Welcome to the TBI-HELP Live Chat

Today's topic is: "Early Management of Coma"

Our Guest is: Dr. Mihai DiManccesu, Neurosurgeon, South Nassau Community Hospital

[18:58:32] Mod: Welcome to all! Tonight we are privileged to have as our guest speaker Dr. Mihai DiManccesu, Neurosurgeon from South Nassau Community Hospital. Dr. DiManccesu will be discussing "Early Management of Coma". Welcome Dr. DiManccesu.
[19:05:23] Mod1: Dr. Mihai DiManccesu will rejoin us shortly - sorry for the delay.
[19:06:06] MihaiDimancescu: I am on line and look forward to this evening's chat room.. Early management of coma consists first of all of emergency room treatment, second of all surgery or direct transfer to an intensive care unit.. and thirdly, once the individual's condition has stabilized, a good program of coma arousal.. A person is no longer in a coma when he or she can consistently show signs of awareness..
[19:08:03] Mod: Susan: I first, heard, rather saw your sensory stimulation routine in a 5 pt series in Newsday by Thomas Maier about 5 years ago. If my son had not just come out of coma I would have tied balloons t his toes, shined bright lights at him and do anything else that was in that article, even having been in a unit where stimulation was to be metered out in small doses.
[19:09:03] MihaiDimancescu: If you had needed to do all those things, you would have been doing some of the right things. However, there is much more that can be done to help an individual out of coma..
[19:10:13] Mod: Susan: Is the amount of stimulation while in coma still so controversial?
[19:10:15] MihaiDimancescu: I am glad for you that you did not have to go through the process.. In many places, stimulation as part of a process to help a person out of a coma is no longer controversial.. but there are still pockets of skeptics who do not feel that stimulation has any part to play..
[19:12:57] Mod: Fred: What are some of the recommended techniques for the treatment of coma in an E/R?..
[19:13:53] MihaiDimancescu: Techniques for the management of coma in the ER consist of making sure that an individual has a good airway, secondly making sure that there is no active bleeding anywhere or that there has not been an overdose and then rapidly proceeding with a CAT scan to determine what is going on in the brain. Administration of medication is usually rapidly started to diminish increased intracranial pressure as soon as possible..
[19:14:13] Mod: Steve: What are the most common injuries that cause coma?
[19:16:00] MihaiDimancescu: The most common causes of coma are a blow to the head, lack of oxygen from a near drowning or suffocation, or from a cardiac arrest, and overdose of drugs..
[19:17:28] Mod: Susan: Do these doubting Thomases also still believe that whatever you are at 6 mos after the TBI is how you will remain?
[19:17:44] MihaiDimancescu: The doubting Thomases do indeed still believe that a coma at 6 months is irreversible, even though there is lots of evidence to the contrary..
[19:18:39] Mod: Steve: Are people in a coma able to hear and comprehend what is being said around them?
[19:19:01] MihaiDimancescu: It is not known whether or not people in a coma can hear and comprehend what is being said around them but it is known that when an individual goes into a coma the last thing to go is the hearing and the first thing to come back is the hearing therefore one always has to assume that even in a coma a person might be able to hear and understand what you say.. It is not known why that is so except that both sides of the brain are involved in the hearing process..
[19:20:34] Mod: Fred: How can we better educate the usual E/R trauma staff to understand and recognize the need for rapid eval and treatment?
[19:21:37] MihaiDimancescu: Much is being done to educate ER teams to intervene rapidly and in most major institutions, this is not an issue..: It is possible that intensified hearing compensates for other losses. This has been observed more than once after a severe head injury..
[19:23:44] Mod: Carol: If a patient is in coma and can hear, can the unconscious play a role in their ability to hear information and process it?
[19:24:16] MihaiDimancescu: I do not understand Carol's question about the role of the unconscious..-- If information is heard and processed appropriately, then the individual most likely is no longer in a coma..
[19:25:34] Mod: Susan: What type of stimulation can families do to help with arousal?
[19:26:46] MihaiDimancescu: Families can do a lot to help with arousal. First of all, talking to the patient frequently, in soothing and encouraging tones, letting the patient know where he/she is and who is around the bedside. If the individual is sufficiently stable medically then family members can move the arms, legs and hands about. Music, the patient's favorite, is also helpful.. Providing various types of input to the patient in a fairly organized way rather than in a helter skelter manner is also useful..
[19:28:45] Mod: What is a vegetative state?
[19:30:34] MihaiDimancescu: The vegetative state is a state of prolonged coma that extends beyond three months and in which an individual still shows no signs of awareness of their surroundings even though their eyes may be open. This is still not necessarily an irreversible condition..
[19:31:43] Mod: Susan: How common is the use of aromatherapy?
[19:32:30] MihaiDimancescu: Aroma therapy is helpful once the individual has been stabilized medically but not in the sense that the term aromatherapy is usually described..
[19:33:20] MihaiDimancescu: In my experience, use of smells such as peppermint, orange peel, soap, perfume or cologne, etc.. are helpful in arousing the sense of smell..
[19:33:09] Mod: Steve: Are there any new or breakthrough interventions available in helping people who are in a coma?
[19:33:56] MihaiDimancescu: I am not aware of any new or breakthrough discoveries helpful in coma arousal..
[19:34:09] Mod: Dex: Have there been any studies or information to show that one type of music is more effective for example Jazz vs. classical etc.?
[19:34:47] MihaiDimancescu: I find that the most useful music is the type of the music that the person usually liked.. A patient in a coma with open eyes usually cannot see..
[19:35:52] Mod: Dex: If a patient is in a coma and their eyes are open are they able to, in any way see? If so what type of sight stimulation is good to try?
[19:36:28] MihaiDimancescu: I like to provide these individuals with intermittent flashes of bright light on a regular basis until I see a blink response..
[19:37:50] Mod: Susan: Doesn't having a sense of smell an reactions to scents mean memory?
[19:37:58] MihaiDimancescu: It is usually my hope that the presentation of different scents to a patient will awaken their memory of that scent.. Sometimes, though, the presentation of scents, even without evoking memories, can jog other areas of the brain into activity..
[19:40:57] Mod: Susan: Does someone in a coma snore, or is that only when asleep?
[19:40:04] MihaiDimancescu: If a person in a coma snores, that usually means that their tongue has fallen back in their mouth or that there is some sort of partial obstruction of the normal airway..
[19:39:46] Mod: Can a person recover after being in a coma for 6 months or more?
[19:40:34] MihaiDimancescu: Yes, a person can recover even after 6 months of coma, however, in general, the longer the coma lasts before arousal occurs, the greater the likelihood that there will be permanent handicaped..
[19:42:24] Mod: Dex: Is there any research on the horizon that will help in the repair of damaged brain cells or promote growth of new cells?
[19:42:53] MihaiDimancescu: The current research in repair of damaged brain cells has to do with stem cell research.. stem cells are primitive cells that under the right conditions can develop into specialized cells.. Current research suggest that this can happen with brain cells and studies are currently underway to see if damaged areas of the brain can be repaired by implantation of stem cells..
[19:46:53] Mod: Susan: As more acute coma recovery units emerge are more studies being done as to best way to do coma stim, when to start?
[19:47:06] MihaiDimancescu: Unfortunately, coma stim studies do not seem to be a priority..
[19:47:47] Mod: Sarg: How far away is stem cell therapy from becoming a reality in treatment?
[19:48:11] MihaiDimancescu: I believe stem cell therapy is very close to becoming a reality. I would not be surprised to see some very real applications within the next five years..
[19:48:37] Mod: Does coma cause brain damage?
[19:49:20] MihaiDimancescu: No, coma does not cause brain damage. Brain damage causes coma..
[19:50:03] Mod: Are there some "special cases" where this is the reverse?
[19:50:04] MihaiDimancescu: Occasionally the damage is minor and a good recovery is possible. Occasionally the damage is extremely severe, and recovery is not likely.. The degree of damage usually cannot be predicted early on in the patient's course..
[19:52:48] Mod: Sarg: I don't mean to keep asking about the stem cell therapy but you mentioned in about five years or so you coud see some real applications.. what would those applications be?
[19:53:10] MihaiDimancescu: There are many areas of research in stem cell therapy. Replacement of cells in the pancreas of diabetics will probably be one of the early applications. Other organs will benefit from stem cell therapy also. The brain is a target of studies at the present time and may well be one of the early beneficiaries of stem cell therapy..
[19:54:00] Mod: Where can a person in a coma receive treatment?
[19:55:14] MihaiDimancescu: Treatment for coma can be applied at the patient's bedside in intensive care units, on regular floor units and in rehab facilities and in some instances, in the home setting.. Where it is applied depends on the enthusiasm of the staff and the drive of the family members..
[19:56:47] Mod: Susan: New techniques are keeping the injured alive, sometimes with a good recover, others not. It seems the younger you are the better chance of brain retraining. Is that real or just something someone says with no med. backup?
[19:57:18] MihaiDimancescu: If a child is under the age of 6 the brain has a tremendous capacity for recovery from injury.. but beyond the age of six, it does not matter how old the individual is as long as there are not coexisting chronic illnesses such as diabetes or heart disease.. In general, families and staff tend to be more attentive to a young individual than to an older person.. Once an individual reaches a certain age and size, the physical aspects of the care are much harder to apply..
[19:59:13] Mod: Well we have had a very interesting chat this evening. I want to first thank Dr. Dimancescu for a wonderful discussion group. Thank you and please be our guest in the future. Also there are two areas I would like to direct you to. One is Dr. Dimancescu site http://neurosurgeryny.com/Mihai.htm and also our new coma section on our site
[20:00:09] MihaiDimancescu: Thank you..