Variation among trauma centers' calculation of Glasgow Coma Scale score: results of a national survey

Early death prediction in children with traumatic brain injury using computed tomography scoring systems

PURPOSE

Marshall and Rotterdam are the most commonly used CT scoring systems to predict the outcome following traumatic brain injury (TBI). Although several studies have compared the performance of the two scoring systems in adult patients, none of these studies has evaluated the performance of the two scoring systems in pediatric patients. This study aimed to determine the predictive value of the Marshall and Rotterdam scoring systems in pediatric patients with TBI.

METHODS

This retrospective study included 105 children with admission GCS < 12, with a mean age of 6.2 (±3.5) years. Their initial CT and status at hospital discharge (dead or alive) were reviewed, and both the Marshall and Rotterdam scores were calculated. We examined whether each score was related to the early death of pediatric patients.

RESULTS

The pediatric patients with higher Marshall and Rotterdam scores had a higher mortality rate. There was a good correlation between the Marshall and Rotterdam scoring systems (Spearman's rho = 0.618, significant at the 0.05 level). Both systems demonstrated a high degree of discrimination when predicting early mortality. The Marshall scoring system had reasonable discrimination (AUC 0.782), and the Rotterdam scoring system had good discrimination (AUC 0.729). Comparing the two CT scoring systems, the Marshall scoring system provided a better positive predictive value (90%) for early mortality than the Rotterdam scoring system (78%).

CONCLUSIONS

Both the Marshall and Rotterdam scoring systems have good predictability for assessing mortality in pediatric patients with TBI. The performance of the Marshall scoring system was equal to or slightly better than that of the Rotterdam scoring system.

Outcome Prediction in Patients of Traumatic Brain Injury Based on Midline Shift on CT Scan of Brain

Background Clinicians treating patients with head injury often take decisions based on their assessment of prognosis. Assessment of prognosis could help communication with a patient and the family. One of the most widely used clinical tools for such prediction is the Glasgow coma scale (GCS); however, the tool has a limitation with regard to its use in patients who are under sedation, are intubated, or under the influence of alcohol or psychoactive drugs. CT scan findings such as status of basal cistern, midline shift, associated traumatic subarachnoid hemorrhage (SAH), and intraventricular hemorrhage are useful indicators in predicting outcome and also considered as valid options for prognostication of the patients with traumatic brain injury (TBI), especially in emergency setting.

Materials and Methods 108 patients of head injury were assessed at admission with clinical examination, history, and CT scan of brain. CT findings were classified according to type of lesion and midline shift correlated to GCS score at admission. All the subjects in this study were managed with an identical treatment protocol. Outcome of these patients were assessed on GCS score at discharge.

Results Among patients with severe GCS, 51% had midline shift. The degree of midline shift in CT head was a statistically significant determinant of outcome (p = 0.023). Seventeen out of 48 patients (35.4%) with midline shift had poor outcome as compared with 8 out of 60 patients (13.3%) with no midline shift.

Conclusion In patients with TBI, the degree of midline shift on CT scan was significantly related to the severity of head injury and resulted in poor clinical outcome.

Full Outline of UnResponsiveness score versus Glasgow Coma Scale in critically ill patients with altered sensorium: A comparison of inter-observer variability and outcomes

Background and Aims:

Glasgow Coma scale (GCS), the most widely used tool for evaluation of the level of consciousness has various limitations. The Full Outline of UnResponsiveness (FOUR) score is a possible alternative. The present study was designed to examine the inter-rater reliability and outcome predictability of these scores in the Intensive Care Unit (ICU).

Methods:

The GCS and FOUR scores of 111 adult patients with altered sensorium, admitted to the ICU, were assessed as early as possible after admission by the Senior Resident (SR), Junior Resident (JR) and Staff Nurse (SN) of ICU. The outcomes measured survival and modified Rankin Scale (mRS) and Glasgow outcome scale (GOS) of the patients at discharge.

Results:

The inter-observer agreement was measured using the kappa ('k') statistic. For GCS it was higher (k = 0.472 to 0.555) than FOUR score (k = 0.352 to 0.448). A higher 'k' score in either score was recorded between SR and JR. Linear regression analysis showed no significant association of either score with the duration of ICU stay or mechanical ventilation. Survival in ICU was correlated with both GCS and FOUR scores on logistic regression. GOS and mRS were correlated with either GCS or FOUR scores on ordinal regression.

Conclusion:

The inter-observer agreement with FOUR score was not superior to GCS in this study, possibly due to lack of familiarity with the FOUR score. Both the scores were statistically correlated with the rate of survival.

Altered Mental Status: Current Evidence-based Recommendations for Prehospital Care

Introduction

In the United States emergency medical services (EMS) protocols vary widely across jurisdictions. We sought to develop evidence-based recommendations for the prehospital evaluation and treatment of a patient with an acute change in mental status and to compare these recommendations against the current protocols used by the 33 EMS agencies in the State of California.

Methods

We performed a literature review of the current evidence in the prehospital treatment of a patient with altered mental status (AMS) and augmented this review with guidelines from various national and international societies to create our evidence-based recommendations. We then compared the AMS protocols of each of the 33 EMS agencies for consistency with these recommendations. The specific protocol components that we analyzed were patient assessment, point-of-care tests, supplemental oxygen, use of standardized scoring, evaluating for causes of AMS, blood glucose evaluation, toxicological treatment, and pediatric evaluation and management.

Results

Protocols across 33 EMS agencies in California varied widely. All protocols call for a blood glucose check, 21 (64%) suggest treating adults at <60mg/dL, and half allow for the use of dextrose 10%. All the protocols recommend naloxone for signs of opioid overdose, but only 13 (39%) give specific parameters. Half the agencies (52%) recommend considering other toxicological causes of AMS, often by using the mnemonic AEIOU TIPS. Eight (24%) recommend a 12-lead electrocardiogram; others simply suggest cardiac monitoring. Fourteen (42%) advise supplemental oxygen as needed; only seven (21%) give specific parameters. In terms of considering various etiologies of AMS, 25 (76%) give instructions to consider trauma, 20 (61%) to consider stroke, and 18 (55%) to consider seizure. Twenty-three (70%) of the agencies have separate pediatric AMS protocols; others include pediatric considerations within the adult protocol.

Conclusion

Protocols for patients with AMS vary widely across the State of California. The evidence-based recommendations that we present for the prehospital diagnosis and treatment of this condition may be useful for EMS medical directors tasked with creating and revising these protocols.

Bispectral index value correlates with Glasgow Coma Scale in traumatic brain injury patients

Background

Accuracy of consciousness level assessment is very important. It may determine and influence further clinical decisions, thus influences patients’ outcomes. The widest method in determining the level of awareness is the Glasgow Coma Scale (GCS). Despite its common use, GCS scores obtained by one clinician may differ from others depending on their interpretations and past experience. One of the tools used to assess the level of consciousness objectively is bispectral index (BIS). The aim of this study was to identify the correlation between BIS and GCS score in patients with traumatic brain injury.

Patients and Methods

A total of 78 patients who were admitted to emergency room for traumatic brain injury were included in this study. One observer evaluated the GCS of all patients to minimize subjectivity. Another investigator then obtained the BIS values for each patient. Spear-man’s rank correlation coefficient was used to determine whether GCS correlated with BIS value.

Results

In 78 patients, the BIS was found to be significantly correlated with GCS (r=0.744, p<0.01). The BIS values increased with an increasing GCS. Mean BIS values of mild, moderate, and severe head injury were 88.1±5.6, 72.1±11.1, and 60.4±11.7, respectively.

Conclusion

In this study, a significant correlation existed between GCS and BIS. This finding suggests that BIS may be used for assessing GCS in patients with traumatic brain injury. However, the scatters of BIS values for any GCS level may limit the BIS in predicting GCS accurately.

Observations on the Ethical and Social Aspects of Disorders of Consciousness

The care of chronically unconscious patients raises vexing medical, ethical, and social questions concerning diagnosis, prognosis, communication with family members, and decision making, including the withdrawal of life support. We provide updates on major controversies surrounding disorders of consciousness. Issues such as withdrawal of artificial nutrition and hydration – which had been considered “settled” by many in the medical, legal and ethical communities – have resurfaced under the pressure of social groups and religious authorities. Some assumptions about the level of awareness and the prognosis of vegetative state and minimal conscious patients are questioned by advances in clinical care because of insights produced by neuroscience research techniques, particularly functional neuroimaging. Both the clinical and neuroscience dimensions of disorders of consciousness raise complex issues such as resource allocation and high levels of diagnostic inaccuracies (at least, for the vegetative state). We conclude by highlighting areas needing further research and collaboration.

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).

Role of computed tomography scores and findings to predict early death in patients with traumatic brain injury: A reappraisal in a major tertiary care hospital in Nepal

Background:

Glasgow Coma Scale has been a long sought model to classify patients with head injury. However, the major limitation of the score is its assessment in the patients who are either sedated or under the influence of drugs or intubated for airway protection. The rational approach for prognostication of such patients is the utility of scoring system based on the morphological criteria based on radiological imaging. Among the current armamentarium, a scoring system based on computed tomography (CT) imaging holds the greatest promise in conquering our conquest for the same.

Methods:

We included a total of 634 consecutive neurosurgical trauma patients in this series, who presented with mild-to-severe traumatic brain injury (TBI) from January 2013 to April 2014 at a tertiary care center in rural Nepal. All pertinent medical records (including all available imaging studies) were reviewed by the neurosurgical consultant and the radiologist on call. Patients’ worst CT image scores and their outcome at 30 days were assessed and recorded. We then assessed their independent performance in predicting the mortality and also tried to seek the individual variables that had significant interplay for determining the same.

Results:

Both imaging score (Marshall) and clinical score (Rotterdam) can be used to reliably predict mortality in patients with acute TBI with high prognostic accuracy. Other specific CT characteristics that can be used to predict early mortality are traumatic subarachnoid hemorrhage, midline shift, and status of the peri-mesencephalic cisterns.

Conclusion:

We demonstrated in this cohort that though the Marshall score has the high predictive power to determine the mortality, better discrimination could be sought through the application of the Rotterdam score that encompasses various individual CT parameters. We thereby recommend the use of such comprehensive prognostic model so as to augment our predictive power for properly dichotomizing the prognosis of the patients with TBI. In the future, it will therefore be important to develop prognostic models that are applicable for the majority of patients in the world they live in, and not just a privileged few who can use resources not necessarily representative of their societal environment.

A comparative study between Marshall and Rotterdam CT scores in predicting early deaths in patients with traumatic brain injury in a major tertiary care hospital in Nepal

PURPOSE

CT plays a crucial role in the early assessment of patients with traumatic brain injury (TBI). Marshall and Rotterdam are the mostly used scoring systems, in which CT findings are grouped differently. We sought to determine the values of the scoring system and initial CT findings in predicting the death at hospital discharge (early death) in patients with TBI.

METHODS

There were consecutive 634 traumatic neurosurgical patients with mild-to-severe TBI admitted to the emergency department of College of Medical Sciences. Their initial CT and status at hospital discharge (dead or alive) were reviewed, and both CT scores were calculated. We examined whether each score is related to early death; compared the two scoring systems' performance in predicting early death, and identified the CT findings that are independent predictors for early death.

RESULTS

Both imaging score (Marshall) and clinical score (Rotterdam) can be used to reliably predict mortality in patients with acute traumatic brain injury with high prognostic accuracy. Other specific CT characteristics that can be used to predict early mortality are traumatic subarachnoid hemorrhage, midline shift and status of the peri-mesencephalic cisterns.

CONCLUSIONS

Marshall CT classification has strong predictive power, but greater discrimination can be obtained if the individual CT parameters underlying the CT classification are included in a prognostic model as in Rotterdam score. Consequently, for prognostic purposes, we recommend the use of individual characteristics rather than the CT classification. Performance of CT models for predicting outcome in TBI can be significantly improved by including more details of variables and by adding other variables to the models.

Clinical monitoring scales in acute brain injury: assessment of coma, pain, agitation, and delirium

Serial clinical examination represents the most fundamental and basic form of neurological monitoring, and is often the first and only form of such monitoring in patients. Even in patients subjected to physiological monitoring using a range of technologies, the clinical examination remains an essential tool to follow neurological progress. Key aspects of the clinical examination have now been systematized into scoring schemes, and address consciousness, pain, agitation, and delirium (PAD). The Glasgow Coma Scale has been the traditional tool to measure consciousness, but the full outline of unresponsiveness (FOUR) score has recently been validated in a variety of settings, and at present, both represent clinically useful tools. Assessment of PAD in neurologically compromised patients present special challenges. For pain, the Numeric Rating Scale is the preferred initial approach, with either the Behavioral Pain Scale or the Critical Care Pain Observation Tool in subjects who are not able to respond. The Nociception Coma Scale-Revised may be useful in patients with severe disorders of consciousness. Conventional sedation scoring tools for critical care, such as the Richmond Area Sedation Scale (RASS) and Sedation-Agitation Scale (SAS) may provide reasonable tools in some neurocritical care patients. The use of sedative drugs and neuromuscular blockers may invalidate the use of some clinical examination tools in others. The use of sedation interruption to assess neurological status can result in physiological derangement in unstable patients (such as those with uncontrolled intracranial hypertension), and is not recommended.

Evidence-based improvement of the National Trauma Triage Protocol: The Glasgow Coma Scale versus Glasgow Coma Scale motor subscale

BACKGROUND

Ideal triage uses simple criteria to identify severely injured patients. Glasgow Coma Scale motor (GCSm) may be easier for field use and was considered for the National Trauma Triage Protocol (NTTP). This study evaluated performance of the NTTP if GCSm is substituted for the current GCS score ≤ 13 criterion.

METHODS

Subjects in the National Trauma Data Bank undergoing scene transport were included. Presence of NTTP physiologic (Step 1) and anatomic (Step 2) criteria was determined. GCSm score ≤ 5 was defined as a positive criterion. Trauma center need (TCN) was defined as Injury Severity Score (ISS) > 15, intensive care unit admission, urgent operation, or emergency department death. Test characteristics were calculated to predict TCN. Area under the curve was compared between GCSm and GCS scores, individually and within the NTTP. Logistic regression was used to determine the association of GCSm score ≤ 5 and GCS score ≤ 13 with TCN after adjusting for other triage criteria. Predicted versus actual TCN was compared.

RESULTS

There were 811,143 subjects. Sensitivity was lower (26.7% vs. 30.3%), specificity was higher (95.1% vs. 93.1%), and accuracy was similar (66.1% vs. 66.3%) for GCSm score ≤ 5 compared with GCS score ≤ 13. Incorporated into the NTTP Steps 1 + 2, GCSm score ≤ 5 traded sensitivity (60.4% vs. 62.1%) for specificity (67.1% vs. 65.7%) with similar accuracy (64.2% vs. 64.2%) to GCS score ≤ 13. There was no difference in the area under the curve between GCSm score ≤ 5 and GCS score ≤ 13 when incorporated into the NTTP Steps 1 + 2 (p = 0.10). GCSm score ≤ 5 had a stronger association with TCN (odds ratio, 3.37; 95% confidence interval, 3.27-3.48; p < 0.01) than GCS score ≤ 13 (odds ratio, 3.03; 95% confidence interval, 2.94-3.13; p < 0.01). GCSm had a better fit of predicted versus actual TCN than GCS at the lower end of the scales.

CONCLUSION

GCSm score ≤ 5 increases specificity at the expense of sensitivity compared with GCS score ≤ 13. When applied within the NTTP, there is no difference in discrimination between GCSm and GCS. GCSm score ≤ 5 is more strongly associated with TCN and better calibrated to predict TCN. Further study is warranted to explore replacing GCS score ≤ 13 with GCSm score ≤ 5 in the NTTP.

LEVEL OF EVIDENCE

Prognostic study, level III.

Cumulative incidence and predictors of neurosurgical interventions following nonsevere traumatic brain injury with mildly abnormal head imaging findings

BACKGROUND

Incidence and predictors of neurosurgical interventions following nonsevere traumatic brain injury (TBI) with mildly abnormal head computed tomographic (CT) findings are poorly defined. Despite this, neurosurgical consultation is routinely requested in this patient population. Our objective was to determine incidence of neurosurgical intervention in this patient population and identify clinical and radiographic features predicting the subsequent need for these interventions.

METHODS

We identified all consecutive adult patients with nonsevere TBI admitted from January 1, 2001, through December 31, 2010. The definitions of "mildly abnormal initial head CT findings" and "neurosurgical interventions" were determined a priori by author consensus. Cumulative incidence of neurosurgical interventions was determined, and multivariate logistic regression was used to identify independent predictors of neurosurgical intervention.

RESULTS

Of 677 patients, 51 underwent neurosurgical intervention for a cumulative incidence of 7.5%. Only 1.6% required an intracranial procedure. In adjusted analysis, presence of coagulopathy (odds ratio [OR], 2.21; 95% confidence interval [CI], 1.13-4.3; p = 0.02), suspected cerebrospinal fluid leak (OR, 11.36; 95% CI, 2.83-45.58; p = 0.001), any basal cistern or sylvian fissure subarachnoid hemorrhage (OR, 2.94; 95% CI, 1.56-5.57; p = 0.001), depressed skull fracture (OR, 2.84; 95% CI, 1.29-6.28; p = 0.01), or unstable repeated head CT findings (OR, 2.81; 95% CI, 1.52-5.2; p = 0.001) remained an independent predictor of the need for subsequent neurosurgical intervention.

CONCLUSION

Among patients with nonsevere TBI and mildly abnormal head imaging findings in which routine neurosurgical consultation is obtained, there is a low incidence of neurosurgical interventions. Our findings suggest that routine early neurosurgical consultation in this patient population may not be necessary; however, this should be tested in a prospective, comparative study.

LEVEL OF EVIDENCE

Prognostic study, level III; therapeutic study, level IV.

Are initial radiographic and clinical scales associated with subsequent intracranial pressure and brain oxygen levels after severe traumatic brain injury?

BACKGROUND

Prediction of clinical course and outcome after severe traumatic brain injury (TBI) is important.

OBJECTIVE

To examine whether clinical scales (Glasgow Coma Scale [GCS], Injury Severity Score [ISS], and Acute Physiology and Chronic Health Evaluation II [APACHE II]) or radiographic scales based on admission computed tomography (Marshall and Rotterdam) were associated with intensive care unit (ICU) physiology (intracranial pressure [ICP], brain tissue oxygen tension [PbtO2]), and clinical outcome after severe TBI.

METHODS

One hundred one patients (median age, 41.0 years; interquartile range [26-55]) with severe TBI who had ICP and PbtO2 monitoring were identified. The relationship between admission GCS, ISS, APACHE II, Marshall and Rotterdam scores and ICP, PbtO2, and outcome was examined by using mixed-effects models and logistic regression.

RESULTS

Median (25%-75% interquartile range) admission GCS and APACHE II without GCS scores were 3.0 (3-7) and 11.0 (8-13), respectively. Marshall and Rotterdam scores were 3.0 (3-5) and 4.0 (4-5). Mean ICP and PbtO2 during the patients' ICU course were 15.5 ± 10.7 mm Hg and 29.9 ± 10.8 mm Hg, respectively. Three-month mortality was 37.6%. Admission GCS was not associated with mortality. APACHE II (P = .003), APACHE-non-GCS (P = .004), Marshall (P < .001), and Rotterdam scores (P < .001) were associated with mortality. No relationship between GCS, ISS, Marshall, or Rotterdam scores and subsequent ICP or PbtO2 was observed. The APACHE II score was inversely associated with median PbtO2 (P = .03) and minimum PbtO2 (P = .008) and had a stronger correlation with amount of time of reduced PbtO2.

CONCLUSION

Following severe TBI, factors associated with outcome may not always predict a patient's ICU course and, in particular, intracranial physiology.

Early clinical indicators of developmental outcome in abusive head trauma

PURPOSE

The purpose of the study was to determine the developmental prognostic significance of early clinical indicators in abusive head trauma.

METHODS

Seventy-one children were diagnosed with abusive head trauma and followed in a post-injury growth and development clinic. A retrospective chart review was completed to gather clinical features at the time of injury, including presence or absence of early post-traumatic seizures, presence or absence of intubation, and presence or absence of pediatric intensive care unit admission. Children then underwent developmental testing with use of the Capute Scales of the Cognitive Adaptive Test (CAT) and the Clinical Linguistic and Auditory Milestone Scale (CLAMS) during follow-up clinic visits. Clinical features at initial injury were compared to developmental outcome.

RESULTS

Thirty-four of 71 patients with seizures during their admission hospitalization scored significantly lower on follow-up developmental testing than patients who did not have seizures. Twenty-one of 71 patients who required intubation scored lower on developmental testing than patients who did not require intubation. Thirty-five of 71 patients who required pediatric intensive care unit admission scored lower on developmental testing than patients who did not require pediatric intensive care unit admission.

CONCLUSIONS

This study demonstrates that clinical factors at the time of injury, such as early post-traumatic seizures and intubation requirement, are associated with poorer developmental outcome. This study also suggests that close developmental follow-up should be obtained for all children with abusive head trauma, regardless of whether or not the child was admitted to the PICU.

Neurocritical care nursing research priorities

The science of nursing has long been discussed as a blending of the art and science of caring, and nursing research builds the evidence of support for nursing practice. Nurses and nursing care are key to successful neurocritical care research endeavors. Ideally nursing care should be evidence based and supported by solid research. The goal of nursing research is to expand the knowledge of caring for patients. Within the scope of nursing research, the priorities for research in neurocritical care should support this goal. In this manuscript, we discuss what we believe are the priorities of neurocritical care nursing research, the obstacles, and some possible solutions.

Predictors of extubation success in patients with middle cerebral artery acute ischemic stroke

Introduction. Stroke patients often meet respiratory guidelines for extubation, but uncertainty exists if patients will protect their airway due to impaired mental status. Patients with middle cerebral artery (MCA) acute ischemic stroke (AIS) might have specific predictors of successful extubation. Methods. Retrospective cohort of MCA AIS patients requiring intubation. Results. Thirty-seven MCA AIS patients were extubated successfully and ten failed extubation. Those who successfully extubated had higher extubation composite and eye response Glasgow Coma Scale (GCS) scores compared to those who failed (median 10T (IQR 9T-11T) versus 9.5T (8T-10T), P = 0.047, and 4 (3-4) versus 2.5 (1-3), P < 0.01). When adjusted for age, admission National Institutes of Health Stroke Scale score and laterality, patients with a GCS score ≥8T trended toward extubating successfully (OR 23.30 (CI 0.94-580.27), P = 0.055). Conclusions. The GCS score might be important in predicting successful extubation in MCA AIS patients. Further prospective study is warranted to better assess factors predictive of extubation outcome in stroke and other brain-injured patients.

Evaluation of coma: a critical appraisal of popular scoring systems

Numerous scoring scales have been proposed and validated to evaluate coma for rapid pre-hospital assessment and triage, disease severity, and prognosis for morbidity and mortality. These scoring systems have been predicated on core features that serve as a basis for this review and include ease of use, inter-rater reliability, reproducibility, and predictive value. Here we review the benefits and limitations of the most popular coma scoring systems. The methods include search of Medline, databases, and manual review of article bibliographies. Few of the many available coma scales have gained widespread approval and popularity. The best known and widely accepted scale is the Glasgow Coma Scale (GCS). The Reaction Level Scale (RLS85) has utility and proven benefit, but little acceptance outside of Scandinavia. The newer Full Outline of UnResponsiveness (FOUR) score provides an attractive replacement for all patients with fluctuating levels of consciousness and is gradually gaining wide acceptance.

Classification and prediction of outcome in traumatic brain injury based on computed tomographic imaging

Traumatic brain injury (TBI) is a common and potentially devastating problem. The classification of TBI is necessary for accurate diagnosis and the prediction of outcomes. The increased use of early sedation, intubation and ventilation in more severely injured patients has decreased the value of the Glasgow Coma Scale for the purposes of classification. An alternative is the classification of TBI according to morphological criteria based on computed tomography (CT) investigations. This article reviews the current classification and prediction of outcomes in TBI based on CT imaging. Classifications based on the presence or absence of intracranial local lesions, diffuse injury, signs of subarachnoid or intra-ventricular haemorrhage and fractures or foreign bodies are considered, and their predictive value is discussed. Future studies should address the complicated issue of how optimally to combine CT characteristics for prognostic purposes and how to improve on currently used CT classifications to predict outcomes more accurately.

Knowledge of Glasgow coma scale by air-rescue physicians

Objective

To assess the theoretical and practical knowledge of the Glasgow Coma Scale (GCS) by trained Air-rescue physicians in Switzerland.

Methods

Prospective anonymous observational study with a specially designed questionnaire. General knowledge of the GCS and its use in a clinical case were assessed.

Results

From 130 questionnaires send out, 103 were returned (response rate of 79.2%) and analyzed. Theoretical knowledge of the GCS was consistent for registrars, fellows, consultants and private practitioners active in physician-staffed helicopters. The clinical case was wrongly scored by 38 participants (36.9%). Wrong evaluation of the motor component occurred in 28 questionnaires (27.2%), and 19 errors were made for the verbal score (18.5%). Errors were made most frequently by registrars (47.5%, p = 0.09), followed by fellows (31.6%, p = 0.67) and private practitioners (18.4%, p = 1.00). Consultants made significantly less errors than the rest of the participating physicians (0%, p < 0.05). No statistically significant differences were shown between anesthetists, general practitioners, internal medicine trainees or others.

Conclusion

Although the theoretical knowledge of the GCS by out-of-hospital physicians is correct, significant errors were made in scoring a clinical case. Less experienced physicians had a higher rate of errors. Further emphasis on teaching the GCS is mandatory.

Paramedic Rapid Sequence Intubation for Severe Traumatic Brain Injury: Perspectives from an Expert Panel

Although early intubation has become standard practice in the prehospital management of severe traumatic brain injury (TBI), many patients cannot be intubated without neuromuscular blockade. Several emergency medical services (EMS) systems have implemented paramedic rapid sequence intubation (RSI) protocols, with published reports documenting apparently conflicting outcomes effects. In response, the Brain Trauma Foundation assembled a panel of experts to interpret the existing literature regarding paramedic RSI for severe TBI and offer guidance for EMS systems considering adding this skill to the paramedic scope of practice. The interpretation of this panel can be summarized as follows: (1) the existing literature regarding paramedic RSI is inconclusive, and apparent differences in outcome can be explained by use of different methodologies and variability in comparison groups; (2) the use of Glasgow Coma Scale score alone to identify TBI patients requiring RSI is limited, with additional research needed to refine our screening criteria; (3) suboptimal RSI technique as well as subsequent hyperventilation may account for some of the mortality increase reported with the procedure; (4) initial and ongoing training as well as experience with RSI appear to affect performance; and (5) the success of a paramedic RSI program is dependent on particular EMS and trauma system characteristics.

Design and validation of a critical pathway for hospital management of patients with severe traumatic brain injury

BACKGROUND

Critical pathways for the management of patients with severe traumatic brain injury (STBI) may contribute to reducing the incidence of hospital complications, length of hospitalization stay, and cost of care. Such pathways have previously been developed for departments with significant resource availability. In Mexico, STBI is the most important cause of complications and length of stay in neurotrauma services at public hospitals. Although current treatment is designed basically in accordance with the Brain Trauma Foundation guidelines, shortfalls in the availability of local resources make it difficult to comply with these standards, and no critical pathway is available that accords with the resources of public hospitals. The purpose of the present study was to design and to validate a critical pathway for managing STBI patients that would be suitable for implementation in neurotrauma departments of middle-income level countries.

METHODS

The study comprised two phases: design (through literature review and design plan) and validation (content, construct, and appearance) of the critical pathway.

RESULTS

The validated critical pathway for managing STBI patients entails four sequential subprocesses summarizing the hospital's care procedures, and includes three components: (1) nodes and criteria (in some cases, indicators are also included); (2) health team members in charge of the patient; (3) maximum estimated time for compliance with recommendations.

CONCLUSIONS

This validated critical pathway is based on the current scientific evidence and accords with the availability of resources of middle-income countries.

Assessing the level of consciousness in children: A plea for the Glasgow Coma Motor subscore

AIM

The Glasgow Coma Scale (GCS) is not always easy to score and its reliability has been questioned. In adults the GCS Motor score has proven a valuable alternative, as it is easier to assess yet shows similar predictive capacity for outcome. We wanted to test the non-inferiority of the Glasgow Coma Motor score GCS-M versus the Total score GCS-T for predicting outcome in children.

MATERIALS AND METHODS

As part of the Flemish paediatric trauma registry (PENTA) we collected data on 96 consecutive children (0-18 years) with moderate to severe traumatic brain injury. Outcome was evaluated using a three level ordinal scale: [normal to mild disability, moderate to severe disability and death]. A number of proportional odds models were fitted for various choices of predictive variables (GCS-T, GCS-M, age, sex, and injury severity score ISS). For each model we calculated Somers'D(xy) rank correlation and NagelKerke's R(2)N index, both measures of the predictive performance of the model.

RESULTS

All children had an injury to the brain that resulted in a hospital stay of more than 48h. Half of them had a "best" initial GCS of 15; 60%, a Motor score of 6. The median Injury Severity Score ISS was 16. Outcome was 'normal to mild' in 79 children, 'moderate to severe' in 7, and 'death' in 10. D(xy) values were 0.983 for the model with the Motor score and 0.972 for that with the total GCS, indicating excellent predictive performance for both. R(2)N indices were 0.862 and 0.813, respectively. Overall the difference between all models was small.

CONCLUSION

The GCS Motor subscore was shown to have at least the same predictive ability for outcome as the total GCS. It is our opinion that the total GCS is unnecessarily complicated (especially in children). Using the Motor score alone will improve scoring compliance and statistical performance. We do not believe that the reduction in number of potential scores from 13 to 6 would decrease the descriptive capacity significantly, since clinical algorithms typically group values of the total GCS into five or fewer ranges.

Prognostic value of computerized tomography scan characteristics in traumatic brain injury: results from the IMPACT study

Computerized tomography (CT) scanning provides an objective assessment of the structural damage to the brain following traumatic brain injury (TBI). We aimed to describe and quantify the relationship between CT characteristics and 6-month outcome, assessed by the Glasgow Outcome Scale (GOS). Individual patient data from the IMPACT database were available on CT classification (N = 5209), status of basal cisterns ( N = 3861), shift ( N = 4698), traumatic subarachnoid hemorrhage (tSAH) ( N = 7407), and intracranial lesions ( N = 7613). We used binary logistic and proportional odds regression for prognostic analyses. The CT classification was strongly related to outcome, with worst outcome for patients with diffuse injuries in CT class III (swelling; OR 2.50; CI 2.09-3.0) or CT class IV (shift; OR 3.03; CI 2.12-4.35). The prognosis in patients with mass lesions was better for patients with an epidural hematoma (OR 0.64; CI 0.56-0.72) and poorer for an acute subdural hematoma (OR 2.14; CI 1.87-2.45). Partial obliteration of the basal cisterns (OR 2.45; CI 1.88-3.20), tSAH (OR 2.64; CI 2.42-2.89), or midline shift (1-5 mm-OR 1.36; CI 1.09-1.68); >5 mm-OR 2.20; CI 1.64-2.96) were strongly related to poorer outcome. Discrepancies were found between the scoring of basal cisterns/shift and the CT classification, indicating observer variation. These were less marked in studies that had used a central review process. Multivariable analysis indicated that individual CT characteristics added substantially to the prognostic value of the CT classification alone. We conclude that both the CT classification and individual CT characteristics are important predictors of outcome in TBI. For clinical trials, a central review process is advocated to minimize observer variability in CT assessment.

The predictive value of field versus arrival Glasgow Coma Scale score and TRISS calculations in moderate-to-severe traumatic brain injury

BACKGROUND

Glasgow Coma Scale (GCS) scores are widely used to quantify level of consciousness in the prehospital environment. The predictive value of field versus arrival GCS is not well defined but has tremendous implications with regard to triage and therapeutic decisions as well as the use of various predictive scoring systems, such as Trauma Score and Injury Severity Score (TRISS). This study explores the predictive value of field GCS (fGCS) and arrival GCS (aGCS) as well as TRISS calculations using field (fTRISS) and arrival (aTRISS) data in patients with moderate-to-severe traumatic brain injury (TBI).

METHODS

Major trauma victims with head Abbreviated Injury Scores of 3 or greater were identified from our county trauma registry over a 16-year period. The predictive ability of fGCS with regard to aGCS was explored using univariate statistics and linear regression modeling. The difference between aGCS and fGCS was also modeled against mortality and the composite endpoint using logistic regression, adjusting for fGCS. The predictive value of preadmission GCS (pGCS), defined as either fGCS or aGCS in nonintubated patients without a documented fGCS, with regard to mortality and a composite endpoint representing the need for neurosurgical care (death, craniotomy, invasive intracranial pressure monitoring, or intensive care unit care >48 hours) was determined using receiver-operator curve (ROC) analysis. Finally, fTRISS and aTRISS predicted survival values were compared with each other and to observed survival.

RESULTS

A total of 12,882 patients were included. Mean values for fGCS and aGCS were similar (11.4 and 11.5, respectively, p = 0.336), and a strong correlation (r = 0.67, 95% CI 0.66-0.69, p < 0.0001) was observed between them. The difference between fGCS and aGCS was also predictive of outcome after adjusting for fGCS. Good predictive ability was observed for pGCS with regard to both mortality and neurosurgical intervention. Both fTRISS and aTRISS predicted survival values were nearly identical to observed survival. Observed and fTRISS predicted survival were nearly identical in patients undergoing prehospital intubation

CONCLUSIONS

Values for fGCS are highly predictive of aGCS, and both are associated with outcome from TBI. A change in GCS from the field to arrival is highly predictive of outcome. The use of field data for TRISS calculations appears to be a valid methodological approach, even in severely injured TBI patients undergoing prehospital intubation.

Prediction of Outcome in Traumatic Brain Injury with Computed Tomographic Characteristics: A Comparison between the Computed Tomographic Classification and Combinations of Computed Tomographic Predictors

BACKGROUND AND OBJECTIVE

The Marshall computed tomographic (CT) classification identifies six groups of patients with traumatic brain injury (TBI), based on morphological abnormalities on the CT scan. This classification is increasingly used as a predictor of outcome. We aimed to examine the predictive value of the Marshall CT classification in comparison with alternative CT models.

METHODS

The predictive value was investigated in the Tirilazad trials (n = 2269). Alternative models were developed with logistic regression analysis and recursive partitioning. Six month mortality was used as outcome measure. Internal validity was assessed with bootstrapping techniques and expressed as the area under the receiver operating curve (AUC).

RESULTS

The Marshall CT classification indicated reasonable discrimination (AUC = 0.67), which could be improved by rearranging the underlying individual CT characteristics (AUC = 0.71). Performance could be further increased by adding intraventricular and traumatic subarachnoid hemorrhage and by a more detailed differentiation of mass lesions and basal cisterns (AUC = 0.77). Models developed with logistic regression analysis and recursive partitioning showed similar performance. For clinical application we propose a simple CT score, which permits a more clear differentiation of prognostic risk, particularly in patients with mass lesions.

CONCLUSION

It is preferable to use combinations of individual CT predictors rather than the Marshall CT classification for prognostic purposes in TBI. Such models should include at least the following parameters: status of basal cisterns, shift, traumatic subarachnoid or intraventricular hemorrhage, and presence of different types of mass lesions.

Physician Knowledge of the Glasgow Coma Scale

Appropriate triage is critical to optimizing outcome from battle related injuries. The Glasgow Coma Scale (GCS) is the primary means by which combat casualties, who have suffered head injury, are triaged. For the GCS to be reliable in this critical role, it must be applied accurately. To determine the level of knowledge of the GCS among military physicians with exposure and/or training in the scale we administered a prospective, voluntary, and anonymous survey to physicians of all levels of training at military medical centers with significant patient referral base. The main outcome measures were correct identification of title and categories of the GCS along with appropriate scoring of each category. Overall performance on the survey was marginal. Many were able to identify what "GCS" stands for, but far fewer were able to identify the titles of the specific categories, let alone identify the specific scoring of each category. When evaluated based on medical specialties, those in surgical specialties outperformed those in the medical specialties. When comparing the different levels of training, residents and fellows performed better than attending staff or interns. Finally, those with Advanced Trauma Life Support (ATLS) certification performed significantly better than those without the training. Physician knowledge of the GCS, as demonstrated in this study, is poor, even in a population of individuals with specific training in the use of the scale. It is concluded that, to optimize outcome from combat related head injury, methods for improving accurate quantitation of neurologic state need to be explored.

Predicting Outcome after Traumatic Brain Injury: Development and Validation of a Prognostic Score Based on Admission Characteristics

The early prediction of outcome after traumatic brain injury (TBI) is important for several purposes, but no prognostic models have yet been developed with proven generalizability across different settings. The objective of this study was to develop and validate prognostic models that use information available at admission to estimate 6-month outcome after severe or moderate TBI. To this end, this study evaluated mortality and unfavorable outcome, that is, death, and vegetative or severe disability on the Glasgow Outcome Scale (GOS), at 6 months post-injury. Prospectively collected data on 2269 patients from two multi-center clinical trials were used to develop prognostic models for each outcome with logistic regression analysis. We included seven predictive characteristics-age, motor score, pupillary reactivity, hypoxia, hypotension, computed tomography classification, and traumatic subarachnoid hemorrhage. The models were validated internally with bootstrapping techniques. External validity was determined in prospectively collected data from two relatively unselected surveys in Europe (n = 796) and in North America (n = 746). We evaluated the discriminative ability, that is, the ability to distinguish patients with different outcomes, with the area under the receiver operating characteristic curve (AUC). Further, we determined calibration, that is, agreement between predicted and observed outcome, with the Hosmer-Lemeshow goodness-of-fit test. The models discriminated well in the development population (AUC 0.78-0.80). External validity was even better (AUC 0.83-0.89). Calibration was less satisfactory, with poor external validity in the North American survey (p < 0.001). Especially, observed risks were higher than predicted for poor prognosis patients. A score chart was derived from the regression models to facilitate clinical application. Relatively simple prognostic models using baseline characteristics can accurately predict 6-month outcome in patients with severe or moderate TBI. The high discriminative ability indicates the potential of this model for classifying patients according to prognostic risk.

Comparing logistic models based on modified GCS motor component with other prognostic tools in prediction of mortality: results of study in 7226 trauma patients

A simple reproducible and sensitive prognostic trauma tool is still needed. In this article we have introduced modified GCS motor response (MGMR) and evaluated the performance of logistic models based on this variable. The records of 8452 trauma patients admitted to major hospitals of Tehran from 1999 to 2000 were analysed. 7226 records with known outcome were included in our study. Logistic models based on outcome (death versus survival) as a dependent variable and Injury Severity Score (ISS), Revised Trauma Score (RTS), Glasgow Coma Scale (GCS), GCS motor component (GMR) and MGMR (following command [=2], movement but not following [=1] command and without movement [=0]) were compared based on their accuracy and area under the Receiver Operating Characteristic (ROC) curve. The accuracy of the Trauma and Injury Severity Score (TRISS), RTS, GCS, GMR and MGMR models were almost the same. Considering both the area under the ROC curve and accuracy, the age included MGMR model was also comparable with other age included models (RTS+age, GCS+age, GMR+age). We concluded that although in some situations we need more sophisticated models, should our results be reproducible in other populations, MGMR (with or without age added) model may be of considerable practical value.

Escala de Coma de Glasgow: subestimação em pacientes com respostas verbais impedidas

Questão freqüente no uso da Escala de Coma de Glasgow (ECGl), na fase aguda, em pacientes internados devido ao trauma crânio-encefálico (TCE) é a subestimação decorrente de situações impeditivas como intubação endotraqueal/traqueostomia, sedação e edema palpebral. O objetivo deste estudo foi identificar e determinar a subestimação na pontuação total da ECGl quando se utiliza a pontuação 1 nas situações de impedimento para a sua avaliação. A amostra estudada foi de 76 pacientes internados com TCE no Hospital das Clínicas da FMUSP. Em 42 (55,3%) pacientes, não havia impedimentos e foram realizadas 136 avaliações. Em 34 (44,7%), havia impedimentos caracterizados por intubação ou traqueostomia, podendo estar ou não associados com edema palpebral e sedação, e o total de avaliações foi de 310. A pontuação nesses pacientes total variou de 3 a 11, com os escores mais freqüentes de 3 e 6. Pelos valores estimados pela regressão linear, a partir das pontuações obtidas em AO e MRM foram obtidas as seguintes subestimações: média=1,03 ±1,36, mediana=0,54 (intubação ou traqueostomia); média=0,40 ±0,79, mediana=0,00 (intubação ou traqueostomia + sedação); média=0,57 ±0,96, mediana=0,27 (intubação ou traqueostomia + sedação + edema palpebral). Conclui-se que, no TCE grave, a pontuação total da ECGl fixando a MRV em 1, embora subestimada, encontra-se próxima da real.

A comparison of the Glasgow Coma Scale score to simplified alternative scores for the prediction of traumatic brain injury outcomes

STUDY OBJECTIVE

The 15-point Glasgow Coma Scale (GCS) is extensively used in the initial evaluation of traumatic brain injury in emergency department (ED) settings. We hypothesized that the GCS might be unnecessarily complex and that a simpler scoring system might demonstrate similar accuracy in the prediction of traumatic brain injury outcomes.

METHODS

We analyzed a prospectively maintained trauma registry of patients evaluated at our Level I trauma center from 1990 to 2002. We calculated the test performance of ED GCS scores relative to 4 clinically relevant traumatic brain injury outcomes (emergency intubation, neurosurgical intervention, brain injury, and mortality) using areas under their receiver operating characteristic (ROC) curves. We performed similar analyses for each of the 3 GCS components and for 2 simplified 3-point scores (simplified verbal score: oriented=2, confused conversation=1, inappropriate words or less=0; simplified motor score: obeys commands=2, localizes pain=1, withdrawal to pain or less=0). We then compared the test performance of each of these 5 to the total GCS score using a priori thresholds for clinically important differences.

RESULTS

Each of the 3 GCS components alone and the 2 simplified 3-point scores demonstrated ROC areas within 9% of that of the GCS score for the 4 outcomes, with a median difference of 3.0% (interquartile range 1.6% to 4.5%). These differences were all below our a priori definitions of clinical importance.

CONCLUSION

The 3 individual GCS components alone and two 3-point simplified scores demonstrated test performance similar to the total GCS score for the prediction of 4 clinically relevant traumatic brain injury outcomes. Despite the widespread use of the GCS for the initial evaluation of traumatic brain injury, this score may be unnecessarily complex for this indication.

Interrater reliability of Glasgow Coma Scale scores in the emergency department

STUDY OBJECTIVE

Emergency physicians often use the Glasgow Coma Scale (GCS) to help guide decisions in patient care, yet the reliability of the GCS has never been tested in a typical broad sample of emergency department (ED) patients. We determined the interrater reliability of the GCS between emergency physicians when adult patients with altered levels of consciousness are assessed.

METHODS

In this prospective observational study at a university Level I trauma center, we enrolled a convenience sample of ED patients older than 17 years who presented with an altered level of consciousness. Two residency-trained attending emergency physicians independently assessed and recorded the GCS score and its components (eye, verbal, and motor) in blinded fashion within a 5-minute period. Data were analyzed for interrater reliability by using standard ordinal calculations. We also created scatter plots and Bland-Altman plots for each GCS component and for the GCS score.

RESULTS

One hundred thirty-one patients were screened and enrolled in the study, with 15 excluded because of protocol violations. Of the 116 remaining patients, the agreement percentage for exact total GCS was 32% (tau-b=0.739; Spearman rho=0.864; Spearman rho2=75%). Agreement percentage for GCS components were eye 74% (tau-b=0.715; Spearman rho=0.757; Spearman rho2=57%), verbal 55% (tau-b=0.587; Spearman rho=0.665; Spearman rho2=44%), and motor 72% (tau-b=0.742; Spearman rho=0.808; Spearman rho2=65%). Our Spearman's analyses found that only approximately half (44% to 65%) of the observed variance could be explained by the relationship between the paired component measures. For GCS components, only 55% to 74% of paired measures were identical, and 6% to 17% of them were 2 or more points apart.

CONCLUSION

We found only moderate degrees of interrater agreement for the GCS and its components.

A Comparison of Prehospital and Hospital Data in Trauma Patients

OBJECTIVE

The use of prehospital data as an indicator for trauma team activation has been established. The relationship between field (Fd) and emergency department (ED) systolic blood pressure (SBP), Glasgow Coma Scale (GCS) score, and airway control as it relates to outcomes is unclear. We hypothesized that ED and Fd physiologic parameters are equally valid predictors of outcomes. In addition, we hypothesized that early field intubation will improve survival compared with later ED intubation.

METHODS

Trauma registry data from two academic Level I centers from 1994 to 2001, excluding all transfers and burn patients, were analyzed using Wilcoxon signed-rank test and multivariate logistic regression with appropriate adjustments.

RESULTS

There were 19,409 patients, 16,277 blunt and 3,132 penetrating trauma. There were 3,571 Fd and 746 ED intubations. ED intubation was associated with increased risk of fatal outcome compared with nonintubated patient (adjusted odds ratio, 3.1; p < 0.0001) and field intubations (adjusted odds ratio, 3.0; p < 0.0001). ED-GCS score was not significantly different from Fd-GCS score, with 82% having the same GCS category. This was not the case for SBP, and only in 60% of the cases were ED-SBP and Fd-SBP in the same category. In 31% of the patients, the ED-SBP increased, and in 9% of cases, the ED-SBP decreased compared with Fd-SBP. This was true for both blunt and penetrating trauma. Both Fd-SBP and ED-SBP were independent predicators of fatal outcome, and mortality rate significantly increased if ED-SBP category decreased compared with Fd-SBP.

CONCLUSION

Early field intubation was associated with a decreased risk of fatal outcome compared with ED intubation. ED-GCS score was not significantly different from Fd-GCS score, and either one can be used to predict fatal outcome. However, ED-SBP was different from Fd-SBP in 40% of the patients, with the majority of cases having higher ED-SBP. Although ED-SBP was a better predictor of outcome, the best model is achieved when both ED and field SBP are used.

Glasgow Coma Scale Score, Mortality, and Functional Outcome in Head-Injured Patients

BACKGROUND

Preresuscitation Glasgow Coma Scale (P-GCS) score is frequently obtained in injured patients and incorporated into mortality prediction. Data on functional outcome in head injury is sparse. A large group of patients with head injuries was analyzed to assess relationships between P-GCS score, mortality, and functional outcome as measured by the Functional Independence Measure (FIM).

METHODS

Records for patients with International Classification of Diseases, Ninth Revision diagnosis codes indicating head injury in a statewide trauma registry between 1994 and 2002 were selected. P-GCS score, mortality, and FIM score at hospital discharge were integrated and analyzed.

RESULTS

Of 138,750 patients, 22,924 patients were used for the mortality study and 7,150 patients for the FIM study. A good correlation exists between P-GCS score and FIM, as determined by rank correlation coefficients, whereas mortality falls steeply between a P-GCS score of 3 and a P-GCS score of 7 followed by a shallow fall. Although P-GCS score is related to mortality in head-injured patients, its relationship is nonlinear, which casts doubt on its use as a continuous measure or an equivalent set of categorical measures incorporated into outcome prediction models. The average FIM scores indicate substantial likelihood of good outcomes in survivors with low P-GCS scores, further complicating the use of the P-GCS score in the prediction of poor outcome at the time of initial patient evaluation.

CONCLUSION

Although the P-GCS score is related to functional outcome as measured by the FIM score and mortality in head injury, current mortality prediction models may need to be modified to account for the nonlinear relationship between P-GCS score and mortality. The P-GCS score is not a good clinical tool for outcome prediction in individual head-injured patients, given the variability in mortality rates and functional outcomes at all scores.

The status of the Glasgow Coma Scale

The Glasgow Coma Scale (GCS) was first introduced in the 1970s to provide a simple and reliable method of recording and monitoring change in the level of consciousness of head injured patients. Since its introduction, the GCS has been widely utilized in the trauma community and its use expanded beyond the original intentions of the score. In the context of traumatic injury, this paper discusses the use of the GCS as a predictor of outcome, the limitations of the GCS, the reliability of the GCS and potential alternatives through a critical review of the literature. The relevance to Australian trauma populations is also addressed.

A new "TRISS-like" probability of survival model for intubated trauma patients

BACKGROUND

Prehospital trauma patient field intubations and paralyzations, using neuromuscular blocking agents before emergency department respiratory and neurologic assessments are made, bias assessments and outcome evaluations using probability-of-survival models, such as TRISS and A Severity Characterization of Trauma (ASCOT). We present a newly developed "TRISS-like" probability-of-survival model for intubated blunt- and penetrating-injured patient assessment.

METHODS

From a population of 51397 consecutively admitted trauma patients, this study used all 5740 (11.2% of the total injured population) intubated patients with complete data from a statewide trauma registry from October 1, 1993, to September 30, 1996. Model performance was evaluated using standard calibration and discrimination measures and z and W statistics of significance.

RESULTS

The new model accurately predicted survival for blunt- and penetrating-injured intubated patients and is applicable to 11 etiologic patient populations.

CONCLUSION

Study findings suggest that the new TRISS-like model should be used to assess both blunt- and penetrating-injured intubated patients. Use of this new model provides an analytical method for addressing a significant limitation of both the standard TRISS and ASCOT models, which are not applicable to intubated injured patient assessment. In addition, use of this model will complement TRISS/ASCOT assessments of nonintubated trauma patients and thus permit appropriate assessments for both intubated and nonintubated injured patient study populations.

Impact of American College of Surgeons verification on trauma outcomes

OBJECTIVE

The purpose of this study was to compare the impact of trauma patient outcomes before and after Level II American College of Surgeons (ACS) verification was received in a not-for-profit community hospital.

METHODS

This was a retrospective analysis of hospital discharge data for timeframes before and after Level II ACS verification was conducted. Originally, 8,674 patients were identified using the International Classification of Diseases, 9th Revision codes for trauma. These data were parsed to 7,811 patients by using International Classification of Diseases, 9th Revision codes 800 xx through 959.9 x, which signify an admitting diagnosis of trauma; 3,835 of the patients were admitted after the July 28, 1998, verification date. Blunt injuries constituted the vast majority of the patients (n = 7,488). Outcome measures studied included changes in length of stay (LOS), mortality, and total cost. Internal control was coronary artery bypass graft patients at the same hospital, and external control was trauma patients at a non-ACS hospital over the same time period. Data are presented with p values and SE and the ratio of observed/expected values on the basis of the all-payer severity-adjusted diagnosis-related group severity model.

RESULTS

The two timeframes exhibited statistically different outcomes in several variables. Adjusting for severity postverification, LOS was 10% less (p < 0.000). Similarly, severity-adjusted mortality observed/expected ratios were significantly different: 0.81 before versus 0.59 after (p < 0.000). The severity-adjusted ratio of costs found that the postverification era was 5% lower (p < 0.000). The contribution margin of the trauma patient population to the hospital well exceeded any postverification costs. Both control groups exhibited no significant changes in their severity-adjusted outcomes, which could have invalidated these results.

CONCLUSION

This study suggests that the efforts and resources consumed achieving ACS Level II trauma center verification appear to result in desired outcomes as evidenced by decreased LOS, reduced in-hospital mortality rates, reduced cost, and improved contribution margins.

Improving the Glasgow Coma Scale score: motor score alone is a better predictor

BACKGROUND

The Glasgow Coma Scale (GCS) has served as an assessment tool in head trauma and as a measure of physiologic derangement in outcome models (e.g., TRISS and Acute Physiology and Chronic Health Evaluation), but it has not been rigorously examined as a predictor of outcome.

METHODS

Using a large trauma data set (National Trauma Data Bank, N = 204,181), we compared the predictive power (pseudo R2, receiver operating characteristic [ROC]) and calibration of the GCS to its components.

RESULTS

The GCS is actually a collection of 120 different combinations of its 3 predictors grouped into 12 different scores by simple addition (motor [m] + verbal [v] + eye [e] = GCS score). Problematically, different combinations summing to a single GCS score may actually have very different mortalities. For example, the GCS score of 4 can represent any of three mve combinations: 2/1/1 (survival = 0.52), 1/2/1 (survival = 0.73), or 1/1/2 (survival = 0.81). In addition, the relationship between GCS score and survival is not linear, and furthermore, a logistic model based on GCS score is poorly calibrated even after fractional polynomial transformation. The m component of the GCS, by contrast, is not only linearly related to survival, but preserves almost all the predictive power of the GCS (ROC(GCS) = 0.89, ROC(m) = 0.87; pseudo R2(GCS) = 0.42, pseudo R2(m) = 0.40) and has a better calibrated logistic model.

CONCLUSION

Because the motor component of the GCS contains virtually all the information of the GCS itself, can be measured in intubated patients, and is much better behaved statistically than the GCS, we believe that the motor component of the GCS should replace the GCS in outcome prediction models. Because the m component is nonlinear in the log odds of survival, however, it should be mathematically transformed before its inclusion in broader outcome prediction models.

Emergency Medical Services Outcomes Project III (EMSOP III): the role of risk adjustment in out-of-hospital outcomes research

The purpose of the Emergency Medical Services Outcomes Project (EMSOP) is to develop a foundation and framework for out-of-hospital outcomes research. Fundamental to that purpose is the identification of priority conditions, risk-adjustment measures (RAMs), and outcome measures. In this third EMSOP article, we examine the topic of risk adjustment, discuss the relevance of risk adjustment for out-of-hospital outcomes research, and recommend RAMs that should be evaluated for potential use in emergency medical services (EMS) research. Risk adjustment allows better judgment about the effectiveness and quality of alternative therapies; it fosters a better comparison of potentially dissimilar groups of patients. By measuring RAMs, researchers account for an important source of variation in their studies. Core RAMs are those measures that might be necessary for out-of-hospital outcomes research involving any EMS condition. Potential core RAMs that should be evaluated for their feasibility, validity, and utility in out-of-hospital research include patient age and sex, race and ethnicity, vital signs, level of responsiveness, Glasgow Coma Scale, standardized time intervals, and EMS provider impression of the presenting condition. Potential core RAMs that could be obtained through linkage to other data sources and that should be evaluated for their feasibility, validity, and utility include principal diagnosis and patient comorbidity. We recommend that these potential core RAMs be systematically evaluated for use in risk adjustment of out-of-hospital patient groups that might be used for outcomes research