Traumatic Brain Injury (TBI) in children has been poorly studied, and the literature is limited. We evaluated 146 children with severe TBI (coma score less than 8) in an attempt to establish the prognostic factors of severe TBI in children.
Although disturbance of consciousness in delirium patients have been well
established, but sudden drop of Glasgow Coma Scale (GCS) level to three is
frightening and mysterious. We are reporting a case of a delirious elderly
man with multiple medical illnesses presented with acute precipitous
decrement of GCS with pin point pupils bilaterally after given a course of
benzodiazepines and regained full consciousness spontaneously 32 hours
later. We discussed the use of deliriogenic medications in the context of
delirious elderly gentleman with multiple medical illnesses. We also looked
into the possible differentials of sudden drop of conscious level with bilateral
pin point pupils.
We report a patient with hyperosmolar non-ketotic hyperglycaemia who presented with chorea and septic arthritis on his knee. The chorea resolved completely and quickly with correction of the metabolic disturbance, only to return just as quickly when his metabolic disturbance subsequently deteriorated as a result of overwhelming septicaemia, suggesting coexisting cerebral ischaemia, although the basis of focal neurological sign in non-ketotic hyperglycaemia remains controversial.
All post-neonatal children with acute non-traumatic coma admitted over an 8-month period were analysed and followed up for 18-24 months to determine the aetiology and outcome of their coma. One hundred and sixteen children, 72 boys and 44 girls, were recruited. Half the children were under 1 year of age and only 16 (14%) were more than 6 years of age. Eighty cases (69%) were due to infection, 15 (13%) to toxic metabolic causes, six (5%) to hypoxic ischaemic insults, four (3.5%) had intracranial haemorrhage, nine (7.8%) were due to miscellaneous causes and in two (1.7%) the cause was unknown. Seven cases were lost to follow-up. Of the remainder, 39 (35.7%) died, 32 (29.3%) developed permanent neurological deficit, and 38 (35%) were discharged well. The outcome was worst in the infectious group. Age of onset and sex did not significantly affect outcome. Our findings are similar to experience in Japan, where infection accounts for 74% of non-traumatic coma, but differ considerably from Western data on childhood coma where only a third of cases are due to infection.
Barbiturate coma therapy (BCT) is a choice treatment for refractory intracranial hypertension after all surgical or medical managements have failed to control the intracranial pressure (ICP). It helps to reduce cerebral blood flow, cerebral metabolic rate of oxygen consumption and ICP. However, this therapy can also cause many complications. One of the underreported, but life-threatening complications is refractory hypokalemia, which can lead to subsequent rebound hyperkalemia after sudden cessation. We report our experience of managing unusual complication of refractory hypokalemia during BCT with thiopentone in postdecompressive craniectomy patient.
Sixty-nine severely head-injured patients treated by general surgeons over a 28 month period with admission Glasgow Coma Scale motor scores of 3 to 8 were reviewed retrospectively. Fifty-one patients were comatose on admission with periods from injury to admission exceeding 4 h in 34 patients who were referred from peripheral hospitals. Forty patients with acute intracranial bleeding underwent emergency decompressive surgery with 13 good recoveries and 18 deaths; good recoveries were observed in 11 of 20 patients with extradural haemorrhages, one out of eight patients with subdural haemorrhages, and one of 12 patients with intracerebral and/or combined haemorrhages. Twenty-nine patients with no evidence of acute mass lesions were treated medically with sedation, mechanical ventilation and mannitol infusion for cerebral decompression with seven good recoveries and 16 deaths. There were 15 good outcomes in 40 patients with admission motor scores of 6, 7 or 8 and five good outcomes in 29 patients with scores of 3, 4 or 5. A good outcome of 29% in the study may be improved by (i) better neurosurgical training of surgical and nursing staff; (ii) provision of technologically advanced diagnostic and treatment modalities; (iii) an efficient referral system; and (iv) provision of effective long-term rehabilitation.
Matched MeSH terms: Coma/radiography; Coma/surgery; Glasgow Coma Scale
Head injury is common and preventable. Assessment of the head injury patient includes airway, cervical spine protection, breathing, circulation, haemorrhage control and the Glasgow Coma Scale. Hypotension, hypoxia, hypocarbia and hypercarbia should be avoided by continuous monitoring of vital signs and hourly head chart to prevent secondary brain injury. This paper aims to assist primary healthcare providers to select the appropriate patient for transfer and imaging for further management of head injury.
We report a case of Wernicke's encephalopathy in a patient with nasopharyngeal carcinoma with a 3-month history of poor oral intake related to nausea and vomiting due to chemotherapy. The patient later developed deep coma while receiving in-patient therapy. Magnetic resonance imaging of the brain revealed typical findings of Wernicke's encephalopathy. The patient was treated with thiamine injections, which resulted in subsequent partial recovery of neurological function. This paper stresses the importance of magnetic resonance imaging for prompt diagnosis of Wernicke's encephalopathy.
Barbiturate coma therapy (BCT) is a treatment option that is used for refractory intracranial hypertension after all other options have been exhausted. Although BCT is a brain protection treatment, it also has several side effects such as hypotension, hepatic dysfunction, renal dysfunction, respiratory complications and electrolyte imbalances. One less concerning but potentially life-threatening complication of BCT is dyskalaemia. This complication could present as severe refractory hypokalaemia during the therapy with subsequent rebound hyperkalaemia after cessation of the therapy. Judicious potassium replacement during severe refractory hypokalaemia and gradual cessation of the therapy to prevent rebound hyperkalaemia are recommended strategies to deal with this complication, based on previous case series and reports. In this case report, we show that these strategies were applicable in improving severe hypokalaemia and preventing sudden, life-threatening rebound hyperkalaemia. However, even with use of these strategies, BCT patients could still present with mild, asymptomatic hyperkalaemia.
Non-traumatic Altered States of Consciousness (ASC) are a non-specific consequence of various etiologies, and are normally monitored by Glasgow Coma Scale (GCS). The GCS gives varriable results among untrained emergency medicine personel in developing countries where English is not the first language. An In House Scoring System (IHSS) scale was made by the first author for the purpose of triaging so as to quickly asses patients when seen by medical personel. This IHSS scale was compared to the GCS to determine it's specificity and sensitivity in the accident and emergency department (ED) of Hospital University Sains Malaysia (HUSM). All patients with non-traumatic ASC were selected by purposive sampling according to pre-determined criteria. Patients were evaluated by the two systems, IHSS and GCS, by emergency physicians who were on call. Patient demographics, clinical features, investigations, treatment given and outcomes were collected and followed for a period of 14 days. A total of 221 patients with non-traumatic ASC were studied, 54.3% were males. The mean age of the patients was 56 years old. The mean overall GCS score on presentation to the ED was 10.3. The mean duration of ASC was 11.6 hours. One hundred thirty patients (58.8%) experienced ASC secondary to general or focal cerebral disorders. The mortality rate was 40.3% 2 weeks after the ED visit. Fifty-four point three percent of the patients were awake and considered to have good outcomes while 45.7% of the patients had poor outcomes (comatose or dead) 2 weeks after the ED visit. The mean overall GCS score, verbal and motor subscores as well as the IHSS had significantly decreased (worsened) after treatment in the ED. A poor IHSS scale, hypertension, current smoking, abnormal pupillary reflexes and acidosis were associated with a worse 2-week outcome. The mean age and WBC count was lower and the mean overall GCS score and eye, verbal and motor subscores were higher as well as those having a lower IHSS scale for the good outcome category. Multivariate analysis revealed that smokers and hypertensives were at higher risk for a poor outcome. Higher eye scores on the GCS were associated fewer poor outcomes. There was significant agreement between the IHSS scale and GCS scores in the assessment of non-traumatic ASC. The sensitivity and specificity of the IHSS score versus GCS were 71.9% and 100.0%, respectively.
Ventriculostomy or external ventricular drain (EVD) placement by free-hand technique has a high malplacement rate. It is a blind procedure that often requires multiple attempts and revisions. To date, no neurological complication due to EVD malplacement has been reported in the literature. In this report, we present the first case of coma induced by a malplaced EVD and the patient regained consciousness after the drain was adjusted. Our discussion focused on various techniques that can improve the accuracy of EVD insertion. EVD insertion under image guidance provides better accuracy with limited disadvantages. We hypothesized that the patient's coma was due to the mass effect and irritation of the malplaced EVD exerted onto the ventral periaqueductal grey matter and the ascending neurons from upper brainstem.
Matched MeSH terms: Coma/etiology*; Glasgow Coma Scale