Acute Nontraumatic Coma Research Articles

Case report: \u201can unexpected origin of coma in a young adult\u201d

We report a peculiar case of acute non-traumatic coma due to neuromuscular hypoventilation syndrome caused by a non-traumatic spinal cord injury (NTSCI). A 21-year-old patient presented to the emergency room complaining of sudden onset weakness in his lower limbs and shortness of breath. While in the ER, he briefly became comatose and labs revealed an acute respiratory acidosis. Detailed neurologic examination ultimately revealed upper motor neuron signs and quadriplegia. He was ultimately diagnosed with a non-traumatic spinal cord injury, in particular, a cervical transverse myelitis which had caused acute diaphragmatic weakness. Although a very rare cause of coma, emergency medicine physicians need to be aware of transverse myelitis, a disorder that may result in rapidly progressive neurologic decline and is treated with immunomodulation.

Value of coma scale in prediction of mortality in non-traumatic coma in 1-12 years old children

Background: Acute non-traumatic coma is a common problem in pediatric practice accounting for 10-15% of all hospital admissions and is associated with significant mortality. Assessment of the severity of coma is essential to comment on the likelihood of survival in comatose children. In the last three decades, various scores have been used to assess the severity of coma and to predict its outcome. Glasgow Coma Scale (MGCS) in spite of its various drawbacks has been widely used for assessing pediatric coma, though only few studies are available to support its use in pediatric coma as a whole. Hence the study was undertaken to evaluate the usefulness of coma scale in prediction of mortality in children between 1-12 years old admitted with coma of non-traumatic origin. Methods: A prospective study was conducted at Inpatient services of intensive medical care unit and general medical wards of Institute of child Health and Hospital for children, Egmore, Chennai, between October 2018 to November 2019. A Study Population consisting of children in the age group 1-12 years admitted in intensive care unit and medical wards with alteration in sensorium as one of the predominant complaints and admitted within 7 days of onset of coma were included. Sample size was 148. Chi-square test was used to study the association between the scores at Various times points and outcome. Results: It was observed that when the scores were between 3‐ 5 mortality rate was 67.0%, it was 17% when the minimal observed score was between 6-8. The group in which the minimal score never decreased be1ow 9 had no mortality. As the score increases the proportion of death decreases and the proportion having good recovery increases and vice versa. This type of association has been observed at different time points (Initial, 24 hrs, 48 hrs and 72 hrs). The significance of this association increases with the progression of time since admission. P value for the degree of association at various time points are: At presentation P < 0.00001, 24hrs - P < 0.000001, 48 hrs - P < 0.000001 and 72 hrs P < 0.00000001. Conclusion: There is highly statistically significant association between the GSC score levels and outcome. As the score increases the proportion of death decreases and the proportion having good recovery increases and vice versa.

Clinical Utility of MRI Brain in Children with Non-traumatic Coma.

To determine characteristics that help identify children with acute encephalopathy who benefit from an MRI (magnetic resonance imaging) of the brain. The secondary objective was to determine the adverse events associated with the MRI procedure. In this single center, prospective, observational study. Children (2 mo - 12 y) presenting with impaired consciousness were screened. Those with acute non-traumatic encephalopathy (Glasgow Coma Score of 12 or less) undergoing their first in-patient MRI brain were included. The decision regarding MRI brain was taken by the treating unit. The clinician taking care of the child was requested to categorize the information obtained from MRI into one of the following categories (as per definition): Contributory MRI [Diagnostic and/or Therapeutic, Suggestive or Additive and/or Prognostic (as per definitions)] OR Non-contributory MRI (If results of the MRI did not alter the management of the child in any manner). During the study period, 16,667 children presented to the pediatric emergency, of which 496 children were admitted with a diagnosis of acute encephalopathy and100 children were enrolled for this study. Ninety-two children had a febrile encephalopathy. Seventy-seven (77%, 95% CI 69-85%) children had an MRI that was contributory. In 64(78%) out of 82 children who underwent both CT and MRI, the MRI showed additional findings. Those with abnormal CT were significantly more likely to have a contributory MRI (65.6% vs. 22.2%, P=0.001). There were 18 adverse events during the MRI procedure. MRI contributes in management decisions in over three-fourth of children presenting with non-traumatic coma and should be the neuroimaging of choice in acute non-traumatic coma. There are no pre-MRI clues to identify which child is likely to benefit from the MRI. However, if CT detects an abnormality, MRI is likely to significantly add to the information, contributing directly to the management.

Abnormal intra-aural pressure waves associated with death in African children with acute nontraumatic coma.

Background:We explored the relationship between tympanic membrane displacement (TMD) measurements, a tool to monitor intracranial pressure noninvasively, and clinical features and death in children with acute coma in Kilifi, Kenya.Methods:Between November 2007 and September 2009, we made serial TMD measurements and clinical observations on children with acute coma (Blantyre coma score (BCS) ≤ 2) on the pediatric high dependency unit of Kilifi District Hospital, and on well children presenting to the hospital's outpatient department for routine follow-up. We examined middle ear function using tympanometry and measured cardiac pulse (CPA) and respiratory pulse pressure amplitudes (RPA) using the TMD analyzer.Results:We recruited 75 children (32 (43%) females; median age 3.3 (IQR: 2.0, 4.3) years). Twenty-one (28%) children died. Higher TMD measurements predicted death. Adjusting for diagnosis, every 50 nl rise in both semirecumbent and recumbent CPA was associated with increased odds of death associated with intracranial herniation (OR: 1.61, 95% confidence interval (CI): 1.07, 2.41; P = 0.02 and OR: 1.35, 95% CI: 1.10, 1.66; P ≤ 0.01 respectively).Conclusion:Raised TMD pulse pressure measurements are associated with death and may be useful in detecting and monitoring risk of intracranial herniation and intracranial pressure in childhood coma.

English

BACKGROUND: Acute non-traumatic coma is a common problem in pediatric practice accounting for 10-15% of all hospital admission and is associated with significant morality. Assessment of the severity of coma is essential to comment on the likelihood of survival in comatose children. OBJECTIVES: To assess outcome in pediatric non-traumatic coma with role of Glasgow Coma Scale and Modified Glasgow Coma Scale. METHODS:30 cases of non-traumatic coma between 2 months to 12 years, coma severity were assessed by using Glasgow Coma Scale and Modified Glasgow Coma Scale. A score of less than 8 and more than 8 were used for analysis of outcome. RESULTS: Out of 30 Cases, 5 cases expired (16.66%), 2 cases were discharged against medical advice (6.67%, 23 cases improved and discharged, among these, 3 cases were discharged with complication (76.67%). Overall mortality was (16.66%) (5/30), males outnumbered females in frequency with ratio of 1.41:1. CNS infection accounted for almost about 75%. CONCLUSION: Children with GCS and MGCS scores of less than 8 have poor prognosis and very high probability of death. Those with GSC score of more than 8 have good prognosis. Identification of these cases at the outset can help prepare of outcome to the family.

Fosphenytoin for seizure prevention in childhood coma in Africa: A randomized clinical trial

PurposeWe conducted a double-blind trial to determine whether a single intramuscular injection of fosphenytoin prevents seizures and neurologic sequelae in children with acute coma. MethodsWe conducted this study at Kilifi District Hospital in coastal Kenya and Kondele Children's Hospital in western Kenya. We recruited children (age, 9 months to 13 years) with acute nontraumatic coma. We administered fosphenytoin (20 phenytoin equivalents/kg) or placebo and examined the prevalence and frequency of clinical seizures and occurrence of neurocognitive sequelae. ResultsWe recruited 173 children (median age, 2.6 [interquartile range, 1.7-3.7] years) into the study; 110 had cerebral malaria, 8 had bacterial meningitis, and 55 had encephalopathies of unknown etiology. Eighty-five children received fosphenytoin and 88 received placebo. Thirty-three (38%) children who received fosphenytoin had at least 1 seizure compared with 32 (36%) who received placebo (P = .733). Eighteen (21%) and 15 (17%) children died in the fosphenytoin and placebo arms, respectively (P = .489). At 3 months after discharge, 6 (10%) children in the fosphenytoin arm had neurologic sequelae compared with 6 (10%) in the placebo arm (P = .952). ConclusionA single intramuscular injection of fosphenytoin (20 phenytoin equivalents/kg) does not prevent seizures or neurologic deficits in childhood acute nontraumatic coma.

Unexpected Relationship Between Tympanometry and Mortality in Children With Nontraumatic Coma

We sought to further examine the relationship between tympanometry and mortality after noting an unexpected association on assessment of baseline data of a study whose primary aim was to investigate the utility of noninvasive tympanic membrane displacement measurement for monitoring intracranial pressure in childhood coma. We recruited children who presented with acute nontraumatic coma to the high-dependency unit of Kilifi District Hospital on the rural coast of Kenya. We excluded children with sickle cell disease, epilepsy, and neurodevelopmental delay. We performed tympanometry on the right ear before tympanic membrane displacement analyzer measurements. All children were managed according to standard World Health Organization guidelines. We recruited 72 children with a median age of 3.2 years (interquartile range [IQR]: 2.0-4.3 years); 31 (43%) were female. Thirty-eight (53%) had cerebral malaria, 8 (11%) acute bacterial meningitis, 4 (6%) sepsis, and 22 (30%) encephalopathy of unknown etiology. Twenty (28%) children died. Tympanometry was normal in 25 (35%) children. Adjusting for diagnosis and clinical features of increased intracranial pressure, both associated with death on univariable analysis, children with abnormal tympanometry had greater odds of dying than did those with normal tympanometry (adjusted odds ratio: 17.0; 95% confidence interval: 1.9-152.4; P = .01). Children who died had a lower compliance (0.29 mL; IQR: 0.09-0.33 mL) compared with those who survived (0.48 mL; IQR: 0.29-0.70 mL) (P < .01). Abnormal tympanometry appears to be significantly associated with death in children with acute nontraumatic coma. This finding needs to be explored further through a prospective study that incorporates imaging and intensive physiologic monitoring.

Childhood acute non-traumatic coma: aetiology and challenges in management in resource-poor countries of Africa and Asia

Objective: This review examines the best available evidence on the aetiology of childhood acute non-traumatic coma in resource-poor countries (RPCs), discusses the challenges associated with management, and explores strategies to address them.Methods: Publications in English and French which reported on studies on the aetiology of childhood non-traumatic coma in RPCs are reviewed. Primarily, the MEDLINE database was searched using the keywords coma, unconsciousness, causality, aetiology, child, malaria cerebral, meningitis, encephalitis, Africa, Asia, and developing countries.Results: 14 records were identified for inclusion in the review. Cerebral malaria (CM) was the commonest cause of childhood coma in most of the studies conducted in Africa. Acute bacterial meningitis (ABM) was the second most common known cause of coma in seven of the African studies. Of the studies in Asia, encephalitides were the commonest cause of coma in two studies in India, and ABM was the commonest cause of coma in Pakistan. Streptococcus pneumoniae was the most commonly isolated organism in ABM. Japanese encephalitis, dengue fever and enteroviruses were the viral agents most commonly isolated.Conclusion: Accurate diagnosis of the aetiology of childhood coma in RPCs is complicated by overlap in clinical presentation, limited diagnostic resources, disease endemicity and co-morbidity. For improved outcomes, studies are needed to further elucidate the aetiology of childhood coma in RPCs, explore simple and practical diagnostic tools, and investigate the most appropriate specific and supportive interventions to manage and prevent infectious encephalopathies.

End-of-Life and Brain Death in Acute Coma and Disorders of Consciousness

Consulting neurologists are often asked to evaluate patients in acute nontraumatic coma. The authors review prognostication of functional outcomes, determining brain death, and managing end-of-life care. Prognostication of outcome after cardiac arrest in comatose patients is a frequently encountered scenario with high-stakes implications. However, current guidelines are limited by a failure to address the use of therapeutic hypothermia and thus may lead to overly pessimistic outcome prediction. Pupillary light responses and corneal reflexes remain highly predictive clinical signs of a poor prognosis. Motor responses have a high false-positive rate for predicting a poor outcome, especially in patients treated with therapeutic hypothermia. Ancillary testing with electroencephalography, somatosensory evoked potentials, serum neuron-specific enolase, and neuroimaging is often useful in predicting outcomes. Brain death is a clinical condition of irreversible coma of known cause with absent brainstem reflexes and apnea. An understanding of the value of confirmatory testing and the potential for confounding factors is essential in making a correct diagnosis. As coma carries a high mortality rate, neurologists must be capable of guiding goals of care, discussing end-of-life issues, and understanding organ-procurement procedures.

Middle Ear Function and Mortality in African Children with Acute Non-Traumatic Coma (P01.026)

Middle Ear Function and Mortality in African Children with Acute Non-Traumatic Coma (P01.026)

Changing trends in incidence and aetiology of childhood acute non-traumatic coma over a period of changing malaria transmission in rural coastal Kenya: a retrospective analysis

ObjectivesRecent changes in malaria transmission have likely altered the aetiology and outcome of childhood coma in sub-Saharan Africa. The authors conducted this study to examine change in incidence, aetiology, clinical...

Cortical Information Processing in Coma

To evaluate cortical information processing (particularly, semantic processing) in acute nontraumatic coma by means of event-related brain potentials (ERPs). The tests included measures of obligatory auditory processing (N100), automatic (Mismatch Negativity) and controlled (P300) detection of stimulus deviance, and semantic processing (ERP effects in word pairs and sentences). The tests were presented to 20 healthy participants and 42 coma patients with Glasgow Coma Scale <9. Responders (ie, patients whose ERP data indicate that their brain was able to process the corresponding stimuli) were found in each ERP test, and their distribution was statistically different from that expected by chance. Particularly, 7 responders were found in the word pair paradigm and 3 responders in the sentence paradigm. The P300 responsiveness highly correlated with other ERP responses, with Glasgow Coma Scale and with the future development of coma (ie, P300 on day 4 was related to the clinical state on day 20). Results suggest a wide range of cortical information processing in coma, including semantic processing. The question is discussed of whether, and to what extent, these processing operations are related to conscious awareness of stimuli.

Long-term outcome in coma

To assess the relationship between Modified Glasgow Coma Scale, its components, brain stem reflexes and long term functional outcome in children with acute non-traumatic coma. MGCS and brainstem reflexes were assessed at 6 hourly intervals for 72 hours from the time of admission. The children were followed up regularly and functional outcome was assessed at the end of 9 months. The lowest score of the MGCS and worst brain stem reflexes were used for the analysis. Higher total MGCS score and verbal response score had a significant positive correlation with better functional outcome as measured by GOS and intelligence quotient. There was no association between the language function and the initial MGCS, its components and brain stem reflexes. Lower verbal response (P = 0.005) was the only factor that was found to be individually associated with poorer long term GOS score and intelligence quotient by multivariate linear regression analysis. In the long term prediction of outcome in acute non-traumatic coma, MGCS is not useful. However, verbal response, a component of MGCS, correlates well with long term functional outcome and intelligence quotient.

Visual impairment in children with acute nontraumatic coma.

To determine the incidence and severity of visual impairment in children following acute nontraumatic coma. An 18-month prospective epidemiologic study of acute nontraumatic coma was undertaken in the former Northern NHS Region of England. Children aged >1 month and <16 years were included in the study if they had a Glasgow Coma Score of < or = 12 for >6 hours or if they died within 6 hours of the onset of decreased levels of consciousness. For survivors, ophthalmologic assessments were performed 6 weeks and 12 months after presentation. Two hundred eighty-seven children were included in the study, of whom 127 died. Of the 137 examined survivors, 35 had visual abnormalities suspected by the examining neurologist during the ophthalmic assessment. Of these, visual impairment was confirmed in 10 children at the 6-week assessment by the pediatric ophthalmologist. At the 1 2-month assessment, visual impairment remained stable in 9 children and improved in 1. In this study, 6.6% of children surviving acute nontraumatic coma had visual impairment that persisted at the 12-month follow-up examination. Incidence of visual impairment in acute nontraumatic coma is 0.97 per 100,000 children per year.

Childhood non-traumatic coma in Kuala Lumpur, Malaysia.

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.