Evaluation of coma: a critical appraisal of popular scoring systems

Postoperative organ dysfunction assessed using simplified eSOFA is associated with mortality: a single-center retrospective cohort study

PURPOSE

This study aimed to determine the association between postoperative organ dysfunction evaluated using eSOFA, a simplified measure of organ dysfunction, and postoperative mortality following noncardiac surgery.

METHODS

This study retrospectively analyzed adult patients who underwent noncardiac surgery under general anesthesia between 2009 and 2019. The primary exposure was postoperative organ dysfunction evaluated using eSOFA within 2 postoperative days (positive eSOFA), and the primary outcome was 90-day mortality. Multivariable Cox regression analysis was employed to investigate the association between positive eSOFA and 90-day mortality. In a subanalysis of patients in the surgical intensive care unit (ICU), the predictive performance of the number of eSOFA-positive items for 90-day mortality was compared with those of the Sequential Organ Failure Assessment (SOFA) score and the Acute Physiology And Chronic Health Evaluation (APACHE) II score using Harrell's C-statistic.

RESULTS

This study included 24,558 patients, of whom 7.5% had positive eSOFA, and the postoperative 90-day mortality was 0.9%. Positive eSOFA was independently associated with the occurrence of 90-day mortality (adjusted hazard ratio [HR]: 3.03, 95% confidence interval: 2.16-4.25, P < 0.001). As the number of positive eSOFA items increased, the adjusted HR for 90-day mortality increased. The C-statistics for predicting 90-day mortality in surgical ICU patients using the number of eSOFA-positive items, SOFA score, and APACHE II score were 0.72 (0.65-0.79), 0.73 (0.65-0.80), and 0.74 (0.68-0.81), respectively.

CONCLUSION

Postoperative organ dysfunction evaluated using the eSOFA within 2 postoperative days was independently associated with 90-day mortality in patients who underwent noncardiac surgery.

Delirium at the intensive care unit and long-term survival: a retrospective study

BACKGROUND

Delirium is a common complication in patients at the intensive care unit (ICU) and is associated with prolonged ICU-stay and hospitalization and with increased morbidity. The impact of ICU-delirium on long-term survival is not clearly understood.

METHODS

This retrospective single center observational study was conducted at the Institute of Intensive Care Medicine at the University Hospital Zurich, Switzerland. All adult ICU-survivors over a four-year period were screened for eligibility. ICU-delirium was defined based on the Intensive Care Delirium Screening Checklist (ICDSC), together with the coded diagnosis F05 in the International Classification of Diseases (ICD-2019). ICU-survivors who developed delirium during their ICU stay (group D) were compared with ICU-survivors who did not (group ND). Survival was evaluated according to data from hospital electronic health records up to four years from ICU-discharge. The survival analysis was reported using Kaplan-Meier curves and absolute risk differences (ARD). A multivariable logistic regression model was fitted with long-term survival at four years after ICU-discharge as outcome of interest, including several clinical conditions and interventions associated with long-term survival for ICU patients. For subgroup analysis, ICU-survivors were grouped based on age at the time of admission (45-54, 55-64, ≥ 65 years), and on relevant clinical conditions.

RESULTS

A total of 9'604 patients fulfilled the inclusion criteria, of them 22.6% (n = 2'171) developed ICU-delirium. Overall, patients in the group D had a significantly lower probability of survival than patients in the group ND (p < 0.0001, ARD = 11.8%). In the multivariable analysis, ICU-delirium was confirmed as independently associated with long-term survival. After grouping for age categories, patients between 55 and 64 years of age in the group D were less likely to survive than patients in the group ND at every time point analyzed, up to four years after ICU discharge (p < 0.001, ARD = 7.3%). This difference was even more significant in the comparison between patients over 65 years (p < 0.0001, ARD 11.1%). No significant difference was observed in the other age groups.

CONCLUSIONS

In the study population, ICU-delirium was independently associated with a reduced long-term survival. Patients who developed ICU-delirium had a reduced survival up to four years after ICU discharge and this association was particularly evident in patients above 55 years of age.

Unlocking Coma Assessments: Exploring Healthcare Professionals' Knowledge and Perception of the Full Outline of Unresponsiveness (FOUR) Score in Saudi Arabia

Background Coma scales play a critical role in assessing the consciousness level of comatose patients, guiding clinical decisions, and predicting patient outcomes. Although the Glasgow Coma Scale (GCS) has been the standard for decades, the Full Outline of UnResponsiveness (FOUR) score offers a more comprehensive assessment. In this study, the awareness, knowledge, and utilization of the FOUR scores among healthcare professionals in Saudi Arabia were explored. Methods This multisite, cross-sectional study was conducted between January and April 2023 and involved physicians specializing in emergency medicine, neurology, neurosurgery, or intensive care. Participants completed a self-administered questionnaire. Results Among 335 participating physicians, only 33% (111) reported having prior knowledge of the FOUR score; 54% (60) of physicians in this group rarely or never used the FOUR score, largely owing to the perception that the GCS suffices (45%, 61), and a lack of awareness among other healthcare professionals (43%, 58). A significant proportion of physicians unfamiliar with the FOUR score have expressed a willingness to adopt alternative scoring systems, and 67% (148) were open to using a system evaluating brainstem reflexes. For respiration and intubation, 65% (143) and 85% (187) of the physicians were open to alternative scoring systems, respectively. There was a significant difference in knowledge between specialties, level of training, and previous neurocritical training (p-values <0.001, 0.032, <0.001, respectively). Conclusion This study revealed a notable gap in knowledge and utilization of the FOUR score in Saudi Arabia, a willingness to explore alternative systems for assessing consciousness, and an interest in comparative studies of various coma scales. Efforts to improve education about the FOUR score among relevant healthcare professionals in Saudi Arabia, in addition to exploring alternative systems, is suggested.

The Predictive Validity of the Full Outline of UnResponsiveness Score Compared to the Glasgow Coma Scale in the Intensive Care Unit: A Systematic Review

The Full Outline of UnResponsiveness (FOUR) score was developed to overcome the limitations of the Glasgow Coma Scale (GCS) when assessing individuals with impaired consciousness. We sought to review the evidence regarding the predictive validity of the GCS and FOUR score in intensive care unit (ICU) settings. This review was prospectively registered in PROSPERO (CRD42023420528). Systematic searches of CINAHL, MEDLINE, and Embase were undertaken. Prospective observational studies were included if both GCS and FOUR score were assessed in adults during ICU admission and if mortality and/or validated functional outcome measure scores were collected. Studies were excluded if they exclusively investigated patients with traumatic brain injury. Screening, data extraction, and quality assessment using the Quality in Prognosis Studies tool were conducted by two reviewers. Twenty studies of poor to moderate quality were included. Many studies only included patients with neurological illness and excluded sedated patients, despite high proportions of intubated patients. The FOUR score achieved higher area under the receiver operating characteristic curve values for mortality prediction compared with the GCS, and the FOUR score achieved significantly higher area under the receiver operating characteristic curve values for predictions of ICU mortality. Both coma scales showed similar accuracy in predicting "unfavorable" functional outcome. The FOUR score appeared to be more responsive than the GCS in the ICU, as most patients with a GCS score of 3 obtained FOUR scores between 1 and 8 due to preserved brainstem function. The FOUR score may be superior to the GCS for predicting mortality in ICU settings. Further adequately powered studies with clear, reliable methods for assessment of index and outcome scores are required to clarify the predictive performance of both coma scales in ICUs. Inclusion of sedated patients may improve generalizability of findings in general ICU populations.

Epidemiology and outcomes of brain trauma in rural and urban populations: a systematic review and meta-analysis

OBJECTIVE

To identify and describe differences in demographics, injury characteristics, and outcomes between rural and urban patients suffering brain injury.

DATA SOURCES

CINAHL, Emcare, MEDLINE, and Scopus.

REVIEW METHODS

A systematic review and meta-analysis of studies comparing epidemiology and outcomes of rural and urban brain trauma was conducted in accordance with PRISMA and MOOSE guidelines.

RESULTS

36 studies with ~ 2.5-million patients were included. Incidence of brain injury was higher in males, regardless of location. Rates of transport-related brain injuries, particularly involving motorized vehicles other than cars, were significantly higher in rural populations (OR:3.63, 95% CI[1.58,8.35], p = 0.002), whereas urban residents had more fall-induced brain trauma (OR:0.73, 95% CI[0.66,0.81], p < 0.00001). Rural patients were 28% more likely to suffer severe injury, indicated by Glasgow Coma Scale (GCS)≤8 (OR:1.28, 95% CI[1.04,1.58], p = 0.02). There was no difference in mortality (OR:1.09, 95% CI[0.73,1.61], p = 0.067), however, urban patients were twice as likely to be discharged with a good outcome (OR:0.52, 95% CI[0.41,0.67], p < 0.00001).

CONCLUSIONS

Rurality is associated with greater severity and poorer outcomes of traumatic brain injury. Transport accidents disproportionally affect those traveling on rural roads. Future research recommendations include addition of prehospital data, adequate follow-up, standardized measures, and sub-group analyses of high-risk groups, e.g. Indigenous populations.

The Glasgow Coma Scale and Full Outline of Unresponsiveness score evaluation to predict patient outcomes with neurological illnesses in intensive care units in West Bank: a prospective cross-sectional study

BACKGROUND

Determining the clinical neurological state of the patient is essential for making decisions and forecasting results. The Glasgow Coma Scale and the Full Outline of Unresponsiveness (FOUR) Scale are commonly used tools for measuring behavioral consciousness. This study aims to compare scales among patients with neurological disorders in intensive care units (ICUs) in the West Bank.

METHODS

A prospective cross-sectional design was employed. All patients admitted to ICUs who met inclusion criteria were involved in this study. Data were collected from from An-Najah National University, Al-Watani, and Rafedia Hospital. Both tools were used to collect data.

RESULTS

A total of 84 patients were assessed, 69.0% of the patients were male, and the average length of stay was 6.4 days. The mean score on the Glasgow Coma scale was 11.2 on admission 11.6 after 48 hours, and 12.2 on discharge. The mean FOUR Scale score was 12.2 on admission, 12.4 after 48 hours, and 12.5 at discharge.

CONCLUSIONS

This study indicates that both the Glasgow Coma Scale and the FOUR scale are effective in predicting outcomes for neurologically deteriorated critically ill patients. However, the FOUR scale proved to be more reliable when assessing outcomes in ICU patients.

The burden of head trauma in rural and remote North Queensland, Australia

BACKGROUND

Head trauma is a leading cause of death and disability worldwide. Young males, Indigenous people, and rural/remote residents have been identified as high-risk populations for head trauma, however, Australian research is limited. Our aim was to define and describe the incidence, demographics, causes, prehospital interventions, and outcomes of head trauma patients transported by aeromedical services within North Queensland, Australia. We hypothesized that young, Indigenous males living remotely would be disproportionately affected by head trauma.

METHODS

We conducted a retrospective study of all head trauma patients transferred by air to or between Townsville, Cairns, Mount Isa and Mackay Hospitals between January 1, 2016 and December 31, 2018. Patients were identified from the Trauma Care in the Tropics data registry and followed for a median 30-months post-injury. Primary endpoints were patient and injury characteristics. Secondary outcome measures were hospital stay and mortality.

RESULTS

A total of 981 patients were included and 31.1 % were Indigenous. Sixty-seven percent of injuries occurred remotely and the median time from injury to hospital was 5.8-hours (range 67-3780 min). Eighty percent of severe head injuries occurred in males (p = 0.007). Indigenous and remote patients were more likely to sustain mild injuries. The most common mechanism of injury overall was vehicle accident (37.5 %), compared to assault in the Indigenous subgroup (46.6 %, p<0.001). The overall mortality rate was 4.9 %, with older age and lower initial Glasgow Coma Score significant predictors of in-hospital mortality. Prehospital intubation was associated with a 7-fold increased risk of mortality (p = 0.056), while patients that received tranexamic acid (TXA) were almost 5-times more likely to die.

CONCLUSIONS

In North Queensland, young Indigenous males are at highest risk of traumatic head injuries. Vehicle accidents are an important preventable cause of head injury in the region. TXA administration is an important consideration for remote head trauma retrievals, in which time to emergency care is prolonged. Appropriate treatment and risk stratification strategies considering time to definitive care, severity of injury, and other prehospital patient factors require further investigation.

Development of a Novel Neurological Score Combining GCS and FOUR Scales for Assessment of Neurosurgical Patients with Traumatic Brain Injury: GCS-FOUR Scale

BACKGROUND

Consciousness assessment is crucial for patients with traumatic brain injury. In this study, we developed a novel scoring system combining the Glasgow coma scale (GCS) and the full outline of unresponsiveness (FOUR) and evaluated its association with the intensive care unit (ICU) length of stay, mortality, and functional outcome.

METHODS

We retrospectively analyzed the data from patients with traumatic brain injury admitted to the neurosurgical ICU of our institution during a 2-year period. The eye and motor components of the GCS and the brainstem reflex component of the FOUR were used to compute the GCS-FOUR. We performed statistical analysis to demonstrate the association between the GCS, FOUR, and GCS-FOUR and the ICU length of stay, mortality, the development of a persistent vegetative state, and desirable recovery.

RESULTS

A total of 140 patients were included. The mean age was 30.6 years, and 89.3% were male. All 3 scores were associated with the ICU length of stay, mortality, a persistent vegetative state, and good recovery. In terms of predicting mortality, the GCS score exhibited a slight superiority compared with the other indexes, and the GCS-FOUR score showed a slight superiority over the other indexes in predicting for good recovery.

CONCLUSIONS

The GCS-FOUR is a novel scoring system comparable to the GCS and FOUR regarding its association with functional status after injury, ICU length of stay, and mortality. The GCS-FOUR score provides greater neurological detail than the GCS due to the inclusion of brainstem reflexes, in addition to using the experience of healthcare providers with the GCS score compared with the FOUR in most settings.

Comparison of different scores as predictors of mechanical ventilation and intensive care unit admission in acute theophylline poisoning

Background

Theophylline is commonly used to control respiratory diseases, especially in developing countries. Theophylline has a narrowed therapeutic index, and its toxicity is associated with morbidity and mortality. Physicians should be aware of the early prediction of the need for intensive care unit admission (ICU) and mechanical ventilation (MV).

Aim

This study aimed to assess the power of the Rapid Emergency Medicine Score (REMS), Modified Early Warning Score (MEWS) and Simple Clinical Score (SCS) in predicting the need for ICU admission and/or MV in acute theophylline-poisoned patients.

Patients and methods

This cross-sectional study included 58 patients with acute theophylline poisoning who were admitted to our Poison Control Center from the 1st of July 2022 to the 31st of January 2023. The REMS, MEWS and SCS were calculated for all patients on arrival at the hospital. The area under the curve (AUC) and receiver operating characteristics were tested to compare scores.

Results

The median values of all studied scores were significantly high among patients who needed MV and/or ICU admission. The AUC of SCS was >0.9, with a sensitivity of 92.9% and specificity of 90.9% for the prediction of ICU admission. Meanwhile, MEWS was an excellent predictor of the need for MV (AUC = 0.996, 95% CI = 0.983-1.000).

Conclusions

We recommend using SCS as an early predictor for ICU admission in acute theophylline-poisoned patients. However, MEWS could effectively predict MV requirements in acute theophylline-poisoned patients.

Comparison of the prognostic validity of three simplified consciousness assessment scales with the Glasgow Coma Scale

BACKGROUND

Various tools simpler than the Glasgow Coma Scale (GCS) have been proposed for the assessment of consciousness. In this study, the validity of three coma scales [Simplified Motor Scale, Modified GCS Motor Response, and AVPU (alert, verbal, painful, unresponsive)] is evaluated for the recognition of coma and the prediction of short- and long-term mortality and poor outcome. The predictive validity of these scales is also compared to the GCS.

METHODS

Patients treated in the Department of Neurosurgery and the Intensive Care Unit in need of consciousness monitoring were assessed by four raters (two consultants, a resident and a nurse) using the GCS. The corresponding values of the simplified scales were estimated. Outcome was recorded at discharge and at 6 months. Areas Under the Receiver Operating Characteristic Curve (AUCs) were calculated for the prediction of mortality and poor outcome, and the identification of coma.

RESULTS

Eighty-six patients were included. The simplified scales showed good overall validity (AUCs > 0.720 for all outcomes of interest), but lower than the GCS. For the identification of coma and the prediction of long-term poor outcome, the difference was significant (p < 0.050) for all the ratings of the most experienced rater. The validity of these scales was comparable to the GCS only in predicting in-hospital mortality, but without this being consistent for all raters.

CONCLUSION

The simplified scales showed inferior validity than the GCS. Their potential role in clinical practice needs further investigation. Thus, the replacement of the GCS as the main scale for consciousness assessment cannot be currently supported.

Development and validation of a novel poisoning agitation-sedation score for predicting the need for endotracheal intubation and mechanical ventilation in acutely poisoned patients with disturbed consciousness

BACKGROUND

Accurate assessment of disturbed consciousness level (DCL) is crucial for predicting acutely poisoned patients' outcomes.

AIM

Development of a novel Poisoning Agitation-Sedation Score (PASS) to predict the need for endotracheal intubation (ETI) and mechanical ventilation (MV) in acutely poisoned patients with DCL. Validation of the proposed score on a new set of acutely poisoned patients with DCL.

METHODS

This study was conducted on 187 acutely poisoned patients with DCL admitted to hospital from June 2020 to November 2021 (Derivation cohort). Patients' demographics, toxicological data, neurological examination, calculation of the Glasgow Coma Scale (GCS), Full Outline of Unresponsiveness (FOUR) score, Richmond Agitation-Sedation Scale (RASS), and outcomes were gathered for developing a new score. The proposed score was externally validated on 100 acutely poisoned patients with DCL (Validation cohort).

RESULTS

The PASS assessing sedation consists of FOUR (reflexes and respiration) and GCS (motor) and provides a significantly excellent predictive power (AUC = 0.975) at a cutoff ≤9 with 100% sensitivity and 92.11% specificity for predicting the need for ETI and MV in sedated patients. Additionally, adding RASS (agitation) to the previous model exhibits significantly good predictive power (AUC = 0.893), 90.32% sensitivity, and 73.68% specificity at a cutoff ≤14 for predicting the need for ETI and MV in disturbed consciousness patients with agitation.

CONCLUSION

The proposed PASS could be an excellent, valid and feasible tool to predict the need for ETI and MV in acutely poisoned disturbed consciousness patients with or without agitation.

Elevated C-reactive protein-to-albumin ratio with fever is a predictor of poor functional outcome in patients with mild traumatic brain injury

Introduction

The C-reactive protein -to-albumin ratio (CAR), a novel inflammation-based prognostic score, is useful in predicting clinical outcomes, including those in central nervous system diseases. However, no report has identified the relationship between CAR and long-term clinical outcomes in patients with mild traumatic brain injury (mTBI). We aimed to evaluate the relationship between CAR and long-term functional outcomes in patients with mTBI and analyze whether CAR is associated with the presence of fever.

Methods

This was a retrospective observational study includes 387 adult patients with mTBI who were treated at a level-1 trauma center between 2017 and 2021. The main exposure variable was an elevated CAR, and the main outcomes were degrees of disability and quality of life measured using the modified Rankin Scale (mRS). A multivariable logistic regression analysis was performed to estimate the effect size of CAR on study outcomes. An interaction analysis was performed between CAR and fever on study outcomes.

Results

Elevated CAR had no significant association with poor functional outcomes (aOR [95% CI]: 1.35 [0.39-4.69]) in patients with mTBI. In the interaction analysis, elevated CAR was not associated with increased poor functional outcomes in the absence of fever (1.08 [0.55-2.13]), but a significant increase in poor functional outcomes was observed when elevated CAR was accompanied by fever (1.32 [1.14-2.56)).

Conclusions

Elevated CAR with fever increased the risk of poor functional recovery at 6 months after hospital discharge in patients with mTBI. Our study findings suggest the need for strategies for the prevention of long-term poor functional recovery in the presence of high CAR and fever in patients with mTBI.

Comparison of the prognostic value of coma scales among health-care professionals: a prospective observational study

OBJECTIVE

To assess the predictive value of the Full Outline of Unresponsiveness (FOUR) Score and the Glasgow Coma Scale (GCS), investigating whether they are comparable in predicting short- and long-term functional outcome and if their predictive ability remains unaffected by the raters' background and experience.

METHODS

Patients treated in the Neurosurgery Department and the Intensive Care Unit in need for consciousness monitoring were assessed between October 1st, 2018, and December 31st, 2020, by four raters (two consultants, a resident and a nurse) using the two scales on admission and at discharge. Outcome was recorded at discharge and at 6 months. Areas under the receiver operating characteristic curve (AUCs) were calculated for the prediction of mortality and poor outcome, and the identification of coma.

RESULTS

Eighty-six patients were included. AUCs values were > 0.860 for all outcomes and raters. No significant differences were noted between the two scales. Raters' experience did not affect the scales' predictive value. Both scales showed excellent accuracy in identifying comatose patients (AUCs > 0.950). The difference between admission and discharge values was not a reliable predictor.

CONCLUSION

Both the FOUR Score and GCS are reliable predictors of short- and long-term outcome, with no clear superiority among them. The application of the FOUR Score by inexperienced raters is equally reliable, without influencing negatively the predictive value.

Clinimetric study and review of the Reaction Level Scale

OBJECTIVES

Although the Reaction Level Scale (RLS) is still used for the assessment of the level of consciousness in distinct centers, its clinical characteristics and significance have been incompletely researched. In the current study, the clinimetric properties, the prognostic value, and the impact of the raters' background on the application of the RLS, in comparison with the Glasgow Coma Scale (GCS), are investigated.

MATERIALS AND METHODS

A systematic review on the available clinical evidence for the RLS was first carried out. Next, the RLS was translated into Greek, and patients with neurosurgical pathologies in need of consciousness monitoring were independently assessed with both RLS and GCS, by four raters (two consultants, one resident, and one nurse) within one hour. Interrater reliability, construct validity, and predictive value (mortality and poor outcome, at discharge and at 6 months) were evaluated.

RESULTS

Literature review retrieved 9 clinimetric studies related to the RLS, most of low quality, indicating that the scale has not been thoroughly studied. Both versions of the RLS (original and modified) showed high interrater reliability (κ_w >0.80 for all pairs of raters), construct validity (Spearman's p > .90 for all raters), and prognostic value (areas under the curve >0.85 for all raters and outcomes). However, except for broader patients' coverage, it failed to show any advantage over the GCS.

CONCLUSIONS

The RLS has not succeeded in showing any advantage over the GCS in terms of reliability and validity. Available evidence cannot justify its use in clinical practice as a substitute to the widely applied GCS.

The brain in pediatric critical care: unique aspects of assessment, monitoring, investigations, and follow-up

As survival after pediatric intensive care unit (PICU) admission has improved over recent years, a key focus now is the reduction of morbidities and optimization of quality of life for survivors. Neurologic disorders and direct brain injuries are the reason for 11-16% of admissions to PICU. In addition, many critically ill children are at heightened risk of brain injury and neurodevelopmental difficulties affecting later life, e.g., complex heart disease and premature birth. Hence, assessment, monitoring and protection of the brain, using fundamental principles of neurocritical care, are crucial to the practice of pediatric intensive care medicine. The assessment of brain function, necessary to direct appropriate care, is uniquely challenging amongst children admitted to the PICU. Challenges in assessment arise in children who are unstable, or pharmacologically sedated and muscle relaxed, or who have premorbid abnormality in development. Moreover, the heterogeneity of diseases and ages in PICU patients, means that high caliber evidence is harder to accrue than in adult practice, nonetheless, great progress has been made over recent years. In this 'state of the art' paper about critically ill children, we discuss (1) patient types at risk of brain injury, (2) new standardized clinical assessment tools for age-appropriate, clinical evaluation of brain function, (3) latest evidence related to cranial imaging, non-invasive and invasive monitoring of the brain, (4) the concept of childhood 'post intensive are syndrome' and approaches for neurodevelopmental follow-up. Better understanding of these concepts is vital for taking PICU survivorship to the next level.

Assessment of Correlation Between Brain Function Index and Three Common Sedation Scales in Intensive Care Unit Patients

Objectives: This study aimed to evaluate the correlation of the Brain Function Index (BFI) with three criteria of consciousness (Glasgow, Richmond, and FOUR score) in the intensive care unit. Methods: We enrolled patients aged over 15 years who required no muscle relaxants and had no hearing and visual impairment, mental retardation, mental disorder, hemodynamic instability (MAP < 60 mmHg), and hypoxia (SpO2 < 90%), as well as patients with no brain electrical activity disorders such as epilepsy and focal brain disease, and those who had not undergone anesthesia and surgery for the past 24 hours. Results: All ICU patients were enrolled in the study in the autumn and winter based on inclusion and exclusion criteria (n = 85). During 24 hours, BFI and three clinical criteria of sedation and consciousness including RASS, GCS, and FOUR score were assessed three times with a minimum of four-hour intervals. Among the patients, 45 (52.9%) were males, and 40 (47.1%) were females; 24 (28.2%) patients were under 40 years of age, 13 (15.3%) patients were between 41 and 60 years old, and 48 (56.5%) patients were over 61 years old. There was a significant positive relationship between the BFI score of ICU patients and the score of patient consciousness based on RASS, FOUR score, and GCS. The correlation of BFI with the FOUR score was higher than those with the other two criteria. Conclusions: Objective criteria for assessing the consciousness level such as BFI are sufficiently accurate and can be used instead of clinical criteria to assess the level of consciousness in special wards.

Pediatric age-adjusted shock index as a tool for predicting outcomes in children with or without traumatic brain injury

BACKGROUND

The pediatric age-adjusted shock index (SIPA) accurately identifies severely injured children following trauma without accounting for neurological status. Understanding how the presence of traumatic brain injury (TBI) affects the generalizability of SIPA as a bedside triage tool is important given high rates of TBI in the pediatric trauma population. We hypothesized that SIPA combined with TBI (SIPAB+) would more accurately identify severely injured children.

METHODS

Patients (1-18 years old) in the American College of Surgeons Pediatric Trauma Quality Improvement Program database (2014-2017) with an elevated SIPA upon arrival to a pediatric trauma center were included. Pediatric age-adjusted shock index combined with TBI was defined as elevated SIPA with Glasgow Coma Scale score of ≤8. Pediatric age-adjusted shock index without TBI (SIPAB-) was defined as elevated SIPA with Glasgow Coma Scale score of >9. Patients were stratified into SIPAB+ and SIPAB-. A subanalysis of patients with isolated brain injury and those with brain injury and multisystem injuries was also performed. Data were compared through univariate models and three separate logistic regression models.

RESULTS

Overall, 25,068 had an elevated SIPA, with 12.3% classified as SIPAB+ and the remainder SIPAB-. Patients classified as SIPAB+ received more blood transfusions within 4 hours of injury and had higher mortality rates. On logistic regression, SIPAB+ patients had significantly higher odds of early blood transfusion and a combination of both. Mortality and early blood transfusion were also higher in SIPAB+ patients on subanalysis for patients with isolated TBI and those with multisystem injuries.

CONCLUSION

The use of SIPAB+ as a bedside triage tool accurately identifies traumatically injured children at high risk for early blood transfusion and/or death while incorporating the presence of neurological injury. This is true for patients with isolated TBI and those with multisystem injury, indicating its utility in predicting outcomes for TBI patients with elevated SIPA regardless of presence of concomitant injuries. Incorporation of this as a triage tool should be considered to better predict resources in this population.

LEVEL OF EVIDENCE

Prognostic, level III.

Cross-Cultural Adaptation and Validation of the Greek Version of the "Full Outline of Unresponsiveness Score": A Prospective Observational Clinimetric Study in Neurosurgical Patients

Background

The Full Outline of Unresponsiveness (FOUR) score is a clinical instrument for the assessment of consciousness which is gradually gaining ground in clinical practice, as it incorporates more complete neurological information than the Glasgow Coma Scale (GCS). The main objectives of the current study were the following: (1) translate and cross-culturally adapt the FOUR score into Greek; (2) evaluate its clinimetric properties, including interrater reliability, internal consistency, and construct validity; and (3) evaluate the reliability of assessments among health care professionals with different levels of experience and training.

Methods

The FOUR score was initially translated into Greek. Next, patients with neurosurgical pathologies in need of consciousness monitoring were independently assessed with the GCS and FOUR score within one hour by four raters who had different levels of experience and training (two board-certified neurosurgeons, a neurosurgery resident, and a registered nurse). Interrater reliability, internal consistency, and construct validity were evaluated for the scales using weighted Cohen’s κ (κ_w) and intraclass correlation coefficients (ICC), Cronbach’s α and Spearman’s ρ values, respectively.

Results

A total of 408 assessments were performed for 99 patients. The interrater reliability was excellent for both the FOUR score (ICC = 0.941) and GCS (ICC = 0.936). The values of κ_w exceeded 0.90 for all pairs, suggesting that the FOUR score can be reliably applied by raters with varying experience. Among the scales’ components, FOUR score’s brainstem and respiratory items showed the lowest, yet high enough (κ_w > 0.60), level of agreement. The interrater reliability remained excellent (κ_w > 0.85, ICC > 0.90) for all diagnosis and age groups, with a trend toward higher FOUR score values in the most severe cases (ICC = 0.813 vs. 0.723). Both the FOUR score and GCS showed high internal consistency (Cronbach’s α > 0.70 for all occasions). The FOUR score correlated strongly with GCS (Spearman’s ρ > 0.90 for all raters), suggesting high construct validity.

Conclusions

The Greek version of the FOUR score is a valid and reliable tool for the clinical assessment of patients with disorders of consciousness. It can be applied successfully by nurses, residents, and specialized physicians. Therefore, its use by medical practitioners with different levels of experience and training is strongly encouraged.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12028-021-01342-w.

Serial Neurologic Assessment in Pediatrics (SNAP): A New Tool for Bedside Neurologic Assessment of Critically Ill Children

OBJECTIVES

We developed a tool, Serial Neurologic Assessment in Pediatrics, to screen for neurologic changes in patients, including those who are intubated, are sedated, and/or have developmental disabilities. Our aims were to: 1) determine protocol adherence when performing Serial Neurologic Assessment in Pediatrics, 2) determine the interrater reliability between nurses, and 3) assess the feasibility and acceptability of using Serial Neurologic Assessment in Pediatrics compared with the Glasgow Coma Scale.

DESIGN

Mixed-methods, observational cohort.

SETTING

Pediatric and neonatal ICUs.

SUBJECTS

Critical care nurses and patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Serial Neurologic Assessment in Pediatrics assesses Mental Status, Cranial Nerves, Communication, and Motor Function, with scales for children less than 6 months, greater than or equal to 6 months to less than 2 years, and greater than or equal to 2 years old. We assessed protocol adherence with standardized observations. We assessed the interrater reliability of independent Serial Neurologic Assessment in Pediatrics assessments between pairs of trained nurses by percent- and bias- adjusted kappa and percent agreement. Semistructured interviews with nurses evaluated acceptability and feasibility after nurses used Serial Neurologic Assessment in Pediatrics concurrently with Glasgow Coma Scale during routine care. Ninety-eight percent of nurses (43/44) had 100% protocol adherence on the standardized checklist. Forty-three nurses performed 387 paired Serial Neurologic Assessment in Pediatrics assessments (149 < 6 mo; 91 ≥ 6 mo to < 2 yr, and 147 ≥ 2 yr) on 299 patients. Interrater reliability was substantial to near-perfect across all components for each age-based Serial Neurologic Assessment in Pediatrics scale. Percent agreement was independent of developmental disabilities for all Serial Neurologic Assessment in Pediatrics components except Mental Status and lower extremity Motor Function for patients deemed "Able to Participate" with the assessment. Nurses reported that they felt Serial Neurologic Assessment in Pediatrics, compared with Glasgow Coma Scale, was easier to use and clearer in describing the neurologic status of patients who were intubated, were sedated, and/or had developmental disabilities. About 92% of nurses preferred to use Serial Neurologic Assessment in Pediatrics over Glasgow Coma Scale.

CONCLUSIONS

When used by critical care nurses, Serial Neurologic Assessment in Pediatrics has excellent protocol adherence, substantial to near-perfect interrater reliability, and is feasible to implement. Further work will determine the sensitivity and specificity for detecting clinically meaningful neurologic decline.

Prognostic value of the 2010 consensus definition of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage

BACKGROUND AND PURPOSE

Delayed cerebral ischemia (DCI) complicates the recovery of approximately 30% of patients with aneurysmal subarachnoid hemorrhage (aSAH). The definition of DCI widely varies, even though a consensus definition has been recommended since 2010. This study aimed to evaluate the prognostic value of the 2010 consensus definition of DCI in a cohort of patients with aSAH.

METHODS

We conducted a single-center, retrospective, observational study that included consecutive adult patients with aSAH who were admitted to the intensive care unit from January 2010 to December 2014. DCI was evaluated 48 h to 14 days after onset of aSAH symptoms using the 2010 consensus criteria and outcome was assessed by the Glasgow Outcome Scale (GOS) at discharge from hospital.

RESULTS

A total of 340 patients were analyzed and the incidence of DCI was 37.1%. The median time from primary hemorrhage to the occurrence of DCI was 97 h. Neurological deterioration was observed in most (89.7%) of the patients who fulfilled the DCI criteria. The occurrence of DCI was strongly associated with an unfavorable outcome (GOS 1-3) at hospital discharge (OR 2.65, 95% CI 1.69-4.22, p < 0.001).

CONCLUSIONS

The incidence of DCI after aSAH is high and its occurrence is strongly associated with an unfavorable neurological outcome. This finding adds to the previous literature, which has shown that DCI appears to be a major contributor affecting the functional ability of survivors of aSAH. To further advance reliable knowledge of DCI, future studies should adhere to the consensus definition of DCI.

Data quality of Glasgow Coma Scale and Systolic Blood Pressure in scientific studies involving physician-staffed emergency medical services: Systematic review

BACKGROUND

Emergency physicians on-scene provide highly specialized care to severely sick or injured patients. High-quality research relies on the quality of data, but no commonly accepted definition of EMS data quality exits. Glasgow Coma Score (GCS) and Systolic Blood Pressure (SBP) are core physiological variables, but little is known about the quality of these data when reported in p-EMS research. This systematic review aims to describe the quality of pre-hospital reporting of GCS and SBP data in studies where emergency physicians are present on-scene.

METHODS

A systematic literature search was performed using CINAHL, Cochrane, Embase, Medline, Norart, Scopus, SweMed + and Web of Science, in accordance with the PRISMA guidelines. Reported data on accuracy of reporting, completeness and capture were extracted to describe the quality of documentation of GCS and SBP. External and internal validity assessment was performed by extracting a set of predefined variables.

RESULTS

We included 137 articles describing data collection for GCS, SBP or both. Most studies (81%) were conducted in Europe and 59% of studies reported trauma cases. Reporting of GCS and SBP data were not uniform and may be improved to enable comparisons. Of the predefined external and internal validity data items, 26%-45% of data were possible to extract from the included papers.

CONCLUSIONS

Reporting of GCS and SBP is variable in scientific papers. We recommend standardized reporting to enable comparisons of p-EMS.

The current significance of the FOUR score: A systematic review and critical analysis of the literature

BACKGROUND

The Full Outline of Un-Responsiveness Score (FOURs) is a scale for clinical assessment of consciousness that was introduced to overcome disadvantages of the widely accepted Glasgow Coma Scale (GCS).

OBJECTIVE

To carry out a systematic review and critical analysis of the available literature on the clinical application of FOURs and perform a comparison to GCS, in terms of reliability and predictive value.

METHODS

Initial search retrieved a total of 147 papers. After applying strict inclusion criteria and further article selection to overcome data heterogeneity, a statistical comparison of inter-rater reliability, in-hospital mortality and long-term outcome prediction between the two scales in the adult and pediatric population was done.

RESULTS

Even though FOURs is more complicated than GCS, its application remains quite simple. Its reliability, validity and predictive value have been supported by an increasing number of studies, especially in critical care. A statistically significant difference (p = .034) in predicting in-hospital mortality in adults, in favor of FOURs when compared to GCS, was found. However, whether it poses a clinically significant advantage in detecting patients' deterioration and outcome prediction, compared to other scaling systems, remains unclear.

CONCLUSIONS

Further studies are needed to discern the FOURs' clinical usefulness, especially in patients in non-critical condition, with milder disorders of consciousness.

Inter-Rater Reliability Between Critical Care Nurses Performing a Pediatric Modification to the Glasgow Coma Scale

OBJECTIVES

Estimate the inter-rater reliability of critical care nurses performing a pediatric modification of the Glasgow Coma Scale in a contemporary PICU.

DESIGN

Prospective observation study.

SETTING

Large academic PICU.

PATIENTS/SUBJECTS

All 274 nurses with permanent assignments in the PICU were eligible to participate. A subset of 18 nurses were selected as study registered nurses. All PICU patients were eligible to participate.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

PICU nurses were educated and demonstrated proficiency on a pediatric modification of the Glasgow Coma Scale we created to make it more applicable to a diverse PICU population that included patients who are sedated, mechanically ventilated, and/or have developmental disabilities. Each study registered nurse observed a sample of nurses perform the Glasgow Coma Scale, and they independently scored the Glasgow Coma Scale. Patients were categorized as having developmental disabilities if their preillness Pediatric Cerebral Performance Category score was greater than or equal to 3. Fleiss' Kappa (κ), intraclass correlation coefficient, and percent agreement assessed inter-rater reliability for each Glasgow Coma Scale component (eye, verbal, motor) and age-specific scale (≥ 2 and < 2-yr-old). The overall percent agreement between study registered nurses and nurses was 89% for the eye, 91% for the verbal, and 79% for the motor responses. Inter-rater reliability ranged from good (intraclass correlation coefficient = 0.75) to excellent (intraclass correlation coefficient = 0.96) for testable patients. Agreement on the motor response was significantly lower for children with developmental disabilities (< 2 yr: 59% vs 95%; p = 0.0012 and ≥ 2 yr: 55% vs 91%; p = 0.0012). Agreement was significantly worse for intermediate range Glasgow Coma Scale motor responses compared with responses at the extremes (e.g., motor responses 2, 3, 4 vs 1, 5, 6; p < 0.05).

CONCLUSIONS

A pediatric modification of the Glasgow Coma Scale performed by trained PICU nurses has excellent inter-rater reliability, although reliability was reduced in patients with developmental disabilities and for intermediate range Glasgow Coma Scale responses. Further research is needed to determine the effectiveness of this Glasgow Coma Scale modification to detect clinical deterioration.

Development and validation of a new score for predicting functional outcome of neurocritically ill patients: The INCNS score

Aims

To develop and validate a novel score for prediction of 3‐month functional outcome in neurocritically ill patients.

Methods

The development of the novel score was based on two widely used scores for general critical illnesses (Acute Physiology and Chronic Health Evaluation II, APACHE II; Simplified Acute Physiology Score II, SAPS II) and consideration of the characteristics of neurocritical illness. Data from consecutive patients admitted to neurological ICU (N‐ICU) between January 2013 and June 2016 were used for the validation. The modified Rankin Scale (mRS) was used to evaluate 3‐month functional outcomes. APACHE II scores, SAPS II scores, and our novel scores at 24 hours and 72 hours in N‐ICU were obtained. We compared the prognostic performance of our score with APACHE II and SAPS II.

Results

We developed a 44‐point scoring system named the INCNS score, and it includes 19 items which were categorized into five parts: inflammation (I), nutrition (N), consciousness (C), neurological function (N), and systemic function (S). We validated the INCNS score with a cohort of 941 N‐ICU patients. The 72‐hours INCNS score achieved an area under the receiver operating characteristic curve (AUC) of 0.828 (95% CI: 0.802‐0.854), and the 24‐hours INCNS score achieved an AUC of 0.788 (95% CI: 0.759‐0.817). The INCNS score exhibited significantly better discriminative and prognostic performance than APACHE II and SAPS II at both 24 hours and 72 hours in N‐ICU.

Conclusion

We developed an INCNS score with superior predictive power for functional outcome of neurocritically ill patients.

Survey of Bedside Clinical Neurologic Assessments in U.S. PICUs

OBJECTIVE

To understand how routine bedside clinical neurologic assessments are performed in U.S. PICUs.

DESIGN

Electronic survey.

SETTING

Academic PICUs throughout the United States.

SUBJECTS

Faculty representatives from PICUs throughout the United States.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We surveyed how routine bedside neurologic assessments are reported to be performed in U.S. PICUs and the attitudes of respondents on the utility of these assessments. The survey contained questions regarding 1) components of neurologic assessments; 2) frequency of neurologic assessments; 3) documentation and communication of changes in neurologic assessment; and 4) optimization of neurologic assessments. Surveys were received from 64 of 67 institutions (96%). Glasgow Coma Scale and pupillary reflex were the most commonly reported assessments (80% and 92% of institutions, respectively). For patients with acute brain injury, 95% of institutions performed neurologic assessments hourly although assessment frequency was more variable for patients at low risk of developing brain injury and those at high risk for brain injury, but without overt injury. In 73% of institutions, any change detected on routine neuroassessment was communicated to providers, whereas in 27%, communication depended on the severity or degree of neurologic decline. Seventy percent of respondents thought that their current practice for assessing and monitoring neurologic status was suboptimal. Only 57% felt that the Glasgow Coma Scale was a valuable tool for the serial assessment of neurologic function in the ICU. Ninety-two percent felt that a standardized approach to assessing and documenting preillness neurologic function would be valuable.

CONCLUSIONS

Routine neurologic assessments are reported to be conducted in nearly all academic PICUs in the United States with fellowship training programs although the content, frequency, and triggers for communication vary between institutions. Most physicians felt that the current paradigms for neurologic assessments are suboptimal. These data suggest that optimizing and standardizing routine bedside nursing neurologic assessments may be warranted.

The value of the identification of predisposing factors for post-traumatic amnesia in management of mild traumatic brain injury

OBJECT

To identify the risk factors for post-traumatic amnesia (PTA) and to document the incidence of PTA after mild traumatic brain injuries.

METHODS

This was a prospective study, affecting mild TBI (mTBI) (Glasgow Coma Scale 14-15) cases attending to the Emergency Department between January 2009 and April 2012 (40 months duration). Patients were divided into two groups (Group A: without PTA, and Group B: with PTA, and they were assessed according to the risk factors.

RESULTS

A total of 1762 patients (males: 1002, 56.8%) were meeting study inclusion criteria [Group A: n = 1678 (83.8%), Group B: n = 84 (4.2%)]. Age, CT findings: (traumatic focal HCs in the frontal and temporal lobes or more diffuse punctate HCs, and skull base fractures), anticoagulation therapy and seizures were independent factors of PTA. There was no statistically significant correlation between PTA and sex, convexity fractures, stroke event, mechanism of mTBI (fall +/or beating), hypertension, coronary heart disease, chronic smokers and diabetes (p > 0.005).

CONCLUSION

CT findings: (traumatic focal HCs in the frontal and temporal lobes or more diffuse punctate HCs and skull base fractures), age, seizures and anticoagulation/antiplatelet therapy, were independent factors of PTA and could be used as predictive factors after mTBI.

Factors Influencing the Reliability of the Glasgow Coma Scale: A Systematic Review

BACKGROUND

The Glasgow Coma Scale (GCS) characterizes patients with diminished consciousness. In a recent systematic review, we found overall adequate reliability across different clinical settings, but reliability estimates varied considerably between studies, and methodological quality of studies was overall poor. Identifying and understanding factors that can affect its reliability is important, in order to promote high standards for clinical use of the GCS.

OBJECTIVE

The aim of this systematic review was to identify factors that influence reliability and to provide an evidence base for promoting consistent and reliable application of the GCS.

METHODS

A comprehensive literature search was undertaken in MEDLINE, EMBASE, and CINAHL from 1974 to July 2016. Studies assessing the reliability of the GCS in adults or describing any factor that influences reliability were included. Two reviewers independently screened citations, selected full texts, and undertook data extraction and critical appraisal. Methodological quality of studies was evaluated with the consensus-based standards for the selection of health measurement instruments checklist. Data were synthesized narratively and presented in tables.

RESULTS

Forty-one studies were included for analysis. Factors identified that may influence reliability are education and training, the level of consciousness, and type of stimuli used. Conflicting results were found for experience of the observer, the pathology causing the reduced consciousness, and intubation/sedation. No clear influence was found for the professional background of observers.

CONCLUSION

Reliability of the GCS is influenced by multiple factors and as such is context dependent. This review points to the potential for improvement from training and education and standardization of assessment methods, for which recommendations are presented.

Management of intracranial hemorrhage in adult patients on extracorporeal membrane oxygenation (ECMO): An observational cohort study

BACKGROUND

Intracranial hemorrhage (ICH) is a common complication in adults treated with extracorporeal membrane oxygenation (ECMO). The aim of this study was to identify predictors of outcome and investigate intervention strategies following ICH development in ECMO-treated adult patients.

METHODS

We conducted a retrospective review of adult patients (≥18 years) who developed an ICH during ECMO treatment at the Karolinska University Hospital (Stockholm, Sweden) between September 2005 and May 2017. Outcome was assessed by 30-day mortality and Glasgow Outcome Scale (GOS) after 6 months. The statistical analysis was supplemented by a case series of patients who were surgically treated for an ICH.

RESULTS

Sixty-five patients developed an ICH during ECMO treatment. 30-day mortality was 74% (n = 48), and was significantly associated with low level of consciousness at ICH diagnosis (p = 0.036), presence of intraparenchymal hematoma (IPH) (p = 0.049), IPH volume (p = 0.002), presence of intraventricular hemorrhage (p = 0.001), subarachnoid hemorrhage Fisher grade (p<0.001), hydrocephalus (p<0.001), midline shift (p = 0.026) and absent basal cisterns (p<0.001). Among the 30-day survivors (n = 17), 63% (n = 10) had favorable neurological outcome (GOS 4-5) after six months. Five patients were surgically treated for their ICH, some with dire hemorrhagic consequences, however one patient made a complete recovery.

CONCLUSIONS

ICH in adult ECMO patients is associated with a high mortality rate. Outcome predictors can help to identify patients where ICH treatment is indicated. Treating a patient with an ICH during ECMO represents an intricate balance between pro- and anticoagulatory demands. Furthermore, surgical treatment is associated with several risks but may be indicated in life-threatening lesions. Prospective studies are warranted.

Validation of the Full Outline of Unresponsiveness score coma scale in patients clinically suspected to have acute stroke in the emergency department

Introduction:

The Full Outline of Unresponsiveness score coma scale is a recently introduced coma scale. The objectives of this study were to assess the interrater reliability of the Full Outline of Unresponsiveness score coma scale when physicians and nurses in the emergency department apply the Full Outline of Unresponsiveness score on patients clinically suspected to have acute stroke and to look for any association between Full Outline of Unresponsiveness score coma scale and in-hospital mortality.

Methods:

Prospective study of 105 patients clinically suspected to have acute stroke recruited in an emergency department in a 4-month period. The Full Outline of Unresponsiveness score coma scale and Glasgow Coma Scale of each patient were assessed by one doctor and one nurse independently. The interrater reliability between physicians and nurses using the Full Outline of Unresponsiveness score and Glasgow Coma Scale score was assessed. The association between the Full Outline of Unresponsiveness score coma scale and in-hospital mortality was analysed using logistic regression, controlled for age, sex and diagnosis.

Results:

Full Outline of Unresponsiveness score had a good interrater reliability when applied to patients suspected to have acute stroke (kappa = 0.742, 95% confidence interval = 0.626–0.858). This was comparable to Glasgow Coma Scale score with a kappa = 0.796 (95% confidence interval = 0.694–0.898). For every 1-point increase in Full Outline of Unresponsiveness score coma scale, a reduction in in-hospital mortality was observed with an odds ratio of 0.76 (95% confidence interval = 0.63–0.91, p = 0.003), controlled for age, sex and diagnosis.

Conclusion:

The Full Outline of Unresponsiveness score may be a tool that can be used by emergency department doctors and nurses in assessing clinical stroke patients.

Time-dependent risk of seizures in critically ill patients on continuous electroencephalogram

OBJECTIVE

Find the optimal continuous electroencephalographic (CEEG) monitoring duration for seizure detection in critically ill patients.

METHODS

We analyzed prospective data from 665 consecutive CEEGs, including clinical factors and time-to-event emergence of electroencephalographic (EEG) findings over 72 hours. Clinical factors were selected using logistic regression. EEG risk factors were selected a priori. Clinical factors were used for baseline (pre-EEG) risk. EEG findings were used for the creation of a multistate survival model with 3 states (entry, EEG risk, and seizure). EEG risk state is defined by emergence of epileptiform patterns.

RESULTS

The clinical variables of greatest predictive value were coma (31% had seizures; odds ratio [OR] = 1.8, p < 0.01) and history of seizures, either remotely or related to acute illness (34% had seizures; OR = 3.0, p < 0.001). If there were no epileptiform findings on EEG, the risk of seizures within 72 hours was between 9% (no clinical risk factors) and 36% (coma and history of seizures). If epileptiform findings developed, the seizure incidence was between 18% (no clinical risk factors) and 64% (coma and history of seizures). In the absence of epileptiform EEG abnormalities, the duration of monitoring needed for seizure risk of <5% was between 0.4 hours (for patients who are not comatose and had no prior seizure) and 16.4 hours (comatose and prior seizure).

INTERPRETATION

The initial risk of seizures on CEEG is dependent on history of prior seizures and presence of coma. The risk of developing seizures on CEEG decays to <5% by 24 hours if no epileptiform EEG abnormalities emerge, independent of initial clinical risk factors. Ann Neurol 2017;82:177-185.

A Comparative Study of Glasgow Coma Scale and Full Outline of Unresponsiveness Scores for Predicting Long-Term Outcome After Brain Injury

PURPOSE

The aim of this study was to compare predictive ability of hospital Glasgow Coma Scale (GCS) scores and scores obtained using a novel coma scoring tool (the Full Outline of Unresponsiveness [FOUR] scale) on long-term outcomes among patients with traumatic brain injury. Preliminary research of the FOUR scale suggests that it is comparable with GCS for predicting mortality and functional outcome at hospital discharge. No research has investigated relationships between coma scores and outcome 12 months postinjury.

METHODS

This is a prospective cohort study. Data were gathered on adult patients with traumatic brain injury admitted to urban level I trauma center. GCS and FOUR scores were assigned at 24 and 72 hours and at hospital discharge. Glasgow Outcome Scale scores were assigned at 6 and 12 months.

RESULTS

The sample size was n = 107. Mean age was 53.5 (SD = ±21, range = 18-91) years. Spearman correlations were comparable and strongest among discharge GCS and FOUR scores and 12-month outcome (r = .73, p < .000; r = .72, p < .000). Multivariate regression models indicate that age and discharge GCS were the strongest predictors of outcome. Areas under the curve were similar for GCS and FOUR scores, with discharge scores occupying the largest areas.

CONCLUSION

GCS and FOUR scores were comparable in bivariate associations with long-term outcome. Discharge coma scores performed best for both tools, with GCS discharge scores predictive in multivariate models.

Comparison of outcome predictions by the Glasgow coma scale and the Full Outline of UnResponsiveness score in the neurological and neurosurgical patients in the Intensive Care Unit

Assessment of level of consciousness is very important in predicting patient's outcome from neurological illness. Glasgow coma scale (GCS) is the most commonly used scale, and Full Outline of UnResponsiveness (FOUR) score is also recently validated as an alternative to GCS in the evaluation of the level of consciousness. We carried out a prospective study in 97 patients aged above 16 years. We measured GCS and FOUR score within 24 h of Intensive Care Unit admission. The mean GCS and the FOUR scores were lower among nonsurvivors than among the survivors and were statistically significant (P < 0.001). Discrimination for GCS and FOUR score was fair with the area under the receiver operating characteristic curve of 0.79 and 0.82, respectively. The cutoff point with best Youden index for GCS and FOUR score was 6.5 each. Below the cutoff point, mortality was higher in both models (P < 0.001). The Hosmer-Lemeshow Chi-square coefficient test showed better calibration with FOUR score than GCS. A positive correlation was seen between the models with Spearman's correlation coefficient of 0.91 (P < 0.001).

Comparison of different scores as predictors of mechanical ventilation in drug overdose patients

The decision of intubation and mechanical ventilation in poisoned patients with impaired consciousness can be a difficult task. The present study aimed to evaluate the power of Glasgow Coma Scale (GCS), acute physiology and chronic health evaluation (APACHE II), rapid acute physiology score (RAPS) and rapid emergency medicine score (REMS) at admission in predicting the need of intubation and mechanical ventilation in drug overdose patients with disturbed consciousness level (DCL). This prospective observational study was conducted on 104 poisoned patients who were admitted to Tanta Toxicological Unit with a DCL. Four scoring systems (GCS, APACHE II, RAPS and REMS) were recorded for all patients on admission. Discrimination was evaluated using receiver operating characteristics curve and calculating the area under the curve (AUC). Twenty-four cases required mechanical ventilation. The mechanically ventilated patients had significantly lower value of GCS and higher values of APACHE II, REMS and RAPS than other group ( p < 0.001). Although the APACHE II score has the best AUC value (0.796) in predicting mechanical ventilation, there was no statistically significant difference between the four scores. GCS > 8 had 100% negative predictive value, while REMS > 8 had 100% positive predictive value.

Indicators of Subarachnoid Hemorrhage as a Cause of Sudden Cardiac Arrest

Subarachnoid hemorrhage (SAH) may present with cardiac arrest (SAH-CA). We report a case of SAH-CA to assist providers in distinguishing SAH as an etiology of cardiac arrest despite electrocardiogram findings that may be suggestive of a cardiac etiology. SAH-CA is associated with high rates of return of spontaneous circulation, but overall poor outcome. An initially non-shockable cardiac rhythm and the absence of brain stem reflexes are important clues in indentifying SAH-CA.

Clinical Course Score (CCS): a new clinical score to evaluate efficacy of neurotrauma treatment in traumatic brain injury and subarachnoid hemorrhage

BACKGROUND

Neurotrauma continues to represent a challenging public health issue requiring continual improvement in therapeutic approaches. As no such current system exists, we present in this study the Clinical Course Score (CCS) as a new clinical score to evaluate the efficacy of neurotrauma treatment.

METHODS

The CCS was calculated in neurotrauma patients to be the difference between the grade of the Glasgow Outcome Scale 6 months after discharge from our department and the grade of a 1 to 5 point reduced Glasgow Coma Scale on admission. We assessed the CCS in a total of 248 patients (196 traumatic brain injury [TBI] patients and 52 subarachnoid hemorrhage [SAH] patients) who were treated in our Department of Neurosurgery between January 2011 and December 2012.

RESULTS

We found negative CCS grades both in mild TBI and in mild SAH patients. In patients with severe TBI or SAH, we found positive CCS grades. In SAH patients, we found higher CCS scores in younger patients compared with elderly subjects in both mild and severe cases.

CONCLUSIONS

The CCS can be useful in evaluating different therapeutic approaches during neurotrauma therapy. This new score might improve assessment of beneficial effects of therapeutic procedures.

A pediatric specific shock index in combination with GMS identifies children with life threatening or severe traumatic brain injury

PURPOSE

We have previously demonstrated that a shock index, pediatric age adjusted (SIPA) accurately identifies severely blunt injured children. We aimed to determine if SIPA could more accurately identify children with severe traumatic brain injury (TBI) than hypotension alone.

METHODS

We performed subset analysis of those children with TBI among a cohort of children age 4-16 years with blunt trauma and injury severity score ≥15 from 1/07 to 6/13. We evaluated the ability of four markers to identify the most severely brain injured children. Markers included hypotension, elevated SIPA, abnormal GCS motor score (GMS), and elevated SIPA or abnormal GMS. We aimed to determine which of these four markers had the highest sensitivity in identifying severely injured children.

RESULTS

Three hundred and ninety-two (392) children were included. Hypotension was present in 24 patients (6%); elevated SIPA in 106 (27 %), abnormal GMS in 172 (44%), and elevated SIPA or abnormal GMS in 206 (53%). All markers were able to accurately identify severely injured children with TBI. Elevated SIPA or abnormal GMS identified a greater percentage of patients with each of seven complications with higher sensitivity than each of the three other markers.

CONCLUSION

Among blunt injured children with TBI, elevated SIPA or abnormal GMS identifies severely brain injured children.

Duration of post-traumatic amnesia as a predictor of functional outcome in school-age children: a systematic review

AIM

In adults, duration of post-traumatic amnesia (PTA) is a powerful early predictor of functional outcomes in traumatic brain injury. The aim of this work was to assess the predictive validity of PTA duration for outcomes in children (6-18y).

METHOD

PsycINFO, MEDLINE, Web of Science, and Embase were searched for papers published to January 2014. Ten studies met inclusion criteria: they used standardized instruments to assess PTA and functional outcomes, and examined relationships between the two. Outcomes were classified according to (1) the International Classification of Functioning, Disability and Health (ICF) core sets for neurological conditions for post-acute care and (2) global functioning and quality of life. Methodological quality was rated for each study.

RESULTS

The search identified 10 studies of moderate mean quality (M=11.8 out of 18). Longer PTA duration related to worse functional outcomes: global functioning and in the two ICF categories ('body function', 'activities and participation'). Relationships between PTA duration and quality of life and the ICF category of 'body structure' were not examined. PTA duration was, in 46 out of 60 (76.67%) instances, a stronger predictor of outcomes than other indices of injury severity.

CONCLUSION

Longer PTA duration is a valid predictor of worse outcomes in school-age children. Thus, PTA should be routinely assessed in children after traumatic brain injury.

Standards of scoring, monitoring, and parameter targeting in German neurocritical care units: a national survey

BACKGROUND

Optimal management of physiological parameters in neurological/neurosurgical intensive care units (NICUs) is largely unclear as high-quality evidence is lacking. The aim of this survey was to investigate if standards exist in the use of clinical scores, systemic and cerebral monitoring and the targeting of physiology values and in what way this affects clinical management in German NICUs.

METHODS

National survey, on-line anonymized questionnaire. German departments stating to run a neurological, neurosurgical or interdisciplinary neurological/neurosurgical intensive care unit were identified by a web-based search of all German hospitals and contacted via email.

RESULTS

Responses from 78 German NICUs were obtained. Of 19 proposed clinical/laboratory/radiological scores only 5 were used regularly by >60 %. Bedside neuromonitoring (NM) predominantly consisted of transcranial Doppler sonography (94 %), electroencephalography (92 %) and measurement of intracranial pressure (ICP) (90 %), and was installed if patients had or were threatened by elevated ICP (86 %), had specific diseases like subarachnoid hemorrhage (51 %) or were comatose (35 %). Although mean trigger values for interventions complied with guidelines or wide-spread customs, individual trigger values varied widely, e.g., for hyperglycemia (maximum blood glucose between 120 and 250 mg/dl) or for anemia (minimum hemoglobin values between 5 and 10 g/dl).

CONCLUSIONS

Although apparently aiming for standardization in neurocritical care, German NICUs show substantial differences in NM and monitoring-associated interventions. In terms of scoring and monitoring methods, German NICUs seem to be quite conservative. These survey results suggest a need of prospective and randomized interventional trials in neurocritical care to help define standards and target values.

[Survey study: update on neurological intensive care in Germany 2012: structure, standards and scores in neurological intensive care units]

BACKGROUND

Neurological critical care lacks high-quality evidence to guide optimal treatment. Furthermore, it is presently rather unclear as to what extent German neurological intensivists adhere to guidelines, employ standard operating procedures or use scoring tools.

METHODS

An e-mail-based questionnaire was distributed to physicians directing German neurological, neurosurgical and neurological/neurosurgical interdisciplinary intensive care units (ICUs).

RESULTS

Of the 326 departments 78 answered the questionnaire and of these 53% were university units. The ICUs were either led by neurologists (37%), neurosurgeons (22%), anesthetists (28%) or a combination of these (13%). The mean number of ICU beds was 11.2 and the mean number of intensivists 7.7. Guideline adherence was stated to amount to 75 % by 41 % of the ICUs. Applications of standard procedures was achieved by more than 80 % for several ICU management aspects, while only 5 out of 19 of the respondents routinely used scoring tools in > 60% of the ICUs. The extent of protocol and score applications differed significantly according to hospital status or leading speciality.

CONCLUSION

This survey suggests an obvious interest in but also an unfulfilled need of guidance in a standardized approach to neurological critical care in Germany. More activity in multicentre clinical research with a neurocritical focus to provide optimization of protocols, scores and guidelines appears to be warranted.

A multicenter prospective study of interobserver agreement using the Full Outline of Unresponsiveness score coma scale in the intensive care unit

OBJECTIVE

The classification of the comatose patient has been greatly improved with the use of coma scales. The Full Outline of Unresponsiveness score has emerged as an alternative to the Glasgow Coma Scale in that it incorporates essential information needed to assess the depth of coma. One set of patients for which the Full Outline of Unresponsiveness score could be particularly beneficial is those admitted to an intensive care unit, where approximately 30%-35% of all patients are intubated or ventilated. This manuscript reports on a study that examined the inter-rater reliability of the Full Outline of Unresponsiveness score in five intensive care units.

SETTING

Seven intensive care units at five U.S. hospitals partici-pated.

SUBJECTS

Patients admitted during parts of 2010 and 2011 had their Full Outline of Unresponsiveness score assessed independently by two nurses within 1 hr of admission.

DESIGN

We evaluated the weighted kappa statistic of the Full Outline of Unresponsiveness score over all patients and stratified by mechanical ventilation status. Finally, we looked for evidence of heterogeneity in Full Outline of Unresponsiveness score agreement across hospitals.

MEASUREMENTS AND MAIN RESULTS

A total of 907 adult critically ill patients had Full Outline of Unresponsiveness score assessments by two evaluators. The overall weighted kappa statistic was 0.92, and this did not differ by whether or not a patient was on a ventilator. Among hospitals there was modest heterogeneity for the weighted kappa; however, all of the values were >0.80.

CONCLUSIONS

The Full Outline of Unresponsiveness score showed excellent inter-rater agreement overall and at each of the five hospitals. This demonstrates that the Full Outline of Unresponsiveness score can be utilized reliably in critically ill patients.

Full Outline of UnResponsiveness score and Glasgow Coma Scale in medical patients with altered sensorium: interrater reliability and relation to outcome

PURPOSE

Full Outline of UnResponsiveness, or FOUR score (FS), is a recently described scoring system for evaluation of altered sensorium. This study examined interrater reliability for FS and Glasgow Coma Scale (GCS) among medical patients with altered mental status and compared outcome predictability of GCS, FS, and Sequential Organ Failure Assessment score.

PATIENTS AND METHODS

Adult patients with altered mental status due to medical causes were rated by neurology consultants and internal medicine residents on FS and GCS. Interobserver reliability for GCS and FS was assessed using κ score. Relation with outcomes was explored using univariate and multivariate analyses.

MAIN RESULTS

Of the 100 patients (age, 62 ± 17 years), 60 had neurologic conditions; 26, metabolic encephalopathy; 9, infections; and 7, others. Thirty-nine patients died at 3 months. κ Scores ranged from 0.71 to 0.85 for GCS and from 0.71 to 0.95 for FS. On multivariate analysis, GCS was predictive of outcome at 3 months; FS was predictive of mortality. Area under the receiver operating characteristic curves suggested equivalent performance of both scoring systems.

CONCLUSIONS

Interrater reliability and outcome predictability for FS were comparable with those for GCS. This study supports the use of FS for evaluation of altered mental status in the medical wards.