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PubMedDate not supplied

[Early predictors of outcome in children with head injuries].

In an attempt to determine whether the clinical data obtained by primary survey may be used as early outcome predictors in children who had sustained head trauma, children aged 0-14 with clinical diagnoses of coma, contusion, comotio, skull fracture or a combination of these diagnoses or who had been hospitalized for at least 3 days, between 1987 and 1990, were reviewed retrospectively. The outcome was defined by the clinical condition of children 6 months following head trauma using a Glasgow outcome scale (GOS), and was classified: good (good recovery and moderate disability) and poor (severe disability, persistent vegetative state, death). Of 70 children with trauma, 43 patients (61.4%) were separated by this method. The pupillary appearance and reactivity, Glasgow coma scale (GCS) and motor response graded by GCS were compared with the outcome. The analysis demonstrated that the early significant predictors of outcome of head trauma are the pupillary appearance and reactivity as well as Glasgow coma scale. Motor response graded by GCS did not achieve statistical significance (z = 1.5, P > 0.05) as a predictor of outcome. In this analysis, we have graded motor response according to the GCS criteria, thus it is not excluded that the use of different criteria could demonstrate the importance of motor response as an outcome predictor. In order to ascertain the significance of predictors in early outcome prognosis of head trauma, a relative risk for poor outcome was calculated. Our results showed that the significant predictors in descending order of preference are: pupillary reactivity, pupillary appearance and GCS.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1993

Medical technology at the end of life. What would physicians and nurses want for themselves?

BACKGROUND: Advance directives assume that patients are able to decide what interventions they would wish in the event of catastrophic illness. This study examines the preferences of nurses and physicians, who have extensive exposure to sick patients, for care at the end of life. METHODS: Nursing and medical staff of a community teaching hospital were asked to complete the medical directive, detailing which of 12 interventions they would wish for themselves in each of four scenarios. Two additional scenarios were added to ascertain preferences for care in the event of severe illness in a previously healthy 85-year-old subject and in a chronically ill 75-year-old subject. RESULTS: Refusal rate among the 127 nurses and 115 physicians who completed the questionnaire, averaged over the four scenarios, was 78%. Nurses and physicians refused 31% of proposed therapies in the case of acute illness in a previously healthy 85-year-old subject and 57% of interventions in the case of major illness in a 75-year-old subject with multiple debilitating chronic illnesses. Nurses reported significantly higher refusal rates than physicians for the scenarios involving possible reversible coma, the healthy 85-year-old subject, and the chronically ill 75-year-old subject. Factors predicting refusal patterns were age and being a nurse. CONCLUSION: We conclude that physicians and nurses, who have extensive exposure to hospitals and sick patients, are unlikely to wish aggressive treatment if they become terminally ill, demented, or are in a persistent vegetative state. Many would also decline aggressive care on the basis of age alone, especially in the presence of functional impairment. These findings call into question the utility of detailed advance directives and suggest a need to focus on the goals of treatment for all elderly patients.

Adult↗
PubMed1993

[Traumatic primary brain stem injury and ambient cistern hematoma evaluated with magnetic resonance imaging].

Traumatic hemorrhage in the ambient cistern is thought to be an indirect indication of brain stem injury. In many cases such brain stem lesions cannot be clearly demonstrated by conventional CT scans. Magnetic resonance imaging (MRI) provides a more sophisticated display of the brain stem with improved contrast resolution of structures not appreciated on CT. We present four patients with traumatic ambient cistern hematoma on CT. They showed consciousness disturbance at the initial neurological examination and a Glasgow Coma Scale (GCS) of 7-10. All patients had hemothorax or clavicular fracture ipsilateral to the ambient cistern hematoma that suggested a severe mechanical force from the same direction. Axial, coronal and sagittal MRI scans were obtained with a super-conductive 1.5 T unit (Picker) within 6 days after trauma. Two standard pulse sequences were used; (1) Spin-echo (TR/TE = 500/20) or Inversion Recovery (TR/TI/TE = 3300/600/30) to obtain T1-weighted information and (2) Spin-echo (TR/TE = 2000/100) to obtain T2-weighted information. In case 1 (3-year-old girl) the hematoma which was thought to be located in the ambient cistern on CT was found to be present in the subpial region in the tegmentum on MRI. On T2 weighted image, a high signal intensity area was seen in the perifocal area. This area was demonstrated as a low density area on CT. This patient has remained in a persistent vegetative state 6 months after trauma. In case 3 (31-year-old man) CT demonstrated no abnormal findings in the brain stem. MRI demonstrated a high intensity area in the right cerebral peduncle and left tegmentum.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1993

Near drowning: is emergency department cardiopulmonary resuscitation or intensive care unit cerebral resuscitation indicated?

OBJECTIVES: a) To report the neurologic outcome of a series of near-drowning victims treated with supportive management without aggressive cerebral resuscitation; and b) to identify patient characteristics that indicate prognosis and guide therapy at the scene, the Emergency Department, and in the intensive care unit (ICU). DESIGN: Retrospective review of all near-drowning patients requiring admission to the ICU over a 6-yr period (1/1/82 to 12/31/88). Hospital records were examined for the circumstances of submersion and rescue, patient condition on arrival in the Emergency Department and ICU, treatments, hospital course, and ultimate outcome. SETTING: Emergency departments of the referring hospital and ICU of Children's Hospital. PATIENTS: Forty-four pediatric submersion victims were treated with therapy limited to the support of vital functions. Three patients who met cold-water drowning criteria were excluded from the analysis for predictors of neurologic outcome. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In our warm-water near-drowning patients, 56% survived neurologically intact, 32% survived in a persistent vegetative state, and the remaining 32% died. Unreactive pupils in the Emergency Department and a Glasgow Coma Score of < or = 5 on arrival to the ICU were the best independent predictors of poor neurologic outcome (odds ratio and 95% confidence intervals 374 [17 to 16,000] and 51 [5 to 2,200], respectively). However, no predictor was absolute and two nonhypothermic patients who arrived to the Emergency Department without vital signs, requiring cardiopulmonary resuscitation and cardiotonic medications, had full neurologic recovery. CONCLUSIONS: Our results cast further doubt on the utility of aggressive forms of cerebral monitoring and resuscitation and emphasize the need for initial full resuscitation in the Emergency Department.

Adolescent↗
PubMed1996

The low frequency of futility in an adult intensive care unit setting.

BACKGROUND: It is widely assumed that "futile" treatment consumes significant health care resources. This is a prospective cohort study. SETTING: The setting was the medical intensive care unit of Ben Taub General Hospital, a large public hospital in Houston, Tex. OBJECTIVE: To assess the frequency of intensive care unit patients meeting any of three broad definitions of futility. SUBJECTS: Subjects consisted of 129 consecutive patients admitted to the study intensive care unit during a 6-week period in the fall of 1993. MAIN OUTCOME MEASURES: Operational definitions for three types of futility described in the literature were developed: Imminent demise futility, death imminent regardless of intervention, was assessed by using the APACHE II (Acute Physiology and Chronic Health Evaluation II) scoring system to determine the likelihood of mortality at more than the 90%, 95%, and 99% probabilities. Lethal condition futility, conditions incompatible with long-term survival, included five separate disease processes. Qualitative futility, conditions with an unacceptable quality of life, was assessed as a persistent vegetative state or as meeting criteria for poor prognosis due to a hypoxic ischemic coma. RESULTS: Only 2 bed-days (0.3%) were used by patients with more than 90% predicted mortality; 22 bed-days (3.6%) were used by patients with poor prognosis due to hypoxic ischemic coma; and 101 bed-days (16.4%) were used by patients satisfying criteria for the five lethal conditions. CONCLUSIONS: The frequency of futile interventions appears to be low unless one is willing to accept a definition that includes patients who could survive for many months. If confirmed in other settings, this suggests that concepts of futility will not play a major role in costs containment.

Cohort Studies↗
PubMed1996

[Hypothalamic-adenohypophysial function of corticotropin releasing hormone (CRH)-ACTH system in hypoxic coma].

To evaluate the hypothalamic-adenohypophysial function of corticotropin releasing hormone (CRH)-ACTH system in severe hypoxic coma, basal serum values of ACTH and cortisol was measured, and insulin-tolerance test (ITT) and CRH stimulation test was performed in 15 cases. They were divided into two groups according to their prognosis: brain death (group A, 7 cases) and persistent vegetative state (group B, 8 cases). Basal values were within normal range in most cases apart from those measured in few days after the brain death, however, stimulation tests were negative in many cases. In group A, basal values in impending stage were significantly higher han those after the brain death (p < 0.05), however, both stimulation tests were negative regardless of the stage. In group B, basal values in acute stage, which was measured within a week after the hypoxia, were slightly higher (without significance) than those in chronic stage, which was measured more than a months after the hypoxia. CRH test and ITT were positive in 0/4 and 2/5 in acute stage, and in 4/8 and 3/8 in chronic stage, respectively. In early stage of group A, the impending stage, showed slightly higher basal values than those in acute stage of group B (without significance). ITT was negative in the former whereas positive in some cases (2/5) of the latter, however, CRH test was negative in both groups. These results suggest that endocrinological evaluation of the hypothalamic-adenohypophysial function may help to predict outcome in early stage of hypoxic coma.

Adolescent↗
PubMed1996

[Irreversible coma and the physician's treatment responsibility].

Whether and how patients with clinically revealed persistant vegetative state (PVS) should be treated is a difficult question. In this paper the different approaches from maximum therapy to forego even nutrition and hydration are analysed and their underlying concepts examined. Within this context the official guidelines of the Swiss, the German as well as the British Medical Association are discussed.

Advance Directives↗
PubMed1996

[Use of cortical SEP for the prediction of neurological prognosis after cardiopulmonary resuscitation].

The improved technique of cardiopulmonary resuscitation (CPR) resulted in survival of many patients who had experienced cardiopulmonary arrest (CPA). However, when the recovery of brain function is poor, patients suffer from severe neurological sequelae, including persistent vegetative state. There have been no conclusive methods to predict the outcome of anoxic encephalopathy after CPR. Madl et al (1993) recorded cortical SEP over the parietal scalp electrodes after bilateral median nerve stimulation at the wrists in anoxic patients experiencing CPR. Their results indicated that the median SEP is useful for the early prediction of neurological prognosis after CPR. We studied short and long latency cortical SEPs evoked by the left median nerve stimulation in 18 consecutive anoxic patients within 48 hours after CPR. The absence of N20, N35, P45 indicated mortality of 86.4% (100% in Madl's results). Preserved N60 peak indicated the recovery of consciousness, while Madl's results showed that patients did not regain consciousness when the N60 latency was longer than 121 ms. Neurological prognosis showed the significant correlation with N20, P25 amplitude and not with amplitude ratio (N20 P25/P15 N20). Reduced amplitude of N20 P25 was consistent with the high score of GOS. N20 P25 was greater than 3.7 microV in all patients who regained consciousness. Recording of cortical SEP within 48 hours after CPR was useful for the prediction of neurological outcome.

Adult↗
PubMed1997

[Measurement of intracranial pressure as a factor in the prognosis of the course of serious cranio-encephalic injuries].

We have analyzed the course and outcome in 100 consecutive cases with severe head injuries, all were treated in a uniform manner. Surgery was performed immediately in patients with extracerebral or intracerebral hematomas. Intracranial pressure (ICP) was monitored in all. Forty-five patients recovered with no or minimal neurological deficit, fifteen patients are moderately disabled, four are severely disabled and eight remain in a persistent vegetative state. The mortality was 28%. The favourable outcome in this series suggests that control of intracranial hypertension with careful attention to medical complication can improve the outcome in patients with severe head injuries.

Adult↗
PubMed1997

[Functional, neuropsychological and social outcome of polytrauma patients with severe craniocerebral trauma].

The aim of this study was to identify, in (pre-) clinically obtained data, parameters predicting the outcome of patients with multiple trauma and severe head injury. Fifty-eight patients aged 27 +/- 10 years were investigated an average of 5.8 years after the accident. The Hanover Polytrauma Score was 34 +/- 11 points, the initially assessed Glasgow Coma Scale (GCS) was 6.2 +/- 3.2 points; and the duration of coma was 15.4 +/- 14.4 days. The primary length of stay in hospital averaged 33.4 days, including 22.9 days in the intensive care unit and 20.2 days of ventilation. For a further 223 days the patients were treated at the Neurologic Clinic of Hessisch Oldendorf. Besides different neurologic deficiency symptoms, the psychometric tests showed deficits in all areas. In particular, information processing speed, concentration, recent memory and learning performance were impaired. There was free mobility of all joints in 33% of the patients. Due to injury the elbow and ankle joint developed the worst restriction. Central paralysis and heterotopic ossification also caused a restriction in joint mobility. Half of the patients were confronted with different social changes. The rate of return to work was dependent on age. Some 42% of all patients had taken up their former profession, 5% were still in training or at college, 32% were retrained to other professions, 16% were unemployed and 5% were completely retired on pension. Age, injury severity, GCS, duration of coma and duration of weaning were suitable predictors in correlation- and regression analysis. The Glasgow Outcome Scale showed good recovery and moderate disability in 53%, severe disability in 33% and persistent vegetative state in 14% of the patients.

Activities of Daily Living↗
PubMed1997

[Beyond maternal death?].

Three women, aged 33, 27, and 31 years, had serious gestational problems (pre-eclampsia with cerebral haemorrhage, toxic shock syndrome with multiple organ failure, and hypertension complicated by prolonged circulatory arrest, respectively), but eventually survived, albeit with serious handicap (cognitive and motor disturbances, blindness, and persistent vegetative state, respectively). When the maternal mortality ratio is as low as it currently is in the Netherlands (10 women in 100,000 live births), it is worthwhile to assess cases of severe maternal morbidity. The cases presented lead to the pertinent question whether obstetric interventions to prevent death may not sometimes be worse than accepting death itself.

Adult↗
PubMed1997

Some observations on post-coma unawareness patients and on other forms of unconscious patients: policy proposals.

The concern of this paper is with various forms of unconsciousness. Special attention will be given to patients in PCU commonly termed as Persistent Vegetative State (PVS). I reject the term PVS, arguing that for ethical reasons we should strive to resort to terminology that does not offend the patients and their loved ones. I further urge hospitals not to cease treatment of PCU patients younger than 50 years old within a period of less than two years. This is especially true for patients who entered a state of unawareness due to traumatic causes. The two-years waiting period should be regarded as the minimum period of evaluation before foregoing hopes for patients' rehabilitation and return to some form of cognition. I provide data and human stories from the Israeli experience to substantiate this argument.

Adolescent↗
PubMed1998

Saccadic ping-pong gaze.

Ping-pong gaze (PPG), or short-cycle periodic alternating gaze, consists of horizontal conjugate ocular deviations alternating every few seconds. This alternating gaze has been described as appearing to be smooth. However, our electrooculographic study of four consecutive unconscious patients with PPG showed smooth waveforms in one patient but saccadic cog-wheeling in three patients. In one of the three patients with saccadic PPG, a transition from smooth to saccadic waveforms was noted with clinical improvement. Whereas the patient with smooth PPG died immediately, the patients with saccadic PPG survived in a persistent vegetative state. These findings suggest that saccadic PPG is a clinical variant of PPG in patients in a lighter state of consciousness, possibly related to less extensive brain damage.

Adult↗
PubMed2006

Soil-geomorphic heterogeneity governs patchy vegetation dynamics at an arid ecotone.

Soil properties are well known to affect vegetation, but the role of soil heterogeneity in the patterning of vegetation dynamics is poorly documented. We asked whether the location of an ecotone separating grass-dominated and sparsely vegetated areas reflected only historical variation in degradation or was related to variation in inherent soil properties. We then asked whether changes in the cover and spatial organization of vegetated and bare patches assessed using repeat aerial photography reflected self-organizing dynamics unrelated to soil variation or the stable patterning of soil variation. We found that the present-day ecotone was related to a shift from more weakly to more strongly developed soils. Parts of the ecotone were stable over a 60-year period, but shifts between bare and vegetated states, as well as persistently vegetated and bare states, occurred largely in small (<40 m2) patches throughout the study area. The probability that patches were presently vegetated or bare, as well as the probability that vegetation persisted and/or established over the 60-year period, was negatively related to surface calcium carbonate and positively related to subsurface clay content. Thus, only a fraction of the landscape was susceptible to vegetation change, and the sparsely vegetated area probably featured a higher frequency of susceptible soil patches. Patch dynamics and self-organizing processes can be constrained by subtle (and often unrecognized) soil heterogeneity.

Ecosystem↗
PubMedDate not supplied

Neurophysiological correlates of persistent vegetative and minimally conscious states.

The evaluation of patients after severe brain injury is a complex process for the clinician, even with the information provided by a detailed neurological examination. The clinical examination often does not provide sufficient information to fully evaluate these patients due to several factors. Limited and inconsistent motor responses may obscure expression of greater cognitive capacities. More importantly, evaluation of the functional integrity of the cerebral cortical, thalamic and basal ganglia system is poorly indicated by the clinical examination in many patients. Neurophysiological studies provide a complementary set of objective data for evaluating brain-injured patients, as well as predicting and following the course of their recovery. This additional information can be of great importance since vegetative patients may be difficult to distinguish clinically from those in the minimally conscious state. This is important because the latter category of patients may have a significantly better prognosis for recovery in the initial phase of injury. Electrodiagnostic and imaging studies can help the practitioner to determine the degree of preserved and recovering neurological function. In this review we will assess the various neurophysiological studies currently at our disposal to evaluate and follow the clinical course of patients who have suffered severe brain injuries.

Cognition Disorders↗