Brandon Yeagley - Comatose Patients

56 patients successfully resuscitated from CA were admitted during the study time period to our ICU. 47 patients fulfilled the inclusion criteria and were included. 2 patients were excluded because of a violation of the sedation protocol: 1 patient received too high doses of midazolam and 1 patient was not paralysed at all. Overall 45 patients were included in the final analysis

Patient characteristics and findings in patients with BIS values of 0 during their ICU stay.

No.	Pupils in ICU on day 1	SSEP	MRI/CT-scan	NSE (ng/ml)	CPC end ICU	CPC at 6 months	Cause of death	Day of death
1	Fixed mydriasis for 6 h	Delayed response	Severe hypoxic damage	–	5	–	Neuro (coma) withholding	22
2 a	Reactive	Normal	Diffuse hypoxic damage	–	4	4	–	–
3	Fixed mydriasis for 4 h	Delayed response	Hypoxic lesions of thalamus	–	5	–	Neuro (coma) withholding	32
4	Fixed mydriasis	–	–	10	5	–	Cardiac	2
5	Mydriasis for 6 h	–	Severe hypoxic damage	187	5	–	Neuro (coma) withholding	16
6	Mydriasis for 20 h	–	Subarachnoidal haemorrhage, diffuse cerebral oedema	35	5	–	Brain death	2
7	Initially Reactive	–	Severe hypoxic oedema	99	5	–	Brain death	3
8 a	Reactive	–	Diffuse hypoxic damage	79	5	–	Cardiac	5
9	Reactive	Diminished amplitude	Diffuse hypoxic damage	82	3	3	–	–
10	Persistant anisocoria	Absent right side	Frontal hypodensity	5	3	3	–	–
11	Reactive	Absent left side	Normal	33	4	5	Neuro (coma) withholding	129
12	Fixed mydriasis	Absent	Subarachnoidal haemorrhage, severe anoxic damage	25	5	–	Brain death	1
13 a	Reactive	Normal	Severe hypoxic damage	87	5	–	Neuro (coma) withholding	12
14	Persistant anisocoria	Normal	Severe hypoxic damage	103	5	–	Neuro (coma) withholding	8

For six weeks in 2000 I lay in a coma in the high dependency unit of Newcastle General Hospital. I was 62 and had had a brain bleed. During that time my damaged brain made up a complex and vivid fantasy world. At first I believed I worked for an airline that flew from Hexham (a town about 20 miles west of Newcastle upon Tyne) to Charlottesville in the United States. As time passed my fantasy became more nightmarish and medical. I was in some sort of institution, in which all the nurses had Northern Irish accents. I think one of the nurses really did come from Northern Ireland, and my brain picked up this detail and generalised recklessly. In the fantasy, staff played cruel tricks, including tying my hands together. This, too, had a connection to the real world. I had many pipes plumbed into me, and once muzzily tried to pull them out. I did myself a lot of damage, and the staff tied my hands together to stop me doing it again. I fantasised about Newcastle’s Metro electric railway. In my fantasy it ran under the North Sea to Moscow, and Russian trains came along it. The Russians once held me forcibly on their part of the platform and made it hard for me to breathe. This unpleasant fantasy episode may have reflected the real world, for I had developed a chest infection. In my fantasy I plotted escapes, which always failed. In the real world two friends from the Netherlands came to visit me. My fantasy converted them into a large contingent of cyclists who had had strokes and were being treated by the NHS. Perhaps my brain was returning to reality, in associating Dutch people with bicycles and recognising I was in an NHS stroke ward. My return to full reality was slow. When my brother took me for an outing in my wheelchair I was staggered to discover I was in Newcastle. I had thought I was in Hexham. I recalled the films I had seen where someone recovers from unconsciousness to ask ‘where am I?’ It is a serious question. No one had ever thought to tell me where I was. I recovered well and today, amazingly, most of my linguistic abilities have returned. But I am always sad to hear or read of anyone unconscious or with fragmented awareness. I imagine them trapped in their internal fantasy, building on any clue from reality. Be kind to anyone in that state, even if they fail to react in any way. You may be making more of an impression than you know. David Jones is a retired staff member of the natural sciences department of Newcastle University

The outcome of a patient can be associated with their best response in the first twenty-four hours after injury. Using the Glasgow Coma Scale (3 to 15, with 3 being a person in a coma with the lowest possible score, and 15 being a normal appearing person) research shows that if the best scale is 3 to 4 after twenty four hours, 87% of those individuals will either die or remain in a vegetative state and only 7% will had a moderate disability or good recovery. In patients with a scale from 5 to 7, 53% will die or remain in a vegetative state, while 34% will have a moderate disability and/or good recovery. In patients with a Glasgow Coma Scale of 8 to 10, 27% will die or remain in a coma, while 68% will have a moderate disability and/or good recovery. In patients who have a scale from 11 to 15, only 7% will be expected to die or remain in a coma, while 87% would expect to have at least a moderate disability and/or good recovery (remembering again that this is not an exact science).

Most comas end with eye opening and regaining of consciousness, however 10% of patients who open there eyes fail to regain consciousness. (Sometimes called Apallic Syndrome). These patients do not usually respond to environmental stimuli.

There is a syndrome which occurs in children, who after waking from the coma, display delayed recovery of consciousness in response to the psychological stresses of being in the hospital, rather then continued biological cause.

Studies show that patients remaining in a vegetative state for at least one year after injury are unlikely to gain consciousness, although they may live for many years.

90% of brain injured patients who are vegetative for one month or longer will fail to improve to a state better than severe disability. However, two thirds of patients who were unconsciousness for two weeks or less may make a moderate to good recovery.