Glasgow Coma Scale in clinical practice: a critique.

Nurses need to be able to assess a patient's neurological state and record changes in this status over time. One instrument for classifying neurological status is the Glasgow Coma Scale (GCS). Its use is now widespread, although it has not been validated. This article describes the weaknesses of this method and points to an alternative.

Glasgow Coma Scale↗
PubMed1999

Coma.

Comatose patients are unresponsive to all external stimuli, noxious or otherwise. Neuro-ophthalmic techniques are paramount in the neurologic assessment of comatose patients, especially with regard to brain stem localization and diagnosis. Examination of the pupils, fundi, and corneal reflexes are all helpful; however, the ocular motility examination is especially important because the pathways governing ocular motility traverse the entire brain stem, so pathology in this region often produces recognizable eye movement abnormalities. Conversely, if the eye movements are all normal, it is likely that the entire brain stem is normal. This article details the pupillary, eye movement, and funduscopic abnormalities in coma.

Coma↗
PubMed1999

Acute isoniazid intoxication: seizures, acidosis and coma.

Isoniazid (INH) is the most widely used of the antituberculosis drugs. An acute overdose is potentially fatal and is characterized by the clinical triad of repetitive seizures unresponsive to the usual anticonvulsants, metabolic acidosis with a high anion gap and coma. The diagnosis of INH overdose should be considered in any patient who presents with an unexplained metabolic acidosis and convulsions. The cornerstone of therapy consists in pyridoxine (vitamin B6) and the dose should be equal to the amount of INH ingested. When conservative therapy fails or in case of renal insufficiency, dialysis must be considered. Severe central nervous toxicity can also be caused by chronic ingestion of higher than therapeutic doses of INH. In those cases pyridoxine-therapy can be useful as well. In the present paper a case of acute overdose of INH is reported, followed by a review of the literature.

Acidosis↗
PubMedDate not supplied

A case of hyperosmolar nonketotic coma occurring during chemotherapy using cisplatin for gallbladder cancer.

A 61 year-old woman was admitted to our hospital because of an abdominal tumor. She was diagnosed with recurrent gallbladder cancer, and treated with cisplatin (CDDP). On day 6, after the 1st cycle of chemotherapy, she developed confusion and suddenly became comatose. She was diagnosed as having hyperosmolar nonketotic coma (HNC) on day 7. She had no history of diabetes mellitus. She recovered from HNC after 3 days of treatment with continuous infusion of 0.45% saline and moderate amounts of insulin. HNC may be a complication of CDDP chemotherapy in patients with malignancy. Early diagnosis and appropriate treatment is necessary for HNC occurring during chemotherapy for malignant disease.

Antineoplastic Agents↗
PubMed2000

[Sudden-onset coma revealing neurosarcoidosis].

BACKGROUND: Central nervous system involvement is uncommon in sarcoidosis, particularly in cases discovered in circumstances described in our case. CASE REPORT: A 38-year-old man with a history of pulmonary sarcoidosis diagnosed in 1991 was treated by budesonide. The clinical course was generally favorable until 1995 when the patient complained of rapid onset headache which suddenly progressed to coma. The patient died 26 days later. DISCUSSION: The course of the neurological manifestations was remarkable in this case of neurosarcoidosis. The anatomic localization was also unusual with 3 distinct foci outside the central nervous system.

Adult↗
PubMed2000

[Phenobarbital coma for psychogenic status epilepticus].

Among patients seen for epileptic seizures, there is a subgroup of those who do not have epilepsy but suffer from psychogenic paroxysmal events which mimic epileptic seizures. The differential diagnosis between them is of the utmost importance, as incorrect diagnosis of seizures subjects the patient to incorrect management. In the case psychogenic status epilepticus, the treatment may endanger the patient. We report 3 women, aged 20, 20 and 28 and a man aged 24 with psychogenic status epilepticus admitted to an intensive care unit and treated by induction of phenobarbital coma when other antiepileptic medication failed.

Adult↗
PubMed1975

[Circulatory survival of irreversible comas].

On the basis of a series of 53 cases of irreversible coma maintained in circulatory survival with the aim of removing the kidneys, the authors discuss the mode of treatment, with particular reference to the intravenous fluids used and the use of medications influencing the circulation. Fluid and electrolytes given must be adjusted hourly to ensure the exact replacement of urinary losses. Isoprotenerol is the only medication usually necessary. In the event of circulatory insufficiency, which is difficult to foresee and hence prevent, immediate volume expansion in a short a time as possible and isoprotenerol most frequently correct the situation (14 out of 17 cases). Thus effective circulation may be maintained until the kidneys are removed (48 out of 53 cases). 92 p.cent of the grafted kidneys functioned from the first day onwards.

Adolescent↗
PubMed2000

Postoperative coma induced by hyponatremia after laparoscopy--a case report.

Hyponatremia is a common clinical entity which may occur during the course of many medical illnesses. However disastrous sequelae or even death may develop in young, generally healthy patients who receive simple elective surgery. Here we present a case of a 34-year-old female, without past history of cardiopulmonary or renal disease, after undergoing laparoscopic surgery developed mental status changes and lapsed into coma on the second postoperative day. She was found to have a serum sodium level of 110 mEq/L. After careful treatment and a protracted hospital stay, the patient recovered uneventfully. The pathophysiology of postoperative hyponatremia is discussed and attention is called to the special vulnerability of menstruant women who carry a much increased risk of mortality and morbidity associated with hyponatremia.

Adult↗
PubMed1975

Hypoglycemic coma associated with benign pleural mesothelioma.

A case of hypoglycemic coma and benign pleural mesothelioma is described. Serum insulin levels, as measured by insulin radioimmunoassay, were appropriately suppressed and consistent with hypoglycemia. Assay of the tumor showed insulin to be undectable. The mechanisms for hypoglycemia probably included increased glucose consumption by the tumor and, more important, the inhibition of lipolysis and hepatic gluconegenesis caused by tumor release of L-tryptophan and its metabolites and/or possibly nonsuppressible insulin-like activity, soluble in acid-ethanol(NSILA-s).

Coma↗
PubMed2000

[Nursing intervention in the case of coma concerning the patient and his family].

This article presents a standardized treatment plan for the first few weeks an adult is in coma, after the acute phase, as a practical guide clarifying the treatment to follow in this process. First, the authors spell out the process to follow. Second, they standardize the characteristics which define persons undergoing these processes. As a fundamental aspect, the authors highlight the importance to work under treatment conditions which the patient and his/her family must confront so as to provide a standard preventive treatment for these problems. Nursing diagnoses are viewed as prevalent. The treatment situations and the diagnoses which enter in this study fall under the V. Henderson model.

Adult↗
PubMed2001

Prolonged coma and loss of brainstem reflexes following amitriptyline overdose.

Severe tricyclic antidepressant (TCA) overdose is generally manifested by cardiovascular and/or central nervous system toxicity. Although the majority of patients who are comatose following these overdoses regain consciousness within 24 h, this case had 5-days of coma with associated loss of brainstem reflexes. Severe central nervous system depression can occur as a sole manifestation of TCA overdose without concomitant cardiovascular toxicity.

Adult↗
PubMedDate not supplied

Hypercapnic coma due to diaphragmatic involvement in a patient with dermatomyositis.

We report an acute respiratory distress by diaphragmatic involvement due to dermatomyositis. A fifty year-old patient with typical dermatomyositis presented an acute respiratory insufficiency with hypercapnic coma due to diaphragmatic muscle involvement. Respiratory state required mechanical ventilation initially and improved secondarily gradually upon corticosteroids and intravenous immunoglobulins. Only few cases of acute respiratory distress in dermatomyositis due to respiratory muscle involvement are reported in literature.

Coma↗
PubMed2001

[Septicemia of dental origin and post-extraction coma. Apropos of 3 cases].

The authors report 3 cases of septicaemia and coma post dental extraction. These 3 patients had dental extraction in the same confessional dental clinic. After these acts the situation were so severe and they came to central hospital in Yaounde. Infections from dental origin proven by blood culture necessitate an early antibiotherapy and treatment, which propriate and sustain, but adapted to the antibiogram. The streptococcus of group F and Klebsiella pneumonia were challenged. One of the cases was negative. The presence of common signs (fever, tachycardia, chill) need the search for a secondary localisation which can be determine by X-ray.

Adolescent↗
PubMed1975

The late neurological, psychological, and social aspects of severe traumatic coma.

Thirty patients who had survived a heavy head trauma and a post-traumatic coma, lasting for more than one week, were investigated 8 to 14 years after the trauma. The patients have been followed up from a social, psychological, and neurological point of view. Fifty per cent of these patients are considered to be well rehabilitated. All the investigated patients showed slight to severe reduction in mental capacity. Eighty per cent of the patients had neurological defects which were not as important with respect to social rehabilitation as was the mental capacity reduction.

Accidents, Traffic↗
PubMed2001

Pancytopenia, hyperglycemia, shock, coma, rhabdomyolysis, and pancreatitis associated with acetaminophen poisoning.

It is well recognized that acetaminophen overdose can cause severe hepatic injury. However, extra-hepatic manifestations may also develop following inappropriate use or ingestion of large amounts of acetaminophen. We present a 44-y-o female who manifested coma, metabolic acidosis, shock, hypothermia, hyperglycemia, rhabdomyolysis, hepatotoxicity, and renal insufficiency after suicidal ingestion of an unknown amount of acetaminophen. Although her consciousness and hemodynamic status gradually improved after treatment with N-acetylcysteine and other supportive measures, she was found to have pancytopenia, pancreatitis and hepatorenal failure during the hospitalization and eventually died 18 d post-admission. Review of relevant literature reports and the clinical findings in our patient suggests that direct toxic effects mediated by acetaminophen or its metabolites were most likely responsible for most of the observed clinical features.

Acetaminophen↗