1. Introduction

Coma is defined as a state of non-arousable unconsciousness due to dysfunction of the brain's ascending reticular activating system [1].It is a frequent diagnostic and therapeutic emergency requiring rapid and adequate treatment. In France in 2012, the admission rate to intensive care for coma was 48.83% [2]. In Africa, studies have reported an admission rate for comas to intensive care units ranging from 44.4 to 72% [5–8]. In Niamey, Niger in 2016, Yahaya's team recorded an admission rate for serious adult coma of 12.65%.[9]and in 2020, the Boukari MB team reported a rate of 24% among children[10]. The etiology partly determines the prognosis. At the Zinder National Hospital (HNZ), no work has been published on comas. What etiologies and prognosis for these patients? This is how we set ourselves the objective for this work, to list the etiologies and prognosis of comas at the level of our service.

2. Patient and Method

The study took place at the Zinder national hospital in its multipurpose intensive care unit. This was a descriptive, cross-sectional study with prospective data collection which was carried out at the HNZ multipurpose intensive care unit covering a period of 8 months from May 1 to December 31, 2021. All patients admitted to the department multipurpose resuscitation unit of the HNZ. All comatose patients (Glasgow score from 3/15 to 12/15) admitted to the multipurpose intensive care unit of the HNZ during our study period were included in the study. Not included were patients admitted to the intensive care unit with a Glasgow score greater than 12/15, patients operated on under sedation and those comatose after their admission (during hospitalization). The variables studied were age, gender, profession, origin, mode of transport, clinical condition at admission, etiologies, length of stay, outcome. The data collected were recorded and analyzed using Excel 2016 and Epi info version 7 software. Chi2 statistical tests were used to compare qualitative variables, and Kruskal-Wallis and Student to compare proportions and means. . The statistical significance threshold retained was less than 5%.

Informed consent was obtained from the family by explaining the purpose of our study.

The anonymity of the patients was respected: before data analysis, each patient's first and last name was replaced by a number.

3. Results

During the study period, 830 patients were admitted to the intensive care unit, including 112 cases of comatose patients, representing a frequency of 13.5%. The average age was 41.64 ±22.54 years with extremes of 3 and 90 years. The age group of 21 to 40 years was the most represented with 27.6% of cases (n=31).

Figure 1: Distribution of patients by age group

The male gender represented 59.8% of cases (n=67), i.e. a sex ratio of 1.5.

Table 1: Distribution of patients according to profession

Housewives were the most affected with a rate of 33.9% of cases (n=38).

Table 2: Distribution of patients according to origin

The vast majority of patients came from the Zinder region with 91.07% of cases followed by the Maradi region with a rate of 8%.

Table 3: Distribution of patients according to history

The history consisted mainly of arterial hypertension in 12 patients. More than half (78%) of the patients had no history (n=88). The onset of symptoms was sudden in 66.9% of patients (n=75).More than half (49.1%) of the patients (n=55) were admitted 24 hours after the onset of symptoms. The average delay was 25.5 hours. Patients benefited from medical transport in 59.8% of cases.

Table 4: Distribution of patients according to admission constants

Hyperthermia, tachycardia and hypertension were observed in 43.1% respectively; 57.5%; 45.9%. SpO2 was below 95% in 46.1% (n=41) of patients.

In 47.3% (n=53) of patients, the Glasgow score at admission was between 6 and 8, 38.3% between 9 and 12 and 14.2% had a score between 3 and 5.

Hemiplegia was the main focal sign observed in 24.2% of cases (n=25).

Table 5: Distribution of patients according to additional examinations

The main tests carried out were blood sugar, CBC, serum creatinine in 71.4% respectively; 57.1%; 53.5%. Brain scanning was only performed in 35.7% of patients.

Table 6: Distribution of patients according to etiologies

Others: intoxication, obstetric, not determined

Cranioencephalic trauma was the most common etiology with a rate of 36.4% (n=41) followed by metabolic coma (25%).

Table 7: Distribution of patients according to decompensations

Respiratory distress was the main decompensation recorded with a rate of 23.6% (n=26).

Figure 2: Distribution of patients according to prognosis

The death rate was 48.2% (n=54).

Table 8: Influence of age on prognosis

Chi2=7.29 p-value<0.01

Age over 60 years was significantly linked to the occurrence of patient death.

Table 9: Influence of history on prognosis

Chi2=5.04 p-value=0.02

In 17 cases or 68%, the presence of a history was a factor favoring death.

Table 10: Influence of time to admission to intensive care on prognosis

Fisher exact= 0.30 p-value= 0.49

Deceased patients were admitted beyond 6 hours in 48.4% of cases.

Table 11: Influence of mode of transport on prognosis

Chi2=0.78 p-value=0.37

Non-medical transport had a mortality rate of 55.2%.

Table12: Influence of altered state of consciousness on prognosis

Fisher exact=0.004 p-value<0.01

The deterioration of consciousness significantly influenced the occurrence of death.

4. Discussion

During the study period, 830 patients were recorded, including 112 cases of comas, representing a frequency of 13.5%. Mapoure in Senegal in 2009[5]and Kouamé in Ivory Coast in 2021 [6] had recorded respectively with a rate of 48.99% and 72.11%. The result of this study could be explained by the death of certain patients before admission to the intensive care unit. The average age was 41.64 years with extremes of 3 and 90 years. The age group of 21 to 40 was the most affected with a rate of 27.6%. The youth of the patients was often reported by African authors. Indeed Otiobanda and Mohamed had found a respective average age of 40.5 and 43.9 years [36.37]. However, Adukauskienè in Lithuania in 2020 reported a mean age of 67.6 ± 15.2 years [38]. In Latin America, 69% of patients admitted to the intensive care unit for traumatic coma were aged under 40 [3].The young age found in this study could be explained by the youth of the Nigerien population [39] and the exposure of these young people to public road accidents. We recorded a male predominance with a rate of 59.8%. Which is similar to literature data [40–44]. The explanation lies in the fact that men are more exposed to potential risk factors such as road accidents. But for the Vallin team, to this is added caution, which was much higher among women than men [45]. Housewives were the most affected with a rate of 33.9% in this study. This observation was made by Maimouna Saidou in Mali with 34.2% of housewives [46]. On the other hand, in Benin, Tchaou and Adelin had observed a predominance of independent workers [47.48].This proves that the occurrence of coma is not correlated with occupation. Most patients came from the city of Zinder followed by the department of Magaria and the region of Maradi. This result could be explained for the city of Zinder by the proximity of the intensive care unit; for Magaria it was the absence of an intensive care unit and for Maradi it was the non-functioning of certain services. Arterial hypertension was the main antecedent recorded in 10% of cases. In India in 2020, stroke was the most common cause of non-traumatic coma with a rate of 48.99% [4]. The result of this series was similar to those of Sène Diouf in Senegal in 2009 [49] and Mahamadou Coulibaly in Mali in 2019 [50]. The growing number of hypertensive patients in Niger could be the cause[51–53]. In this series, the beginning was brutal in66.9% of cases.

HoweverBoukari in Niger in 2020 [10] found 71.43% of cases of progressive onset of non-traumatic comas in children aged 7 days to 15 years. In addition, in children, the majority of cases of coma occurred gradually. Infection was the etiology the main etiology of coma in pediatric settings [54–57].Patients were admitted to intensive care 24 hours after the start of symptoms in 49.1% of cases. This result waslower than that ofIbekwe who reported 80% of admission cases after the onset of signs [58]. For Lukman in Nigeria in 2012 59.8% of patients were admitted within 24 hours[59].The result of this study could be explainedby the lack of medical transport and the delay in carrying out the brain scan.Nearly half of the patients had hyperthermia (43.1%), tachycardia (57.5%), hypertension (45.9%) and low SPO2 (46.1%) in this series. In this series, patients with a Glasgow score between 6 and 8 represented 47.3% of cases. Masson had recorded a score below 8 in 69% of patients [61]. The result of this study could be explained by the severity of comas due to the delay in early consultation.

In the majority of patients essentially benefited from: blood sugar, blood count, and serum creatinine. CT was performed in only 35.7% of patients due to the fact that the HNZ did not have a scanner during the study period.The dominant etiologies were cranioencephalic trauma followed by metabolic coma with respectively 36.4% and 24.8% of cases. This same observation was made by Adelin in Benin in 2015. Which also justified the compulsory wearing of helmets in Benin [47]. However, for William's team in the United States in 2002, cranio-encephalic trauma was the third cause of coma with 14% of cases [62]. The result of this study could be explained by the non-compliance with road safety rules favoring public road accidents (AVP), mainly source of the traumatic comas observed in our regions.[63,64]. Respiratory distress was the maindecompensationin this series with a rate of 23.6%. Rate lower than that of Djibril in Togo which reported 51% of cases of respiratory distress[65]. This disorder is due to lesional or metabolic damage to the central structures controlling breathing.[66]. In this series, 48.2% of patients died. However, this result was close to the data in the European literature varying between 43 to 46% [67–71].However, higher mortality was reported by Obiako in Nigeria with a rate of 76% of cases.[72].

The delay in consulting, the delay in treatment and the insufficiency of therapeutic means could explain the result of this study. In this study, older age (over 60 years) was statistically correlated with death (P<0.01). The same observation was reported byOssou-Nguiet PM et al in Brazzaville in 2013[73]and Firsching in Germany in 2017 [74].In fact, elderly people present comorbidities with an increased risk of decompensations further worsening the management [75].Previous history was associated with a significant increase in mortality in this series (P=0.02).Raveloson made the same observation[76]. Delay in seeking consultation was correlated with death (P=0.49). Indeed, the short time to consult would improve the vital prognosis of patients. For some authors this time should not exceed 1 to 3 hours to obtain a good prognosis [77.78].In this series, medical transport improved the vital prognosis of patients. Mendy J in a study carried out in Senegal in 2014 reported a medical transport rate of 5.4% with an overall mortality rate of 34.8% [79]. The result of this study was explained by the absence of an emergency medical aid service (SAMU) in the city and region of Zinder.The most lethal etiologies were stroke, comas of metabolic and infectious origin (P respectively 0.18, 0.51 and 0.49). The study carried out byAdukauskiene in Lithuania in 2020 showed that 74% of deaths were from metabolic coma (P=0.004)[38]. In Niger in 2019, Mansour reported that malaria comas significantly increased the case fatality rate (P=0.0001)[30].

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