Changes In Level Of Consciousness Research Articles

Duration of life-threatening antecedents prior to intensive care admission.

To document the characteristics and incidence of serious abnormalities in patients prior to admission to intensive care units. Prospective follow-up study of all patients admitted to intensive care in three acute-care hospitals. The study population totalled 551 patients admitted to intensive care: 90 from the general ward, 239 from operating rooms (OR) and 222 from the Emergency Department (ED). Patients from the general wards had greater severity of illness (APACHE II median 21) than those from the OR (15) or ED (19). A greater percentage of patients from the general wards (47.6%) died than from OR (19.3%) and ED (31.5%). Patients from the general wards had a greater number of serious antecedents before admission to intensive care 43 (72%) than those from OR 150 (64.4%) or ED 126 (61.8%). Of the 551 patients 62 had antecedents during the period 8-48 h before admission to intensive care, and 53 had antecedents both within 8 and 48 h before their admission. The most common antecedents during the 8 h before admission were hypotension (n=199), tachycardia (n=73), tachypnoea (n=64), and sudden change in level of consciousness (n=42). Concern was expressed in the clinical notes by attending staff in 70% of patients admitted from the general wards. In over 60% of patients admitted to intensive care potentially life-threatening abnormalities were documented during the 8 h before their admission. This may represent a patient population who could benefit from improved resuscitation and care at an earlier stage.

Description of ambulance diversions in Edmonton region.

AbstractBackground:Diversion of ambulances by hospital emergency departments has become a day-to-day occurrence in many jurisdictions within Canada. Yet, despite the increasing prevalence of this phenomenon, its impact on transported patients, on the EMS system, and on the health care system overall has not, to date, been well quantified. Despite the increasing sophistication and capabilities of North American EMS systems, it is difficult to argue with the principle that unstable or potentially unstable patients are best served by expeditious transport for definitive care to acute care facilities. T o this end, this study represents an effort to assess the systemic and patient care impacts of ambulance diversions.Methods:Patient-care and corresponding ambulance trip records for all patients transported by this EMS system for a five week period were abstracted to identify those patients in which an ambulance was diverted from its initial destination. Adverse events include hypotensive episodes, airway compromise, changes in level of consciousness, and the onset of violent behavior. Response and transport times also were abstracted, comparisons utilized student's t-test and 95% Confidence Intervals. Results: Ambulance diversions increased EMS response times and prehospital transport times. Adverse medical events occurred during 4.3% of diverted ambulance runs. Patients, when faced with the prospect of transport to other than their hospital of choice, not infrequently cancelled EMS transport and sought other means of transport. Subsequent interfacility transport was required for 4.3% of the diverted patients.Conclusions:Diversion of ambulances impacts the EMS system by increasing response and transport times; the region, by generating subsequent interfacility transports; and patients, as adverse medical events can occur during the diverted transport.

A comparison of two immediate-early genes, c-fos and c-jun in rat brain after occlusion of superior mesenteric artery (SMAO)

Changes in level of consciousness and/or emotion are frequently experienced in the lethal gut necrosis. However, little is yet known about what a mechanism is underlying beneath the alteration of neuronal function. The aim of the present study was to investigate how the brain was influenced by massive gut necrosis. In an attempt to examine functionally activated neuron, we applied immunohistochemistry (IHC) for c-Fos and c-Jun, cellular transcriptional factors encoded by immediate early genes c-fos and c-jun, respectively, and widely used as metabolic markers for neuronal activity.

Clinical characteristics of the West Nile fever outbreak, Israel, 2000.

West Nile (WN) virus is endemic in Israel. The last reported outbreak had occurred in 1981. From August to October 2000, a large-scale epidemic of WN fever occurred in Israel; 417 cases were confirmed, with 326 hospitalizations. The main clinical presentations were encephalitis (57.9%), febrile disease (24.4%), and meningitis (15.9%). Within the study group, 33 (14.1%) hospitalized patients died. Mortality was higher among patients >70 years (29.3%). On multivariate regressional analysis, independent predictors of death were age >70 years (odds ratio [OR] 7.7), change in level of consciousness (OR 9.0), and anemia (OR 2.7). In contrast to prior reports, WN fever appears to be a severe illness with high rate of central nervous system involvement and a particularly grim outcome in the elderly.

Part 5: New Guidelines for First Aid

Part 5: New Guidelines for First Aid

Vascular surgical society of great britain and ireland: near-infrared spectroscopic monitoring of patients undergoing carotid endarterectomy under locoregional anaesthesia

BACKGROUND: The level of cerebral desaturation, which is associated with a change in level of consciousness during carotid endarterectomy, was measured by near-infrared spectroscopy. METHODS: Patients were recruited in two centres over 24 months. Surgery was performed under deep and superficial cervical block using 0.5 per cent bupivacaine, with temazepam as a premedication. Cerebral oxygenation was measured by Critikon 2020 near-infrared spectrophotometers (Johnson and Johnson Medical, Newport, UK). RESULTS: Forty-nine procedures were performed on 45 patients (39 men; age range 52-84 (mean 68) years). Recordings were made from the ipsilateral frontal site in 38 patients, from the ipsilateral temporal site in 23 and bifrontally in eight patients. Monitoring failed in three subjects. Percentage changes in regional cerebral oxygen saturation are detailed below. CONCLUSION: Significantly different levels of cerebral desaturation occur in patients with neurological compromise during carotid endarterectomy compared with those who are unaffected.

State-dependent laryngomalacia.

We have observed 5 infants who demonstrate normal breathing when awake, but develop stridor while asleep. Flexible laryngoscopy in the awake state reveals either a normal larynx or redundancy of the aryepiglottic folds or arytenoid soft tissue without prolapse into the laryngeal inlet. When these children are sedated, however, the classic signs of laryngomalacia appear. Wet inspiratory stridor with concomitant supraglottic prolapse can be demonstrated by flexible videolaryngoscopy in this state. As these findings vary with level of consciousness, we have dubbed this condition "state-dependent" laryngomalacia. We believe the appearance and disappearance of classic laryngomalacia with changes in level of consciousness adds credence to the neurogenic theory of laryngomalacia.

Nonfebrile seizures.

Nonfebrile seizures.

Percivall Pott: an 18th century neurosurgeon

This paper examines neurosurgery in the 18th century and suggests that the origins of the specialty can be recognized at the time when surgeons began to use the neurological status of the patient as a guide for surgical intervention. Percivall Pott (1714-1788) was one of the leading surgeons in London in the 18th century. He is remembered through eponyms of Pott's puffy tumor, Pott's fracture, and Pott's disease. A review of his writings and those of his contemporaries indicates that these surgeons were aware of the importance of changes in level of consciousness after head injury. The recognition and significance of the lucid interval was described and understood as a neurosurgical sign in the 18th century. Because of Pott's pre-eminence in the surgery of his time through his writings and lectures, he should be considered one of the founders of neurosurgery as a separate surgical discipline.

Epileptic nystagmus

We report a 52-year-old woman with episodes of vertigo accompanied by right beating nystagmus and left posterior temporoparietal sharp waves and spikes on electroencephalogram without change in level of consciousness. Electrooculography demonstrated that the episodes of nystagmus were not preceded by gaze deviation and that nystagmus slow component velocities were linear. This patient's epileptic nystagmus may have been the result of excitation of cerebral ocular pursuit pathways.

Serial changes in acute extradural hematoma size and associated changes in level of consciousness and intracranial pressure.

The authors report the cases of 37 patients encountered during the past 4 years who exhibited acute extradural hematoma but were initially treated conservatively because no or only small hematomas were observed on admission. The frequency of hematoma enlargement, hematoma size, and changes in the level of consciousness and intracranial pressure (ICP) were examined in these patients. The hematomas enlarged in 24 (64.9%) of the 37 patients, and attained a maximum thickness of 25 mm or greater in 19 patients (51.3%). The level of consciousness could be closely observed during enlargement of the hematomas in 13 patients: the level remained unchanged in eight, deteriorated in two, and improved in three, indicating relative stability in the state of consciousness despite the marked changes in hematoma size. The patients whose hematoma enlarged after the initial examination included three who underwent initial CT examination 5 hours after the injury. In five patients enlargement of extradural hematomas was observed unexpectedly during conservative treatment under ICP monitoring. The ICP also remained stable in three patients until the follow-up examination, but showed a rapid increase in two after a period of stability. However, there was no difference in the final size of the hematomas between the patients showing an increase in ICP and those who did not. These findings suggest that extradural hematomas enlarge progressively at rates varying with the condition of the source of hemorrhage. Moreover, a period of stability in the level of consciousness, such as the lucid interval seen in patients with extradural hematoma, is considered to be a period during which compensatory mechanisms can maintain the stability of the intracranial condition during progressive enlargement of the hematoma.

Treatment of experimental stroke with opiate antagonists. Effects on neurological function, infarct size, and survival.

The effects are reported of acute and long-term continuous administration of three opiate antagonists--naloxone, naltrexone, and diprenorphine--on neurological function, survival, and infarct size in a feline model of acute focal cerebral ischemia. All three drugs produced statistically significant improvement in motor function following acute administration without concomitant changes in level of consciousness; saline had no effect. Naloxone and naltrexone significantly prolonged survival (p less than 0.01); diprenorphine did not. Infarct size was not altered by any treatment administered. These findings confirm previous work suggesting that, with the appropriate methodology, treatment with opiate antagonists partially reverses neurological deficits. They also show that opiate antagonists prolong survival in certain conditions of acute and subacute focal cerebral ischemia without altering the area of infarcted tissue.

Phencyclidine: effects on the fetus and neonate.

As phencyclidine hydrochloride (PCP) has become one of the more frequently abused drugs in the United States, there has been increasing interest in its effect on the fetus and neonate of the pregnant abuser. Two groups of women enrolled in a comprehensive perinatal addiction program were studied: 7 women abused PCP prior to and during pregnancy, and these women were compared to a group of 27 drug-free women. No differences between the two groups were seen in maternal age, gravidity, gestational age or Apgar scores. At birth, there was no difference in birth weight, length, or head circumference between the two groups of neonates. The most characteristic features of the PCP-exposed infants were the sudden outbursts of agitation and rapid changes in level of consciousness, similar to responses described in adults intoxicated with PCP. Scores on the Brazelton Neonatal Behavioral Assessment Scale revealed a significant increase in lability of states and poor consolability in PCP-exposed infants. 3-month scores on the Bayley Scales of Infant Development revealed no significant difference between the two groups of infants.

Tuberculous Meningitis and BCG Vaccination in Burmese Children

One hundred and fifty consecutive cases of tuberculous meningitis admitted to Children's Hospital in Rangoon were analysed and the presenting symptoms, linical manifestations, investigative findings and the factors influencing the outcome are presented.At the time of discharge, 61 children (40.7 %) had no motor neurological deficit, 59 (39.3 %) were left with motor neurological deficit and 30 (20%) died. The children were not followed up long enough to estimate their mental state. The factors which increase mortality and sequelae rates were young age, change in level of consciousness on admission, motor paralyses or neurological deficit on admission, high cerebro-spinal fluid protein level of more than 300 mg/100 ml and associated miliary tuberculosis. 39 children had received BCG vaccinations in their newborn period and the possible causes for ineffective protection against tuberculous meningitis in Burma are discussed.

Handling of nonsevere head injuries

In emergency patients with nonsevere head injuries, there are conflicting opinions over which patients should be admitted for observation, but little data directly useful to the emergency physician in making this decision. The literature was reviewed and records of 182 patients presenting for head injury were examined. Although many factors must be considered, by far the most helpful element in predicting outcome is the mental status of the patient as observed in the emergency department. Features suggesting depressed skull fracture or possible foreign bodies require radiographic examination. Most patients can be observed in the emergency department mainly for changes in level of consciousness and discharged with instructions for further observation at home.

Electrical signs of epileptic discharge

Abstract 1. 1. The only form of electrical activity which is though to characterize a local epileptogenic lesion of the cortex is the random spike discharge. 2. 2. The local spike discharge must become repetitive at a fairly rapid frequency before sufficient activation occurs to cause a change in behaviour or awareness of the patient. 3. 3. The spread of epileptic activation is manifest by an enhancement of the background spontaneous rhythms before the form of its activity is changed to a multiple spike pattern indicating violent local autonomous activation of this distant cortical area. Specific regions may produce a depression in background activity at the onset of an attack. 4. 4. Large areas of the cortex may be activated by electrical signs of epileptic activity, with little obvious change in the patient, these areas being the anterior frontal region and large portions of the temporal and parietal lobes. Spread to subcortical structures seems likely when changes in level of consciousness and behaviour automatisms are associated with epileptic discharge. 5. 5. The cerebral cortex alone, isolated from connections to subcortical structures, is capable of maintaining epileptic after-discharge, so that long reverberating circuits are not required for this process. 6. 6. Rhythmic epileptic activity of large areas of the cortex synchronized in one hemisphere or bilaterally synchronous from homologous regions of the two hemispheres, most probably has its pacemaker in the thalamus since from the thalamus, such rhythmic bilateral disturbances can be induced by local electrical stimulation. Other subcortical projection systems may also be involved. 7. 7. Local cortical epileptic discharge may also be initiated by local thalamic stimulation of the more directly projecting thalamic nuclei. 8. 8. Subcortical rhythmic systems, projecting to large areas of both hemispheres can also be actuated by local cortical epileptic discharge, most readily in certain portions of frontal and temporal regions. 9. 9. The clinical pattern of an epileptic seizure is not closely related to the form of associated E E G disturbance but rather to the functional area of the brain primarily involved and the functional characteristics of the neuronal circuits involved in the path of spread.

THE SIGNIFICANCE OF ALPHA VARIANTS IN THE EEG, AND THEIR RELATIONSHIP TO AN EPILEPTIFORM SYNDROME

1. Evidence has been presented to show that the cerebral psychomotor patterns of Gibbs, Gibbs and Lennox are related to certain variations of the 10-cycle or alpha rhythm of the brain, which have been termed alpha variants. The most common variants consist of a halving or doubling of the alpha rate. 2. Even in cases of known psychomotor epilepsy the amount of the alpha variants recorded in the EEG between attacks may vary widely both among and within individuals, but practically all such patients show traces of the variants between seizures. 3. There is a high incidence of alpha variants in certain other conditions, notably psychoneurosis and idiopathic epilepsy. Their presence in the so-called psychoneurotic group shows a high correlation with a symptom complex that includes cranialgia, episodic changes in levels of consciousness, and emotional and vasomotor disturbances. 4. A high incidence of alpha variants among patients with grand mal epilepsy has been noted. The alpha variants may be correlated in these cases with altered states of consciousness (which cannot be identified electroencephalographically with petit mal), or with neurotic traits superimposed on the major epilepsy. It is concluded that mixed epilepsy of a grand mal—psychic variant type is of frequent occurrence. 5. The alpha variants are not pathognomonic of the epileptiform states. The significance of their appearance in the EEG without the accompanying symptom complex, as in the case of a small proportion of presumably normal individuals, has not yet been elucidated. 6. The alpha variants are of diagnostic assistance in cases where the neurological findings are essentially negative, and where the EEG is otherwise within broad normal limits. Under these circumstances, their presence in the EEGs of patients with vasomotor instability (cranialgia, dizziness, etc.), emotional disturbances of an episodic nature, or changes in the state of consciousness, indicate that the condition may be related to an epileptiform syndrome, rather than to a purely psychosomatic etiology. 7. The term psychomotor epilepsy is inadequate to describe the entire range of psychic variants in the epileptiform syndrome, and in our opinion should either be replaced by a more descriptive term, or its use restricted to conditions in which motor manifestations of a bizarre nature are present.