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1.
Medicine (Baltimore) ; 98(41): e17493, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31593114

RESUMO

The aim of this study was to assess the bedside brain function monitoring of color density spectral array (CDSA) for early prognostic evaluation of coma patients in pediatric intensive care unit (PICU).Forty-two consecutive pediatric coma patients were enrolled. The individual conscious state was evaluated according to the Glasgow coma scale (GCS). CDSA parameters including CDSA pattern (CDSAP), sleep-wake cycle (SWC), sleep stage (SS), and drug-induced fast wave activity (DIFWA) were recorded. Three months later, prognosis was evaluated according to pediatric cerebral performance category (PCPC) score, based on which the patients were divided into FP-group (favorable prognosis) and PP-group (poor prognosis).The changeable type of CDSAP, appearance of SWC, SS, and DIFWA were significantly correlated with favorable prognosis. Both GCS and SWC were significantly correlated with the prognosis. However, there was substantial overlap in GCS between FP-group and PP-group. Although the absence of SWC was statistically an independent risk factor for poor prognosis but with a high false positive rate (0.143), a linear logistic regression showed the odds ratio of GCS for predicting prognosis was 0.93 (95% confidence interval: 0.48-1.80; P = .83) and that of SWC was 0.12 (95% confidence interval: 0.03-0.47; P = .03). Furthermore, the absence of SWC was correlated with poor prognosis in nonintracranial infection patients.Our study found that several CDSA factors are associated with prognosis of coma patients in PICU. SWC may be a potential indicator for evaluating the prognosis of coma patients in PICU.


Assuntos
Coma/diagnóstico , Monitores de Consciência/estatística & dados numéricos , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Testes Imediatos , Adolescente , Criança , Pré-Escolar , Colorimetria/métodos , Colorimetria/estatística & dados numéricos , Feminino , Escala de Coma de Glasgow , Humanos , Lactente , Modelos Logísticos , Masculino , Valor Preditivo dos Testes , Prognóstico
2.
J Clin Nurs ; 28(21-22): 3827-3839, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31343105

RESUMO

AIMS AND OBJECTIVES: To evaluate nurses' application, understanding and experience of applying painful stimuli when assessing components of the Glasgow Coma Scale. BACKGROUND: The Glasgow Coma Scale has been subjected to much scrutiny and debate since its publication in 1974. However, criticism, confusion and misunderstandings in relation to the use of painful stimuli and its application remain. An absence of evidence-informed guidance on the use and duration of application of painful stimuli remains, with the potential to negatively impact on decision-making, delay responsiveness to neurological deterioration and result in adverse incidents. DESIGN AND METHODS: This international study used an online self-reported survey design to ascertain neuroscience nurses' perceptions and experiences around the application of painful stimuli as part of a GCS assessment (n = 273). The STROBE checklist was used. RESULTS: Data revealed varied practices and a sense of confusion from participants. Anatomical sites for the assessment of pain varied, but most respondents identified the trapezius grip/pinch in assessing eye-opening and motor responses. Most respondents identified they assess eye-opening and motor responses together and apply pain for <6 s to elicit a response. Witnessed complications secondary to applying a painful stimulus were varied and of concern. CONCLUSION: Neuroscience nurses in this study clearly required evidence-informed guidelines to underpin practice both in applying painful stimuli and in managing the experience of the person in their care and the family response. A standardised approach to education is necessary to ensure greater interrater reliability of assessment not only within nursing but across professions. RELEVANCE TO PRACTICE: Results of this study illustrate inconsistency and confusion when using the Glasgow Coma Scale in practice; this has the potential to compromise care. Clarity around the issues highlighted is necessary. Moreover, these results can inform future guidelines and education required for supporting nurses in practice.


Assuntos
Coma/diagnóstico , Escala de Coma de Glasgow , Enfermagem em Neurociência/métodos , Medição da Dor/psicologia , Adulto , Coma/enfermagem , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Masculino , Medição da Dor/métodos , Reprodutibilidade dos Testes , Autorrelato
3.
Med. intensiva (Madr., Ed. impr.) ; 43(5): 270-280, jun.-jul. 2019. graf, tab
Artigo em Espanhol | IBECS | ID: ibc-183239

RESUMO

Objetivo: Describir las variables relacionadas con la capacidad tusígena efectiva y el estado de la conciencia medidas previo a la decanulación y comparar sus valores medidos entre los diferentes ámbitos de atención como la Unidad de Cuidados Intensivos (UCI), sala general y centros de desvinculación de la ventilación mecánica y rehabilitación (CDVMR). Secundariamente analizar la evolución de los pacientes una vez decanulados. Diseño: Serie de casos, longitudinal y prospectiva. Ámbito: Multicéntrico 31 UCI (polivalentes) y en 5 CDVMR. Pacientes: Adultos traqueostomizados previos a la decanulación. Mediciones: Presión espiratoria máxima, pico flujo espiratorio tosido (PFET), Glasgow Coma Scale (GCS). Resultados: Doscientos siete pacientes decanulados, 124 (60%) en UCI, 59 (28%) en sala general y 24 (12%) en CDVMR. El PFET presentó diferencias entre los pacientes (UCI 110 - 190 l/min versus CDVMR 167,5 - 232,5 l/min; p<0,01). El GCS fue diferente entre la sala general (9 -15) versus UCI (10- 15) y CDVMR (12 - 15); p<0,01 y p<0,01, respectivamente. Hubo diferencias en los días de internación (p<0,01), los días con traqueostomía (<0,01) y la cantidad de pacientes derivados a domicilio (p=0,02) entre los distintos escenarios. Conclusión: Existen diferencias en los valores medidos de PFET y GCS entre los diferentes ámbitos. Una considerable cantidad de pacientes son decanulados con valores de PFET y presión espiratoria máxima por debajo de los puntos de corte sugeridos como predictores de falla en la literatura. Ningún paciente de nuestra serie fue decanulado con un SCG <8 puntos, esto refleja la importancia que le otorga el equipo tratante al estado de conciencia al momento de la decanulación


Objective: To describe the variables related to effective cough capacity and the state of consciousness measured prior to decannulation and compare their measured values between the different areas of care such as the Intensive Care Unit (ICU), General ward and Mechanical Ventilation Weaning and Rehabilitation Centers (MVWRC). Secondarily analyze the evolution of patients once decannulated. Design: Case series, longitudinal and prospective. Scope: Multicentric 31 ICUs (polyvalent) and 5 MVWRC. Patients: Tracheostomized adults prior to decannulation. Measurements: Maximum expiratory pressure, peak expiratory flow coughed (PEFC), Glasgow Coma Scale (GCS). Results: Two hundred and seven decannulated patients, 124 (60%) in ICU, 59 (28%) General ward and 24 (12%) in MVWRC. The PEFC presented differences between the patients (ICU 110 - 190 l/min versus MVWRC 167.5 - 232.5 l/min, p <.01). The GCS was different between General ward (9 -15) versus ICU (10-15) and MVWRC (12-15); p <.01 and p <.01, respectively. There were differences in the days of hospitalization (p <.01), days with tracheostomy (<0.01) and the number of patients referred at home (p =.02) between the different scenarios. Conclusion: There are differences in the values of PEFC and GCS observed when decannulating between different areas. A considerable number of patients are decannulated with values of PEFC and maximum expiratory pressure below the suggested cut-off points as predictors of failure in the literature. No patient in our series was decanulated with an GCS <8, this reflects the importance that the treating team gives to the state of consciousness prior to decannulation


Assuntos
Humanos , Adulto , Força Muscular , Estado de Consciência , Estudos Longitudinais , Unidades de Terapia Intensiva , Pressões Respiratórias Máximas/métodos , Pico do Fluxo Expiratório , Estudos Prospectivos , Cateterismo/instrumentação , Coma/diagnóstico
4.
Dtsch Med Wochenschr ; 144(13): 867-875, 2019 07.
Artigo em Alemão | MEDLINE | ID: mdl-31252440

RESUMO

Cerebral diseases such as epileptic seizures, cerebral hemorrhages or meningoencephalitis are the primary cause of approximately 50 % of non-traumatic acute disorders of consciousness. For the differential diagnosis, history and other symptoms are important such as hemiplegia, signs of brain stem dysfunction, meningism or headache. Metabolic, endocrinologic, toxicologic or electrolytic causes of coma usually can be diagnosed by laboratory examinations. Anamnestic informations, body inspection, clinical neurological examination as well as laboratory and imaging findings have to be added and categorized by a multilevel composition to establish a conclusive diagnosis. Simultaneously therapeutic measures for suspected primary cerebral diseases must be initiated, for example a rapid antibiotic treatment in case of a possible bacterial meningitis. A fast and structured diagnostic approach is crucial for ensuring a good prognosis and helps to miss relevant diagnostic steps. Potential diagnostic and therapeutic pitfalls must be kept in mind.


Assuntos
Coma , Transtornos da Consciência , Doença Aguda , Hemorragia Cerebral/complicações , Hemorragia Cerebral/diagnóstico , Coma/diagnóstico , Coma/etiologia , Transtornos da Consciência/diagnóstico , Transtornos da Consciência/etiologia , Diagnóstico Diferencial , Humanos , Meningoencefalite/complicações , Meningoencefalite/diagnóstico , Exame Neurológico , Convulsões/complicações , Convulsões/diagnóstico
5.
J Clin Nurs ; 28(21-22): 3776-3785, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30939215

RESUMO

AIMS AND OBJECTIVES: This study aimed at examining the construct validity and reliability of the Full Outline of UnResponsiveness score in patients with spontaneous subarachnoid haemorrhage caused by aneurysm rupture. BACKGROUND: The Full Outline of UnResponsiveness score is known to be a valid and reliable consciousness assessment tool and provides comprehensive information not given by the Glasgow Coma Scale. However, the validity and reliability of this tool have not been tested in patients with spontaneous subarachnoid haemorrhage. DESIGN: A nonexperimental, descriptive, correlational study design was adopted. METHODS: The STROBE statement was used for reporting this study. The study participants were 72 patients with spontaneous subarachnoid haemorrhage caused by aneurysm rupture, admitted to an intensive care unit in a university hospital between August 2016-July 2017. Data on demographic characteristics, Hunt-Hess clinical stage scores, Fisher CT stage scores, disease-related characteristics, Full Outline of UnResponsiveness scores and 1-month Glasgow Outcome Scale scores were subjected to analysis. RESULTS: Full Outline of UnResponsiveness scores were found to have significant correlations with scores on Hunt-Hess clinical or Fisher CT stage tool and adequately predict 1-month recovery. This tool also exhibited excellent inter-rater agreement and internal consistency. CONCLUSIONS: The Full Outline of UnResponsiveness score is valid and reliable for consciousness evaluation in spontaneous subarachnoid haemorrhage. It has been believed that use of this tool may help prevent negative consequences arising from impaired consciousness and improve the outcomes of patients with spontaneous aneurysmatic subarachnoid haemorrhage. RELEVANCE TO CLINICAL PRACTICE: The Full Outline of UnResponsiveness score is a consciousness assessment tool that provides more neurological detail because it includes consideration of brainstem reflexes, visual tracking, breathing patterns and respiratory drive, and can be applied in cases of spontaneous subarachnoid haemorrhage and other types of brain injury, especially in patients with severe consciousness impairment.


Assuntos
Aneurisma Roto/complicações , Coma/diagnóstico , Hemorragia Subaracnóidea/diagnóstico , Índices de Gravidade do Trauma , Adulto , Idoso , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Índice de Gravidade de Doença , Hemorragia Subaracnóidea/etiologia
6.
Sensors (Basel) ; 19(6)2019 Mar 18.
Artigo em Inglês | MEDLINE | ID: mdl-30889817

RESUMO

Electroencephalography (EEG) signals may provide abundant information reflecting the developmental changes in brain status. It usually takes a long time to finally judge whether a brain is dead, so an effective pre-test of brain states method is needed. In this paper, we present a hybrid processing pipeline to differentiate brain death and coma patients based on canonical correlation analysis (CCA) of power spectral density, complexity features, and feature fusion for group analysis. In addition, time-varying power spectrum and complexity were observed based on the analysis of individual patients, which can be used to monitor the change of brain status over time. Results showed three major differences between brain death and coma groups of EEG signal: slowing, increased complexity, and the improvement on classification accuracy with feature fusion. To the best of our knowledge, this is the first scheme for joint general analysis and time-varying state monitoring. Delta-band relative power spectrum density and permutation entropy could effectively be regarded as potential features of discrimination analysis on brain death and coma patients.


Assuntos
Morte Encefálica/diagnóstico , Coma/diagnóstico , Eletroencefalografia/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Área Sob a Curva , Morte Encefálica/fisiopatologia , Coma/fisiopatologia , Entropia , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Análise de Componente Principal , Curva ROC , Processamento de Sinais Assistido por Computador , Adulto Jovem
7.
IEEE Trans Neural Syst Rehabil Eng ; 27(3): 507-513, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30714927

RESUMO

The coma recovery scale-revised (CRS-R) behavioral scale is commonly used for the clinical evaluation of patients with disorders of consciousness (DOC). However, since DOC patients generally cannot supply stable and efficient behavioral responses to external stimulation, evaluation results based on behavioral scales are not sufficiently accurate. In this paper, we proposed a novel brain-computer interface (BCI) based on 3D stereo audiovisual stimuli to supplement object recognition evaluation in the CRS-R. During the experiment, subjects needed to follow the instructions and to focus on the target object on the screen, whereas EEG data were recorded and analyzed in real time to determine the object of focus, and the detection result was output as feedback. Thirteen DOC patients participated in the object recognition assessments using the 3D audiovisual BCI and CRS-R. None of the patients showed object recognition function in the CRS-R assessment before the BCI experiment. However, six of these DOC patients achieved accuracies that were significantly higher than the chance level in the BCI-based assessment, indicating the successful detection of object recognition function in these six patients using our 3D audiovisual BCI system. These results suggest that the BCI method may provide a more sensitive object recognition evaluation compared with CRS-R and may be used to assist clinical CRS-R for DOC patients.


Assuntos
Interfaces Cérebro-Computador , Transtornos da Consciência/diagnóstico , Imagem Tridimensional , Estimulação Acústica , Adolescente , Adulto , Idoso , Coma/diagnóstico , Simulação por Computador , Transtornos da Consciência/psicologia , Eletroencefalografia , Retroalimentação , Feminino , Voluntários Saudáveis , Humanos , Masculino , Pessoa de Meia-Idade , Estimulação Luminosa , Recuperação de Função Fisiológica , Adulto Jovem
9.
J Clin Neurophysiol ; 36(1): 32-35, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30608366

RESUMO

OBJECTIVE: After-hours EEG is increasingly used in hospital patients. Although the detection of seizures and interictal epileptiform discharges has been shown to be higher with prolonged EEG (pEEG) than routine-duration EEG, the relative value for particular indications can inform utilization. METHOD: The Mayo EEG Report System was queried for after-hours emergent routine EEG (ErEEG) and pEEG performed between January 2015 and June 2015. Total 296 after-hours ErEEG were identified, of which 140 converted into pEEG were included in the study for direct comparison of two modalities. Indications were categorized as: mental status changes, recent seizures rule out continued nonconvulsive seizures, spells, and prognosis after anoxic brain injury. Categorical data were analyzed using the McNemar and Fisher exact tests; a P value of 0.05 was considered significant. RESULT: Prolonged EEG was superior to ErEEG for detection of interictal epileptiform discharges (61 vs. 48/140, P = 0.004) and seizures (29 vs. 17/140, P = 0.012). Seizure detection was greater for pEEG than ErEEG for the indication of evaluating for subclinical seizures after recent observed clinical seizures (14/41 [34.1%] versus 4/41 [9.8%], P = 0.002). There was no significant difference between modalities for seizure detection in patients undergoing evaluation of spells or mental status changes without previous observed seizures. Detection of seizures on pEEG was higher for recordings greater than 24 hours (8/46, 17%, P = 0.014) and 48 hours (19/26, 73%, P < 0.001) than recordings less than 24 hours (2/68, 3%). Seizure detection was higher with pEEG in comatose patients than ErEEG (17/51, 33% vs. 12/89, 13%; P = 0.009). CONCLUSIONS: Increased value was demonstrated for pEEG over ErEEG in patients undergoing evaluation after observed recent clinical seizures and for coma. No significant difference was found between ErEEG and pEEG for seizure detection in the relatively small subgroups of patients with mental status changes other than coma and without preceding seizure or spells.


Assuntos
Coma/diagnóstico , Eletroencefalografia/métodos , Convulsões/diagnóstico , Encéfalo/fisiopatologia , Coma/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Convulsões/fisiopatologia , Fatores de Tempo
10.
J Neurosurg Anesthesiol ; 31(3): 306-310, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29782388

RESUMO

BACKGROUND: The Glasgow Coma Scale (GCS) is an essential coma scale in critical care for determining the neurological status of patients and for estimating their long-term prognosis. Similarly, cerebral autoregulation (CA) monitoring has shown to be an accurate technique for predicting clinical outcomes. However, little is known about the relationship between CA measurements and GCS scores among neurological critically ill patients. This study aimed to explore the association between noninvasive CA multimodal monitoring measurements and GCS scores. METHODS: Acutely comatose patients with a variety of neurological injuries admitted to a neurocritical care unit were monitored using near-infrared spectroscopy-based multimodal monitoring for up to 72 hours. Regional cerebral oxygen saturation (rScO2), cerebral oximetry index (COx), GCS, and GCS motor data were measured hourly. COx was calculated as a Pearson correlation coefficient between low-frequency changes in rScO2 and mean arterial pressure. Mixed random effects models with random intercept was used to determine the relationship between hourly near-infrared spectroscopy-based measurements and GCS or GCS motor scores. RESULTS: A total of 871 observations (h) were analyzed from 57 patients with a variety of neurological conditions. Mean age was 58.7±14.2 years and the male to female ratio was 1:1.3. After adjusting for hemoglobin and partial pressure of carbon dioxide in arterial blood, COx was inversely associated with GCS (ß=-1.12, 95% confidence interval [CI], -1.94 to -0.31, P=0.007) and GCS motor score (ß=-1.06, 95% CI, -2.10 to -0.04, P=0.04). In contrast rScO2 was not associated with GCS (ß=-0.002, 95% CI, -0.01 to 0.01, P=0.76) or GCS motor score (ß=-0.001, 95% CI, -0.01 to 0.01, P=0.84). CONCLUSIONS: This study showed that fluctuations in GCS scores are inversely associated with fluctuations in COx; as COx increases (impaired autoregulation), more severe neurological impairment is observed. However, the difference in COx between high and low GCS is small and warrants further studies investigating this association. CA multimodal monitoring with COx may have the potential to be used as a surrogate of neurological status when the neurological examination is not reliable (ie, sedation and paralytic drug administration).


Assuntos
Circulação Cerebrovascular , Coma/diagnóstico , Coma/fisiopatologia , Escala de Coma de Glasgow , Espectroscopia de Luz Próxima ao Infravermelho , Adulto , Idoso , Idoso de 80 Anos ou mais , Cuidados Críticos , Feminino , Homeostase , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica , Consumo de Oxigênio
11.
Curr Hypertens Rev ; 15(1): 13-16, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30277162

RESUMO

BACKGROUND: Myxedema heart disease is an extremely rare disease entity and should be suspected in patients with unexplained heart failure refractory to conventional treatment. Myxedema coma with co- existent heart disease is not well known and very few cases have been reported. CONCLUSION: Here, we present an interesting case of myxedema coma with severe valvular cardiomyopathy followed by a concise review of the literature with special emphasis on epidemiology, pathophysiology, diagnosis and therapeutic modalities.


Assuntos
Cardiomiopatias , Coma , Insuficiência Cardíaca , Mixedema , Cardiomiopatias/diagnóstico , Cardiomiopatias/epidemiologia , Cardiomiopatias/fisiopatologia , Cardiomiopatias/terapia , Cateterismo de Swan-Ganz , Coma/diagnóstico , Coma/epidemiologia , Coma/fisiopatologia , Coma/terapia , Progressão da Doença , Ecocardiografia Doppler em Cores , Eletrocardiografia , Evolução Fatal , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/terapia , Humanos , Pessoa de Meia-Idade , Mixedema/diagnóstico , Mixedema/epidemiologia , Mixedema/fisiopatologia , Mixedema/terapia , Valor Preditivo dos Testes , Fatores de Risco , Resultado do Tratamento
12.
Neurocrit Care ; 30(1): 1-4, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-29288292

RESUMO

Neurologic examination of the comatose patient has gradually matured. Less than 50 years ago, neurological examination in coma became a regular part of textbooks with separate chapters devoted to the topic but many were deficient in detail. In 1969, C.M. Fisher published an extraordinary 56-page paper on the examination of the comatose patient. The paper-one of Fisher's gems-is not well known and infrequently cited. The many new observations collected in this comprehensive paper are reviewed in this vignette, which highlights not only how these contributions shaped our thinking on coma but also questioned shaky concepts.


Assuntos
Coma/diagnóstico , Exame Neurológico/história , Neurologistas/história , Coma/história , História do Século XX , Humanos
13.
Neurocrit Care ; 30(1): 139-148, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30112686

RESUMO

BACKGROUND: We previously validated simplified electroencephalogram (EEG) tracings obtained by a bispectral index (BIS) device against standard EEG. This retrospective study now investigated whether BIS EEG tracings can predict neurological outcome after cardiac arrest (CA). METHODS: Bilateral BIS monitoring (BIS VISTA™, Aspect Medical Systems, Inc. Norwood, USA) was started following intensive care unit admission. Six, 12, 18, 24, 36 and 48 h after targeted temperature management (TTM) at 33 °C was started, BIS EEG tracings were extracted and reviewed by two neurophysiologists for the presence of slow diffuse rhythm, burst suppression, cerebral inactivity and epileptic activity (defined as continuous, monomorphic, > 2 Hz generalized sharp activity or continuous, monomorphic, < 2 Hz generalized blunt activity). At 180 days post-CA, neurological outcome was determined using cerebral performance category (CPC) classification (CPC1-2: good and CPC3-5: poor neurological outcome). RESULTS: Sixty-three out-of-hospital cardiac arrest patients were enrolled for data analysis of whom 32 had a good and 31 a poor neurological outcome. Epileptic activity within 6-12 h predicted CPC3-5 with a positive predictive value (PPV) of 100%. Epileptic activity within time frames 18-24 and 36-48 h showed a PPV for CPC3-5 of 90 and 93%, respectively. Cerebral inactivity within 6-12 h predicted CPC3-5 with a PPV of 57%. In contrast, cerebral inactivity between 36 and 48 h predicted CPC3-5 with a PPV of 100%. The pattern with the worst predictive power at any time point was burst suppression with PPV of 44, 57 and 40% at 6-12 h, at 18-24 h and at 36-48 h, respectively. Slow diffuse rhythms at 6-12 h, at 18-24 h and at 36-48 h predicted CPC1-2 with PPV of 74, 76 and 80%, respectively. CONCLUSION: Based on simplified BIS EEG, the presence of epileptic activity at any time and cerebral inactivity after the end of TTM may assist poor outcome prognostication in successfully resuscitated CA patients. A slow diffuse rhythm at any time after CA was indicative for a good neurological outcome.


Assuntos
Coma/diagnóstico , Coma/etiologia , Eletroencefalografia/normas , Monitorização Neurofisiológica/normas , Parada Cardíaca Extra-Hospitalar/complicações , Convulsões/diagnóstico , Convulsões/etiologia , Idoso , Idoso de 80 Anos ou mais , Reanimação Cardiopulmonar , Eletroencefalografia/métodos , Feminino , Humanos , Hipotermia Induzida , Masculino , Pessoa de Meia-Idade , Monitorização Neurofisiológica/métodos , Parada Cardíaca Extra-Hospitalar/terapia , Valor Preditivo dos Testes , Prognóstico , Estudos Retrospectivos
14.
IEEE J Biomed Health Inform ; 23(4): 1794-1804, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30369457

RESUMO

Mismatch negativity (MMN) is a component of the event-related potential (ERP) that is elicited through an odd-ball paradigm. The existence of the MMN in a coma patient has a good correlation with coma emergence; however, this component can be difficult to detect. Previously, MMN detection was based on visual inspection of the averaged ERPs by a skilled clinician, a process that is expensive and not always feasible in practice. In this paper, we propose a practical machine learning (ML) based approach for detection of MMN component, thus, improving the accuracy of prediction of emergence from coma. Furthermore, the method can operate on an automatic and continuous basis thus alleviating the need for clinician involvement. The proposed method is capable of the MMN detection over intervals as short as two minutes. This finer time resolution enables identification of waxing and waning cycles of a conscious state. An auditory odd-ball paradigm was applied to 22 healthy subjects and 2 coma patients. A coma patient is tested by measuring the similarity of the patient's ERP responses with the aggregate healthy responses. Because the training process for measuring similarity requires only healthy subjects, the complexity and practicality of training procedure of the proposed method are greatly improved relative to training on coma patients directly. Since there are only two coma patients involved with this study, the results are reported on a very preliminary basis. Preliminary results indicate we can detect the MMN component with an accuracy of 92.7% on healthy subjects. The method successfully predicted emergence in both coma patients when conventional methods failed. The proposed method for collecting training data using exclusively healthy subjects is a novel approach that may prove useful in future, unrelated studies where ML methods are used.


Assuntos
Coma , Eletroencefalografia/métodos , Potenciais Evocados Auditivos/fisiologia , Aprendizado de Máquina , Processamento de Sinais Assistido por Computador , Adulto , Coma/diagnóstico , Coma/fisiopatologia , Humanos , Masculino , Prognóstico , Adulto Jovem
15.
BMJ Open ; 8(11): e023216, 2018 11 28.
Artigo em Inglês | MEDLINE | ID: mdl-30498041

RESUMO

OBJECTIVE: To evaluate utility and equivalence of Glasgow Coma Scale (GCS) and the Alert, Voice, Pain, Unresponsive (AVPU) scale in children with head injury. DESIGN: Cross sectional study. SETTING: UK hospital admissions: September 2009-February 2010. PATIENTS: <15 years with head injury. INTERVENTIONS: GCS and/or AVPU at injury scene and in emergency departments (ED). MAIN OUTCOME: Measures used, the equivalence of AVPU to GCS, GCS at the scene predicting GCS in ED, CT results by age, hospital type. RESULTS: Level of consciousness was recorded in 91% (5168/5700) in ED (43%: GCS/30.5%: GCS+AVPU/17.3%: AVPU) and 66.1% (1190/1801) prehospital (33%: GCS/26%GCS+AVPU/7%: AVPU). Failure to record level of consciousness and the use of AVPU were greatest for infants. Correlation between AVPU and median GCS in 1147 children <5 years: A=15, V=14, P=8, U=3, for 1163 children ≥5 years: A=15, V=13, P=11, U=3. There was no significant difference in the proportion of infants who had a CT whether AVPU=V/P/U or GCS<15. However diagnostic yield of intracranial injury or depressed fracture was significantly greater for V/P/U than GCS<15 :7/7: 100% (95% CI 64.6% to 100%) versus 5/17: 29.4% (95% CI 13.3% to 53.1%). For children >1 year significantly more had a CT scan when GCS<14 was recorded than 'V/P/U only' and the diagnostic yield was greater. Prehospital GCS and GCS in the ED were the same for 77.4% (705/911). CONCLUSION: There was a clear correlation between Alert and GCS=15 and between Unresponsive and GCS=3 but a wider range of GCS scores for responsive to Pain or Voice that varied with age. AVPU was valuable at initial assessment of infants and did not adversely affect the proportion of infants who had head CT or the diagnostic yield.


Assuntos
Lesões Encefálicas/etiologia , Transtornos da Consciência/diagnóstico , Estado de Consciência , Traumatismos Craniocerebrais/complicações , Exame Neurológico/métodos , Índice de Gravidade de Doença , Índices de Gravidade do Trauma , Atenção , Lesões Encefálicas/patologia , Pré-Escolar , Coma/diagnóstico , Coma/etiologia , Transtornos da Consciência/etiologia , Estudos Transversais , Feminino , Escala de Coma de Glasgow , Humanos , Lactente , Masculino , Dor , Tempo de Reação , Tomografia Computadorizada por Raios X , Reino Unido , Voz , Vigília
16.
Continuum (Minneap Minn) ; 24(6): 1708-1731, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30516602

RESUMO

PURPOSE OF REVIEW: This article discusses the diagnostic and therapeutic approach to patients who are comatose and reviews the current knowledge on prognosis from various causes of coma. This article also provides an overview of the principles for determination of brain death as well as advice on how to avoid common pitfalls. RECENT FINDINGS: Technologic advances have refined our understanding of the physiology of consciousness and the spectrum of disorders of consciousness; they also promise to improve our prognostic accuracy. Yet the clinical principles for the evaluation and treatment of coma remain unaltered. The clinical standards for determination of death by neurologic criteria (ie, brain death) are also well established, although variabilities in local protocols and legal requirements remain a problem to be resolved. SUMMARY: Effective evaluation of coma demands a systematic approach relying on clinical information to ensure rational use of laboratory and imaging tests. When the cause of coma is deemed irreversible in the setting of a catastrophic brain injury and no clinical evidence exists for brain and brainstem function, patients should be evaluated for the possibility of brain death by following the clinical criteria specified in the American Academy of Neurology guidelines.


Assuntos
Morte Encefálica/fisiopatologia , Coma/diagnóstico , Coma/terapia , Gerenciamento Clínico , Morte Encefálica/diagnóstico por imagem , Eletroencefalografia , Humanos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Tomógrafos Computadorizados
17.
Continuum (Minneap Minn) ; 24(6): 1732-1752, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30516603

RESUMO

PURPOSE OF REVIEW: Because the whole-body ischemia-reperfusion insult associated with cardiac arrest often results in brain injury, neurologists perform an important role in postresuscitation cardiac arrest care. This article provides guidance for the assessment and management of brain injury following cardiac arrest. RECENT FINDINGS: Neurologists have many roles in postresuscitation cardiac arrest care: (1) early assessment of brain injury severity to help inform triage for invasive circulatory support or revascularization; (2) advocacy for the maintenance of a neuroprotective thermal, hemodynamic, biochemical, and metabolic milieu; (3) detection and management of seizures; (4) development of an accurate, multimodal, and conservative approach to prognostication; (5) application of shared decision-making paradigms around the likely outcomes of therapy and the goals of care; and (6) facilitation of the neurocognitive assessment of survivors. Therefore, optimal management requires early neurologist involvement in patient care, a detailed knowledge of postresuscitation syndrome and its complex interactions with prognosis, expertise in bringing difficult cases to their optimal conclusions, and a support system for survivors with cognitive deficits. SUMMARY: Neurologists have a critical role in postresuscitation cardiac arrest care and are key participants in the treatment team from the time of first restoration of a perfusing heart rhythm through the establishment of rehabilitation services for survivors.


Assuntos
Coma , Gerenciamento Clínico , Parada Cardíaca/complicações , Sobreviventes , Adulto , Temperatura Corporal , Circulação Cerebrovascular/fisiologia , Coma/diagnóstico , Coma/etiologia , Coma/mortalidade , Coma/terapia , Feminino , Humanos , Doenças do Sistema Nervoso/etiologia
18.
Tunis Med ; 96(8-9): 532-535, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30430535

RESUMO

BACKGROUND: Pituitary tuberculosis is very rare. Its diagnosis is difficult unless a bacteriological or histological evidence of tuberculosis. OBSERVATION: We report the case of a 54 years old woman who presented with a pituitary coma that occurred two weeks after the initiation of antituberculous therapy for cervical lymph node tuberculosis. Resonance magnetic imaging showed a pseudotumoral aspect of the pituitary gland. She had hormonal replacement and anti-tuberculous therapy. Outcome was favourable with the normalization of both the pituitary function and the pituitary volume. However, an acute hypopituitarism happened eight months after the withdrawal of antituberculous, which were taken during 12 months. The re initiation of anti tuberculous therapy and its extension to two years leaded to a prolonged remission. CONCLUSION: the three-phase outcome confirms the tuberculous origin of the hypophysitis in our patient.


Assuntos
Coma/diagnóstico , Doenças da Hipófise/diagnóstico , Tuberculose Endócrina/diagnóstico , Coma/microbiologia , Feminino , Humanos , Hipopituitarismo/diagnóstico , Hipopituitarismo/microbiologia , Imagem por Ressonância Magnética , Pessoa de Meia-Idade , Doenças da Hipófise/complicações , Doenças da Hipófise/microbiologia , Tuberculose Endócrina/complicações
19.
Intensive Care Med ; 44(12): 2102-2111, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30478620

RESUMO

PURPOSE: To assess the ability of quantitative pupillometry [using the Neurological Pupil index (NPi)] to predict an unfavorable neurological outcome after cardiac arrest (CA). METHODS: We performed a prospective international multicenter study (10 centers) in adult comatose CA patients. Quantitative NPi and standard manual pupillary light reflex (sPLR)-blinded to clinicians and outcome assessors-were recorded in parallel from day 1 to 3 after CA. Primary study endpoint was to compare the value of NPi versus sPLR to predict 3-month Cerebral Performance Category (CPC), dichotomized as favorable (CPC 1-2: full recovery or moderate disability) versus unfavorable outcome (CPC 3-5: severe disability, vegetative state, or death). RESULTS: At any time between day 1 and 3, an NPi ≤ 2 (n = 456 patients) had a 51% (95% CI 49-53) negative predictive value and a 100% positive predictive value [PPV; 0% (0-2) false-positive rate], with a 100% (98-100) specificity and 32% (27-38) sensitivity for the prediction of unfavorable outcome. Compared with NPi, sPLR had significantly lower PPV and significantly lower specificity (p  < 0.001 at day 1 and 2; p  = 0.06 at day 3). The combination of NPi ≤ 2 with bilaterally absent somatosensory evoked potentials (SSEP; n = 188 patients) provided higher sensitivity [58% (49-67) vs. 48% (39-57) for SSEP alone], with comparable specificity [100% (94-100)]. CONCLUSIONS: Quantitative NPi had excellent ability to predict an unfavorable outcome from day 1 after CA, with no false positives, and significantly higher specificity than standard manual pupillary examination. The addition of NPi to SSEP increased sensitivity of outcome prediction, while maintaining 100% specificity.


Assuntos
Coma/diagnóstico , Coma/etiologia , Parada Cardíaca/complicações , Parada Cardíaca/diagnóstico , Reflexo Pupilar , Idoso , Coma/mortalidade , Cuidados Críticos , Método Duplo-Cego , Potenciais Somatossensoriais Evocados , Feminino , Escala de Coma de Glasgow , Parada Cardíaca/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Sensibilidade e Especificidade
20.
Chin Med J (Engl) ; 131(18): 2152-2157, 2018 Sep 20.
Artigo em Inglês | MEDLINE | ID: mdl-30203788

RESUMO

Background: Whether the Glasgow Coma Scale (GCS) can assess intubated patients is still a topic of controversy. We compared the test performance of the GCS motor component (GCS-M)/Simplified Motor Score (SMS) to the total of the GCS in predicting the outcomes of intubated acute severe cerebral vascular disease patients. Methods: A retrospective analysis of prospectively collected observational data was performed. Between January 2012 and October 2015, 106 consecutive acute severe cerebral vascular disease patients with intubation were included in the study. GCS, GCS-M, GCS eye-opening component, and SMS were documented on admission and at 24, 48, and 72 h after admission to Neurointensive Care Unit (NCU). Outcomes were death and unfavorable prognosis (modified Rankin Scale: 5-6) at NCU discharge. The receiver operating characteristic (ROC) curve was obtained to determine the prognostic performance and best cutoff value for each scoring system. Comparison of the area under the ROC curves (AUCs) was performed using the Z- test. Results: Of 106 patients included in the study, 41 (38.7%) patients died, and 69 (65.1%) patients had poor prognosis when discharged from NCU. The four time points within 72 h of admission to the NCU were equivalent for each scale's predictive power, except that 0 h was the best for each scale in predicting outcomes of patients with right-hemisphere lesions. Nonsignificant difference was found between GCS-M AUCs and GCS AUCs in predicting death at 0 h (0.721 vs. 0.717, Z = 0.135, P = 0.893) and 72 h (0.730 vs. 0.765, Z = 1.887, P = 0.060), in predicting poor prognosis at 0 h (0.827 vs. 0.819, Z = 0.395, P = 0.693), 24 h (0.771 vs. 0.760, Z = 0.944, P = 0.345), 48 h (0.732 vs. 0.741, Z = 0.593, P = 0.590), and 72 h (0.775 vs. 0.780, Z = 0.302, P = 0.763). AUCs in predicting death for patients with left-hemisphere lesions ranged from 0.700 to 0.804 for GCS-M and from 0.700 to 0.824 for GCS, in predicting poor prognosis ranged from 0.841 to 0.969 for GCS-M and from 0.875 to 0.969 for GCS, with no significant difference between GCS-M AUCs and GCS AUCs within 72 h (P > 0.05). No significant difference between GCS-M AUCs and GCS AUCs was found in predicting death (0.964 vs. 0.964, P = 1.000) and poor prognosis (1.000 vs. 1.000, P = 1.000) for patients with right-hemisphere lesions at 0 h. AUCs in predicting death for patients with brainstem or cerebella were poor for GCS-M (<0.700), in predicting poor prognosis ranged from 0.727 to 0.801 for GCS-M and from 0.704 to 0.820 for GCS, with no significant difference between GCS-M AUCs and GCS AUCs within 72 h (P > 0.05). The SMS AUCs (<0.700) in predicting outcomes were poor. Conclusions: The GCS-M approaches the same test performance as the GCS in assessing the prognosis of intubated acute severe cerebral vascular disease patients. The GCS-M could be accurately and reliably applied in patients with hemisphere lesions, but caution must be taken for patients with brainstem or cerebella lesions.


Assuntos
Coma/diagnóstico , Escala de Coma de Glasgow , Intubação Intratraqueal , Acidente Vascular Cerebral/complicações , Adolescente , Adulto , Coma/etiologia , Humanos , Prognóstico , Estudos Retrospectivos
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