These three patients illustrate the different patterns of mid brain damage from hypoxia/ischaemic insults and the effect of oxygen therapy
(Unfortunate lnadequate / Delayed).
Patient 1.
1992 Mid brain damage with spastic quadriplegia after carbon monoxide poisoning.
Female 39 attempted suicide sometime after midnight by locking herself in a hall cupboard with the exhaust from a small motorcycle piped in. Found at 2.30 a.m. she was admitted to a hospital ICU, given 100% oxygen and ventilated. Off the ventilator after 24 hours she was admitted unconscious to a ward for general nursing care. On the third day the clinician-in-charge referred her for hyperbaric oxygen therapy. She recovered consciousness in the first session. She had recall of events and became fully aware and communicative after six sessions. There was limb flaccidity and she developed a spastic quadriplegia over the following weeks.
She is now completely lucid and in long-term care. All four limbs have developed severe contractures.
Comment
From what we now know we should have continued treatment.
1998 Strangulation with asphyxia and carotid artery compression.
Male aged 27 suicide attempt in prison on remand using the cord from his boxer shorts. Period of hanging said to be 10 minutes. Admitted to ICU, ventilated via tracheostomy for two weeks and started opening his eyes. Thrashing ? athetoid movements of his limbs developed. After weaning of the ventilator, but with the tracheostomy still in place, he was transferred to Dundee. Hyperbaric oxygen therapy requested by the clinician-in-charge after four weeks when the neurologist noticed improvement in his EEG. The tracheostomy had been closed on the advice of the anaesthetist. A gastrostomy tube was inserted but was obstructing. His general condition was poor and he was very emaciated with abrasions and sores on his ankles, knees and elbows from friction with his bed. This was despite extensive padding. His lips were cracked and swollen. Only six hyperbaric oxygen treatments (1.75atm abs for one hour daily) were given after grommets were inserted. His general condition improved dramatically with healing of the sores. His lips healed. He had started to follow staff and make sounds. On the evening of the sixth day he aspirated and died.
Comment
Obvious comments about airway maintenance but he staff were astounded to see the general improvement despite inadequate nutrition. The only change in his management was some more oxygen 1999 Cardiac arrest of 30 minutes with defibrillation. Male aged 46 had a cardiac arrest in the community. Defibrillated by paramedics after about 30 minutes. Admitted to CCU and opened his eyes after three days. He began to say single words on day 5. Transferred to general ward on day 6. Gradually declined over 5 weeks with the development of spastic paraplegia, despite daily physiotherapy. Prescribed Lioresol. Slow improvement in mentation. His leg spasticity became so severe that it was very difficult to bend his legs to allow him to use a wheel chair. His arms were also developing mild stiffness. He had periods in which he spoke words clearly, but they made little sense. He recognised his family. Hyperbaric oxygen therapy was started after 5 weeks. A total of 54 daily, one hour, hyperbaric oxygen sessions were undertaken at 1.75 atm abs. His cognition and speech improved and there was dramatic improvement in his spasticity. He left hospital walking without assistance.
Comment
This illustrates Ischaemia with mid brain oedema. Giving high dosage oxygen post arrest would ? on present evidence- have prevented the associated the reperfusion injury and spared some of the cortical damage.
Best wishes to all
Philip James
Wolfson Hyperbaric Medicine Unit
University of Dundee
Reprinted with Permission
Brain Disorders/Neurological Index
