Etiology and outcome of non-traumatic coma in children admitted to pediatric intensive care unit

Non-traumatic coma is a relatively common condition in children that may cause considerable mortality and morbidity. The purpose of this study was to determine clinical presentation, etiology and outcome of non-traumatic coma in children. In a retrospective cross sectional study over a period of 5 years, files of 150 children aged between 1 month and 14 years admitted with non-traumatic coma to pediatric intensive care unit of Rasool Akram hospital were reviewed. Historical, presenting symptoms, clinical and laboratory data were collected. Etiology of coma was determined on the basis of clinical history and relevant investigations. The outcome was recorded as died or neurological condition at discharge as normal, mild or sever disability. Chi-square test was used to test the differences in categorical variables. There were 63 [42%] boys and 87 [58%] girls. The mean +/- SD age of patients was 2.7 +/- 2.35 years. Systemic presentations including nausea, vomiting, fever, lethargy and poor I feeding were more prominent in children under 2 years. Etiology of coma in 49 patients [32.7%] was infectious [meningitis, encephalitis, respiratory and systemic]. Other causes were status epilepticus 44 [29.4%], metabolic [diabetic ketoacidosis, inborn errors of metabolism] 11 [7.3%], intoxications 10 [6.7%], accidental [drowning, electrical shock, suffocation] 9 [6%], shunt dysfunction [secondary to congenital brain malformations] 7 [4.6%], others [acute disseminated encephalomyelitis, vasculitis, hypertensive encephalopathy] 11 [7.3%], unknown 9 [6%]. Infection occurred significantly [P=0.002] in children under 2 years of age, whereas accidents and intoxications were more prominent [P=0.004] in those between 2 and 6 years. Overall 25 children [16.6%] died. Of those survived 16 became severely disabled. Accidents and infections had higher mortality compared to other groups [P<0.001 and P=0.02 respectively]. Our results showed that infection was the most common cause of non-traumatic coma in childhood. Accidents and infection had higher mortality than other causes

Prognosis of Non Traumatic Coma: The Role of some Socio-Economic Factors on its Outcome in Ibadan; Nigeria

Background : Coma occurring in the course of an illness; irrespective of cause; traditionally implies a poor prognosis and many factors may determine its outcome. These factors must be identified and possibly stratified in their order of importance. This research seeks to identify these factors and how they influenced the outcome of non-traumatic coma in our environment. Methods : Two hundred consecutive patients; aged 18-79 years who met the inclusion criteria; the Glasgow coma scale (GCS) score of 8; history and physical findings suggestive of medical illness; no head trauma or sedation; were recruited into the study from August 2004 to March 2005 at the University College Hospital (UCH); Ibadan; after obtaining institutional ethical clearance and consent from patients' guardians. Detailed history of illness including the bio-data and time to present to the hospital and treatments given were noted. Thereafter; the clinical course of the patients was monitored daily for a maximum of 28 days during which the support of the family and/ or the hospital social welfare was evaluated. Results : During the 8-month period of the study; 76(152) of the patients died while 24(48) survived. The following factors were associated with high mortality rate: inability to confirm diagnosis (100); poor family support (97.1); delay in making a diagnosis within 24 h (85.4); poor family understanding of disease (84.1); need for intensive care admission and management (83.3); poor hospital social welfare support (82.4); presentation to UCH after 6 h of coma (76.7); and referral from private health facilities (75.7). Others include substance abuse (100) and seropositivity to HIV (96) and hepatitis B surface antigen (92) antibodies; among others. Conclusion : This study has demonstrated that socio-economic factors such as gender; occupation; risky lifestyle behaviors; late presentation or referral to hospital; late diagnosis and treatment; and poor family support contributed to poor outcome of nontraumatic coma. It is hoped that improvement; modification; or correction of these factors may improve coma outcome

Mode of death shifting from coma to syncope sports utility vehicle (SUV) accidents.

Road traffic accident is a major cause of death assuming epidemic proportion worldwide. After America, India has the largest network of roads. The total length of the road is about 33, 44,000km, out of which national highways occupies only 2% of total road length, whereas they bear 20% of the traffic load. One of the main reasons of the overcrowding of the roads is the tremendous rise in number of vehicles due to increasing distance from residence to workplace, intensive marketing campaign of newer sports utility (SUV) cars by depicting them in movies, media advertisements and easy finance availability has developed a craving to possess these sports utility vehicles in youths (both in males and females). These sports utility vehicles are nowadays becoming the rapid killer of the victims met with road traffic accidents (pedestrians, pedal cyclist and motor cyclist). The present study is based on prospective and retrospective cases of road traffic accidents involving SUV’s, since January 2005 to December 2006. The present study has shown that young adults predominantly males in their most productive year of life (21-30 years) are especially prone to road traffic trauma2. Pedestrians constitute the largest group of victims 78 cases (65%) followed by cyclist 18 cases (50%), spot death unavoidable in 83 cases (55.33%) and the thoraco-abdominal trauma found in 97 cases (80.83%)2,4. The findings of study under score the continue need for preventive strategies; aim to reduce trauma related mortality, particularly those regarding road traffic safety. The study also suggest that the large proportion of death were preventable, if underlying lesion or sequelae of injuries had been promptly addressed but unfortunately the front design of these sports utility vehicles is responsible for causing thoraco-abdominal trauma, leading to rapid death by causing haemorrhagic shock generated from involvement of the structures of thoraco-abdominal region.

Traumatic and non-traumatic coma in children in the referral hospital, Al-Hasa, Saudi Arabia

We determined the incidence, etiology and outcome of paediatric coma patients in King Fahad Hospital, which is the only referral centre for Al-Hasa region, Saudi Arabia. From April 1999 to March 2002, 91 children with coma [age range 28 days to 12 years] were admitted. The Glasgow Coma Scale for children was used for assessment. Neurological outcomes were categorized as intact, impairment or death. Incidence of coma was 4.77 per 100 000 population per year. Trauma [head trauma or polytrauma] was the commonest cause of coma [52.8%], followed by infection [25.3%]. Mortality was 47.2% [35.4% among traumatic cases and 60.5% among non-traumatic cases]. There was impaired outcome in 19.8% of patients [22.9% with traumatic coma and 16.3% with non-traumatic coma]

Coma anóxico-isquémico en 46 pacientes: Evolución a treinta días y su relación con los reflejos de tronco / The absence of brainstem reflexes does not predict short term mortality in anoxic ischemic coma

Background: Anoxic-ischemic coma has a poor outcome with a high rate of mortality and morbidity. Therefore, clinical predictors of prognosis are needed for therapeutic decision-making. Patients and methods: Prospective analysis of 46 patients, 31 male, age range 19-85 years, with anoxic-ischemic coma following cardiac arrest. All the patients included in our study remained comatose with a Glasgow Coma Scale (GCS) score of six or less points, after their stabilization in the Intensive Care Unit. They were evaluated clinically using the pupillary light reflex, corneal reflex and vestibulo-ocular reflex testing, induced by caloric stimulation with cold water. Survival was evaluated using life tables. All patients were followed until the thirtieth day after the anoxic-ischemic event. Results: Thirty five patients (76%) died within the next twenty-nine days, 8 patients (18%) reached the vegetative state, 2 patients (4%) achieved a recovery with disability, and only 1 patient (2%) was discharged without sequelae. One day, five and 30 days survival rates were 89, 53 and 29%, respectively. The abolition of all brainstem reflexes was not a predictor of mortality. Conclusion: Thirty day survival in this group of patients was 29% and the absence of brainstem reflexes was not a predictor of mortality.

Role of Glasgow Coma Scale in pediatric nontraumatic coma.

OBJECTIVE: To assess the relationship between Modified Glasgow Coma Scale (MGCS), its components and survival in children with acute coma. DESIGN: Prospective observational study. SETTING: Tertiary care referral hospital. PATIENTS: Consecutive children (n = 270) with acute nontraumatic coma between 2 months to 12 years. METHODOLOGY: MGCS and brainstem reflexes were assessed at 6 hourly intervals for 72 hours from the time of admission. The lowest score of the MGCS and worst brain stem reflexes were used for the analysis. MAIN OUTCOME MEASURE: Survival. RESULTS: Total score (Spearman rank correlation coefficient IRI = O.577, ocular response (IRI = O.641), motor response (IRI = O.729), verbal response (lRI = 0.608), brain stem response (lRI = O.843) were all found to be associated with adverse outcome. Multivariate regression analysis revealed that ocular response and motor response were individually predictive of short-term outcome. CONCLUSION: A score incorporating the brain stem reflexes, ocular response and motor response in the assessment and prognostication of comatose patients needs to be evaluated.

Modified Glasgow Coma Scale to predict mortality in febrile unconscious children.

A prospective hospital based study was conducted in the Department of Pediatrics of the Kasturba Hospital, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha to predict the mortality in children admitted with fever and unconsciousness using the Modified Glasgow Coma Scale (MGCS) score. Forty eight children were admitted with fever and unconsciousness; cases of febrile convulsions, epilepsy and cerebral palsy were excluded. MGCS scores were assessed on admission and repeated at 12 hours, 24 hours, 48 hours and 72 hours after admission in each case. Diagnosis in each case was confirmed by history, examinations and investigations. All the cases were regularly followed up till death/discharge. The overall mortality was 29.1% (14/48) out of which 85% (12/14) died within the first 24 hours. Mortality was highest in the toddler age group and in patients with pyogenic meningitis. There was a significant association between death and MGCS scores on admission with a post test probability for discharge being only 10% with a score of less than 5 and 99% with a score of more than 10 respectively. MGCS scores on admission can be used to predict mortality in patients hospitalized with fever and unconsciousness. The scale is simple, easy, can be applied at bed side and does not need any investigations. Its application in developing countries with limited investigative and intensive care facilities can help the treating physician decide regarding referral and counseling the parents regarding the probable clinical outcome.

Aspirated pneumonia in toxic coma report 200 cases with 4 died

A retrospective study of 200 cases of aspirated pneumonia suffering from toxic coma with a mortality percentage of 2% in ICU was carried out. Most cases were aspirated at home with a mortality percentage of 30%. This research included clinical presentation, examination, investigations [pH of aspirated, x-ray, blood gas, blood count, bacteriology], complication and analysis of four patients died in ICU