The etiology and outcome of non-traumatic coma in critical care: a systematic review

Coma Prevalence in Critical Care Units in Chile: Results of a Cross-Sectional Survey on World Coma Day

BACKGROUND

The purpose of this study was to assess the prevalence of coma among patients in critical care units in Chile. We also aimed to provide insight into the demographic characteristics, etiologies, and complications associated with coma.

METHODS

A single day cross-sectional study was conducted through a national survey of public and private hospitals with critical and intensive cardiac care units across Chile. Data were collected using an online questionnaire that contained questions regarding critically ill patients' information, demographic characteristics, etiology and duration of coma, medical complications, and support requirements.

RESULTS

A total of 84% of all health facilities answered, accounting for a total of 2,708 patients. The overall coma prevalence was 2.9%. The median age of the comatose patients was 61 years (interquartile range 50-72) and 66.2% were male. The median coma duration was five days (interquartile range 2-9). Cerebral hemorrhage was the most common etiology, followed by severe hypoxic-ischemic encephalopathy, acute ischemic stroke, and traumatic brain injury. A total of 48.1% of coma patients experienced acute and ongoing treatment complications, with pneumonia being the most common complication, and 97.4% required support during comatose management.

CONCLUSIONS

This study provides an overview of the prevalence of coma in Chilean critical and cardiac care units. Coma is a common condition. Comatose patients frequently experience medical complications during their hospitalization.

Outcome of non-traumatic coma in a tertiary referral hospital in Cameroon

Introduction

Coma is a medical emergency, and optimal management, especially in a resource-poor setting, depends on knowledge of its aetiology and predictors of outcome. This study aimed to provide hospital-based data on the prevalence, etiology, and outcome of non traumatic coma (NTC) in adults at a tertiary level in Cameroon.

Methods

A three year retrospective cohort study of medical records of patients aged 18 years and above, who presented in coma of non-traumatic origin at a Cameroon emergency department (ED) was conducted. Data related to sociodemographic, clinical findings, investigations, etiology of the coma, and outcomes were collected.

Results

A total of 408 patients were recruited, 214 (52.5 %) were males. The mean age was 55.9 ± 16.6 years. NTC accounted for 2.2 % of all consultations at the ED during the period of study. Stroke (29.6 %), infections (19.8 %), and metabolic disorders (12.6 %) were the most frequent cause of NTC. Etiology was unknown in 23.3 % of our participants. The in-hospital mortality was 66.4 %. Duration of hospitalization ≤ 3 days, GCS 〈 6, serum creatinine level 〉 13 mg/L, and administration of adrenergic drugs were predictors of mortality. Overall survival rate was 44.3 % after 5 days of admission.

Conclusion

Non-traumatic coma had various aetiologies. Stroke accounted for almost one third of cases. About three out of five patients died in hospital. Deep coma, high serum creatinine level, short hospital stay and administration of adrenergic medications were independent predictors of mortality.

A nomogram based on quantitative EEG to predict the prognosis of nontraumatic coma patients in the neuro-intensive care unit

OBJECTIVE

We aimed to establish a quantitative electroencephalography-based prognostic prediction model specifically tailored for nontraumatic coma patients to guide clinical work.

METHODS

This retrospective study included 126 patients with nontraumatic coma admitted to the First Affiliated Hospital of Chongqing Medical University from December 2020 to December 2022. Six in-hospital deaths were excluded. The Glasgow Outcome Scale assessed the prognosis at 3 months after discharge. The least absolute shrinkage and selection operator regression analysis and stepwise regression method were applied to select the most relevant predictors. We developed a predictive model using binary logistic regression and then presented it as a nomogram. We assessed the predictive effectiveness and clinical utility of the model.

RESULTS

After excluding six deaths that occurred within the hospital, a total of 120 patients were included in this study. Three predictor variables were identified, including APACHE II score [39.129 (1.4244-1074.9000)], sleep cycle [OR: 0.006 (0.0002-0.1808)], and RAV [0.068 (0.0049-0.9500)]. The prognostic prediction model showed exceptional discriminative ability, with an AUC of 0.939 (95 % CI: 0.899-0.979).

CONCLUSION

A lack of sleep cycles, smaller relative alpha variants, and higher APACHE II scores were associated with a poor prognosis of nontraumatic coma patients in the neurointensive care unit at 3 months after discharge.

CLINICAL IMPLICATION

This study presents a novel methodology for the prognostic assessment of nontraumatic coma patients and is anticipated to play a significant role in clinical practice.

GFAP point-of-care measurement for prehospital diagnosis of intracranial hemorrhage in acute coma

BACKGROUND

Prehospital triage and treatment of patients with acute coma is challenging for rescue services, as the underlying pathological conditions are highly heterogenous. Recently, glial fibrillary acidic protein (GFAP) has been identified as a biomarker of intracranial hemorrhage. The aim of this prospective study was to test whether prehospital GFAP measurements on a point-of-care device have the potential to rapidly differentiate intracranial hemorrhage from other causes of acute coma.

METHODS

This study was conducted at the RKH Klinikum Ludwigsburg, a tertiary care hospital in the northern vicinity of Stuttgart, Germany. Patients who were admitted to the emergency department with the prehospital diagnosis of acute coma (Glasgow Coma Scale scores between 3 and 8) were enrolled prospectively. Blood samples were collected in the prehospital phase. Plasma GFAP measurements were performed on the i-STAT Alinity® (Abbott) device (duration of analysis 15 min) shortly after hospital admission.

RESULTS

143 patients were enrolled (mean age 65 ± 20 years, 42.7% female). GFAP plasma concentrations were strongly elevated in patients with intracranial hemorrhage (n = 51) compared to all other coma etiologies (3352 pg/mL [IQR 613-10001] vs. 43 pg/mL [IQR 29-91.25], p < 0.001). When using an optimal cut-off value of 101 pg/mL, sensitivity for identifying intracranial hemorrhage was 94.1% (specificity 78.9%, positive predictive value 71.6%, negative predictive value 95.9%). In-hospital mortality risk was associated with prehospital GFAP values.

CONCLUSION

Increased GFAP plasma concentrations in patients with acute coma identify intracranial hemorrhage with high diagnostic accuracy. Prehospital GFAP measurements on a point-of-care platform allow rapid stratification according to the underlying cause of coma by rescue services. This could have major impact on triage and management of these critically ill patients.

Effectiveness of coma arousal therapy on patients with disorders of consciousness - A systematic review and meta-analysis

BACKGROUND

Disorders of consciousness (DOC) incorporate stages of awareness and arousal. Through coma arousal therapy sensory deprivation experienced by patients with DOC can be mitigated. Nevertheless, consensus concerning its effectiveness on these patients is still fractional.

PURPOSE

This review aims to investigate the effectiveness of coma arousal therapies on patients with DOC.

METHODS

A meta-analysis was performed by searching electronic databases using search terms, the studies investigating the effect of coma arousal therapy in patients with DOC using the Coma Recovery Scale-Revised and Glasgow Coma Scale as outcome measures were included. The risk of bias was assessed, using Cochrane and Joanna Briggs Institute critical appraisal tools. Further, analysis was conducted for the included studies.

RESULTS

Out of 260 studies, 45 trials were reviewed and assessed for bias, with 31 studies included for analysis. The analysis demonstrates a significant difference in pre- and post - sensory stimulation, vagus nerve stimulation, transcranial magnetic stimulation, and transcranial direct current stimulation. Sensory stimulation showed the greatest mean difference of -4.96; 95% CI = -5.76 to - 4.15. The patients who underwent intervention after 3 months of illness showed significant improvement.

CONCLUSION

The result shows that sensory stimulation, transcranial magnetic stimulation, and transcranial direct stimulation can improve behavioral outcomes of patients with DOC, wherein sensory stimulation is found to be more effective.

Etiologies and factors associated with mortality in patients with non-traumatic coma in a tertiary hospital in Bukavu, eastern Democratic Republic of the Congo

Non-traumatic coma (NTC) is a common medical condition often associated with poor outcomes. Identifying underlying causes is crucial for effective management and prognostication, particularly in resource-poor settings. This study aimed to identify the most common causes and prognostic factors of NTC in a tertiary hospital in Bukavu, in the eastern Democratic Republic of the Congo (DRC), using the Glasgow Coma Scale (GCS) as well as other simple and affordable clinical and paraclinical tools. This retrospective observational study included 219 consecutive patients admitted to the intensive care unit of the Provincial General Hospital of Bukavu between January 2016 and December 2018. Sociodemographic, clinical, and laboratory data were also collected. Bivariate and multivariate analyses were performed to identify different causes and factors associated with poor outcomes in these patients. The median age of the patients was 49 (interquartile range [IQR]: 33-61) years, and they were predominantly men (62.8%). The most common causes of NTC were stroke (25.7%), acute metabolic complications of diabetes (21.9%), and primary brain infections (meningoencephalitis, 16.0%; and cerebral malaria, 14.2%). The NTC-related in-hospital mortality rate was 35.2%. A high mortality was significantly and independently associated with a GCS<7 (adjusted odds ratio [OR]: 4.30, 95% confidence interval [CI]: 1.73-10.71), the presence of meningismus at clinical evaluation (adjusted odds ratio [aOR] 3.86, 95%CI: 1.41-10.55), oxygen saturation <90% (aOR 3.99, 95%CI: 1.71-9.28), the consumption of traditional herbal medicines prior to hospital admission (aOR 2.82, 95%CI: 1.16-6.86), and elevated serum creatinine (aOR 1.64, 95%CI: 1.17-2.29). In conclusion, clinical neurological examinations, along with simple and affordable paraclinical investigations, can provide sufficient information to determine the etiology of NTC and evaluate the prognosis of comatose patients, even in resource-poor settings. Physicians may use the GCS as a simple, reliable, and affordable tool to identify patients who require special attention and care.

Survey study of the etiology of non-traumatic altered consciousness in the Emergency Department at Suez Canal University Hospital in Egypt

BACKGROUND

Disorders of consciousness including coma in non-trauma patients can be caused by a wide variety of pathologies affecting the central nervous system. They represent a frequent challenge in emergency medicine and are combined with a very high in-hospital mortality. Hence, early treatment of these patients is vital and increases the likelihood of a good outcome.

AIM

To identify the causes of altered consciousness presentation to the Emergency Department at Suez Canal University Hospital.

METHODS

This was a descriptive cross-sectional study conducted on 87 patients with acute non-traumatic disturbed level of consciousness (DLOC) at the Emergency Department.

RESULTS

The mean age of the studied patients was 60.5 ± 13.6 years. Among them, 60% were males and 40% were females. The most common cause of acute non-traumatic DLOC was systemic infection, such as sepsis and septic shock (25.3%), followed by respiratory causes (24.1%) and neurological causes (18.4%).

CONCLUSION

The most common cause of acute non-traumatic DLOC was systemic infections followed by respiratory and neurological causes.

Etiology and clinical characteristics of patients with severely impaired consciousness in prehospital settings: A retrospective study

Aim

To examine the causes of patients with severely impaired consciousness and the clinical characteristics in prehospital settings that are useful for differential diagnosis, especially stroke.

Methods

We retrospectively examined patients aged ≥16 years with Japan Coma Scale III-digit codes during paramedic contact and transported to our hospital between January 2018 and December 2018. Furthermore, we examined background and physical findings of patients at final diagnosis, and also examined factors associated with stroke.

Results

Overall, 227 patients were included in this study. One hundred and twelve patients (49.3%) were male, and the median age was 71 years (interquartile range, 50-83 years). Stroke was the most common cause (30%). Intoxication and psychiatric disorders were significantly more common in younger patients (p < 0.01). Systolic blood pressure was the highest in patients with stroke. Mortality was the highest in stroke (55.9%). Systolic blood pressure, airway compromise, and ocular abnormalities were factors associated with stroke, with odds ratios of 1.03 (95% confidence interval [CI], 1.02-1.04), 6.88 (95% CI, 3.02-15.64), and 3.86 (95% CI, 1.61-9.27), respectively.

Conclusion

Stroke was the most common cause of severely impaired consciousness. Age could be a useful indicator to consider intoxication and psychiatric disorders. Systolic blood pressure, airway compromise, and ocular abnormalities were factors associated with stroke in the prehospital setting.

Development and validation of a novel poisoning agitation-sedation score for predicting the need for endotracheal intubation and mechanical ventilation in acutely poisoned patients with disturbed consciousness

BACKGROUND

Accurate assessment of disturbed consciousness level (DCL) is crucial for predicting acutely poisoned patients' outcomes.

AIM

Development of a novel Poisoning Agitation-Sedation Score (PASS) to predict the need for endotracheal intubation (ETI) and mechanical ventilation (MV) in acutely poisoned patients with DCL. Validation of the proposed score on a new set of acutely poisoned patients with DCL.

METHODS

This study was conducted on 187 acutely poisoned patients with DCL admitted to hospital from June 2020 to November 2021 (Derivation cohort). Patients' demographics, toxicological data, neurological examination, calculation of the Glasgow Coma Scale (GCS), Full Outline of Unresponsiveness (FOUR) score, Richmond Agitation-Sedation Scale (RASS), and outcomes were gathered for developing a new score. The proposed score was externally validated on 100 acutely poisoned patients with DCL (Validation cohort).

RESULTS

The PASS assessing sedation consists of FOUR (reflexes and respiration) and GCS (motor) and provides a significantly excellent predictive power (AUC = 0.975) at a cutoff ≤9 with 100% sensitivity and 92.11% specificity for predicting the need for ETI and MV in sedated patients. Additionally, adding RASS (agitation) to the previous model exhibits significantly good predictive power (AUC = 0.893), 90.32% sensitivity, and 73.68% specificity at a cutoff ≤14 for predicting the need for ETI and MV in disturbed consciousness patients with agitation.

CONCLUSION

The proposed PASS could be an excellent, valid and feasible tool to predict the need for ETI and MV in acutely poisoned disturbed consciousness patients with or without agitation.

A multicenter study of altered level of consciousness in the emergency room

New-onset altered level of consciousness (ALC) is a challenge in real-world clinical practice. Although its presentation is nonspecific and its etiology is intricate, the term ALC is frequently used in the emergency room (ER). This study aimed to clarify and classify the etiologies and outcomes of the ALC in the ER. We retrospectively investigated ALC patients in the ER of four tertiary referral centers from February 2018 to January 2020. The etiology of ALC was comprehensively analyzed by a consortium of university professors, board-certified clinicians in neurology, emergency medicine, or internal medicine. The time point to determine the etiology of ALC was at the time of discharge from the ER. A total of 315,526 patients who visited ER due to ALC were reviewed and found 7988 eligible patients, of which 4298 (53.8%) were male and 5282 (66.1%) were older than 60. The overall mortality was 13.5%. Except undetermined, the 9 etiologies (n = 7552) were categorized into extra- (n = 4768, 63.1%) or intracranial etiology (n = 2784, 36.9%). The most common etiology of ALC in the ER was metabolic cause (n = 1972, 24.7%), followed by systemic infection (n = 1378, 17.3%). The majority of ALC in the ER was derived from extracranial etiology. ALC in the ER is a neurological manifestation of diverse etiologies; not all can be confirmed in the ER. Not only neurological but also critical systemic illnesses should be considered to assess the protean manifestations of ALC in the ER.

The validity, reliability and feasibility of four instruments for assessing the consciousness of stroke patients in a neurological intensive care unit compared

Background

Early rehabilitation is the foundation for recovery for those admitted to an intensive care unit. Appropriate assessment of consciousness is needed before any rehabilitative intervention begins.

Methods

This prospective study compared the validity, reliability and applicability of the sedation-agitation scale, the Richmond Agitation-Sedation Scale, the motor activity assessment scale and the Glasgow Coma Scale in a working neurological intensive care unit. Eighty-three stroke patients were assessed with the four scales by the same 3 raters acting independently: a senior physician, a senior therapist and a trainee. That generated 996 assessment records for comparison.

Results

Good agreement (r=0.98–0.99) was found among the sedation-agitation scale, the Richmond Agitation-Sedation Scale, the motor activity assessment scale scores, but the Glasgow Coma Scale ratings correlated less well (r=0.72–0.76) with the others. Consistent results were also found among the three raters. After stratification of the ratings by age, gender, level of consciousness and Acute Physiology and Chronic Health Evaluation score, the scales reported significant differences among the levels of consciousness and among those with different Acute Physiology and Chronic Health Evaluation results, but not with different age or gender strata.

Conclusions

The four instruments tested are all reliable enough and feasible for use as a tool for consciousness screening in a neurological intensive care unit.

A retrospective cohort study on association of age and physician decision making for or against rapid sequence intubation in unconscious patients

In unconscious individuals, rapid sequence intubation (RSI) may be necessary for cardiopulmonary stabilisation and avoidance of secondary damage. Opinions on such invasive procedures in people of older age vary. We thus sought to evaluate a possible association between the probability of receiving prehospital RSI in unconsciousness and increasing age. We conducted a retrospective study in all missions (traumatic and non-traumatic) of the prehospital emergency physician response unit in Graz between January 1st, 2010 and December 31st, 2019, which we searched for Glasgow Coma Scale (GCS) below 9. Cardiac arrests were excluded. We performed multivariable regression analysis for RSI with age, GCS, independent living, and suspected cause as independent variables. Of the 769 finally included patients, 256 (33%) received RSI, whereas 513 (67%) did not. Unadjusted rates of RSI were significantly lower in older patients (aged 85 years and older) compared to the reference group aged 50-64 years (13% vs. 51%, p < 0.001). In multivariable regression analysis, patients aged 85 years and older were also significantly less likely to receive RSI [OR (95% CI) 0.76 (0.69-0.84)]. We conclude that advanced age, especially 85 years or older, is associated with significantly lower odds of receiving prehospital RSI in cases of unconsciousness.

Toxic-metabolic encephalopathy in adults: Critical discussion and pragmatical diagnostic approach

Toxic-metabolic encephalopathy (TME) results from an acute cerebral dysfunction due to different metabolic disturbances including medications or illicit-drugs. It can lead to altered consciousness, going from delirium to coma, which may require intensive care and invasive mechanical ventilation. Even if it is a life-threatening condition, TME might have an excellent prognosis if its etiology is rapidly identified and treated adequately. This review summarizes the main etiologies, their differential diagnosis, and diagnostic strategy and management of TME with a critical discussion on the definition of TME.

Aetiology and frequency of coma in Emergency department of the primary healthcare centre

Background/Aim: Coma is the most severe disturbance of consciousness from which the patient cannot wake up and in which there is no verbal and motor response or opening of the eyes. The aim of the research was to establish the frequency of occurrence of coma and the aetiology of coma in the Banja Luka Emergency Department (ED). Also, the goal was to analyse the accuracy of the referral diagnosis and potential factors that can help the doctor in making a correct diagnosis. Methods: A retrospective cross-sectional study was conducted. In the ED database, in the period from January to September 2022, all patients diagnosed with coma have been found. The gender and age of the patient, vital parameters, performed diagnostic methods and therapy were recorded. The referral diagnosis, the department to which the patient was referred, as well as the final diagnosis determined in hospital conditions were recorded. Results: In the period from January to September 2022 there were 95 patients who were diagnosed with coma. The average age of the patients was 67.76 ± 16.56 years, there were 56 (58.9 %) men and 39 (41.1 %) women. Of that number, 41 (43.2 %) patients were diagnosed with hypoglycaemic coma and those patients were treated in the field. Out of 54 patients, 32 (59.3 %) patients had a confirmed referral diagnosis, while 22 (40.7 %) patients had another diagnosis established at the hospital. All patients with suspected intracranial bleeding or stroke were correctly diagnosed and adequately referred, while all patients with a confirmed diagnosis of sepsis and shock were incorrectly referred (ch2 = 30.563, p < 0.001). Conclusion: The most frequent were coma caused by hypoglycaemia and coma caused by brain ischaemia and non-traumatic bleeding, which were adequately recognised and treated and/or referred. Coma caused by sepsis and shock of different aetiology was not recognised as such and was referred to a neurologist, where precious time was wasted. In order to reduce errors in the field, it is necessary to pay more attention to the anamnestic data on diseases and perform a somatic and neurological examination adequately.

Withholding or withdrawing life support in long-term neurointensive care patients: a single-centre, prospective, observational pilot study

PURPOSE

Scarce evidence exists regarding end-of-life decision (EOLD) in neurocritically ill patients. We investigated the factors associated with EOLD making, including the group and individual characteristics of involved healthcare professionals, in a multiprofessional neurointensive care unit (NICU) setting.

MATERIALS AND METHODS

A prospective, observational pilot study was conducted between 2013 and 2014 in a 10-bed NICU. Factors associated with EOLD in long-term neurocritically ill patients were evaluated using an anonymised survey based on a standardised questionnaire.

RESULTS

8 (25%) physicians and 24 (75%) nurses participated in the study by providing their 'treatment decisions' for 14 patients at several time points. EOLD was 'made' 44 (31%) times, while maintenance of life support 98 (69%) times. EOLD patterns were not significantly different between professional groups. The individual characteristics of the professionals (age, gender, religion, personal experience with death of family member and NICU experience) had no significant impact on decisions to forgo or maintain life-sustaining therapy. EOLD was patient-specific (intraclass correlation coefficient: 0.861), with the presence of acute life-threatening disease (OR (95% CI): 18.199 (1.721 to 192.405), p=0.038) and low expected patient quality of life (OR (95% CI): 9.276 (1.131 to 76.099), p=0.016) being significant and independent determinants for withholding or withdrawing life-sustaining treatment.

CONCLUSIONS

Our findings suggest that EOLD in NICU relies mainly on patient prognosis and not on the characteristics of the healthcare professionals.

Eastern Equine Encephalitis: Case Series in Southern New England and Review of the Literature

Purpose of Review

To describe the clinical presentation, diagnosis, management, and outcomes of 4 confirmed Eastern equine encephalitis (EEE) cases and a review of the literature.

Recent Findings

There was a sharp rise in the number of EEE cases in the United States in 2019, with 38 confirmed cases and 15 deaths. Our institution cared for 10% of patients with neuroinvasive EEE nationwide. These were the first cases seen locally since 2010.

Summary

EEE virus causes one of the most lethal types of arboviral encephalitis in the United States with a mortality of 30%-40%. Manifestations of EEE infections can range from mild encephalopathy to coma. Common findings include CSF pleocytosis and involvement of the basal ganglia on MRI. Given the rarity of this disease and nonspecific findings, diagnosis can be challenging, and a high clinical suspicion is important. Management is mainly supportive, and the use of IV immunoglobulin remains controversial. Two of our 4 patients died; these patients had coma within 48 hours, hyponatremia, involvement of bilateral thalami and brainstem, status epilepticus, and severe brain dysfunction in EEG.

Impact on antimicrobial consumption of procalcitonin-guided antibiotic therapy for pneumonia/pneumonitis associated with aspiration in comatose mechanically ventilated patients: a multicenter, randomized controlled study

Background

In comatose patients receiving oro-tracheal intubation for mechanical ventilation (MV), the risk of aspiration is increased. Aspiration can lead to chemical pneumonitis (inflammatory reaction to the gastric contents), or aspiration pneumonia (infection caused by inhalation of microorganisms). Distinguishing between the two types is challenging. We tested the interest of using a decisional algorithm based on procalcitonin (PCT) values to guide initiation and discontinuation of antibiotic therapies in intubated patients.

Methods

The PROPASPI (PROcalcitonin Pneumonia/pneumonitis Associated with ASPIration) trial is a multicenter, prospective, randomized, controlled, single-blind, superiority study comparing two strategies: (1) an intervention group where threshold PCT values were used to guide initiation and discontinuation of antibiotics (PCT group); and (2) a control group, where antibiotic therapy was managed at the physician’s discretion. Patients aged 18 years or over, intubated for coma (Glasgow score ≤ 8), with MV initiated within 48 h after admission, were eligible. The primary endpoint was the duration of antibiotic treatment during the first 15 days after admission to the ICU.

Results

From 24/2/2015 to 28/8/2019, 1712 patients were intubated for coma in the 5 participating centers, of whom 166 were included in the study. Data from 159 were available for intention-to-treat analysis: 81 in the PCT group, and 78 in the control group. Overall, 67 patients (43%) received antibiotics in the intensive care unit (ICU); there was no significant difference between groups (37 (46%) vs 30 (40%) for PCT vs control, p = 0.432). The mean duration of antibiotic treatment during the first 15 days in the ICU was 2.7 ± 3.8 days; there was no significant difference between groups (3.0 ± 4.1 days vs 2.3 ± 3.4 days for PCT vs control, p = 0.311). The mean number of days under MV was significantly higher in the PCT group (3.7 ± 3.6 days) than in controls (2.7 ± 2.5 days, p = 0.033). The duration of ICU stay was also significantly longer in the PCT group: 6.4 ± 6.5 days vs 4.6 ± 3.5 days in the control group (p = 0.043). After adjustment for SAPS II score, the difference in length of stay and duration of mechanical ventilation between groups was no longer significant.

Conclusion

The use of PCT values to guide therapy, in comparison to the use of clinical, biological (apart from PCT) and radiological criteria, does not modify exposure to antibiotics in patients intubated for coma.

Trial registration Clinicaltrials.gov Identifier NCT02862314.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-021-00931-4.

Frequency, clinical presentation and outcome of vigilance impairment in patients with uni- and bilateral ischemic infarction of the paramedian thalamus

Ischemic stroke of the paramedian thalamus is a rare differential diagnosis in sudden altered vigilance states. While efforts to describe clinical symptomatology exist, data on the frequency of paramedian thalamic stroke as a cause of sudden impaired vigilance and on accompanying clinical signs and outcome are scarce. We retrospectively analyzed consecutive patients admitted to a tertiary stroke center between 2010 and 2019 diagnosed with paramedian thalamic stroke. We evaluated frequency of vigilance impairment (VI) due to paramedian thalamic stroke, accompanying clinical signs and short-term outcome in uni- versus bilateral paramedian lesion location. Of 3896 ischemic stroke patients, 53 showed a paramedian thalamic stroke location (1.4%). VI was seen in 29/53 patients with paramedian thalamic stroke and in 414/3896 with any stroke (10.6%). Paramedian thalamic stroke was identified as causal to VI in 3.4% of all patients with initial VI in the emergency department and in 0.7% of all ischemic stroke patients treated in our center. Accompanying clinical signs were detected in 21 of these 29 patients (72.4%) and facilitated a timely diagnosis. VI was significantly more common after bilateral than unilateral lesions (92.0% vs. 21.4%; p < 0.001). Patients with bilateral paramedian lesions were more severely affected, had longer hospital stays and more frequently required in-patient rehabilitation. Paramedian thalamic lesions account for about 1 in 15 stroke patients presenting with impaired vigilance. Bilateral paramedian lesion location is associated with worse stroke severity and short-term outcome. Paying attention to accompanying clinical signs is of importance as they may facilitate a timely diagnosis.

The diagnostic value of the neurological examination in coma of unknown etiology

Background

Identifying the cause of non-traumatic coma in the emergency department is challenging. The clinical neurological examination is the most readily available tool to detect focal neurological deficits as indicators for cerebral causes of coma. Previously proposed clinical pathways have granted the interpretation of clinical findings a pivotal role in the diagnostic work-up. We aimed to identify the actual diagnostic reliability of the neurological examination with regard to identifying acute brain damage.

Methods

Eight hundred and fifty-three patients with coma of unknown etiology (CUE) were examined neurologically in the emergency department following a predefined routine. Coma-explaining pathologies were identified retrospectively and grouped into primary brain pathology with proof of acute brain damage and other causes without proof of acute structural pathology. Sensitivity, specificity and percentage of correct predictions of different examination protocols were calculated using contingency tables and binary logistic regression models.

Results

The full neurological examination was 74% sensitive and 60% specific to detect acute structural brain damage underlying CUE. Sensitivity and specificity were higher in non-sedated patients (87/61%) compared to sedated patients (64%/59%). A shortened four-item examination protocol focusing on pupils, gaze and pyramidal tract signs was only slightly less sensitive (67%) and more specific (65%).

Conclusions

Due to limited diagnostic reliability of the physical examination, the absence of focal neurological signs in acutely comatose patients should not defer from a complete work-up including brain imaging. In an emergency, a concise neurological examination should thus serve as one part of a multimodal diagnostic approach to CUE.

High fever or hypotension predicts non-hypoglycemia in patients with impaired consciousness in prehospital settings

Aim

To evaluate whether vital signs can predict whether hypoglycemia can be eliminated as the cause of impaired consciousness in prehospital settings.

Methods

We extracted the data of patients who underwent blood glucose measurements by paramedics in Kobe City, Japan from April 2015 to March 2019. We used receiver operating characteristic curves and calculated the area under the curve (AUC) to evaluate the validity of the vital signs in distinguishing hypoglycemia. We also calculated stratum-specific likelihood ratios to examine the threshold at which hypoglycemia becomes less likely for each vital sign.

Results

Of the 1,791 patients, 1,242 were eligible for analysis. Hypoglycemia was observed in 324 patients (26.1%). Significant differences in each vital sign were noted between the hypoglycemic and non-hypoglycemic groups. Body temperature was moderately accurate in differentiating between the two groups (AUC, 0.71; 95% confidence interval, 0.68-0.74). Furthermore, in patients with systolic blood pressure <100 mmHg and body temperature ≥38°C, it was unlikely that hypoglycemia caused impaired consciousness (stratum-specific likelihood ratios 0.12 and 0.15; 95% confidence intervals, 0.05-0.25 and 0.06-0.35, respectively).

Conclusion

In the prehospital assessment of patients with impaired consciousness, high fever or hypotension was helpful in differentiating between hypoglycemia and non-hypoglycemia. In particular, body temperature ≥38°C or systolic blood pressure <100 mmHg indicated a low likelihood of hypoglycemia. A validation study is needed to confirm the findings in this study.

The accuracy of initial diagnoses in coma: an observational study in 835 patients with non-traumatic disorder of consciousness

BACKGROUND

Management of patients with coma of unknown etiology (CUE) is a major challenge in most emergency departments (EDs). CUE is associated with a high mortality and a wide variety of pathologies that require differential therapies. A suspected diagnosis issued by pre-hospital emergency care providers often drives the first approach to these patients. We aim to determine the accuracy and value of the initial diagnostic hypothesis in patients with CUE.

METHODS

Consecutive ED patients presenting with CUE were prospectively enrolled. We obtained the suspected diagnoses or working hypotheses from standardized reports given by prehospital emergency care providers, both paramedics and emergency physicians. Suspected and final diagnoses were classified into I) acute primary brain lesions, II) primary brain pathologies without acute lesions and III) pathologies that affected the brain secondarily. We compared suspected and final diagnosis with percent agreement and Cohen's Kappa including sub-group analyses for paramedics and physicians. Furthermore, we tested the value of suspected and final diagnoses as predictors for mortality with binary logistic regression models.

RESULTS

Overall, suspected and final diagnoses matched in 62% of 835 enrolled patients. Cohen's Kappa showed a value of κ = .415 (95% CI .361-.469, p < .005). There was no relevant difference in diagnostic accuracy between paramedics and physicians. Suspected diagnoses did not significantly interact with in-hospital mortality (e.g., suspected class I: OR .982, 95% CI .518-1.836) while final diagnoses interacted strongly (e.g., final class I: OR 5.425, 95% CI 3.409-8.633).

CONCLUSION

In cases of CUE, the suspected diagnosis is unreliable, regardless of different pre-hospital care providers' qualifications. It is not an appropriate decision-making tool as it neither sufficiently predicts the final diagnosis nor detects the especially critical comatose patient. To avoid the risk of mistriage and unnecessarily delayed therapy, we advocate for a standardized diagnostic work-up for all CUE patients that should be triggered by the emergency symptom alone and not by any suspected diagnosis.

Standardized visual EEG features predict outcome in patients with acute consciousness impairment of various etiologies

BACKGROUND

Early prognostication in patients with acute consciousness impairment is a challenging but essential task. Current prognostic guidelines vary with the underlying etiology. In particular, electroencephalography (EEG) is the most important paraclinical examination tool in patients with hypoxic ischemic encephalopathy (HIE), whereas it is not routinely used for outcome prediction in patients with traumatic brain injury (TBI).

METHOD

Data from 364 critically ill patients with acute consciousness impairment (GCS ≤ 11 or FOUR ≤ 12) of various etiologies and without recent signs of seizures from a prospective randomized trial were retrospectively analyzed. Random forest classifiers were trained using 8 visual EEG features-first alone, then in combination with clinical features-to predict survival at 6 months or favorable functional outcome (defined as cerebral performance category 1-2).

RESULTS

The area under the ROC curve was 0.812 for predicting survival and 0.790 for predicting favorable outcome using EEG features. Adding clinical features did not improve the overall performance of the classifier (for survival: AUC = 0.806, p = 0.926; for favorable outcome: AUC = 0.777, p = 0.844). Survival could be predicted in all etiology groups: the AUC was 0.958 for patients with HIE, 0.955 for patients with TBI and other neurosurgical diagnoses, 0.697 for patients with metabolic, inflammatory or infectious causes for consciousness impairment and 0.695 for patients with stroke. Training the classifier separately on subgroups of patients with a given etiology (and thus using less training data) leads to poorer classification performance.

CONCLUSIONS

While prognostication was best for patients with HIE and TBI, our study demonstrates that similar EEG criteria can be used in patients with various causes of consciousness impairment, and that the size of the training set is more important than homogeneity of ACI etiology.

Differential diagnosis of atypical encephalopathy in critical care: a case report

Background

A lower level of consciousness is a common presentation in critical care, with many different causes and contributory factors, of which more than one may be present concurrently.

Case presentation

We described a woman with poorly controlled diabetes and steroid-dependent asthma who presented in a deep coma. She was found to have Streptococcus intermedius bacteremia and pyogenic ventriculitis that originated from right middle lobe pneumonia. Also, multiple small parenchymal lesions were observed on brain magnetic resonance imaging and increased protein concentration was noted in cerebral spinal fluid. Initially, her coma was thought to be due to diabetic ketoacidosis and septic encephalopathy. However, her lowered level of consciousness was disproportionate to either diabetic ketoacidosis or septic encephalopathy, and her clinical course was not as expected for these two conditions. Treatment with antibiotic, corticosteroid and antihelminthic drugs was administered resulting in improving consciousness. The Streptococcus intermedius pneumonia progressed to form a large cavity that needed an early surgical lobectomy and resulted in the unexpected diagnosis of chronic cavitary pulmonary aspergillosus.

Conclusions

In critical care, a lowered level of consciousness may have many etiologies, and critical care clinicians should be familiar with the signs and symptoms of all possible causes to enable prompt diagnosis and appropriate treatment.

Sudden unresponsive patient with normal vital signs: what is going on?

PURPOSE OF REVIEW

To summarize the differential diagnosis and diagnostic approach of sudden unresponsiveness with normal vital signs in various settings, including the ICU.

RECENT FINDINGS

Sudden unresponsiveness may be either transient or persistent, and may result from primary brain diseases or nonstructural systemic conditions. Life-threatening causes should always be discriminated from those more benign. Regional epidemiology, for example regarding intoxications, and evolving therapeutic management, for example for ischemic stroke, should always be taken into account for optimal opportunity for rapid diagnosis and best management.

SUMMARY

Sudden unresponsiveness with normal vital signs should trigger immediate and focused diagnostic evaluation to find or exclude those conditions requiring urgent, and possibly life-saving, management.

Estimating the period prevalence of non-convulsive status epilepticus among comatose adults at the University Teaching Hospital in Lusaka, Zambia

OBJECTIVE

In Western settings, non-convulsive status epilepticus (NCSE) and non-convulsive seizures (NCSz) are associated with high mortality. In comatose patients, interictal epileptiform discharges (IEDs) identified on routine electroencephalogram (EEG) are predictive of NCSE/NCS. Little is known regarding the prevalence, causes, or outcomes of NCSE/NCSz in sub-Saharan Africa (SSA). We sought to investigate the prevalence of IEDs and NCSE/NCSz at a single teaching institution in SSA.

METHODS

From October 3, 2017, to May 21, 2018, adult inpatients on the internal medicine service at Zambia's University Teaching Hospital (UTH) with a Glasgow Coma Score (GCS) of ≤10 were identified, excluding patients with mechanical ventilation or open head wounds. Signed consent by a proxy was required for enrollment and 30-minute EEG. Chart abstractions provided coma duration, presence/absence of clinical seizures during/prior to admission, history of epilepsy, and presumed coma etiology. A structured neurological examination was completed. Patients were followed to discharge or death. Risk factors for IEDs were evaluated.

RESULTS

Of 392 eligible patients, 250 had EEGs. EEGs were not completed on eligible patients due to death (74), improved GCS (37), transfer within UTH (25), or lack of proxy (6). NCSE occurred in 22 of 250 (8.8%), NCSz in 3 of 250 (1.2%), and IEDs in 46 of 250 (18.4%) patients. Of the 250, 197 (78.8%) died. No specific risk factors for IEDs were identified.

SIGNIFICANCE

If the association between IEDs and NCSE among monitored populations in developed settings holds true for SSA, a projected 17%-21% of comatose African adults have NCSE. No clinical characteristics identified those at risk.

Causes of brain dysfunction in acute coma: a cohort study of 1027 patients in the emergency department

Background

Coma of unknown etiology (CUE) is a major challenge in emergency medicine. CUE is caused by a wide variety of pathologies that require immediate and targeted treatment. However, there is little empirical data guiding rational and efficient management of CUE. We present a detailed investigation on the causes of CUE in patients presenting to the ED of a university hospital.

Methods

One thousand twenty-seven consecutive ED patients with CUE were enrolled. Applying a retrospective observational study design, we analyzed all clinical, laboratory and imaging findings resulting from a standardized emergency work-up of each patient. Following a predefined protocol, we identified main and accessory coma-explaining pathologies and related these with (i.a.) GCS and in-hospital mortality.

Results

On admission, 854 of the 1027 patients presented with persistent CUE. Their main diagnoses were classified into acute primary brain lesions (39%), primary brain pathologies without acute lesions (25%) and pathologies that affected the brain secondarily (36%). In-hospital mortality associated with persistent CUE amounted to 25%. 33% of patients with persistent CUE presented with more than one coma-explaining pathology. In 173 of the 1027 patients, CUE had already resolved on admission. However, these patients showed a spectrum of main diagnoses similar to persistent CUE and a significant in-hospital mortality of 5%.

Conclusion

The data from our cohort show that the spectrum of conditions underlying CUE is broad and may include a surprisingly high number of coincidences of multiple coma-explaining pathologies. This finding has not been reported so far. Thus, significant pathologies may be masked by initial findings and only appear at the end of the diagnostic work-up. Furthermore, even transient CUE showed a significant mortality, thus rendering GCS cutoffs for selection of high- and low-risk patients questionable. Taken together, our data advocate for a standardized diagnostic work-up that should be triggered by the emergency symptom CUE and not by any suspected diagnosis. This standardized routine should always be completed - even when initial coma-explaining diagnoses may seem evident.

A 47-Year-Old Man With Progressive Mental Deterioration During Ventilator Management of Asthma in the ICU

CASE PRESENTATION

A 47-year-old man was admitted to the ICU with acute hypercapnic respiratory failure caused by a severe asthma attack. He had a history of asthma, atrial septal defect, chronic heart failure, and atrial fibrillation. He underwent surgical closure of the atrial septal defect at 7 years of age and was asymptomatic until 38 years of age when he developed congestive heart failure because of structural cardiac abnormalities, including left ventricular systolic dysfunction, biatrial enlargement, and mild mitral and tricuspid regurgitation. After ICU admission, he received ventilator management for asthma, IV prednisone, beta-2 agonist via inhalation, and ceftriaxone. Enteral feeding was provided since the day of admission. Hypercapnia gradually improved over 3 days. He remained alert and could communicate through writing during ventilator management until the third day in the ICU. Enteral feeding was titrated up to 32 kcal/kg/d with 1.6 g/kg/d of protein. Despite the recovery from the initial respiratory failure, he became inactive and lethargic on the fourth day in the ICU. ICU-acquired delirium was suspected, and administration of sedatives and analgesics was discontinued. On the following day, he was unresponsive to stimuli.

[Metabolic encephalopathies]

Metabolic encephalopathies (ME) are a common cause of admission to emergency rooms, to hospitalization wards or to intensive care units. They could account for 10 to 20% of causes of comatose states in ICU and could be associated to a poor outcome especially in older patients. Nevertheless, they are often reversible and are associated with a favorable outcome when diagnosed and rapidly treated. They correspond to an altered brain functioning secondary to the deficiency of a substance that is mandatory for the normal brain functioning or to the accumulation of a substance that can be either endogenous or exogenous. It preferably occurs in co-morbid patients, complicating its diagnosis and its management. Altered brain functioning, going from mild neuropsychological impairment to coma, movement disorders especially myoclonus and the absence of any obvious differential diagnosis are highly suggestive of the diagnosis. Whereas some biological samplings and brain MRI are essential to rule out differential diagnosis, some others, such as electroencephalogram, may be able to propose important clues in favor of the diagnosis. Once simple symptomatic measures are introduced, the treatment consists mainly in the correction of the cause. Specific treatment options are only seldom available for ME; this is the case for hepatic encephalopathy and some drug-induced encephalopathies. We will successively describe in this review the main pathophysiological mechanisms, the main causes, favoring circumstances of ME, the differential diagnosis to rule out and the etiological work-up for the diagnosis. Finally, a diagnostic and therapeutic strategy for the care of patients with ME will be proposed.

Retrospective characterization of coma and stupor in dogs and cats presenting to a multicenter out-of-hours service (2012-2015): 386 animals

OBJECTIVE

To describe the signalment, etiology, and short-term outcome of dogs and cats presenting in a coma or stupor.

DESIGN

Retrospective study conducted between May 2012 and February 2015.

SETTING

Multicenter out-of-hours emergency service provider.

ANIMALS

Three hundred eighty-six patients presenting in a coma or stupor to a multicenter out-of-hours emergency care provider.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Records were reviewed to determine the most likely etiology of coma or stupor. Short-term outcomes were defined as deceased (died or euthanized) or transferred (case handed over to a daytime clinic or discharged). There were 168 dogs (coma n = 112, stupor n = 56) and 218 cats (coma n = 148, stupor n = 70) identified. Coma and stupor were more prevalent in cats compared to dogs, and Chihuahuas were over represented. Blood glucose concentrations were frequently outside established reference intervals. Excluding undetermined causes, the most common causes in dogs included traumatic brain injury (TBI) 16.0% (n = 27, deceased n = 22), hypoglycemia 10.7% (n = 18, deceased n = 8), shock 10.1% (n = 17, deceased n = 16), seizure 9.5% (n = 16, deceased n = 13), and renal or hepatic dysfunction 5.3% (n = 9, deceased n = 7). For cats, the most common causes included TBI 21.6% (n = 47, deceased n = 38), renal or hepatic dysfunction 13.3% (n = 29, deceased n = 25), intoxication 10.1% (n = 22, deceased n = 18), hypoglycemia 6.0% (n = 13, deceased n = 4), and shock 5.0% (n = 11, deceased n = 8). When treatment was attempted, 46.0% of dogs (n = 44/96) and 41.2% of cats (n = 35/85) survived to be transferred. Compared to all other etiologies, death was less likely when coma or stupor was attributed to hypoglycemia.

CONCLUSION

In cases where a cause was determined, TBI was the predominant etiology of coma and stupor for both species. With the exception of coma and stupor attributed to hypoglycemia, the overall short-term prognosis was poor.

[Coma in the emergency room]

Coma of unknown origin (CUO) is a frequent unspecific emergency symptom associated with a high mortality. A fast diagnostic work-up is essential given the wide spectrum of underlying diagnoses that are made up of approximately 50% primary central nervous system (CNS) pathologies and approximately 50% extracerebral, almost exclusively internal medical causes. Despite the high mortality associated with this symptom, there are currently no generally accepted management guidelines for adult patients presenting with CUO. We propose an interdisciplinary standard operating procedure (SOP) for patients with acute CUO as has been established in our maximum care hospital. The SOP is triggered by simple triage criteria that are sufficient to identify CUO patients before arrival in hospital. The in-hospital response team is led by a neurologist. Collaboration with nursing staff, internal medicine, anesthesiology, neurosurgery and trauma surgery is organized along structured pathways that include standardized laboratory tests, including cerebrospinal fluid (CSF), toxicology, computed tomography (CT) and CT angiography imaging (CTA). Our data suggest that neurologists and internists need to be placed at the beginning of the diagnostic work-up. Imaging should not just be carried out depending on the clinical syndrome because sensitivity, specificity and inter-rater reliability of the latter are not sufficient and because in many cases, multiple pathologies can be detected that could each explain CUO alone. Clinical examination, imaging and laboratory testing should be regarded as components of an integrative diagnostic approach and the final aetiological classification should only be made after the diagnostic work-up is complete.

A systematic approach to the unconscious patient

Unconscious patients are commonly seen by physicians. They are challenging to manage and in a time sensitive condition, a systematic, team approach is required. Early physiological stability and diagnosis are necessary to optimise outcome. This article focuses on unconscious patients where the initial cause appears to be non-traumatic and provides a practical guide for their immediate care.

Vegetative state outcomes improved over the last two decades

OBJECTIVE

To describe late outcomes in patients with prolonged unawareness, and factors affecting them.

DESIGN

A retrospective study of 154 patients with traumatic brain injury (TBI) and 52 with non-traumatic brain injury (NTBI), admitted for intensive care and consciousness rehabilitation (ICCR), in a vegetative state (VS) lasting over 1 month.

RESULTS

Survival rate (67% total) was higher than in past studies carried out at the same facility (p < 0.01). Consciousness recovery rate (54% total) was higher in NTBI VS patients (p < 0.01) than in earlier cohorts, and similar in TBI VS patients, despite their older age than that of earlier cohorts. No meaningful differences were found in characteristics or in outcomes between the TBI and NTBI groups. Age, length of stay in ICCR, and hydrocephalus were found to affect survival (p < 0.001). Younger age, absence of hydrocephalus, and anti-Parkinsonian medication contributed to consciousness recovery after VS (p < 0.05).

CONCLUSIONS

The present study demonstrated an improvement in survival and recovery of consciousness in VS patients over the last two decades, and similar outcomes for both TBI and NTBI VS. Outcomes suggest that acute medical care and ICCR have contributed to advances in VS care.

Recovery from Coma Post-Cardiac Arrest Is Dependent on the Orexin Pathway

Cardiac arrest (CA) affects >550,000 people annually in the United States whereas 80-90% of survivors suffer from a comatose state. Arousal from coma is critical for recovery, but mechanisms of arousal are undefined. Orexin-A, a hypothalamic excitatory neuropeptide, has been linked to arousal deficits in various brain injuries. We investigated the orexinergic system's role in recovery from CA-related neurological impairments, including arousal deficits. Using an asphyxial CA and resuscitation model in rats, we examine neurological recovery post-resuscitation in conjunction with changes in orexin-A levels in cerebrospinal fluid (CSF) and orexin-expressing neurons. We also conduct pharmacological inhibition of orexin post-resuscitation. We show that recovery from neurological deficits begins between 4 and 24 h post-resuscitation, with additional recovery by 72 h post-resuscitation. Orexin-A levels in the CSF are lowest during periods of poorest arousal post-resuscitation (4 h) and recover to control levels by 24 h. Immunostaining revealed that the number of orexin-A immunoreactive neurons declined at 4 h post-resuscitation, but increased to near normal levels by 24 h. There were no significant changes in the number of neurons expressing melanin-concentrating hormone, another neuropeptide localized in similar hypothalamus regions. Last, administration of the dual orexin receptor antagonist, suvorexant, during the initial 24 h post-resuscitation, led to sustained neurological deficits. The orexin pathway is critical during early phases of neurological recovery post-CA. Blocking this early action leads to persistent neurological deficits. This is of considerable clinical interest given that suvorexant recently received U.S. Food and Drug Administration approval for insomnia treatment.

Neural signature of coma revealed by posteromedial cortex connection density analysis

Posteromedial cortex (PMC) is a highly segregated and dynamic core, which appears to play a critical role in internally/externally directed cognitive processes, including conscious awareness. Nevertheless, neuroimaging studies on acquired disorders of consciousness, have traditionally explored PMC as a homogenous and indivisible structure. We suggest that a fine-grained description of intrinsic PMC topology during coma, could expand our understanding about how this cortical hub contributes to consciousness generation and maintain, and could permit the identification of specific markers related to brain injury mechanism and useful for neurological prognostication.

To explore this, we used a recently developed voxel-based unbiased approach, named functional connectivity density (CD). We compared 27 comatose patients (15 traumatic and 12 anoxic), to 14 age-matched healthy controls. The patients' outcome was assessed 3 months later using Coma Recovery Scale-Revised (CRS-R).

A complex pattern of decreased and increased connections was observed, suggesting a network imbalance between internal/external processing systems, within PMC during coma. The number of PMC voxels with hypo-CD positive correlation showed a significant negative association with the CRS-R score, notwithstanding aetiology. Traumatic injury specifically appeared to be associated with a greater prevalence of hyper-connected (negative correlation) voxels, which was inversely associated with patient neurological outcome. A logistic regression model using the number of hypo-CD positive and hyper-CD negative correlations, accurately permitted patient's outcome prediction (AUC = 0.906, 95%IC = 0.795–1). These points might reflect adaptive plasticity mechanism and pave the way for innovative prognosis and therapeutics methods.

•

A twofold pattern of decreased and increased connections within PMC was observed during coma.

•

The number of PMC voxels with decreased positive connections, was significantly associated with patient's outcome.

•

Greater prevalence of hyperconnected PMC voxels in traumatic brain injury was correlated to outcome in this subgroup.

Brain death during pregnancy and prolonged corporeal support of the body: A critical discussion

AIM

To discuss corporeal support of the brain-dead pregnant woman and to critically examine important aspects of this complex situation that remain as yet unexplored.

BACKGROUND

When brain death of the woman occurs during pregnancy, the fetus may be kept inside the corporeally supported body for prolonged periods to enable continued fetal growth and development. This has been increasingly reported in medical literature since 1982 and has received considerable media attention in the past few years.

IMPLICATIONS FOR MIDWIVES AND NURSES

Sophisticated advances in medical technologies have altered the boundaries of conception and birth, life and death, Western biomedical and cultural conceptions of women and their bodies, fetal personhood, fetal rights and fetal patienthood, profoundly influencing maternal behaviors, medical decisions and the treatment of pregnant women. This is especially so in the rare, but fraught instance of brain death of the pregnant woman, where nurses and midwives working in High Dependency Care units undertake the daily care of the corporeally supported body that holds a living fetus within it. This discussion enables critical and ethical conversation around the complexities of developing appropriate discourse concerning the woman who suffers brain death during pregnancy and considers the complexities for nurses and midwives caring for the Woman/body/fetus in this context. The potential impact on the fetus of growing and developing inside a 'dead' body is examined, and the absence in the literature of long-term follow up of infants gestated thus is questioned.

[Focal point emergency departments]

The number of patients treated in hospital emergency departments in Germany has risen in recent years to approximately 20 million. This escalation also applies to the increasing numbers of patients presenting with neurological symptoms and diseases, which occur in approximately 20 % of emergency patients. In addition to patients with stroke, inflammatory or degenerative central nervous system (CNS) and peripheral nervous system (PNS) disorders who need urgent treatment, more and more patients with nonspecific complaints or conditions attend emergency departments for elective treatment, not least because timely appointments with specialist neurologists in practices could not be obtained. Neurological expertise and presence in emergency departments at the level of specialist standard are therefore indispensable for providing a professional level of treatment, which also corresponds to current legal requirements. The implementation of a generalist emergency physician in Germany, as introduced in some European countries, would mean a retrograde step for neurological expertise in emergency admission management. The discipline of neurology must work together with other emergency disciplines to improve the financing of emergency departments and provide neurologists working there with a substantive curriculum of further and continuing education in emergency-related aspects of neurology. The discipline of neurology has a responsibility to emergency patients within its range of competencies and must, therefore, strengthen and improve its role in healthcare politics and concerning organizational and personnel aspects of neurological emergencies.

Coma of unknown origin in the emergency department: implementation of an in-house management routine

BACKGROUND

Coma of unknown origin is an emergency caused by a variety of possibly life-threatening pathologies. Although lethality is high, there are currently no generally accepted management guidelines.

METHODS

We implemented a new interdisciplinary standard operating procedure (SOP) for patients presenting with non-traumatic coma of unknown origin. It includes a new in-house triage process, a new alert call, a new composition of the clinical response team and a new management algorithm (altogether termed "coma alarm"). It is triggered by two simple criteria to be checked with out-of-hospital emergency response teams before the patient arrives. A neurologist in collaboration with an internal specialist leads the in-hospital team. Collaboration with anaesthesiology, trauma surgery and neurosurgery is organised along structured pathways that include standardised laboratory tests and imaging. Patients were prospectively enrolled. We calculated response times as well as sensitivity and false positive rates, thus proportions of over- and undertriaged patients, as quality measures for the implementation in the SOP.

RESULTS

During 24 months after implementation, we identified 325 eligible patients. Sensitivity was 60 % initially (months 1-4), then fluctuated between 84 and 94 % (months 5-24). Overtriage never exceeded 15 % and undertriage could be kept low at a maximum of 11 % after a learning period. We achieved a median door-to-CT time of 20 minutes. 85 % of patients needed subsequent ICU treatment, 40 % of which required specialised neuro-ICUs.

DISCUSSION

Our results indicate that our new simple in-house triage criteria may be sufficient to identify eligible patients before arrival. We aimed at ensuring the fastest possible proceedings given high portions of underlying time-sensitive neurological and medical pathologies while using all available resources as purposefully as possible.

CONCLUSIONS

Our SOP may provide an appropriate tool for efficient management of patients with non-traumatic coma. Our results justify the assignment of the initial diagnostic workup to neurologists and internal specialists in collaboration with anaesthesiologists.

Lesson of the month 1: Artery of Percheron occlusion - an -uncommon cause of coma in a middle-aged man

Bilateral paramedian thalamic infarction resulting from artery of Percheron occlusion presents with a distinct clinical syndrome comprising impaired consciousness, often with vertical gaze palsy and memory impairment. This uncommon anatomical variant arises as a single artery supplying both paramedian thalami. Early recognition can be challenging in the obtunded patient, where the differential diagnosis is broad. The acute physician should consider this diagnosis in a patient presenting with unexplained coma so that emergent treatments such as thrombolysis can be employed. Early imaging with computerised tomography can often be normal; therefore the use of magnetic resonance imaging is essential in confirming the diagnosis.

Predictive value of EEG-awakening for behavioral awakening from coma

BACKGROUND

A reliable predictor for early recovery of consciousness in comatose patients is of great clinical significance. Here we aimed to investigate the potentially prognostic value of electroencephalogram-reactivity (EEG-R) in combination with sleep spindles, termed EEG-awakening, for behavioral awakening in etiologically diverse comatose patients.

METHODS

We performed a prospectively observational study on a sample of patients, all of whom were in coma lasting longer than 3 days. Continuous EEG monitoring was performed for at least 24 h to detect the presence of EEG-R and sleep spindles. We then followed patients for 1 month to determine their subsequent level of consciousness, classifying them as either awakened or non-awakened. Finally, Univariate and multivariate analyses were employed to assess the association of predictors with consciousness recovery.

RESULTS

One hundred and six patients with different etiologies leading to coma were included in the study. Of these, 48 patients (45.3 %) awoke and 58 patients (54.7 %) did not awake in the month after the onset of the study. Of note, 26 patients (24.5 %) had a good neurological outcome, and 31 patients (29.3 %) died. Univariate analysis revealed that the Glasgow Coma Scale (GCS) score, EEG-R, sleep spindles, and EEG-awakening were all associated with one-month awakening. Comparisons of the area under the receiving operator characteristic curve (AUC) showed that EEG-awakening (0.839; 0.757-0.921) was superior to all of the following: EEG-R (0.798; 0.710-0.886), sleep spindles (0.772; 0.680-0.864), and GCS scores (0.720; 0.623-0.818). However, age, gender, etiology, and pupillary light reflex did not correlate significantly with one-month awakening. Further logistic regression analysis showed that only EEG-awakening and GCS scores at study entry were significant independent predictors of awakening and that the prognostic model containing these two variables yielded an outstanding predictive performance with an AUC of 0.903.

CONCLUSIONS

EEG-awakening incorporates both EEG-R and sleep spindles and is an excellent predictor for early behavioral awakening in comatose patients. The prognostic model combining EEG-awakening and GCS scores shows an outstanding discriminative power for awakening.