The development of acute coma in a patient remains a major medical emergency that requires immediate interventions and diagnostic acumen, and demands significant clinical resources. In the second edition of the textbook, The Comatose Patient, Dr. Eelco F. M. Wijdicks, MD, PhD, professor of neurology and chair of the Division of Critical Care Neurology at the Mayo Clinic, offers a significant reference to target this clinical condition.
As intensivists and anesthesiologists, we are often challenged with patients who present with coma, and we welcome a comprehensive textbook that deals with real-life and clinical issues. In this day of electronic books, PDFs, and online journals, it is increasingly common to forget the joy of holding a real textbook. These diverse media are readily available on the Internet, lightweight for one’s computer bag, and offer the options of multimedia (eg, video options). Nonetheless, many clinicians still continue to enjoy the touch and feel of a textbook to enhance and guide their practices. This text is an important work, highly relevant for the bedside clinician, that provides an intellectual foundation of the neuropathophysiology, coupled with a solid clinical approach for evaluation and treatment of comatose patients. It clearly adds to the classic reference of Plum and Posner’s Diagnosis of Stupor and Coma (Posner, Saper, Schiff, & Plum, 2007).1
This is a single-authored—a rarity in today’s medical publications—well-written text that addresses multiple considerations of this difficult patient population. Pragmatically, the first chapter builds an intellectual foundation for understanding coma, which includes the history of medical science about coma, the neuroscience of the awake state, and specifics of the neurological examination, clinical diagnostic criteria, and differential diagnoses. Essential neuroimaging methods, relevant neurophysiology, and neuropathology are addressed concisely. Detailed sections on the clinical diagnosis discuss prolonged impaired consciousness and the challenging situation of dealing with brain death by neurological criteria, emphasizing bedside physical examination. As an example in the assessment of prolonged comatose state, the descriptions of eye movements in differentiating persistent vegetative state, akinetic mutism, and minimally conscious state are highly germane to intensive care practice.
The subsequent chapters focus on clinical diagnoses and decision making, medical supportive care, and rehabilitation that will appeal to clinicians who must diagnose and stabilize patients at bedside whether in intensive care units, hospital wards, emergency departments, or postanesthesia care units. Given the lay press coverage of selected patients with coma, the chapter on law and bioethics is very relevant and describes multiple high-profile court cases that have dealt with coma and the ethics of organ donation after cardiac death. It addresses the issues that most clinicians must face, including decisions about end-of-life support, inherent controversies, and ethical dilemmas. Finally, the last major section of the text focuses on the clinical approach to the comatose patient, which is both unique and valuable. Dr. Wijdicks describes well over 100 different clinical vignettes, each with a presenting description, the pathophysiology of coma, key diagnostic tests (eg, clinical examination, computed tomography and magnetic resonance imaging scans, and electroencephalogram), a treatment plan, and a discussion of prognosis, accompanied by key references. These cases range from brain trauma, acute stroke, infectious etiologies, adverse drug effects, metabolic aberrations, and selected groups, such as posttransplant and extracorporeal membrane oxygenation patients who develop coma, among others. This method of case-based education is highly readable and can serve as a format for graduate medical education. Accompanying the text are online video clips that display major clinical findings of selected patients with coma (http://oxfordmedicine.com/comatosepatient2e). These include neurological examinations of actual patients—a tremendous educational resource. Throughout the book, the accompanying computed tomography and magnetic resonance imaging scans, summary tables, illustrations, and flow diagrams of clinical pathways increase the readability and the effectiveness of this work.
This textbook will serve as an important reference for multiple medical specialists who care for comatose patients. Clinicians and medical educators will value the extensive breadth of this work because it truly provides a solid foundation for clinical care. For those who prefer the electronic presentation of medical information, it is also available in an electronic format. In all respects, The Comatose Patient by Dr. Wijdicks is a joy to read. It is an important addition to the medical community and to our personal libraries.
J. Steven Hata, MD, MSc, FCCM, FCCPCenter for Critical CareAnesthesiology InstituteCleveland ClinicCleveland, Ohiohataj@ccf.org
Nadeem Rahman, MDCenter for Critical CareAnesthesiology InstituteCleveland ClinicCleveland, OhioCerebrovascular CenterNeurological InstituteCleveland ClinicCleveland, Ohio