Acupuncture in diagnosing prehospital unconsciousness

March 17, 2006

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

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

March 17, 2006

Very interesting article. On a lighter note, I always wondered what

youd say to people if using ren 1 on a patient to resuscitate from

drowning.

Chinese Medicine , " "

< wrote:

>

> 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

> 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

>

March 18, 2006

leabun1 wrote:

> Very interesting article. On a lighter note, I always wondered what

> youd say to people if using ren 1 on a patient to resuscitate from

> drowning.

Hi Lea!

Ren 1 is a very effective point for a lot of things, but I think using

it would lead to misunderstanding until TCM becomes more mainstream. I

never use it except on myself or another TCM practitioner. If I were

married I would use it on my wife if it were indicated.

I think western CPR or the even old-time " artificial respiration " some

of us old folks learned in the boy scouts would probably do as well for

drowning while waiting for the 911 truck.

Regards,

Pete

March 19, 2006

Hi there,

Sorry, that reply was just my sense of humour coming out. I

personally dont use ren 1, although I have heard of some students

who got really into sun si miaos points and needled that on each

other in combination with the others. Also one of my classmates from

University, in her first year of practice, got a guy who had

discovered there was an acupoint there and seemed to really want it

needled, when she declined to needle it, he asked what it was it was

used for and she told him " haemorrhoids " among other things, so the

next week apparantly he turned up saying he had developed

haemorrhoids. I think she needled it in the end.

One thing that seems to get a lot of chiropractors sued in this

country is manipulation of the coccyx (through the rectum) even

when patients consent to it, they end up feeling violated after.

Touchy subject, no pun intended.

Chinese Medicine , petetheisen

<petetheisen wrote:

>

> leabun1 wrote:

> > Very interesting article. On a lighter note, I always wondered

what

> > youd say to people if using ren 1 on a patient to resuscitate

from

> > drowning.

>

> Hi Lea!

>

> Ren 1 is a very effective point for a lot of things, but I think

using

> it would lead to misunderstanding until TCM becomes more

mainstream. I

> never use it except on myself or another TCM practitioner. If I

were

> married I would use it on my wife if it were indicated.

>

> I think western CPR or the even old-time " artificial respiration "

some

> of us old folks learned in the boy scouts would probably do as

well for

> drowning while waiting for the 911 truck.

>

> Regards,

>

> Pete

>

March 19, 2006

I used Ren 1 successfully to revive an infant from drowning. I think in

this case you are protected by good samaritin law if you are in USA.

Cory Trusty

http://chinesetherapeutics.org/catalog/index.php

On Sun, 19 Mar 2006, leabun1 wrote:

> Hi there,

> Sorry, that reply was just my sense of humour coming out. I

> personally dont use ren 1, although I have heard of some students

> who got really into sun si miaos points and needled that on each

> other in combination with the others. Also one of my classmates from

> University, in her first year of practice, got a guy who had

> discovered there was an acupoint there and seemed to really want it

> needled, when she declined to needle it, he asked what it was it was

> used for and she told him " haemorrhoids " among other things, so the

> next week apparantly he turned up saying he had developed

> haemorrhoids. I think she needled it in the end.

> One thing that seems to get a lot of chiropractors sued in this

> country is manipulation of the coccyx (through the rectum) even

> when patients consent to it, they end up feeling violated after.

> Touchy subject, no pun intended.

>

> Chinese Medicine , petetheisen

> <petetheisen wrote:

> >

> > leabun1 wrote:

> > > Very interesting article. On a lighter note, I always wondered

> what

> > > youd say to people if using ren 1 on a patient to resuscitate

> from

> > > drowning.

> >

> > Hi Lea!

> >

> > Ren 1 is a very effective point for a lot of things, but I think

> using

> > it would lead to misunderstanding until TCM becomes more

> mainstream. I

> > never use it except on myself or another TCM practitioner. If I

> were

> > married I would use it on my wife if it were indicated.

> >

> > I think western CPR or the even old-time " artificial respiration "

> some

> > of us old folks learned in the boy scouts would probably do as

> well for

> > drowning while waiting for the 911 truck.

> >

> > Regards,

> >

> > Pete

> >

>

Subscribe to the new FREE online journal for TCM at

> Times http://www.chinesemedicinetimes.com

>

> Download the all new TCM Forum Toolbar, click,

> http://toolbar.thebizplace.com/LandingPage.aspx/CT145145

>

> and

> adjust accordingly.

>

> Messages are the property of the author. Any duplication outside the

> group requires prior permission from the author.

>

> Please consider the environment and only print this message if absolutely

> necessary.

>

March 19, 2006

Wow, that must be an amazing story. Im pretty sure that under

Australian law, if you are a trained first aider in the western

medicine sense, (which you have to be to be a CM practitioner) then

it is a breach of your duty of care to use anything else. Of course,

if that then failed, then I guess duty of care would dictate that

you use all skills at your disposal, as duty of care dictates that

once duty of care has been established, you cannot then relinquish

that care. Where there is a grey area here, is that as a common

citizen, there is no implied duty of care in all situations, it is

only if you stop to render assistance, however, medical

professionals always have a duty of care to everyone in all

situations. So are government registered chinese medicine

practitioners then assumed to be medical practitioners? We are for

tax purposes (goods and services tax exemption) but otherwise?

Sorry, Ill stop now, Im boring myself, even, with all this

legalese...

Chinese Medicine , cory wrote:

>

> I used Ren 1 successfully to revive an infant from drowning. I

think in

> this case you are protected by good samaritin law if you are in

USA.

>

> Cory Trusty

> http://chinesetherapeutics.org/catalog/index.php

>

> On Sun, 19 Mar 2006, leabun1 wrote:

>

> > Hi there,

> > Sorry, that reply was just my sense of humour coming out. I

> > personally dont use ren 1, although I have heard of some students

> > who got really into sun si miaos points and needled that on each

> > other in combination with the others. Also one of my classmates

from

> > University, in her first year of practice, got a guy who had

> > discovered there was an acupoint there and seemed to really want

it

> > needled, when she declined to needle it, he asked what it was it

was

> > used for and she told him " haemorrhoids " among other things, so

the

> > next week apparantly he turned up saying he had developed

> > haemorrhoids. I think she needled it in the end.

> > One thing that seems to get a lot of chiropractors sued in this

> > country is manipulation of the coccyx (through the rectum) even

> > when patients consent to it, they end up feeling violated after.

> > Touchy subject, no pun intended.

> >

> > Chinese Medicine , petetheisen

> > <petetheisen@> wrote:

> > >

> > > leabun1 wrote:

> > > > Very interesting article. On a lighter note, I always

wondered

> > what

> > > > youd say to people if using ren 1 on a patient to resuscitate

> > from

> > > > drowning.

> > >

> > > Hi Lea!

> > >

> > > Ren 1 is a very effective point for a lot of things, but I

think

> > using

> > > it would lead to misunderstanding until TCM becomes more

> > mainstream. I

> > > never use it except on myself or another TCM practitioner. If I

> > were

> > > married I would use it on my wife if it were indicated.

> > >

> > > I think western CPR or the even old-time " artificial

respiration "

> > some

> > > of us old folks learned in the boy scouts would probably do as

> > well for

> > > drowning while waiting for the 911 truck.

> > >

> > > Regards,

> > >

> > > Pete

> > >

> >

> > Subscribe to the new FREE online journal for TCM at Chinese

Medicine

> > Times http://www.chinesemedicinetimes.com

> >

> > Download the all new TCM Forum Toolbar, click,

> > http://toolbar.thebizplace.com/LandingPage.aspx/CT145145

> >

and

> > adjust accordingly.

> >

> > Messages are the property of the author. Any duplication outside

the

> > group requires prior permission from the author.

> >

> > Please consider the environment and only print this message if

absolutely

> > necessary.

> >

March 20, 2006