Continuation of care

The long term care of patients in coma may be undertaken in an intensive care unit, on a specialist ward, or in a rehabilitation unit or long stay hospital. It is important that those patients in whom prognosis is hopeless should not be permanently exposed to the rigors of intensive care medicine,

Table 1.4 Sensitivity and specificity of individual signs

Severe disability or worse

Moderate or good recovery

Sensitivity

Specificity

Positive predictive value

Negative predictive value

Likelihood ratio

(negative test)

Verbal response Incomprehensible or none Orientated, confused, or inappropriate

187 8

45 16

0-96

0-26

0-81

0-67

1-30

0-16

Eye opening response To pain/none Spontaneous/to noise

270 34

42 38

0-89

0-48

0-87

0-53

1-69

0-24

3upillary light reflex Absent Present

78 225

1 79

0-26

0-99

0-99

0-26

20-59

0-75

Corneal reflex Absent Present

90 190

0 77

0-32

1-00

1-00

0-29

20*

0-68

Spontaneous eye movements Roving dysconjugate, other or none

210

19

0-69

0-77

0-92

0-40

2-94

0-40

Orienting or roving 94 62

conjugate

Orienting or roving 94 62

conjugate

(Continued)

Table 1.4 (Continued)

Severe disability or worse

Moderate or good recovery

Sensitivity

Specificity

Positive predictive value

Negative predictive value

Likelihood ratio

(negative test)

Oculocephalic responses Abnormal/absent Normal

292 13

61 19

0-96

0-24

0-83

0-59

1-26

0-18

Oculovestibular responses Abnormal Normal

265 12

45 21

0-96

0-32

0-85

0-64

1-40

0-14

Motor responses (best limb) Flexion, extension or none Obeying, localising or withdrawing

206 98

15 66

0-68

0-81

0-93

0-40

3-66

0-40

Deep tendon reflexes Absent Present

67 213

4 74

0-24

0-95

0-94

0-26

4-67

0-80

Skeletal muscle tone Absent

120

8

0-44

0-89

0-94

0-30

3-98

Present 155 65

*Not able to calculate exactly.

but should continue to receive basic care within routine hospital wards or a more long stay environment. So long as patients are considered to have a potential for recovery they should be looked after in intensive care units or in specialist wards. Their respiration, skin, circulation, and bladder and bowel function need attention, seizures must be controlled, and the level of consciousness should be regularly assessed and monitored. It is important that the mobility of joints and circulation to pressure areas are maintained during the long term care of the patient and the possibility of aspiration pneumonia, peptic ulceration, and other complications of long term intensive care need to be considered. Techniques such as mechanical ventilation and steroid therapy are not to be used routinely in the management of a comatose patient as they do not improve prognosis and may compromise recovery.36

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