Journal of Emergencies, Trauma, and Shock
Home About us Editors Ahead of Print Current Issue Archives Search Instructions Subscribe Advertise Login 
Users online:1473   Print this pageEmail this pageSmall font sizeDefault font sizeIncrease font size   


 
 Table of Contents    
ORIGINAL ARTICLE  
Year : 2011  |  Volume : 4  |  Issue : 3  |  Page : 365-368
Correlates of new onset peripheral nerve injury in comatose psychotropic drug overdose patients


Department of Traumatology and Critical Care Medicine, National Defense Medical College (NDMC), Japan

Click here for correspondence address and email

Date of Submission18-Jul-2010
Date of Acceptance29-Sep-2010
Date of Web Publication16-Aug-2011
 

   Abstract 

Aims : To investigate the relationship between the duration of comatose state, severity of rhabdomyolysis and frequency of peripheral nerve injury (PNI) in patients following psychotropic drug overdose. Materials and Methods : Medical charts were retrospectively reviewed for 41 patients admitted for disturbance of consciousness induced by an overdose of psychotropic drugs with rhabdomyolysis between October 2004 and February 2010. Subjects were divided into PNI group (n=9) and non-PNI control group (n=32). Results : Mean interval between drug ingestion and arrival, frequency of pressure ulcers, CK level at the time of patient's arrival and maximum CK level during hospitalization, duration of hospitalization and morbidity rate were all significantly higher in the PNI group than in the control group. Conclusion : In patients with a psychotropic drug overdose leading to a comatose state, the longer the comatose state, the more likely that pressure ulcers and PNI will occur.

Keywords: Overdose, peripheral nerve injury, rhabdomyolysis

How to cite this article:
Yanagawa Y. Correlates of new onset peripheral nerve injury in comatose psychotropic drug overdose patients. J Emerg Trauma Shock 2011;4:365-8

How to cite this URL:
Yanagawa Y. Correlates of new onset peripheral nerve injury in comatose psychotropic drug overdose patients. J Emerg Trauma Shock [serial online] 2011 [cited 2019 Nov 17];4:365-8. Available from: http://www.onlinejets.org/text.asp?2011/4/3/365/83865



   Introduction Top


Compartment syndrome involves injury to the nerves, vasculature and muscles by raised pressure within the compartment due to muscle injury, fracture, ischemia, or inflammation. [1],[2],[3] However, crush syndrome is characterized by major shock and renal failure following a skeletal muscle injury, as commonly seen with events such as earthquakes, where victims become trapped under collapsed buildings. [4] These two syndromes can also result in peripheral nerve injury (PNI) by direct compressive or traumatic nerve injury, or indirect injury from the raised pressure within the compartment. [1],[2],[5],[6] A patient in a comatose state induced iatrogenically or by drug overdose may also show complications of PNI due to compression of parts of body by the body itself following prolonged immobilization, resulting in the formation of a compartment or crush syndrome. [7],[8],[9],[10],[11] A longer duration of immobilization would thus seem likely to lead to more severe muscle injury, [12] following a more frequent occurrence of PNI in comatose patients following an overdose. However, few reports to date have examined this possibility. We therefore retrospectively investigated the relationship between duration of the comatose state, severity of rhabdomyolysis, and frequency of PNI in comatose patients following psychotropic drug overdose.


   Materials and Methods Top


Our institutional review board approved this study and waived the requirement for informed consent. During the investigation period between October 2004 and February 2010, a total of 199 patients were admitted for treatment following a psychotropic drug overdose, including 45 patients with rhabdomyolysis.

In this study, rhabdomyolysis was defined as present in a patient who showed creatinine kinase (CK) level on admission >160 IU/L, as the upper limit of normal as defined in our institution.

Two patients showing convulsions on arrival and two patients with neuroleptic malignant syndrome on arrival were excluded, as these conditions can also induce rhabdomyolysis. Medical charts were retrospectively reviewed for the 41 patients admitted with disturbance of consciousness induced by psychotropic drug overdose with rhabdomyolysis. These 41 patients were then subdivided into those with PNI (PNI group, n=9) and those without (control group, n=32). The presence of PNI was confirmed by the existence of extremity palsy or sensory disturbance after the patient regained consciousness. No PNI events were seen among the 158 patients who were excluded from analysis. Age, sex ratio, psychiatric diseases, physical data on arrival (Glasgow Coma Scale (GCS), systolic blood pressure, heart rate, and temperature), estimated interval between ingestion of the overdosed drugs and arrival, frequency of pressure ulcers (redness, swelling, or blister formation), CK level on arrival, duration of hospitalization, frequency of sequelae, and survival rate were all compared between the PNI and control groups. In the PNI group, the PNIs encountered, the drug overdosed, and estimated dose of each drug ingested were analyzed.

Statistical analyses were performed using Student's unpaired t-test and a χ2 analysis. Values of P<0.05 were considered as statistically significant.


   Results Top


Background data for the two groups are summarized in [Table 1]. Age, sex ratio, psychiatric diseases, and physical data on admission did not differ significantly between the two groups. The interval of time between drug ingestion, frequency of pressure ulcers and CK levels were all significantly higher in the PNI group than the control group. [Figure 1] shows a scatter chart representing CK levels on admission. If the cut-off for CK level was set at 10,000 IU/L to predict the existence of PNI among patients in a coma due to drug overdose, sensitivity was 77.8% (7/9) and specificity was 93.8% (30/32).
Table 1: Background data for subjects


Click here to view
Figure 1: Scatter chart depicting creatinine kinase (CK) values on admission. If the cut - off point for CK was set at 10 000 IU/L to diagnose the presence of PNI among patients in a coma following drug overdose, sensitivity was 77.8% (7/9) and specificity was 93.8% (30/32)

Click here to view


CK level, PNIs identified, and treatments provided for the PNI group are shown in [Table 2]. The list of drugs overdosed by the PNI group is shown in [Table 3]. No trends were identified concerning specific PNIs. Two of nine patients who demonstrated sensory disturbances without paresis had symptoms that subsided within three months. However, while seven patients who demonstrated motor disturbances displayed improved paresis, none obtained complete recovery.
Table 2: List of peripheral nerve injury and values of creatinine kinase in the peripheral nerve injury (PNI) group


Click here to view
Table 3: List of ingested drugs in the peripheral nerve injury group


Click here to view


[Table 4] shows the outcomes for the two groups. Duration of hospitalization was significantly longer and morbidity rate was significantly higher in the PNI group that in the control group.
Table 4: Outcomes for the two groups


Click here to view



   Discussion Top


The present results confirm that increased duration of comatose state is associated with increased risk of the development of both pressure ulcers and PNI.

In crush syndrome, significant correlations have been observed between the size of muscle injury and the duration of time trapped, peak serum CK level, and duration of hospitalization. [13] As expected, experimental studies suggest a dose-response curve in which greater duration and amount of pressure result in more significant neural dysfunction. [14] Among unconscious patients who were in a comatose state following a psychotropic drug overdose, a significant positive correlation has been found between the estimated interval between ingestion and admission and the CK level of admission to hospital. [15] In the present study, all patients in the PNI group experienced prolonged immobilization and showed pressure ulcers. Pressure ulcers also develop due to morphological and biochemical changes triggered by the combined effects of mechanical deformation, ischemia, and reperfusion that occur during extended periods of immobilization. [16] Accordingly, direct nerve compression or indirect nerve injury due to raised pressure in the body compartment containing the nerve during prolonged immobilization, resulted in the development of either paresis or sensory disturbances.

In terms of treatment for compartment syndrome, immediate fasciotomy is recommended when the compartment pressure exceeds 30 mmHg or when clinical symptoms are overt. [1],[2] However, these recommendations were made based on clinical experience, and the level of evidence is still not definitive. [2] Conservative treatment has been reported to lead to functionally favorable outcome in at least some cases. [9] While, concerning the treatment of crush syndrome, Matsuoka et al. investigated peripheral nerve function two years after the 1995 Hanshin-Awaji earthquake in 42 patients with crush syndrome. That study found no evidence that fasciotomy had improved patient outcomes. Moreover, delayed rescue, delayed fasciotomy, and radical debridement may have worsened the physical prognosis. They therefore concluded that the indications for fasciotomy in crush syndrome during the acute phase require further deliberation, as suggested by Huang et al. when describing the Chi-Chi earthquake. [17],[18] The present study did not measure compartmental pressure except in one case, as all subjects in the PNI group had a delayed diagnosis of compartment or crush syndrome due to their unconscious state on arrival. The morbidity rate was significantly higher in the PNI group than in the control group. As evidenced-based guidelines concerning fasciotomy for the treatment of either compartment or crush syndrome are lacking, prospective randomized control studies are needed in the future to clarify the details of PNI among comatose patients following psychotropic drug overdose.


   Conclusion Top


In patients with a psychotropic drug overdose leading to a comatose state, the longer the comatose state, the more likely that pressure ulcers and PNI will occur. In this study, patients with PNI, with paresis due to a comatose state following a psychotropic drug overdose, did not have a complete recovery.

 
   References Top

1.Konstantakos EK, Dalstrom DJ, Nelles ME, Laughlin RT, Prayson MJ. Diagnosis and management of extremity compartment syndromes: an orthopaedic perspective. Am Surg 2007;73:1199-209.  Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.Frink M, Hildebrand F, Krettek C, Brand J, Hankemeier S. Compartment syndrome of the lower leg and foot. Clin Orthop Relat Res 2010;468:940-50.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Lam R, Lin PH, Alankar S, Yao Q, Bush RL, Chen C, Lumsden AB. Acute limb ischemia secondary to myositis-induced compartment syndrome in a patient with human immunodeficiency virus infection. J Vasc Surg 2003;37:1103-5.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Better OS. Rescue and salvage of casualties suffering from the crush syndrome after mass disasters. Mil Med 1999;164:366-9.  Back to cited text no. 4
[PUBMED]    
5.Uzun N, Savrun FK, Kiziltan ME. Electrophysiologic evaluation of peripheral nerve injuries in children following the Marmara earthquake. J Child Neurol 2005;20:207-12.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.Yoshida T, Tada K, Uemura K, Yonenobu K. Peripheral nerve palsies in victims of the Hanshin-Awaji earthquake. Clin Orthop Relat Res 1999;362:208-17.  Back to cited text no. 6
[PUBMED]    
7.Jacobs D, Azagra JS, Delauwer M, Bain H, Vanderheyden JE. Unusual complication after pelvic surgery: unilateral lower limb crush syndrome and bilateral common peroneal nerve paralysis. Acta Anaesthesiol Belg 1992;43:139-43.  Back to cited text no. 7
[PUBMED]    
8.Lachiewicz PF, Latimer HA. Rhabdomyolysis following total hip arthroplasty. J Bone Joint Surg Br 1991;73:576-9.  Back to cited text no. 8
[PUBMED]  [FULLTEXT]  
9.Kao CL, Yuan CH, Cheng YY, Chan RC. Lumbosacral plexus injury and brachial plexus injury following prolonged compression. J Chin Med Assoc 2006;69:543-8.  Back to cited text no. 9
[PUBMED]  [FULLTEXT]  
10.Hsu JD. Brachial plexus injury following barbiturate overdose. Report of three cases with five-year follow-up. J Bone Joint Surg Am 1979;61:1252-3.  Back to cited text no. 10
[PUBMED]  [FULLTEXT]  
11.Schreiber SN, Liebowitz MR, Bernstein LH. Limb compression and renal impairment (crush syndrome) following narcotic and sedative overdose. J Bone Joint Surg Am 1972;54:1683-92.  Back to cited text no. 11
[PUBMED]  [FULLTEXT]  
12.Mubarak S, Owen CA. Compartmental syndrome and its relation to the crush syndrome: A spectrum of disease. A review of 11 cases of prolonged limb compression. Clin Orthop Relat Res 1975;113:81-9.  Back to cited text no. 12
[PUBMED]    
13.Chang HR, Kao CH, Lian JD, Shu KH, Cheng CH, Wu MJ, et al. Evaluation of the severity of traumatic rhabdomyolysis using technetium-99m pyrophosphate scintigraphy. Am J Nephrol 2001;21:208-14.  Back to cited text no. 13
[PUBMED]  [FULLTEXT]  
14.Mackinnon SE. Pathophysiology of nerve compression. Hand Clin 2002;18: 231- 41.  Back to cited text no. 14
[PUBMED]    
15.Yanagawa Y, Sakamoto T, Okada Y. Recovery from a psychotropic drug overdose tends to depend on the time from ingestion to arrival, the Glasgow Coma Scale, and a sign of circulatory insufficiency on arrival. Am J Emerg Med 2007;25:757-61.  Back to cited text no. 15
[PUBMED]  [FULLTEXT]  
16.Solis LR, Hallihan DP, Uwiera RR, Thompson RB, Pehowich ED, Mushahwar VK. Prevention of pressure-induced deep tissue injury using intermittent electrical stimulation. J Appl Physiol 2007;102:1992-2001.  Back to cited text no. 16
[PUBMED]  [FULLTEXT]  
17.Matsuoka T, Yoshioka T, Tanaka H, Ninomiya N, Oda J, Sugimoto H, Yokota J. Long-term physical outcome of patients who suffered crush syndrome after the 1995 Hanshin-Awaji earthquake: prognostic indicators in retrospect. J Trauma 2002;52:33-9.  Back to cited text no. 17
[PUBMED]  [FULLTEXT]  
18.Huang KC, Lee TS, Lin YM, Shu KH. Clinical features and outcome of crush syndrome caused by the Chi-Chi earthquake. J Formos Med Assoc 2002;101:249-56.  Back to cited text no. 18
[PUBMED]    

Top
Correspondence Address:
Youichi Yanagawa
Department of Traumatology and Critical Care Medicine, National Defense Medical College (NDMC)
Japan
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-2700.83865

Rights and Permissions


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]

This article has been cited by
1 Independent risk factors for a complicated hospital course in intensive care unit overdose patients
Takehiko Tarui,Kei Yoshikawa,Yasuhiko Miyakuni,Yasuhiko Kaita,Nao Tamada,Taketo Matsuda,Hiroshi Miyauchi,Kenji Yamada,Takeaki Matsuda,Yoshihiro Yamaguchi
Acute Medicine & Surgery. 2014; : n/a
[Pubmed] | [DOI]



 

Top
  
 
  Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
   Introduction
    Materials and Me...
   Results
   Discussion
   Conclusion
    References
    Article Figures
    Article Tables

 Article Access Statistics
    Viewed2007    
    Printed137    
    Emailed0    
    PDF Downloaded13    
    Comments [Add]    
    Cited by others 1    

Recommend this journal