E-Book, Englisch, 168 Seiten, ePub
Dolce / Sazbon The Post-traumatic Vegetative State
1. Auflage 2002
ISBN: 978-3-13-257808-1
Verlag: Thieme
Format: EPUB
Kopierschutz: 6 - ePub Watermark
E-Book, Englisch, 168 Seiten, ePub
ISBN: 978-3-13-257808-1
Verlag: Thieme
Format: EPUB
Kopierschutz: 6 - ePub Watermark
The authors have compiled into a practical text their experiences encompassing over 20 years of work in the rehabilitation of patients in a persistent vegetative state. In addition to the partial or complete recovery of mental and neurological functions, another condition has been gaining in recognition in recent years: the state of minimal responder, which they elucidate in their book.
This title bridges a gap in the specialized literature by providing neurologists, emergency physicians, physiatrists, and internists, as well as therapists, with a new set of tools to aid them in obtaining more rapid progress in the treatment of these patients, whose improvement is wholly dependent upon them.
A second equally relevant aspect considered is the relationship of the care-giving physician with the patient's family. Particular attention is given to the approach the physician must take towards family members of the patient lacking mental activity.
A third part illustrates the structural and instrumental devices useful in planning and operating a unit specialized in the treatment of patients in the persistent vegetative state, with particular attention given to the rules governing the unit.
Zielgruppe
Ärzte
Autoren/Hrsg.
Fachgebiete
Weitere Infos & Material
1. Introduction
2. Preliminary Concepts
3. Neurophysiopathology
4. Clinical Picture
5. Ancillary Examination
6. Therapy
7. Practical Guide to the Management of Patients in the Vegetative State
8. Minimal Response Syndrome
9. Ethical Aspects
10. Treating Families of Patients in Vegetative State: Adjustment and Interaction with Hospital Staff
11. Covert Cognitive Abilities of a Person with Altered Consciousness
12. Intensive-Care Unit for Vegetative State: Management Guidelines
Epilogue and Future Prospects
2 Preliminary Concepts
Leon Sazbon and Giuliano Dolce
Etiology Vegetative state (VS) is defined behaviorally as the absence of an adequate response to the outside world and absence of any evidence of reception or projection of information in the presence of sleep – wake cycles. Patients may have periods of wake-fulness with open eyes and movement, but responsiveness is limited to primitive postural and reflex movements of the limbs. They never speak, and some never regain recognizable mental function [1]. According to the Oxford English Dictionary [2], individuals in VS “live a merely physical life, devoid of intellectual activity or social intercourse; [they are] capable of growth and development but devoid of sensation and thought.” The term was coined in 1972 by Jennett and Plum [1] to eliminate the confusion caused by the multitude of disorders in the literature, such as akinetic mutism, apallic syndrome, and prolonged coma, which share the common denominators of wakefulness with unawareness. These clinical criteria for VS were more recently confirmed by the Multi-Society Task Force [3]. Over the years, certain qualifiers have been added to the term VS, often incorrectly. The term “persistent vegetative state” (PVS) has been used by some researchers to refer to any type of VS, and by others to refer specifically to VS of long duration [3–6]. The word “persistent” is defined by Webster's Tenth Collegiate Dictionary [7] as “continuing to exist in spite of interference or treatment", and "persistence” is defined by the COBUILD Collins English Language Dictionary [8] as continuing “to exist, even after you have tried to make it disappear.” The indiscriminate use of “persistent” in relation to VS has led to the misconception that the syndrome is always irreversible, when the term actually refers merely to a disorder that began in the past and is continuing in the present. This problem is exacerbated when (as is not uncommon), “persistent” is replaced with “permanent". The latter term describes to a state that began in the present and will continue through the future – implying a negative and irreversible prognosis. There is a fine line between reversible and the irreversible VS, and a clear clinical definition is still lacking. On the basis of our experience, we consider VS, using practical criteria, irreversible when it has persisted for 1 year in patients after coma of traumatic origin, or for 6 months in patients after coma of non-traumatic etiology. These distinctions have importance for medical decisions regarding the introduction or continuation of therapy and its intensity. The International Working Party [9] has recommended that both terms – persistent and permanent – should be dropped altogether. VS should be differentiated from coma, which is characterized by an inability to obey commands, utter recognizable words, or open the eyes, and the absence of sleep – wake cycles. Coma is always a transient state. According to Plum [10], comatose patients who survive for more than a few days or weeks will regain cyclic electroencephalographic patterns of arousal/nonarousal with or without their behavioral appearance. These patients may live indefinitely, provided they retain hypothalamic functions and a majority of tegmental brain-stem functions [10]. VS is always an expression of a direct primary brain pathology and is not an extension of coma. Although it exists from the start, the VS is masked by the state of coma, thus hindering diagnosis. The causes of VS may be acute (traumatic or non-traumatic) or chronic (degenerative and metabolic disorders or developmental malformations). Examples of traumatic injury are motor vehicle accidents, gunshot wounds, domestic accidents, and birth injury; nontraumatic causes include hypoxic – ischemic encephalopathy, central nervous system (CNS) infection, CNS tumor, cerebrovascular injury, and CNS toxins or poisoning. Examples of degenerative disorders are Alzheimer's disease, multi-infarct dementia, and Creutzfeldt-Jakob disease, and examples of developmental malformations include congenital hydrocephalus and severe microcephaly. The most common acute causes in adults and children are injury-induced head trauma and hypoxic-ischemic encephalopathy, generally following coma of several days to weeks. In rare cases, VS may occur immediately after traumatic injury (documented, for example, in boxers after a knockout). The duration of VS can vary widely, from only a few seconds to many years. Epidemiology The early editions of the International Classification of Diseases (ICD) grouped vegetative state (VS) with acute coma (code 780.01), and it was only 9 years ago that VS was first listed as a distinct entity (code 780.03). No epidemiological studies of VS have been conducted since the new classification, so figures are hard to establish. The estimated annual incidence of brain trauma in the United States varies widely, from 180 to 400 patients per 100 000 population [11–13]. The prevalence of VS is unknown, although in some American publications the suspicion is stated that the numbers range between 10 000 and 25 000 adults and 6000 to 10 000 children [14–18]. Researchers in Japan, France, Italy and other countries have calculated a national annual incidence of 0.9–2 per 100 000 [19–22]. The percentage of patients remaining in VS has been estimated in different studies to range from 0.2 % to 14 % of all cases of acute coma in various studies [19,23–28], depending on patient age, etiology, and the temporal criteria used. The actual rate may be even higher, as patients with open eyes are often misdiagnosed as being comatose. In Israel, until recently, all patients in the country who were in traumatic VS for at least 1 month were referred to the Loewenstein Rehabilitation Hospital. This center therefore provides an excellent setting for an epidemiological analysis of VS in Israel. From 1975 to 1998, a total of 580 patients with VS of traumatic origin were admitted, an average of 23.2 new cases per year. The true incidence may of course be higher, as these figures exclude patients with short-term VS. For the first 8 years (1975–1983), an average of 16.3 patients were admitted per year, whereas in the last 15 years, this number jumped to 30. This increase may be explained by the increased use of intensive life support already at the accident site, the more rapid means of transport to neurosurgical centers, and the accelerated growth of the population. According to Israeli population studies, the incidence of traumatic VS is in the order of 0.4–0.5 per 100 000 inhabitants [29,30] Age and Gender The age distribution of patients in VS was calculated in an Israeli series of 580 patients at the Loewenstein Hospital and correlated with recovery [31]. The findings are shown in Table 2.1. There were 446 males and 134 females, a ratio of 3.3 : 1.0. In an earlier series of 134 patients reported by the same authors [30], the mean age was 26.8 ± 14.6 years, with a range of 3–79 and a male/female ratio of 4 : 1. Most of the cases of VS (72.24 %) occurred in patients between the ages of 16 and 45. Age was apparently related to recovery of consciousness, with the highest recovery rate (about 70 %) being recorded in patients less than 30 years old, followed closely by the 31–45-year-old group. Only 50.5 % of patients aged over 46 years recovered consciousness. The mean age in the recovered group was 28.1 ± 14.2 years, and in the nonrecovered group, 33.4 ± 16.9 years; this difference was statistically significant (P > 0.001) [31]. However, in our experience, children have a poorer functional outcome than adults. Some authors hypothesize that the lesser myelination in the young brain and its lower ability to regulate vascular perfusion make it subject to greater shearing forces during acute injury [32–34]. However, other authors disagree, claiming that the chances for both vital and functional recovery decrease with age [35,36]. Season and Time of Day The rate of occurrence of new cases of VS shows seasonal variability. The highest frequency has been noted in fall (autumn), followed in order by summer, winter, and spring [30,37]. In the Israeli study by Sazbon et al. [20], the frequency peaked in October and August (P < 0.003), coinciding with the school holiday and the Jewish High Holy Days. Time of day is also a factor, with 70 % of patients being injured between 5 p. m. and midnight [30]. Circumstances of VS Most cases of VS can be traced to traumatic head injury. In Israel, the most common cause of traumatic head injury leading to VS is road accidents (Table 2.2), with a considerably higher rate of blunt injuries (95 %) than penetrating injuries (5 %). Sazbon et al. [30] studied 70 patients in VS admitted to Loewenstein Rehabilitation Hospital who were victims of car accidents. They found that 39 had been pedestrians, 36% passengers in the vehicle, 16% drivers of the vehicle, and 9% cyclists. Interestingly, the pedestrians received only 17–21 % of the acute brain injuries and the passengers 19–21 %, whereas the drivers received 37 % of the acute head injuries, but accounted for only 16% of the VS cases. The pedestrians and cyclists...
