How to make early diagnosis and treatment when encountering a comatose patient?

*Only for medical professionals to read and refer to Professor Su Yingying's lecture, not to be missed! At the 24th National Neurology Conference of the Chinese Medical Association to be held on September 24-26, 2021, Professor Su Yingying from Xuanwu Hospital of Capital Medical University told us about the "two aspects of coma patients".
"A dream" means "how to evaluate the brain function of coma patients" and "promote the recovery of coma patients", which is confirmed by abundant clinical research evidence.
Let us take a look at these two dreams.
How can we wake up? How to evaluate the brain function of coma patients is currently in clinical practice, we can use video electroencephalogram (EEG), resting EEG network, evoked potential (EP) + event-related potential (ERP), transcranial Doppler (TCD), Intracranial pressure (ICP), brain tissue oxygen, brain injury markers (such as NCES-100) and other technologies are used to assess the patient's brain injury or predict the outcome of the patient
.

But the most commonly used is neuroelectrophysiological technology, which mainly includes two technologies-EEG and EP
.

1.
Four stages of EEG evaluation technology research (1998-2021) (1) EEG model and grading research: predictable HIE (hypoxic ischemic encephalopathy) patients with poor prognosis according to the relevant research published by Professor Su in Resuscitation in 2020 : Collect 160 HIE patients from 2002 to 2018, the purpose is to determine whether EEG can predict the awakening of HIE patients.
The results show that the awakening of patients can be predicted in the slow wave mode (level 1); the best time for prediction In 8-14d
.

(2) EEG classification (semi-quantization) (3) EEG quantification study According to an EGG parameter quantification study published in Neurological Research: 60 HIE patients were included; three parameters were compared, namely DTABR (slow/fast wave relative Power ratio), BSI (bilateral cerebral hemisphere symmetry), BSR (burst suppression ratio); the results show that BSR is the best parameter for predicting poor prognosis, with a predictive death threshold> 39.
8%, and a poor prognostic threshold ＞3.
9%
.

According to a quantitative study of EGG responsiveness published in Neurosci let: 96 HIE patients were enrolled, and the pain level of the nail bed was stimulated, and EEG-R energy analysis was performed.
The results showed that the quantification of the responsiveness analysis can predict the recovery of HIE patients
.

According to a quantitative study of reactive stimulation published in Evid Based Complement Alternat Med: EP DC square wave electrical stimulation (> 2 seconds) can predict the awakening of HIE patients
.

(4) EEG resting state brain network research According to the resting state EEG study, the stronger the brain network connection, the greater the possibility of awakening in HIE patients
.

2.
Three stages of evoked potential evaluation technology research (2002-2021) (1) Parameter evaluation According to a study published in Journal of Clinical Neurophysiology in 2011: A total of 77 HIE patients were included; the results showed: bilateral short-latency somatosensory The absence of evoked potential (SLSEP)-N20 is the best predictor of poor prognosis; the absence of auditory evoked potential (SLAEP)-V5 on either side is the best predictor of poor prognosis
.

(2) Grading evaluation is based on a study published in the Chinese Journal of Neurology in 2005: 44 patients were enrolled, SLSEP and SLAEP were combined, and the results showed that: the sensitivity and sensitivity of predicting poor prognosis The specificity is improved, suggesting that multi-mode is better than single-mode
.

(3) Multimodal evaluation A study published in Neurocritical Care in 2021 suggested that: the combination of N60 and MMN has an accurate prediction performance of 85.
2%.
Due to a single parameter and the Glasgow Coma Score (GCS), 7 days after illness The accuracy of detection is the highest
.

A systematic review and analysis published in Intensive Care Med in 2020.
By searching 94 studies (30,200 patients) between 2013 and 2020, the poor prognosis was evaluated within 7 days, and the conclusions were drawn: 1.
Pupil reflex, corneal reflex, and N20 loss are reliable indicators of poor prognosis after cardiopulmonary resuscitation (CPR)
.

2.
The new evidence is the EEG model index based on the standardized terminology of the American Clinical Neurophysiology Society (ACNS)
.

3.
Brain CT and other imaging parameters, such as gray-white matter ration (GWR) and serum biomarker prediction results are different, and the methodology needs to be standardized
.

4.
Clinical examination and EEG detection may be affected by sedative drugs
.

5.
There is no single indicator that can accurately predict poor prognosis.
The combination of multiple indicators is the most prudent forecasting strategy
.

How to promote the awakening of comatose patients How to promote the awakening of comatose patients has always been a difficult point in clinical treatment.
Let's learn from the neurologist Professor Su, how to make patients "wake up"! 1.
Lower intracranial pressure (LHI): A study published in Neurocritical care by Professor Su’s team of decompressive craniectomy in 2012 showed that compared with conservative treatment, decompressive craniectomy has a significant decrease in intracranial pressure.
In addition, patients undergoing decompressive craniectomy have better postoperative neurological function recovery than conservative treatment
.

2.
Termination of status epilepticus: The multi-center randomized controlled study published by Professor Su's team of Phenobarbital (PB) on Epilepsy Research showed that the study used PB 20mg/kg, pumping speed: 50mg/min, and EEG testing was performed at the same time.
The results showed that the epilepsy control rate was as high as 81.
1% after using PB.
Compared with the control group, its control rate was twice that of valproic acid.
At the same time, its epilepsy recurrence rate was lower than that of the control group
.

3.
Hypothermic brain protection therapy: It can reduce the damage of injured neurons and reduce the re-injury of damaged neurons: reduce brain metabolism rate, delay ATP consumption; reduce brain oxygen consumption (CMRO2); reduce lactic acid accumulation; slow down more Release of a kind of endogenous toxic mediator; reduce the toxic release of excitatory amino acids; reduce the chain reaction of oxygen free radical lipid peroxidation; reduce intracellular Ca2+ overload; reduce intracranial pressure: protect Na+-K+-ATPase activity and reduce cytotoxicity Cerebral edema; protect the blood-brain barrier and reduce vasogenic edema; reduce cerebral blood flow volume; adverse reactions: cause a decrease in heart rate (arrhythmia); decrease in blood pressure; decrease in platelets; decrease in blood potassium; increase in blood viscosity; spread of inflammation; general Use mild hypothermia (mild hypothermia), control the temperature at 32-34℃, not too high or too low; the characteristics of low temperature treatment: safe, easier to obtain, widely used, low economic cost; wide range: including invasive and Non-invasive
.

Invasive: systemic (arterial perfusion, ventricular perfusion, intravenous perfusion, intravascular hypothermia device), local (epidural, subdural, subarachnoid space, cerebrovascular intervention); non-invasive: systemic (drugs, Environment, body surface cryogenic device), local (head ice cap, neck ice pack, upper respiratory tract cooling stick); for which cryotherapy, each has its advantages and disadvantages, but according to an article published in Critical Care in 2020 The meta-analysis showed that a total of 4391 patients with cardiac arrest and resuscitation were included in the study, compared with intravascular hypothermia (20 articles) and body surface hypothermia (3018 articles).
The results show that intravascular body temperature has a better effect than body surface hypothermia.
But the difference between the two did not reach statistical significance
.

Finally, Professor Su said that it is actually very difficult in clinical practice to regain coma patients, and it is even more difficult to conduct wake-up studies, but we still need to continue and share with all neurologically ill doctors.
" "Wake up from dream", the happiness of time! The content of this article is compiled from the lecture by Professor Su Yingying at the 24th National Neurology Conference of the Chinese Medical Association-"Early Diagnosis and Treatment of Consciousness Disorders"
.