The arousal effect of An-Gong-Niu-Huang-Wan on alcoholic-induced coma rats: A research based on EEG

ETHNOPHARMACOLOGICAL RELEVANCE

Acute alcohol intoxication is one of the leading causes of coma. A well-regarded Chinese herbal formula, known as An-Gong-Niu-Huang-Wan (AGNHW), has garnered recognition for its efficacy in treating various brain disorders associated with impaired consciousness, including acute alcohol-induced coma. Despite its clinical effectiveness, the scientific community lacks comprehensive research on the mechanistic aspects of AGNHW's impact on the electroencephalogram (EEG) patterns observed during alcohol-induced coma. Gaining a deeper understanding of AGNHW's mechanism of action in relation to EEG characteristics would hold immense importance, serving as a solid foundation for further advancing its clinical therapeutic application.

AIM OF THE STUDY

The study sought to investigate the impact of AGNHW on EEG activity and sleep EEG patterns in rats with alcoholic-induced coma.

MATERIALS AND METHODS

A rat model of alcohol-induced coma was used to examine the effects of AGNHW on EEG patterns. Male Sprague-Dawley rats were intraperitoneally injected with 32% ethanol to induce a coma, followed by treatment with AGNHW. Wireless electrodes were implanted in the cortex of the rats to obtain EEG signals. Our analysis focused on evaluating alterations in the Rat Coma Scale (RCS), as well as assessing changes in the frequency and distribution of EEG patterns, sleep rhythms, and body temperature subsequent to AGNHW treatment.

RESULTS

The study found a significant increase in the δ-band power ratio, as well as a decrease in RCS scores and β-band power ratio after modeling. AGNHW treatment significantly reduced the δ-band power ratio and increased the β-band power ratio compared to naloxone, suggesting its superior arousal effects. The results also revealed a decrease in the time proportion of WAKE and REM EEG patterns after modeling, accompanied by a significant increase in the time proportion of NREM EEG patterns. Both naloxone and AGNHW effectively counteracted the disordered sleep EEG patterns. Additionally, AGNHW was more effective than naloxone in improving hypothermia caused by acute alcohol poisoning in rats.

CONCLUSION

Our study provides evidence for the arousal effects of AGNHW in alcohol-induced coma rats. It also suggests a potential role for AGNHW in regulating post-comatose sleep rhythm disorders.

Clinical characteristics of acute lacosamide poisoning: Pavia Poison Control Centre experience

AIMS

Lacosamide is a third-generation antiepileptic drug used as adjunctive therapy for partial seizures. Since its approval in 2008 very few cases of lacosamide overdose have been described in literature. The aim of our study was to evaluate clinical characteristics of acute lacosamide poisoning.

METHODS

A retrospective observational study was performed including all cases of acute lacosamide poisoning referred to Pavia Poison Control Centre from January 2012 to December 2021. For each patient age, sex, ingested dose, coingestants, clinical manifestations, treatment and outcome were collected.

RESULTS

A total of 31 subjects (median age 39 years, [interquartile range: 26.5-46.5]; females 22/31) were included. The median lacosamide ingested dose was 1500 mg [650-2800]. In 35.5% of cases lacosamide was the single ingested substance, while in 64.5% coingestants were also present. Coingestants varied from a minimum of 1 to a maximum of 3, with the more common being benzodiazepines and valproic acid. Clinical manifestations were present in 87% patients the most common were: vomiting (29%); seizures (29%), coma (25.8%), drowsiness (25.8%), confusion (12.9%), agitation (12.9%), tachycardia (12.9%), tremors (9.7%), bradycardia (9.7%), headache (6.5%) and hypertension (3.2%). The median lacosamide ingested dose was significantly higher in patients that experienced coma compared to patient who did not (2800 vs. 800 mg; P = .0082). Orotracheal intubation was necessary in 32.3% of patients. All patients fully recovered.

CONCLUSION

Lacosamide acute overdose may lead to a severe clinical picture. Dentral nervous system symptoms predominated, particularly seizures and coma occurred in a high percentage of cases.

Effect of prehospital high-dose glucocorticoid on hemodynamics in patients resuscitated from out-of-hospital cardiac arrest: a sub-study of the STEROHCA trial

BACKGROUND

Following resuscitated out-of-hospital cardiac arrest (OHCA), inflammatory markers are significantly elevated and associated with hemodynamic instability and organ dysfunction. Vasopressor support is recommended to maintain a mean arterial pressure (MAP) above 65 mmHg. Glucocorticoids have anti-inflammatory effects and may lower the need for vasopressors. This study aimed to assess the hemodynamic effects of prehospital high-dose glucocorticoid treatment in resuscitated comatose OHCA patients.

METHODS

The STEROHCA trial was a randomized, placebo-controlled, phase 2 trial comparing one prehospital injection of methylprednisolone 250 mg with placebo immediately after resuscitated OHCA. In this sub-study, we included patients who remained comatose at admission and survived until intensive care unit (ICU) admission. The primary outcome was cumulated norepinephrine use from ICU admission until 48 h reported as mcg/kg/min. Secondary outcomes included hemodynamic status characterized by MAP, heart rate, vasoactive-inotropic score (VIS), and the VIS/MAP-ratio as well as cardiac function assessed by pulmonary artery catheter measurements. Linear mixed-model analyses were performed to evaluate mean differences between treatment groups at all follow-up times.

RESULTS

A total of 114 comatose OHCA patients were included (glucocorticoid: n = 56, placebo: n = 58) in the sub-study. There were no differences in outcomes at ICU admission. From the time of ICU admission up to 48 h post-admission, patients in the glucocorticoid group cumulated a lower norepinephrine use (mean difference - 0.04 mcg/kg/min, 95% CI - 0.07 to - 0.01, p = 0.02). Moreover, after 12-24 h post-admission, the glucocorticoid group demonstrated a higher MAP with mean differences ranging from 6 to 7 mmHg (95% CIs from 1 to 12), a lower VIS (mean differences from - 4.2 to - 3.8, 95% CIs from - 8.1 to 0.3), and a lower VIS/MAP ratio (mean differences from - 0.10 to - 0.07, 95% CIs from - 0.16 to - 0.01), while there were no major differences in heart rate (mean differences from - 4 to - 3, 95% CIs from - 11 to 3). These treatment differences between groups were also present 30-48 h post-admission but to a smaller extent and with increased statistical uncertainty. No differences were found in pulmonary artery catheter measurements between groups.

CONCLUSIONS

Prehospital treatment with high-dose glucocorticoid was associated with reduced norepinephrine use in resuscitated OHCA patients.

TRIAL REGISTRATION

EudraCT number: 2020-000855-11; submitted March 30, 2020. URL: https://www.

CLINICALTRIALS

gov ; Unique Identifier: NCT04624776.

Clinical Results of Accelerated Iontophoresis-Assisted Epithelium-on Corneal Cross-linking for Progressive Keratoconus in Children

PURPOSE

To evaluate the clinical characteristics of pediatric patients with progression of keratoconus after accelerated iontophoresis-assisted epithelium-on corneal cross-linking (I-ON CXL) and to assess the efficacy and safety of re-treatment using accelerated epithelium-off CXL (epi-OFF CXL).

METHODS

Sixteen eyes of 16 patients (mean age: 14.6 ± 2.5 years) with keratoconus underwent I-ON CXL. The main outcome measures were uncorrected distance visual acuity, corrected distance visual acuity, maximum keratometry index (Kmax), minimum corneal thickness, elevation front and elevation back measured at the thinnest point, total higher order aberrations root main square (HOA RMS), coma RMS, and spherical aberration. An increment of Kmax greater than 1.00 diopter (D) and a decrease of greater than 20 µm in pachymetry were considered to determine the progression of keratoconus. Patients with progression of keratoconus after I-ON CXL were re-treated using an epi-OFF CXL protocol.

RESULTS

Two years after I-ON CXL, 12 patients showed progression of keratoconus, whereas 4 patients were stable. There was significant worsening of Kmax (P = .04) and steepest keratometric reading (P = .01). Furthermore, a significant correlation was documented between progression of keratoconus and age (P = .02). These patients were re-treated using an epi-OFF protocol and after 2 years all patients were stable, and a statistically significant reduction of the mean Kmax (P = .007), HOA RMS (P = .05), and coma RMS (P = 05) was observed.

CONCLUSIONS

I-ON CXL was ineffective in the treatment of pediatric keratoconus in younger children, whereas it had an efficacy of 2 years in older children. Re-treatment using epi-OFF CXL proved effective to halt progression of keratoconus after I-ON CXL failure. [J Pediatr Ophthalmol Strabismus. 2024;61(1):44-50.].

Piperacillin-Tazobactam Versus Anti-Pseudomonal Cephalosporins and Renal and Neurologic Outcomes in Critically Ill Adults: A Secondary Analysis of the SMART Trial

Background: Prior studies suggest associations between receipt of piperacillin-tazobactam and development of acute kidney injury and receipt of anti-pseudomonal cephalosporins and neurotoxicity. We compared clinically-relevant renal and neurologic outcomes in critically ill patients who received piperacillin-tazobactam versus anti-pseudomonal cephalosporins. Methods: We conducted a secondary analysis of data from the Isotonic Solutions and Major Adverse Renal Events Trial examining patients who received piperacillin-tazobactam or an anti-pseudomonal cephalosporin within 24 h of intensive care unit admission. We performed multivariable analysis using a proportional odds model to examine the association between the first antibiotic received and the outcomes of Major Adverse Kidney Events within 30 days (MAKE30) and days alive and free of delirium and coma to day 28. Results: 3199 were included in the study; 2375 (74%) receiving piperacillin-tazobactam and 824 (26%) receiving anti-pseudomonal cephalosporin. After adjustment for prespecified confounders, initial receipt of piperacillin-tazobactam, compared to anti-pseudomonal cephalosporins, was not associated with higher incidence of MAKE30 (adjusted odds ratio, 1.03; 95% CI, 0.83-1.27; P = .80) but was associated with a greater number of days alive and free of delirium and coma (adjusted odds ratio, 1.18; 95% CI, 1.00-1.38; P = .04). In a sensitivity analysis adjusting for baseline receipt of medications which may impact neuro function, this finding was not significant. Conclusion: Among critically ill adults, receipt of piperacillin-tazobactam was not associated with an increased incidence of death, renal replacement therapy, or persistent renal dysfunction or a greater number of days alive and free of delirium and coma. Randomized trials are needed to inform the choice of antibiotics for empiric treatment infection in critically ill adults.

Liquid levothyroxine in the treatment of myxoedema coma

Not required for Clinical Vignette.

Role of Hemodialysis in Acute Severe Alcohol Intoxication: A Meta-Analysis

<b><i>Background:</i></b> Hemodialysis therapy has been used in the treatment of acute alcohol intoxication for many years, especially acute severe alcohol intoxication. <b><i>Objectives:</i></b> This study aimed to evaluate whether the combination of conventional treatment and naloxone with hemodialysis has advantages over conventional treatment and naloxone alone in patients with acute severe alcohol intoxication. <b><i>Methods:</i></b> After searching 12 databases and 2 clinical trial centers. According to the established inclusion and exclusion criteria, the qualified literatures were screened. The outcome indicators were length of hospital stay, coma time, time of symptom disappearance, the overall complication rate, the incidence of pancreatitis, the incidence of aspiration pneumonia, the incidence of hepatic and renal dysfunction. Analysis was performed using Revman 5.3. <b><i>Results:</i></b> This meta-analysis included 13 studies, including 932 subjects. In the treatment of acute severe alcohol intoxication, the use of hemodialysis on the basis of conventional treatment and naloxone could reduce the length of hospital stay (WMD = −15.16, 95% CI: −17.45 to −12.86, <i>p</i> &#x3c; 0.001) in hours and (WMD = −4.89, 95% CI: −5.53 to −4.25, <i>p</i> &#x3c; 0.001) in days; coma time (WMD = −5.43, 95% CI: −6.43 to −4.43, <i>p</i> &#x3c; 0.001); time of symptom disappearance (WMD = −3.92, 95% CI: −5.37 to −2.47, <i>p</i> &#x3c; 0.001); the overall complication rate (RR = 0.39, 95% CI: 0.28–0.55, <i>p</i> &#x3c; 0.001); the incidence of pancreatitis (RR = 0.14, 95% CI: 0.05–0.43, <i>p</i> = 0.0006); the incidence of aspiration pneumonia (RR = 0.15, 95% CI: 0.04–0.66, <i>p</i> = 0.01), and the incidence of hepatic and renal dysfunction (RR = 0.21, 95% CI: 0.06–0.72, <i>p</i> = 0.01). <b><i>Conclusions:</i></b> It can be concluded that compared with the use of conventional treatment and naloxone alone, the use of hemodialysis on the basis of conventional treatment and naloxone for acute severe alcohol intoxication can reduce the length of hospital stay, coma time, time of symptom disappearance, and the incidence of some complications rate. Large scale, multicenter, and well-designed RCTs are needed in the future to prove our conclusions.

Myxedema coma: Recognition and treatment

Myxedema coma (MC) develops from a long-standing, unrecognized, or untreated hypothyroidism. This article discusses the pathophysiology, clinical manifestations, treatment, and nursing considerations for patients with MC.

Artemether for severe malaria

BACKGROUND

In 2011 the World Health Organization (WHO) recommended parenteral artesunate in preference to quinine as first-line treatment for people with severe malaria. Prior to this recommendation many countries, particularly in Africa, had begun to use artemether, an alternative artemisinin derivative. This Cochrane Review evaluates intramuscular artemether compared with both quinine and artesunate.

OBJECTIVES

To assess the efficacy and safety of intramuscular artemether versus any other parenteral medication in the treatment of severe malaria in adults and children.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (the Cochrane Library), MEDLINE, Embase, and LILACS, ISI Web of Science, conference proceedings, and reference lists of articles. We also searched the WHO International Clinical Trial Registry Platform, ClinicalTrials.gov, and the metaRegister of Controlled Trials (mRCT) for ongoing trials up to 7 September 2018. We checked the reference lists of all studies identified by the search. We examined references listed in review articles and previously compiled bibliographies to look for eligible studies.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing intramuscular artemether with intravenous/intramuscular quinine or artesunate for treating severe malaria.

DATA COLLECTION AND ANALYSIS

The primary outcome was all-cause death. Two review authors independently screened each article by title and abstract, and examined potentially relevant studies for inclusion using an eligibility form. Two review authors independently extracted data and assessed risk of bias of included studies. We summarized dichotomous outcomes using risk ratios (RRs) and continuous outcomes using mean differences (MDs), and have presented both measures with 95% confidence intervals (CIs). Where appropriate, we combined data in meta-analyses and used the GRADE approach to summarize the certainty of the evidence.

MAIN RESULTS

We included 19 RCTs, enrolling 2874 adults and children with severe malaria, carried out in Africa (12 trials) and in Asia (7 trials).Artemether versus quinineFor children, there is probably little or no difference in the risk of death between intramuscular artemether and quinine (RR 0.97, 95% CI 0.77 to 1.21; 13 trials, 1659 participants, moderate-certainty evidence). Coma resolution time may be about five hours shorter with artemether (MD -5.45, 95% CI -7.90 to -3.00; six trials, 358 participants, low-certainty evidence). Artemether may make little difference to neurological sequelae (RR 0.84, 95% CI 0.66 to 1.07; seven trials, 968 participants, low-certainty evidence). Compared to quinine, artemether probably shortens the parasite clearance time by about nine hours (MD -9.03, 95% CI -11.43 to -6.63; seven trials, 420 participants, moderate-certainty evidence), and may shorten the fever clearance time by about three hours (MD -3.73, 95% CI -6.55 to -0.92; eight trials, 457 participants, low-certainty evidence).For adults, treatment with intramuscular artemether probably results in fewer deaths than treatment with quinine (RR 0.59, 95% CI 0.42 to 0.83; four trials, 716 participants, moderate-certainty evidence).Artemether versus artesunateArtemether and artesunate have not been directly compared in randomized trials in children.For adults, mortality is probably higher with intramuscular artemether (RR 1.80, 95% CI 1.09 to 2.97; two trials, 494 participants, moderate-certainty evidence).

AUTHORS' CONCLUSIONS

Artemether appears to be more effective than quinine in children and adults. Artemether compared to artesunate has not been extensively studied, but in adults it appears inferior. These findings are consistent with the WHO recommendations that artesunate is the drug of choice, but artemether is acceptable when artesunate is not available.

Successful treatment of myxedema coma with a combination of levothyroxine and liothyronine

Myxedema coma is a rare endocrine emergency resulting from the decompensation of severe hypothyroidism, which is associated with a high mortality rate. It is characterized by the deterioration of mental status, hypothermia, hypotension, hyponatremia, and hypoventilation. Early disease diagnosis and advancements in intensive supportive care have reduced the mortality rate. Besides intensive supportive care, appropriate management of the underlying thyroid hormone deficiency is essential. However, as the disease is rare and unrecognized, evidence-based treatment of myxedema has not yet been established in many countries. An 84-year-old Japanese man with a history of Hashimoto's thyroiditis was referred to our hospital. On arrival, conscious disturbance, hypothermia, hypotension, and hypoventilation were observed. He had discontinued thyroid hormone replacement therapy for a year. He was diagnosed with myxedema coma. Immediately, he received intensive supportive care and a combination therapy of 200 μg levothyroxine and 50 μg liothyronine until the fifth hospital day. Subsequently, monotherapy with levothyroxine was continued at a dose of 150 μg daily. The thyroid hormone level reached the normal range a few days later, and cardiovascular disease did not develop during hospitalization. This case demonstrated the efficacy of the combination of levothyroxine and liothyronine in treating myxedema coma.

Seizures, Metabolic Acidosis and Coma Resulting from Acute Isoniazid Intoxication

Isoniazid is an anti-tuberculosis drug, used commonly for treatment and prophylaxis of tuberculosis. Acute isoniazid intoxication is characterized by a clinical triad consisting of metabolic acidosis resistant to treatment with sodium bicarbonate, seizures which may be fatal and refractory to standard anticonvulsant therapy, and coma. Treatment requires admission to the intensive care unit for ventilatory support, management of seizures and metabolic acidosis. Pyridoxine, in a dose equivalent to the amount of isoniazid ingested, is the only effective antidote. We report the successful treatment of two isoniazid intoxication cases: the case of a child developing an accidental acute isoniazid intoxication and an adult case of isoniazid intoxication with the intent of suicide.

Risk Factors for Hypoglycemic Coma: A Study of 33 Patients on Insulin Therapy Who Were Transported to the Hospital by Ambulance

Objective Patients on outpatient insulin therapy are at a high risk of severe hypoglycemia and a high incidence of hypoglycemic coma. However, only a few studies have explored the risk factors for hypoglycemic coma in such patients. We retrospectively analyzed the clinical characteristics of diabetic patients who had developed hypoglycemic coma during outpatient insulin therapy. Methods This study included 33 diabetic patients on insulin therapy who were transported to the hospital by ambulance for severe hypoglycemia. Patients with a Japan Coma Scale score <100 were classified as the non-coma group (n=18), while those with a score ≥100 (n=15) were classified into the coma group. Results Patients in the coma group were significantly older, with a higher proportion of elderly patients ( ≥65 years of age), than those in the non-coma group. Although no marked difference in the basal insulin dose was observed between the two groups, the bolus insulin dose was significantly higher in the coma group. However, no marked differences in the disease type or renal function were noted between the two groups. Conclusion An advanced age and bolus insulin dose are risk factors for hypoglycemic coma in diabetic patients on insulin therapy. Bolus insulin dose minimization should be performed in order to prevent hypoglycemic coma, especially in elderly diabetic patients.

Severe and Recurrent Hypoglycemia Caused by Garenoxacin in a Patient not Taking Hypoglycemic Drugs

Quinolones are known to induce hypoglycemia, although there is no written report of garenoxacin-induced hypoglycemia. We herein report a case of garenoxacin-induced hypoglycemia in a patient not taking hypoglycemic drugs. An 89-year-old Japanese woman with type 2 diabetes and chronic renal insufficiency requiring hemodialysis was admitted to the emergency department in a comatose state. Her serum glucose measured 1 mg/dL on arrival. The patient had not taken any hypoglycemic drugs recently and had never experienced a hypoglycemic episode. She had received a four-day course of garenoxacin treatment before the emergency admission. Clinicians should therefore recognize the potential risk of hypoglycemia during garenoxacin therapy.

Therapeutic monitoring of antiepileptic drugs in comatose patients

OBJECTIVE

In this study, we aimed to analyze the trough plasmatic levels (C0) of the antiepileptic drugs (AED) administered by nasogastric tubes (NGT) in comatose patients and to draw up recommendations for therapeutic drug monitoring (TDM) and for the modalities of AED administration by NGT.

METHODS

We conducted a retrospective study on comatose patients addressed over six years and 10 months in Clinical Pharmacology for C0 measurement of AED administered by NGT.

RESULTS

In this study, the sex-ratio was 2.38 (44 patients). The patients' median age was 24 years. There was 14.5% of children (≤16 years). Among the 103 samples, C0 measurement concerned valproic acid in 57%, phenobarbital in 28 % and carbamazepine in 15%. Two AED or more were associated in 42% of patients. AED were associated to other drugs in 85% of cases. The AED C0 were subtherapeutic in 71% of cases. C0/Dp lower than recommanded in 65 %. In these samples, 55% presented at least one drug association with the concerned AED. In 45% of the cases, there was no drug association but a non-respect of modalities of AED administration by NGT in patients.

CONCLUSION

  The drug monitoring is a useful tool to assess drug-drug interactions and to control modalities of AED administration in comatose patients.

Neurostimulant use is associated with improved survival in comatose patients after cardiac arrest regardless of electroencephalographic substrate

AIM

Identify EEG patterns that predict or preclude favorable response in comatose post-arrest patients receiving neurostimulants.

METHODS

We examined a retrospective cohort of consecutive electroencephalography (EEG)-monitored comatose post-arrest patients. We classified the last day of EEG recording before neurostimulant administration based on continuity (continuous/discontinuous), reactivity (yes/no) and malignant patterns (periodic discharges, suppression burst, myoclonic status epilepticus or seizures; yes/no). In subjects who did not receive neurostimulants, we examined the last 24h of available recording. For our primary analysis, we used logistic regression to identify EEG predictors of favorable response to treatment (awakening).

RESULTS

In 585 subjects, mean (SD) age was 57 (17) years and 227 (39%) were female. Forty-seven patients (8%) received a neurostimulant. Neurostimulant administration independently predicted improved survival to hospital discharge in the overall cohort (adjusted odds ratio (aOR) 4.00, 95% CI 1.68-9.52) although functionally favorable survival did not differ. No EEG characteristic predicted favorable response to neurostimulants. In each subgroup of unfavorable EEG characteristics, neurostimulants were associated with increased survival to hospital discharge (discontinuous background: 44% vs 7%, P=0.004; non-reactive background: 56% vs 6%, P<0.001; malignant patterns: 63% vs 5%, P<0.001).

CONCLUSION

EEG patterns described as ominous after cardiac arrest did not preclude survival or awakening after neurostimulant administration. These data are limited by their observational nature and potential for selection bias, but suggest that EEG patterns alone should not affect consideration of neurostimulant use.

Brain MRS glutamine as a biomarker to guide therapy of hyperammonemic coma

Acute idiopathic hyperammonemia in an adult patient is a life-threatening condition often resulting in a rapid progression to irreversible cerebral edema and death. While ammonia-scavenging therapies lower blood ammonia levels, in comparison, clearance of waste nitrogen from the brain may be delayed. Therefore, we used magnetic resonance spectroscopy (MRS) to monitor cerebral glutamine levels, the major reservoir of ammonia, in a gastric bypass patient with hyperammonemic coma undergoing therapy with N-carbamoyl glutamate and the ammonia-scavenging agents, sodium phenylacetate and sodium benzoate. Improvement in mental status mirrored brain glutamine levels, as coma persisted for 48h after plasma ammonia normalized. We hypothesize that the slower clearance for brain glutamine levels accounts for the delay in improvement following initiation of treatment in cases of chronic hyperammonemia. We propose MRS to monitor brain glutamine as a noninvasive approach to be utilized for diagnostic and therapeutic monitoring purposes in adult patients presenting with idiopathic hyperammonemia.

Successful treatment of a patient with ethylmalonic encephalopathy by intravenous N-acetylcysteine

Ethylmalonic encephalopathy (EE) is an autosomal recessive devastating metabolic disorder affecting the brain, gastrointestinal tract, peripheral vessels and rarely the other vascular organs. We report a 10-month-old girl who presented as a meningococcemia clinic but later diagnosed ethylmalonic encephalopathy. Molecular analyses revealed a homozygous c.554 T > G; p. L185R mutation in ETHE1 gene. She was only partially benefited from riboflavine, coenzyme Q10, metronidazole, N-acetylcysteine and symptomatic treatment and discharged from hospital with the sequela of oxygene dependance and developmental delay. We observed N-acetylcysteine 100 mg/kg/day intravenous infusion theraphy may be the most important drug especially in comatous EE patients.

Spatial variation in automated burst suppression detection in pharmacologically induced coma

Burst suppression is actively studied as a control signal to guide anesthetic dosing in patients undergoing medically induced coma. The ability to automatically identify periods of EEG suppression and compactly summarize the depth of coma using the burst suppression probability (BSP) is crucial to effective and safe monitoring and control of medical coma. Current literature however does not explicitly account for the potential variation in burst suppression parameters across different scalp locations. In this study we analyzed standard 19-channel EEG recordings from 8 patients with refractory status epilepticus who underwent pharmacologically induced burst suppression as medical treatment for refractory seizures. We found that although burst suppression is generally considered a global phenomenon, BSP obtained using a previously validated algorithm varies systematically across different channels. A global representation of information from individual channels is proposed that takes into account the burst suppression characteristics recorded at multiple electrodes. BSP computed from this representative burst suppression pattern may be more resilient to noise and a better representation of the brain state of patients. Multichannel data integration may enhance the reliability of estimates of the depth of medical coma.

Meta-Analysis of the Effects of Xingnaojing Injection on Consciousness Disturbance

Xingnaojing (XNJ) is commonly extracted from Angongniuhuang, a classic Chinese emergency prescription, and widely used in the treatment of nervous system disorders including consciousness disturbance in China. To evaluate the beneficial and adverse effects of XNJ injection, on consciousness disturbance. Seven major electronic databases were searched to retrieve randomized controlled trials designed to evaluate the clinical efficacy of XNJ alone or combined with Western medicine in treating consciousness disturbance caused by conditions such as high fever, poisoning, and stroke. The methodological quality of the included studies was assessed using criteria from the Cochrane Handbook for Systematic Review of Interventions, and analyzed using the RevMan 5.3.0 software. Seventeen randomized controlled trials on XNJ were included in this study and the trials generally showed low methodological quality. The results revealed that XNJ alone or in combination with other medicines and adjuvant methods had a positive effect on patients with fever-, poisoning-, and stroke-induced coma. XNJ effectively treated consciousness disturbances that were caused by high fever, poisoning, or stroke.

Effects of Alda-1, an Aldehyde Dehydrogenase-2 Agonist, on Hypoglycemic Neuronal Death

Hypoglycemic encephalopathy (HE) is caused by a lack of glucose availability to neuronal cells, and no neuroprotective drugs have been developed as yet. Studies on the pathogenesis of HE and the development of new neuroprotective drugs have been conducted using animal models such as the hypoglycemic coma model and non-coma hypoglycemia model. However, both models have inherent problems, and establishment of animal models that mimic clinical situations is desirable. In this study, we first developed a short-term hypoglycemic coma model in which rats could be maintained in an isoelectric electroencephalogram (EEG) state for 2 min and subsequent hyperglycemia without requiring anti-seizure drugs and an artificial ventilation. This condition caused the production of 4-hydroxy-2-nonenal (4-HNE), a cytotoxic aldehyde, in neurons of the hippocampus and cerebral cortex, and a marked increase in neuronal death as evaluated by Fluoro-Jade B (FJB) staining. We also investigated whether N-(1,3-benzodioxole-5-ylmethyl)-2,6-dichlorobenzamide (Alda-1), a small-molecule agonist of aldehyde dehydrogenase-2, could attenuate 4-HNE levels and reduce hypoglycemic neuronal death. After confirming that EEG recordings remained isoelectric for 2 min, Alda-1 (8.5 mg/kg) or vehicle (dimethyl sulfoxide; DMSO) was administered intravenously with glucose to maintain a blood glucose level of 250 to 270 mg/dL. Fewer 4-HNE and FJB-positive cells were observed in the cerebral cortex of Alda-1-treated rats than in DMSO-treated rats 24 h after glucose administration (P = 0.002 and P = 0.020). Thus, activation of the ALDH2 pathway could be a molecular target for HE treatment, and Alda-1 is a potentially neuroprotective agent that exerts a beneficial effect on neurons when intravenously administered simultaneously with glucose.

[Keto acidosis and coma in 44-years old man with diabetes t1 in Internal Diseases Department in Dabrowa Tarnowska]

Diabetic ketoacidosis (DKA) is an acute complication metabolic occur- ring in patients with diabetes type-1 and much less likely to type 2 diabetes. This article shows clinical manifesta- tion, biochemical criteria and algorithm for the immediate assessment and management of diabetic acidosis in a 44 years old men. This specification describes a rare case of keto acidosis and coma therapy and the challenges that these disorders carry.

Modafinil in Endozepine Stupor. A Case Report

Background:

Endozepine-4 stupor is a rare disorder. It presents with recurrent episodes of stupor and coma. Endozepine-4 levels are elevated during an attack with electroencephalogram showing fast activity during the ictal phase. There is no specific treatment and various drugs have been tried without long-term benefit.

Method:

We used the vigilance promoting drug modafinil to prevent such attacks in a case presented with endozepine stupor.

Results:

The vigilance promoting drug modafinil prevented recurrent episodes of stupor and coma in this patient at a dose of 200 mg/day for a period of six months. Upon withdrawal of the drug, the patient experienced recurrent episodes and on reinstitution of modafinil she has remained asymptomatic in the following one year.

Heart failure presenting as myxedema coma: case report and review article

Hypothyroidism is a common medical problem easily treated when diagnosed but requiring regular follow-up and patient medication compliance. At times, this diagnosis can go untreated resulting in the development of severe consequences such as Myxedema Coma. Of all the clinical symptoms, cardiovascular manifestations tend to be especially severe and often life threatening.

Oxycodone overdose causes naloxone responsive coma and QT prolongation

BACKGROUND

Although there are limited data on oxycodone overdose, it has been suggested that, in addition to central nervous system (CNS) depression, oxycodone may cause QT prolongation. Given the high prescription rate and increasing use of oxycodone, an understanding of its effects and treatment in overdose is necessary.

AIM

To investigate the clinical features, electrocardiogram (ECG) parameters and treatment of oxycodone overdose.

DESIGN

Retrospective review of a clinical database.

METHODS

One hundred and thirty-seven oxycodone overdoses were identified from admissions to a toxicology unit between January 2001 and May 2011. Demographic information, details of ingestion, clinical effects, ECG parameters [heart rate (HR), QT and QRS], naloxone use and length of stay (LOS) were extracted from a clinical database. QT was measured manually and plotted on a QT nomogram. LOS was extracted for all overdoses over the same period.

RESULTS

From 137 oxycodone overdoses, 79 (58%) ingested immediate release (IR) and 58 (42%) ingested sustained release (SR) or a combination of IR and SR. The median age was 40 years [interquartile range (IQR): 33-49 years], and 87 were female (64%). The median ingested dose of IR oxycodone was 70 mg (IQR: 40-100, range: 5-200), compared to 240 mg (IQR: 80-530, range: 30-1600) for SR oxycodone. Benzodiazepines were the most frequent co-ingested drug in 52 (38%) cases. No arrhythmias were recorded. Twenty-four patients (18%) had bradycardia of which five had a HR < 50 beats/min. From 116 available ECGs, the median QRS was 95 ms (IQR: 90-102 ms), and there were 20 (17%) abnormal QT-HR pairs. Naloxone boluses were required in 65 admissions (47%), and 34 (25%) required a naloxone infusion. There was higher overall naloxone use with SR and IR + SR (32/58, 55%) compared to IR oxycodone (33/79, 42%). The median LOS was 18 h (IQR: 12-35), which was greater than the median LOS for all toxicology admissions at 15 h (IQR: 8-24) over the same period. Patients requiring a naloxone infusion had an even greater LOS of 36 h (IQR: 20-62 h).

CONCLUSION

In addition to the expected CNS depression, the opioid oxycodone can cause bradycardia and QT prolongation in overdose. The SR formulation is associated with the use of naloxone infusions and a longer LOS.

[The diagnosis and treatment of myxedema coma]

Myxedema coma is defined as severe hypothyroidism leading to decreased mental status, hypothermia, and other symptoms related to dysfunction in multiple organs. It is very rare disease with high mortality rate. Early recognition and therapy of myxedema coma are essential, and treatment should be begun on the basis of clinical suspection. However, regimen of myxedema is not well established even now, especially about thyroid hormone supplementation. Japan Thyroid Association is drawing up "The diagnostic criteria of myxedema coma (3rd draft) and preliminary guide to treatment of it". According to this criteria and preliminary guide, the clinical presentation, diagnosis, and treatment of myxedema coma will be reviewed here.

[Pituitary coma]

Severe or inadequately substituted insufficiency of corticotropic and/or thyrotropic pituitary axes may induce a life-threatening coma. Without any information on patient history the primary diagnosis is difficult but clinical signs of hypogonadism may be helpful. Laboratory diagnostics reveal low serum concentrations of the hormones of the pituitary and the target organs. Low sodium concentrations are induced by stimulated ADH secretion and coincidental hypoglycemia may aggravate the situation. Initial treatment is based on the early substitution of hydrocortisone and is followed by thyroxine substitution according to the laboratory results at an intensive care unit where other coincidental problems also need to be monitored and treated. Differential diagnosis of pituitary pathology and definition of long-term treatment follow after stabilization of the patient's condition.

[Comatose state--think different]

We report the case of a 76-year old woman, who presented with signs of a meningoencephalitis. The result of lumbar puncture showed a mononuclear pleocytosis. Empirical antimicrobial treatment was promptly initiated. Nevertheless a comatose state complicated the clinical course. The diagnosis of neuroborreliosis was made serologically and by molecular biology. Under adequate therapy with intravenous ceftriaxone the patient showed a slow but full recovery. This case illustrates that potentially reversible diseases need very careful decision making regarding therapeutic activities and that neuroborreliosis is a potentially reversible cause of severe neurologic impairment.

[Neuroprotective effects of succinate-containing antihypoxante reamberine in treatment of patients with toxicohypoxic brain injury]

As a result of survey in process of treatment of 60 patients with severe acute poisoning complicated by the toxic-hypoxic brain edema, found that inclusion of reamberin (antihypoxant containing succinate) in basic therapy leads to increase levels of the antioxidant defense system, decrease lipid peroxidation and reduce NR2A titers of autoantibodies. Reduction of degree of toxic-hypoxic encephalopathy promotes improving the clinical course, manifested shortened duration of coma and hospital bad days.

Lipid emulsion improves Glasgow coma scale and decreases blood glucose level in the setting of acute non-local anesthetic drug poisoning--a randomized controlled trial

BACKGROUND

To date, no study has been performed to evaluate the antidotal effect of intravenous lipid emulsion on the poisoned patients' level of consciousness and routine metabolic profile tests in non-local anesthetic drug overdose.

OBJECTIVES

Our aim was to evaluate the effect of intravenous intralipid administration as an antidote on the poisoned patients' Glasgow Coma Scale (GCS), hemodynamic parameters, arterial blood gas analysis, and routine metabolic profile tests (i.e., urea, glucose, sodium, and potassium) in the setting of non-local anesthetic drug overdose.

MATERIAL AND METHODS

In this randomized controlled trial, a total of 30 patients with non-local anesthetic drug intoxication were enrolled and randomly assigned into case (n=15) and control (n=15) groups. In the case group, all patients received 10 cc/kg intralipid 10% infusion. The patients in the control group just received the supportive care. Patients' demographic and clinical characteristics and results of their laboratory tests were evaluated at presentation and 6 hours after that.

RESULTS

Mean age was 23 +/- 5 and 28 +/- 11 years in cases and controls, respectively. There were no significant statistical differences between these two groups regarding age, gender, elapsed time between intubation and extubation, and need for intubation and/or mechanical ventilation (p = 0.70 and p = 1.00, respectively). Also, systolic blood pressure, pulse rate, mean rate pressure product, respiratory rate, results of arterial blood gas analyses, serum sodium, potassium, urea, and creatinine on presentation and six hours later were not statistically significantly different between the two study groups. However, a significant difference was found between the two groups in terms of GCS difference (p = 0.048) and blood glucose six hours after presentation (p = 0.04).

CONCLUSIONS

In the setting of non-local anesthetic drug overdose, intravenous intralipid infusion can increase GCS and interestingly, decrease the blood glucose.

Thyroid emergencies

This review presents current knowledge about the thyroid emergencies known as myxedema coma and thyrotoxic storm. Understanding the pathogenesis of these conditions, appropriate recognition of the clinical signs and symptoms, and their prompt and accurate diagnosis and treatment are crucial in optimizing survival.

[Mechanism of neuroprotector action of metabolic antihypoxant reamberin in patients with toxicohypoxic encephalopathy]

Based on investigation of a group of patients with heavy forms of sharp poisoning by neurotropic substances, it is established that inclusion if antihypoxant reamberin in intensive treatment of toxicohypoxic encephalopathy leads to a decrease in the depth of central nervous system depression. This is manifested by reduced duration of patient stay in coma and decreased total duration of resuscitation treatment. Improvement of the clinical picture is accompanied by a decrease in lipid peroxidation activity, increase in the level of antioxidant enzymes, and decrease in the level of NR2A auto-antibodies. That is objective evidence of the efficiency of neuroprotective therapy by reamberin.

[Comatose patient with neuroleptic malignant syndrome brought by ambulance]

A 27-year-old woman with schizophrenia showed signs of neuroleptic malignant syndrome with disturbed consciousness, high fever, muscle rigidity, and autonomic dysfunction (including tachycardia and enhancement of saliva secretion). Since the age of 15, she had been treated at a local psychiatric clinic with a diagnosis of schizophrenia. On the day she was brought to the emergency room, she was asleep in the morning, but tachycardia was observed in the evening in the absence of consciousness. The patient was brought to our hospital by ambulance. It was revealed that she had taken a massive dose of chlorpromazine hydrochloride in the morning on the same day. On arrival, the Japan coma scale, pulse, respiratory rate, body temperature, and Sp(O2) were 300, 114 beats x min(-1), 26 breaths x min(-1), 39.0 degrees, and 91% (room air), respectively. The CPK level was 1,776 IU x l(-1). Sp(O2), bilateral pneumonia, and right atelectasis improved 2 hours after admission. Endotracheal intubation was performed for artificial respiration. Salivation, marked sweating, and rigidity of the limbs were noted. Under a diagnosis of neuroleptic malignant syndrome, dantrolene was administered. For pneumonia, ceftriaxone and pazufloxacin were administered. The consciousness became clear 2 days after admission. The patient was discharged 10 days after admission.

[Case of Bickerstaff brainstem encephalitis associated with spindle coma and decorticate posture]

A 25-years-old man experienced fever and diarrhea. Ten days later he noticed difficulty walking (day 1). On admission neurological examination revealed lethargy, dysarthria and weakness of limbs. Oculocephalic response was not be elicited and extensor toe signs were positive. In spite of treatment with aciclovir and methylprednisolone, he continued to show progressive deterioration developing to coma with decorticate posture. Autonomic symptoms (hyperhidrosis, hypersalivation and fever) and groaning were observed. Brain magnetic resonance image and brainstem evoked potential presented no abnormality, but electroencephalographic study showed a spindle pattern indicating spindle coma. Laboratory tests including cerebrospinal fluids showed no specific results. High-dose immunoglobulin was administered from day 6, and his consciousness level improved. External ophthalomoplegia and ataxic gait were observed after he became more alert. Because he had IgG type anti-GQ1b antibodies in the serum, a diagnosis was made of Bickerstaff's brainstem encephalitis (BBE). Six months after discharge he had complete resolution of his symptoms. This is the first report of spindle coma observed in a case of serologically confirmed BBE.

Isolated ACTH deficiency presenting with a glucocorticoid-responsive triphasic wave coma

We report the case of a 58-year-old woman who presented with acutely developed coma characterized by electroencephalographic triphasic waves (TWs) in the absence of metabolic derangement. The patient's coma and TWs were promptly resolved after the administration of glucocorticoids, and thereafter isolated ACTH deficiency was diagnosed. Isolated ACTH deficiency may present with glucocorticoid-responsive acute encephalopathy without hypoglycemia, hyponatremia, or systemic hypotension. Electroencephalographic TWs or bursts of slow waves may be a clue to the diagnosis of this rare condition in patients with coma of unknown origin.

A patient with thyroid storm presenting with apathetic thyrotoxicosis and features of meningoencephalitis

BACKGROUND

Apathetic thyrotoxicosis is distinctly unusual in thyroid storm and features of meningoencephalitis are very rare. Here we present such a patient.

PATIENT FINDINGS

The patient was a 67-year-old Chinese woman who presented with acute generalized weakness, decreased mentation, fever, and rapid deterioration to coma, accompanied by meningism, initially mimicking meningoencephalitis. Further investigations excluded intracranial lesions. Laboratory findings were consistent with Graves' thyrotoxicosis. She was treated for thyroid storm with antithyroid drugs, Lugol's iodine solution, and other supportive management. Subsequently, her level of consciousness returned to normal and neurological signs resolved.

SUMMARY

We report a patient with thyroid storm with an apathetic presentation, manifesting as coma with meningism, that mimicked meningoencephalitis. These resolved after treatment for thyroid storm was instituted.

CONCLUSIONS

Apathetic thyrotoxicosis is a rare presentation of thyroid storm. Early recognition and treatment is essential for reducing its morbidity and mortality.

Myxedema coma in a patient with subclinical hypothyroidism

BACKGROUND

Myxedema coma is the extreme manifestation of hypothyroidism, typically seen in patients with severe biochemical hypothyroidism. Its occurrence in association with subclinical hypothyroidism is extremely unusual. We describe a patient with subclinical hypothyroidism who developed clinical manifestations of myxedema coma.

SUMMARY

A 47-year-old woman presented to our endocrine clinic with complaints of fatigue and biochemical findings of subclinical hypothyroidism. She was started on treatment with thyroxine (T4) but remained unwell and was later admitted to hospital with hormone profile showing persisting subclinical hypothyroidism (elevated thyrotropin and normal free T4 [FT4] and free triiodothyronine [FT3]): FT4 10.7 pmol/L (reference range 10.3-24.5), FT3 2.7 pmol/L (reference range 2.67-7.03), and thyrotropin 6.09 mU/L (reference range 0.4-4.0). She subsequently developed hypothermia (temperature 33.2°C), circulatory collapse, and coma. Biochemical profile showed hyponatremia, elevated creatinine phosphokinase, metabolic acidosis, and renal failure. An echocardiogram revealed a moderate-sized pericardial effusion. We diagnosed myxedema coma and started treatment with intravenous T3. She responded dramatically with improvement in level of consciousness and normalization of metabolic parameters. We found no explanation other than hypothyroidism to account for the presentation. Adrenocorticotrophic hormone (ACTH) stimulation tests excluded adrenal insufficiency, and serum gonadotrophins were within the normal reference range. FT4 estimation by equilibrium dialysis excluded analytical interference, and molecular analysis for the thyroid hormone receptor β gene associated with thyroid hormone resistance was negative.

CONCLUSIONS

To the best of our knowledge this is the first report of myxedema coma in a patient with subclinical hypothyroidism. The reason for normal thyroid hormone levels is unclear but may reflect deviation from a higher pre-morbid set-point. The case highlights the importance of careful clinical evaluation in patients with disparate clinical and laboratory findings.

Rationality of administered gentamicin dose in cerebral coma patients treated in an intensive care unit

Gentamicin is still widely used in the treatment of patients in an intensive care unit (ICU). The efficacy of aminoglycosides correlates with the peak serum concentration (Cmax), and the toxicity with the minimum serum concentration (Cmin). The aim of this study was to determine Cmax and Cmin in serum of cerebral coma ICU patients when a dosage of gentamicin of 5 mg/kg body weight was administered once daily; to evaluate the rationality of mentioned dose; and to identify factors associated with these concentrations. Material and METHODS. A total of 24 ICU patients suffering from cerebral coma were included into this analysis. A dosage of gentamicin of 5 mg/kg body weight was administered once a day. Gentamicin concentrations were tested twice after the first dose infusion (immediately and 5 hours after 1-hour infusion). Cmax, Cmin, volume of distribution (Vd), and elimination half-life (T1/2) were obtained. RESULTS. The mean Cmax was 17.96 (SD, 4.31) µg/mL (range, 10.30-27.87 µg/mL). The desirable Cmax (≥ 20 µg/mL) was reached only in 6 patients (25%). Cmin was calculated using a special pharmacokinetic program "Kinetica." Cmin of 0.5 µg/mL was not exceeded in any patient. A correlative analysis indicated a significant inverse direct correlation between Cmax and Vd and between Cmax and treatment duration in the ICU. An inverse correlation was observed between Cmin and T1/2, evaluation of coma according to the Glasgow coma scale, and creatinine clearance. CONCLUSIONS. A dosage of 5 mg/kg body weight once a day was not sufficient in cerebral coma ICU patients. This dose was not associated with the nephrotoxic effect of gentamicin (additional risk factors were absent). It is recommended to obtain gentamicin concentration at two time points following administration of the first dose (e.g., immediately after 1-hour infusion and 5 hours later), and using a special pharmacokinetic software, to calculate a necessary dose and interval of administration.

[Comatose state caused by seizure-free status epilepticus in postoperative period]

We present a rare clinical observation of progressive development of neurological symptoms up to comatose state in a child with extra-intraventricular craniopharyngioma in delayed postoperative period due to seizure-free status epilepticus which was diagnosed only by EEG-monitoring. Concerning this case report, we discuss genesis of seizure-free status epilepticus and its possible role in development of severe condition in patients with different kinds of neurosurgical pathology in postoperative period.

[Antidote against local anaesthetic intoxication: new use of lipid emulsion for intravenous administration]

Local anaesthetics are routinely used for several indications, but despite local administration their use may lead to systemic toxicity. The symptoms include numbness of the tongue, dizziness, tinnitus, visual disturbances, muscle spasms, convulsions, coma, and respiratory and cardiac arrest. Recently, an intravenous lipid emulsion was reported to act as a novel potential antidote for systemic toxicity due to local anaesthetics. We describe the application of this lipid emulsion in a 27-year-old patient with generalized seizures and coma due to local anaesthetic toxicity. She recovered quickly and was responsive again 10 minutes after the intravenous administration of the lipid emulsion.

[Correction of tissue hypoxia with reamberin in severe forms of acute intoxication with neurotropic poisons]

Examination and treatment of 66 patients severely intoxicated with neurotropic poisons showed that inclusion of reamberin in combined therapy decreased the degree of tissue hypoxia as apparent from increased oxygen consumption, oxygen utilization index, and arteriovenous oxygen difference. This in turn accelerated recovery of antioxidant protection and lowered activity of lipid peroxidation. The use of reamberin for the treatment of acute neurotropic intoxication improves clinical conditions of the patients by decreasing duration of the comatose state, requirement for intensive therapy, and lethality.

Clinical observation of Danhong Injection (herbal TCM product from Radix Salviae miltiorrhizae and Flos Carthami tinctorii) in the treatment of traumatic intracranial hematoma

Danhong Injection (DHI), a Chinese Materia Medica standardized product extracted from Radix Salviae Miltiorrhizae and Flos Carthami tinctorii, has the actions of promoting blood circulation and resolving stasis to promote regeneration. The clinical therapeutic effects of DHI on traumatic intracranial hematoma (TICH) were observed. Eighty patients with TICH were randomly assigned to trial group and a control group (40 patients per group), and all were administered with routine medication. Additionally, DIH was administered intravenously to patients in the trial group. Pre and post-treatment GCS was observed in the two groups, along with GOS after therapy. The intracranial hematoma absorption, hemorheological changes, and changes in coagulation indexes pre- and post-treatment were evaluated. The results indicated that GCS and GOS after therapy for the trial group were superior to those for the control group (p<0.05). There was a significant post-treatment difference in the intracranial hematoma absorption between the two groups (p<0.01). Each hemorheological index in the trial group improved significantly as compared with that of the control group (p<0.05 or p<0.01). The plasma levels of fibrinogen and D-dimer in the trial group were significantly decreased after therapy (p<0.01). These results suggest that DHI is conducive to the recovery of patients with TICH.