Acupuncture in diagnosing prehospital unconsciousness

[Guest guest]

Hi All,

 

I salvaged this from a corrupted WWW page at http://tinyurl.com/m27ru

 

K Streitberger, MD, A Gries, MD, (2005) Acupuncture in diagnosing

prehospital unconsciousness. American Journal of Emergency

Medicine (2005) 23, 90[u+2013]91. konrad_streitberger-

heidelberg.de DEAA Department of Anaesthesiology University of

Heidelberg, 69120 Heidelberg, Germany. 0735-6757/$ D 2005 Elsevier

Inc. http://www.elsevier.com/locate/ajem All rights reserved.

doi:10.1016/j.ajem.2003.12.027

 

To the Editor,

 

Quickly finding the cause of coma is always a challenge in emergency

situations. Patients in hysterically induced coma often show a surprising

ability to endure painful stimuli. No interpretable response may be

obtained by painful maneuvers like supraorbital nerve compression and

sternal rubbing. Therefore, sometimes differentiation between

psychogenic and organic origin may be quite difficult. We describe a

case where acupuncture in contrast to other painful maneuvers seemed

to terminate prehospital unconsciousness of the same patient twice at 2

following days. A 19-year-old woman suffered a severe psychological

trauma after arriving at the scene of a motor vehicle accident and

identifying the fatally injured victim as her own 14- year-old sister. The

same day she was admitted to hospital because of a hysterical reaction

and repeatedly becoming unconscious. After she was discharged the

following day, she again experienced short periods of unconsciousness

until she fell into a deep coma, not reacting to any stimulus. The

physician-staffed emergency service was notified. It was reported by the

relatives that she might have hit her head severely when falling down.

Examination showed a deep coma (Glasgow Coma Scale 3) with weak

muscle tone and no reaction to strong pain stimulus at the neck. The

vital parameters were stable (heart rate of 100 beats per minute,

systolic blood pressure 110mm Hg, and oxygen saturation 97%). During

examination of the pupillary reflex, a minimal flickering of the eyelids

occurred and the eyes were deviated toward the ground. However, even

on repeated, strong pain stimulus during transport to the emergency

vehicle and while inserting an intravenous cannula, she did not show

any further reaction. The emergency physician, an anesthetist who was

also trained in acupuncture, inserted an acupuncture needle into the

acupoint GV26 (In Chinese: Shuigou or Renzhong), at the philtrum at a

distance of one third between the nose and upper lip. Immediately after

insertion and strong stimulus by turning the needle, the patient reacted

with some very deep breaths and she began to weep. Subsequently,

the patient woke up and was completely awake within several minutes.

The results of neurological evaluation were normal. For further

observation, she was admitted to a psychiatric hospital with the

diagnosis of dissociative stupor due to posttraumatic stress reaction.

The next day the physician-staffed emergency service was called to this

patient again. This time she was found lying unconscious on the street

in the vicinity of the psychiatric hospital admission office. Examination

showed the same findings as the day before. After acupuncture at

GV26 she awoke much quicker this time. Afterward, she was admitted

to the department of neurology, where a cranial computed tomography

revealed completely normal findings. She was discharged the same day

upon her own request. In this case of deep unconsciousness, a

psychogenic origin was taken into account because of the history and

the minimal eyelid reaction in combination with the bulbus deviation [1].

However, it also had to be considered that the patient might have

acquired a cerebral trauma when she hit her head. A Glasgow Coma

Scale of 3 is usually an indication for intubation. However, the vital signs

were stable and intubation would have represented overtreatment in a

case of psychogenic unconsciousness. When the patient suddenly

awakened after acupuncture without any neurological deficit and without

headache, a cerebral trauma could be excluded. Therefore,

acupuncture was not only of therapeutic but also of diagnostic value.

Until a patient is awake, other therapeutic options described in the

literature such as tetanic stimulation of the nervus ulnaris [2],

administration of thiopentone or diazepam [1], or occlusion of the airway

are not available or not recommended because of breathlessness [3].

Thus, in comparison to these methods, acupuncture at GV26 might be

a more suitable and effective option. In TCM, this acupoint has been

successfully applied, particularly in emergencies. Obviously, stimulation

of this point might be extremely painful and therefore endogenous

catecholamines and blood pressure might be increased. In animal

experiments, acupuncture at GV26 was able to reverse cardiovascular

depression during anesthesia in dogs [4] and to decrease anesthetic

activity in rabbits [5]. To date, no clinical trials have been conducted

regarding a specific effect of this acupuncture point. However, this case

report shows that acupuncture at GV26 might be worth an attempt in

cases of prehospital unconsciousness if a psychogenic cause is

suspected or if no other option is available.

References

[1] Dhadphale M. Eye gaze diagnostic sign in hysterical stupor. Lancet

1980;2:374-5.

[2] Hintze U, Runge U, Hachenberg Th, et al. Dissociative stupor as a

differential diagnosis of coma following injury [Dissoziativer Stuporeine

Differential diagnose des Komas nach Unf7llen]. Ana[u+00a8]sthesiol

Intensivmed Notfallmed Schmerzther 1998;33:753-5.

[3] Maddock H, Carley S, McClusey A. An unusual case of

postoperative coma. Anaesthesia 1999;54:702-3.

[4] Lee DC, Clifford DH, Lee MO, et al. Reversal by acupuncture of

cardiovascular depression induced with morphine during halothane

anaesthesia in dogs. Can Anaesth Soc J 1981;28:129-35.

[5] Chang CL, Lee JC, Tseng CC, et al. Decrease of anesthetics activity

by electroacupuncture on Jen-Chung point in rabbits. Neurosci Lett

1995;202:93-6.

 

Best regards,

Phil