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Yildirim D, Kavala A, Değirmenci Öz S, Sezer E, Kuğu E, Coşkun Z. Inter-rater reliability in the assessment of consciousness in patients receiving palliative care in intensive care: A prospective cross sectional observational study. Nurs Crit Care 2024. [PMID: 38508739 DOI: 10.1111/nicc.13065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 01/14/2024] [Accepted: 03/05/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND The Glasgow Coma Scale (GCS) is one of the methods that has validity for evaluating the consciousness levels of patients in the literature and is accepted by health authorities. AIM The purpose of this study was to evaluate the inter-rater reliability of GCS in intensive care patients receiving palliative care. STUDY DESIGN A prospective cross sectional observational study. The study was conducted in a general intensive care unit with 20 beds with patients receiving palliative care. In the unit, 18 nurses worked in two shifts, day and night. Each patient's primary palliative care nurse and two additional researchers were given one minute to independently record the patient's GCS total and subscale scores. All observations were completed within 5 min as there could be significant changes in the patient's GCS score during observations. RESULTS A total of 258 assessments were completed. For the GCS total scoring, a moderate agreement was found between palliative care nurses and the first researcher-observer (49.0%) and also between palliative care nurses and the second researcher-observer (47.7%). In addition, there was a substantial agreement between the first and second researchers (78.9%) and also between all observers (61.5%) (all p = .001). CONCLUSIONS Although there was a near-perfect agreement between the two researcher-observers, we found only moderate agreement among all observers (palliative care nurses and two researcher-observers) in the evaluation of GCS total and subscale scores. RELEVANCE TO CLINICAL PRACTICE We found that lack of knowledge and training on the standardized use of GCS is still a problem for palliative and intensive care units. Because of the diversity of patients requiring GCS assessment in palliative care units, refresher training programs and hands-on workshops on consciousness assessment should be organized regularly for more experienced nurses.
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Affiliation(s)
- Dilek Yildirim
- Faculty of Health Sciences, Department of Nursing, Istanbul Aydın University, Istanbul, Turkey
| | - Arzu Kavala
- Faculty of Health Sciences, Department of Nursing, Istanbul Aydın University, Istanbul, Turkey
| | - Seda Değirmenci Öz
- Faculty of Health Sciences, Department of Nursing Administration, Zonguldak Bülent Ecevit University, Zonguldak, Turkey
| | - Esra Sezer
- Faculty of Health Sciences, Department of Nursing, Acibadem University, Istanbul, Turkey
| | - Emre Kuğu
- Vocational School of Health Services, Department of Medical Services and Techniques, Anesthesia Programme, Fenerbahçe University, Istanbul, Turkey
| | - Zeynep Coşkun
- Medical Park Florya Hospital, Istanbul Aydin University, Istanbul, Turkey
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K R, Ananda Rao A, D K, Vaishnav PP, Davis S, T A, J DK, Suresh A, Nadig C. Patients With Suicidal Patterns in the Emergency Room: A Clinical and Social Reflection. Cureus 2021; 13:e18570. [PMID: 34765347 PMCID: PMC8575329 DOI: 10.7759/cureus.18570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2021] [Indexed: 11/27/2022] Open
Abstract
Background and objective Emergency physicians come across a myriad of medical afflictions resulting from suicide attempts. The Indian contribution to global suicide deaths is alarming; the social construct of India is unique, and so are the problems and challenges. This study aims to describe the social background, demographic parameters and correlate the clinical profile and outcomes of all patients presenting with an attempted or completed suicide. Materials and methods The present study is a hospital-based prospective observational study conducted by the Department of Emergency Medicine at RL Jalappa Hospital and Research Centre, a rural tertiary-care center in Karnataka, India, from June 2020 to February 2021. After stabilizing the patient, a detailed socio-demographic history was recorded. Details of the suicide attempt and findings of the clinical examination were noted. Results The final study sample consisted of 89 patients who presented to the emergency room (ER). Fifty-three patients were female, and thirty-six were males; the average age of the sample was 28.4 ± 11 years. A higher proportion of men who completed pre-university education (p= 0.0005, c2= 11.98) or had a graduate degree (p= 0.009, c2= 6.71) attempted suicide. Amongst all women who attempted suicide, 73.6% (n=39) were married at the time of the event (p= 0.0006, c2= 11.79). Poisoning (n=59) was the most common method of attempting suicide. We also observed that it was primarily men who attempted suicide when under the influence of alcohol (p= 0.006, c2= 7.57). The most common reason for attempting suicide was familial disharmony, including domestic violence. A Glasgow Coma Scale (GCS) score of 9/15 and less at the time of presentation resulted in a mortality rate of 28.6%, whereas patients with a GCS score of 10 and above had a mortality rate of 6.1% (p= 0.04, c2= 4.14). Discussion Marriage appears to be less protective for Indian women than Indian men. Poisoning was the most common method of attempted suicide in our study, followed by tablet overdose. The reason for the above could be ease of access to household poisons. Insecticides have been a preferred method in the Indian population over the years. Aluminum phosphide poisoning, a common constituent of rodenticides, is associated with a high mortality rate. However, in the West, firearm-related incidents have the highest mortality. Multiple correspondence analysis (MCA) of the National Crime Records Bureau (NCRB), India, data showed that adult males succumb majorly to romantic relations, unemployment, and failure in examinations. The use of alcohol was more in the illiterate and unskilled workers; however, high school educated persons and students used alcohol intentionally to facilitate suicide. Lower Glasgow Coma Scale values are associated with higher fatality; however, some studies found that Full Outline of Unresponsiveness (FOUR) and Acute Physiology and Chronic Health Evaluation Score (APACHE) II scores are better mortality indicators. Conclusion Besides the presentation and GCS score, cognizance of the lethality of different methods in attempting suicide provides clues in anticipating the patient's clinical course. The social patterns of suicide must be considered while designing awareness campaigns and focused outreach programs to decrease suicides. A strict policy must be made and enforced to limit the availability of household poisons.
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Affiliation(s)
- Rajesh K
- Emergency Medicine, Sri Devaraj Urs Medical College and Research Hospital, Kolar, IND
| | - Amogh Ananda Rao
- Internal Medicine, Jagadguru Jayadeva Murugarajendra (JJM) Medical College, Davangere, IND
| | - Krishna D
- Emergency Medicine, Sri Devaraj Urs Medical College and Research Hospital, Kolar, IND
| | - Pratyaksh P Vaishnav
- Internal Medicine, Jagadguru Jayadeva Murugarajendra (JJM) Medical College, Davangere, IND
| | - Sissmol Davis
- Internal Medicine, Jagadguru Jayadeva Murugarajendra (JJM) Medical College, Davangere, IND
| | - Abhinov T
- Emergency Medicine, Sri Devaraj Urs Medical College and Research Hospital, Kolar, IND
| | - Devendraprasad K J
- Emergency Medicine, Sri Devaraj Urs Medical College and Research Hospital, Kolar, IND
| | - Ashutosh Suresh
- Internal Medicine, Jagadguru Jayadeva Murugarajendra (JJM) Medical College, Davangere, IND
| | - Chiranth Nadig
- Internal Medicine, Jagadguru Jayadeva Murugarajendra (JJM) Medical College, Davangere, IND
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Sharif AF, Fayed MM. Evaluation of Multiple Organ Dysfunction Score (MODS) and the Sequential Organ Failure Assessment (SOFA) score as in-hospital outcome predictors among cases of hydrogen cyanamide exposure: a cross-sectional study. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2021; 28:42161-42176. [PMID: 33797718 DOI: 10.1007/s11356-021-13655-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/22/2021] [Indexed: 06/12/2023]
Abstract
Dormex is widely used as a plant growth regulator in developing countries such as Egypt as well as worldwide. Despite the widespread use of Dormex, little is known about the exact mechanism of action and toxic profile. The current study aims to outline the factors that predict in-hospital outcome and the need for intensive care unit (ICU) admission among the patients who presented with acute hydrogen cyanamide exposure as well as to evaluate the roles of the Multiple Organ Dysfunction Score (MODS) and the Sequential Organ Failure Assessment (SOFA) score as unfavorable outcome predictors. This is a retrospective cross-sectional study including all cases diagnosed with acute hydrogen cyanamide exposure who presented to the Tanta Poison Control Center during the past 6 years (January 1, 2015-January 1, 2020). Patient data were collected in a case report form, including the history of exposure, clinical data, laboratory investigations, and radiologic studies. Four scoring systems were carried out upon presentation: the Glasgow Coma Scale, poison severity score, MODS, and SOFA score. Thirty-five patients were enrolled in the current study. Most of the presented cases were males exposed unintentionally in an occupational setting. The mean participant age was 34.1 ± 15.51 years. The most common presenting complaints were throat irritation in all cases, vomiting and hallucinations presented equally in 68.6%, and headache occurred in 51.4%, whereas skin and mucous membrane burn was present in 40% of cases. Patients showing one or more of the following criteria were expected to have an urgent need for ICU admission: MODS >3.5, SOFA >4.5, length of hospital stay >30 hours, prothrombin time >14.75 seconds, serum glutamic pyruvic transaminase >67.5 U/L, and serum glutamic oxaloacetic transaminase >58.5 U/L. When the length of hospital stay was combined with the four scoring systems, only MODS yielded a significant prediction. Study results indicate that MODS and SOFA scores are considered excellent outcome predictors; MODS is more accurate, specific, and treatment independent, whereas the use of the SOFA score is more feasible with simple cardiovascular function assessment.
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Affiliation(s)
- Asmaa Fady Sharif
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, El Geish Street, Tanta, Gharbia, 31527, Egypt.
- Clinical Sciences Department, College of Medicine, Dar Al Uloom University, Riyadh, Saudi Arabia.
| | - Manar Maher Fayed
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, El Geish Street, Tanta, Gharbia, 31527, Egypt
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Kebapçı A, Dikeç G, Topçu S. Interobserver Reliability of Glasgow Coma Scale Scores for Intensive Care Unit Patients. Crit Care Nurse 2021; 40:e18-e26. [PMID: 32737493 DOI: 10.4037/ccn2020200] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Intensive care units frequently use the Glasgow Coma Scale to objectively assess patients' levels of consciousness. Interobserver reliability of Glasgow Coma Scale scores is critical in determining the degree of impairment. OBJECTIVE To evaluate interobserver reliability of intensive care unit patients' Glasgow Coma Scale scores. Methods This prospective observational study evaluated Glasgow Coma Scale scoring agreement among 21 intensive care unit nurses and 2 independent researchers who assessed 202 patients with neurosurgical or neurological diseases. Each assessment was completed independently and within 1 minute. Participants had no knowledge of the others' assessments. RESULTS Agreement between Glasgow Coma Scale component and sum scores recorded by the 2 researchers ranged from 89.5% to 95.9% (P = .001). Significant agreement among nurses and the 2 researchers was found for eye response (73.8%), motor response (75.0%), verbal response (68.1%), and sum scores (62.4%) (all P = .001). Significant agreement among nurses and the 2 researchers (55.2%) was also found for sum scores of patients with sum scores of 10 or less (P = .03). CONCLUSIONS Although the study showed near-perfect agreement between the 2 researchers' Glasgow Coma Scale scores, agreement among nurses and the 2 researchers was moderate (not near perfect) for subcomponent and sum scores. Accurate Glasgow Coma Scale evaluation requires that intensive care unit nurses have adequate knowledge and skills. Educational strategies such as simulations or orientation practice with a preceptor nurse can help develop such skills.
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Affiliation(s)
- Ayda Kebapçı
- Ayda Kebapçı is an assistant professor and Serpil Topçu is a lecturer in the Faculty of Nursing, Koç University, Istanbul, Turkey
| | - Gül Dikeç
- Gül Dikeç is an assistant professor in the Department of Psychiatric Nursing, Faculty of Nursing, University of Health Sciences, Istanbul
| | - Serpil Topçu
- Ayda Kebapçı is an assistant professor and Serpil Topçu is a lecturer in the Faculty of Nursing, Koç University, Istanbul, Turkey
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Burket GA, Horowitz BZ, Hendrickson RG, Beauchamp GA. Endotracheal Intubation in the Pharmaceutical-Poisoned Patient: a Narrative Review of the Literature. J Med Toxicol 2021; 17:61-69. [PMID: 32394224 PMCID: PMC7785763 DOI: 10.1007/s13181-020-00779-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 04/08/2020] [Accepted: 04/16/2020] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Endotracheal intubation (ETI) is an essential component of the supportive care provided to the critically ill patient with pharmaceutical poisoning; however, specific nuances surrounding intubation including techniques and complications in the context of pharmaceutical poisoning have not been well elucidated. DISCUSSION A search of the available literature on ETI in pharmaceutical-poisoned patients was undertaken using Medline, ERIC, Cochrane database, and PsycINFO using the following MeSH and keyword terms: ("toxicology" OR "poisons" OR "drug overdose" OR "poisoning") AND ("intubation, intratracheal" OR "intubation, endotracheal" OR "airway management" OR "respiration, artificial"). A hand-search was also performed when the literature in the above search required additional conceptual clarification, including using the "Similar Articles" feature of PubMed, along with reviewing articles' reference lists that discussed intubation in the context of a poisoning scenario. Articles with any discussion around the ETI process in the context of a pharmaceutical poisoning were then included. Intubation may be performed in patients poisoned with pharmaceuticals in the context of both single and multiple organ dysfunction including central and peripheral nervous system, pulmonary, or cardiovascular toxicity with hemodynamic instability, or localized effects resulting in mechanical airway obstruction. Certain classes of poisonings may require modifications to the standard rapid sequence induction airway management algorithm. CONCLUSIONS ETI is a key component of the supportive care provided to the patient poisoned by a pharmaceutical agent. Clinicians should be aware of the spectrum of toxicities that can necessitate intubation, as well as airway management nuances that are specific to various poisoning presentations.
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Affiliation(s)
- Glenn A Burket
- SCL Health St Mary's Medical Center, 2635 North 7th Street, Grand Junction, CO, 81501, USA
- Mesa County EMS, 215 Rice St, Grand Junction, CO, 81501, USA
| | - B Zane Horowitz
- Oregon Health and Science University, 3181 S.W. Sam Jackson Park Rd, Portland, OR, 97239, USA
- Oregon Poison Center, 3181 S.W. Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Robert G Hendrickson
- Oregon Health and Science University, 3181 S.W. Sam Jackson Park Rd, Portland, OR, 97239, USA
- Oregon Poison Center, 3181 S.W. Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Gillian A Beauchamp
- Lehigh Valley Health Network Department of Emergency and Hospital Medicine, Division of Medical Toxicology, USF Morsani College of Medicine, Lehigh Valley Campus, Cedar Crest Boulevard & I-78, Allentown, PA, 18101, USA.
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Mégarbane B, Oberlin M, Alvarez JC, Balen F, Beaune S, Bédry R, Chauvin A, Claudet I, Danel V, Debaty G, Delahaye A, Deye N, Gaulier JM, Grossenbacher F, Hantson P, Jacobs F, Jaffal K, Labadie M, Labat L, Langrand J, Lapostolle F, Le Conte P, Maignan M, Nisse P, Sauder P, Tournoud C, Vodovar D, Voicu S, Claret PG, Cerf C. Management of pharmaceutical and recreational drug poisoning. Ann Intensive Care 2020; 10:157. [PMID: 33226502 PMCID: PMC7683636 DOI: 10.1186/s13613-020-00762-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 10/09/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Poisoning is one of the leading causes of admission to the emergency department and intensive care unit. A large number of epidemiological changes have occurred over the last years such as the exponential growth of new synthetic psychoactive substances. Major progress has also been made in analytical screening and assays, enabling the clinicians to rapidly obtain a definite diagnosis. METHODS A committee composed of 30 experts from five scientific societies, the Société de Réanimation de Langue Française (SRLF), the Société Française de Médecine d'Urgence (SFMU), the Société de Toxicologie Clinique (STC), the Société Française de Toxicologie Analytique (SFTA) and the Groupe Francophone de Réanimation et d'Urgences Pédiatriques (GFRUP) evaluated eight fields: (1) severity assessment and initial triage; (2) diagnostic approach and role of toxicological analyses; (3) supportive care; (4) decontamination; (5) elimination enhancement; (6) place of antidotes; (7) specificities related to recreational drug poisoning; and (8) characteristics of cardiotoxicant poisoning. Population, Intervention, Comparison, and Outcome (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Analysis of the literature and formulation of recommendations were then conducted according to the GRADE® methodology. RESULTS The SRLF-SFMU guideline panel provided 41 statements concerning the management of pharmaceutical and recreational drug poisoning. Ethanol and chemical poisoning were excluded from the scope of these recommendations. After two rounds of discussion and various amendments, a strong consensus was reached for all recommendations. Six of these recommendations had a high level of evidence (GRADE 1±) and six had a low level of evidence (GRADE 2±). Twenty-nine recommendations were in the form of expert opinion recommendations due to the low evidences in the literature. CONCLUSIONS The experts reached a substantial consensus for several strong recommendations for optimal management of pharmaceutical and recreational drug poisoning, mainly regarding the conditions and effectiveness of naloxone and N-acetylcystein as antidotes to treat opioid and acetaminophen poisoning, respectively.
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Affiliation(s)
- Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, AP-HP, INSERM MURS-1144, University of Paris, 2 Rue Ambroise Paré, Paris, 75010 France
| | - Mathieu Oberlin
- Emergency Department, HuManiS Laboratory (EA7308), University Hospital, Strasbourg, France
| | - Jean-Claude Alvarez
- Department of Pharmacology and Toxicology, Inserm U-1173, FHU Sepsis, Raymond Poincaré Hospital, AP-HP, Paris-Saclay University, Garches, France
| | - Frederic Balen
- Emergency Department, Toulouse University Hospital, Toulouse, France
| | - Sébastien Beaune
- Department of Emergency Medicine, Ambroise Paré Hospital, AP-HP, INSERM UMRS-1144, Paris-Saclay University, Boulogne-Billancourt, France
| | - Régis Bédry
- Hospital Secure Unit, Pellegrin University Hospital, Bordeaux, France
| | - Anthony Chauvin
- Emergency Department, Hôpital Lariboisière, AP-HP, Paris, France
| | - Isabelle Claudet
- Pediatric Emergency Department Children’s Hospital CHU Toulouse, Toulouse, France
| | - Vincent Danel
- Department of Emergency Medicine, University Hospital of Grenoble, Grenoble, France
| | - Guillaume Debaty
- 5525, University Grenoble Alps/CNRS/CHU de Grenoble Alpes/TIMC-IMAG UMR, Grenoble, France
| | | | - Nicolas Deye
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, AP-HP, INSERM U942, University of Paris, Paris, France
| | - Jean-Michel Gaulier
- Laboratory of Toxicology, EA 4483 - IMPECS - IMPact de L’Environnement Chimique Sur La Santé Humaine, University of Lille, Lille, France
| | | | - Philippe Hantson
- Intensive Care Department, Cliniques Universitaires St-Luc, Brussels, Belgium
| | - Frédéric Jacobs
- Polyvalent Intensive Care Unit, Antoine Béclère Hospital, Assistance Publique-Hôpitaux de Paris, Paris-Sud University, Clamart, France
| | - Karim Jaffal
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, AP-HP, INSERM MURS-1144, University of Paris, 2 Rue Ambroise Paré, Paris, 75010 France
| | - Magali Labadie
- Poison Control Centre of Bordeaux, University Hospital of Bordeaux, Bordeaux, France
| | - Laurence Labat
- Laboratory of Toxicology, Federation of Toxicology APHP, Lariboisière Hospital, INSERM UMRS-1144, University of Paris, Paris, France
| | - Jérôme Langrand
- Poison Control Center of Paris, Federation of Toxicology, Fernand-Widal-Lariboisière Hospital, AP-HP, INSERM UMRS-1144, University of Paris, Paris, France
| | - Frédéric Lapostolle
- SAMU 93-UF Recherche-Enseignement-Qualité, Inserm, U942, Avicenne Hospital, AP-HP, Paris-13 University, Bobigny, France
| | - Philippe Le Conte
- Department of Emergency Medicine, University Hospital of Nantes, Nantes, France
| | - Maxime Maignan
- Emergency Department, Grenoble University Hospital, INSERM U1042, Grenoble Alpes University, Grenoble, France
| | - Patrick Nisse
- Poison Control Centre, University Hospital of Lille, Lille, France
| | - Philippe Sauder
- Intensive Care Unit, University Hospital of Strasbourg, Strasbourg, France
| | | | - Dominique Vodovar
- Poison Control Center of Paris, Federation of Toxicology, Fernand-Widal-Lariboisière Hospital, AP-HP, INSERM UMRS-1144, University of Paris, Paris, France
| | - Sebastian Voicu
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, AP-HP, INSERM MURS-1144, University of Paris, 2 Rue Ambroise Paré, Paris, 75010 France
| | - Pierre-Géraud Claret
- Department of Anesthesia Resuscitation Pain Emergency Medicine, Nîmes University Hospital, Nîmes, France
| | - Charles Cerf
- Intensive Care Unit, Foch Hospital, Suresnes, France
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Day R, Bradberry SM, Sandilands EA, Thomas SHL, Thompson JP, Vale JA. Features reported after exposure to automatic dishwashing rinse aids. Hum Exp Toxicol 2020; 39:828-833. [DOI: 10.1177/0960327120901580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: Automatic dishwashing rinse aids are drying aids which contain non-ionic surfactants, usually ethoxylated alcohols, typically at concentrations of ≤30%. Objective: To assess the reported toxicity of rinse aids. Methods: Telephone enquiries to the UK National Poisons Information Service were analysed from January 2008 to June 2019. Results: Ingestion: Ingestion was involved in 976 cases and produced gastrointestinal features, coughing and central nervous system depression, particularly in young children. In those in whom the amount ingested was known, the majority (56%) of children <18 years and of adults (57%) ingested <50 mL of rinse aid. Although moderate or severe exposures (Poisoning Severity Score (PSS) ≥ 2) were uncommon, they occurred significantly ( p < 0.0008) more often in adults (9.0%) than in children (1.8%); however, three of the four adults with PSS ≥ 2 co-ingested other substances. Eye exposure: Ocular exposure was reported in 35 cases, of whom 29 developed features. Eye irritation ( n = 10, 28.6%) and eye pain ( n = 10, 28.6%) were reported most commonly, and three patients (8.6%) developed corneal abrasions (PSS 2). Dermal exposure: Thirty-four patients were exposed dermally, and six (17.6%) reported features, including rash, numbness, pruritus and burns (PSS 1). Conclusions: Overall, clinical features developed in 47% of patients exposed to rinse aids, but more severe features (PSS ≥ 2) were rare (<3%) following exposure by any route.
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Affiliation(s)
- R Day
- NPIS (Birmingham Unit), City Hospital, Birmingham, UK
| | - SM Bradberry
- NPIS (Birmingham Unit), City Hospital, Birmingham, UK
| | - EA Sandilands
- NPIS (Edinburgh Unit), Royal Infirmary, Edinburgh, UK
| | - SHL Thomas
- NPIS (Newcastle Unit), Newcastle Hospitals NHS Foundation Trust, Newcastle, UK
| | - JP Thompson
- NPIS (Cardiff Unit), University Hospital Llandough, Cardiff, UK
| | - JA Vale
- NPIS (Birmingham Unit), City Hospital, Birmingham, UK
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Sauter TC, Rönz K, Hirschi T, Lehmann B, Hütt C, Exadaktylos AK, Müller M. Intubation in acute alcohol intoxications at the emergency department. Scand J Trauma Resusc Emerg Med 2020; 28:11. [PMID: 32041639 PMCID: PMC7011261 DOI: 10.1186/s13049-020-0707-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 02/05/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Guidelines recommend endotracheal intubation in trauma patients with a Glasgow coma scale (GCS) < 9 because of the loss of airway reflexes and consequential risk of airway obstruction. However, in patients with acute alcohol intoxication guidelines are not clear. Thus, we aimed to determine the proportional incidence of intubation in alcohol intoxication and compare the clinical characteristics of intubated and non-intubated patients, as well as reasons for intubation in all patients and in the subgroup of patients with reduced GCS (< 9) but without traumatic brain injury. METHODS We performed a retrospective analysis of all consultations to an urban ED in Switzerland that presented with an acute alcohol intoxication between 1st June 2012 and 31th Mai 2017. Patient and emergency consultations' characteristics, related injuries, intubation and reason for intubations were extracted. As a subgroup analysis, we analysed the patients with a GCS < 9 without a traumatic brain injury. RESULTS Of 3003 consultations included from 01.06.2012 to 31.05.2017, 68 were intubated, leading to a proportional incidence of 2.3% intubations in alcohol-intoxication. Intubated patients had a lower blood alcohol concentration (1.3 g/kg [IQR 1.0-2.2] vs. 1.6 g/kg [IQR1.1-2.2], p = 0.034) and less often suffered from chronic alcohol abuse (1183 [39.4%] patients vs. 14 [20.6%], p = 0.001) than non-intubated patients. Patients with trauma were intubated more often (33 patients [48.5%] vs. 742 [25.3%], p < 0.001). In subgroup analysis, 110/145 patients (74.3%) were not intubated; again, more intubated patients had a history of trauma (9 patients [25.7%] vs. 10 [9.1%], p = 0.011). CONCLUSIONS Intubation in alcohol-intoxicated patients is rare and, among intoxicated patients with GCS < 9, more than two thirds were not intubated in our study - without severe complications. Trauma in general, independent of the history of a traumatic brain injury, and a missing history of chronic alcohol abuse are associated with intubation, but not with blood alcohol concentration. Special caution is required for intoxicated patients with trauma or other additional intoxications or diseases.
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Affiliation(s)
- Thomas C Sauter
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland. .,Medical Skills Lab, Charité Medical School Berlin, Berlin, Germany.
| | - Katharina Rönz
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland.,Department of Anaesthesiology, Hôpital Cantonal Fribourg, Fribourg, Switzerland
| | - Trevor Hirschi
- Department of Anaesthesiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Beat Lehmann
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland
| | - Christopher Hütt
- Department of Anaesthesiology and Intensive Care, University Hospital Bonn, Bonn, Germany
| | - Aristomenis K Exadaktylos
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland
| | - Martin Müller
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland.,Department of Anaesthesiology and Intensive Care, University Hospital Bonn, Bonn, Germany
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Hondebrink L, Rietjens SJ, Donker DW, Hunault CC, van den Hengel-Koot I, Verputten PM, de Vries I, Kaasjager KAH, Dekker D, de Lange DW. A quarter of admitted poisoned patients have a mild poisoning and require no treatment: An observational study. Eur J Intern Med 2019; 66:41-47. [PMID: 31113710 DOI: 10.1016/j.ejim.2019.05.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 04/13/2019] [Accepted: 05/13/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Poisoned patients are frequently admitted following Emergency Department (ED) presentation, while the necessity of such admissions is hardly investigated. We determined the proportion and characteristics of poisoned patients who were admitted, but in retrospect had an uneventful admission. METHODS For this observational cohort study, all patients presented to the ED of a Dutch University Hospital with various poisonings during a 1.5-year period (January 2015-July 2016) were included. The uneventfulness of admissions, defined as patients with a low Poisoning Severity Score (PSS) who received no treatment, was determined in retrospect. RESULTS We included 417 patients who visited the ED for poisoning. 247 Patients were admitted: 30% to a general ward, 58% to a MCU, and 12% to the ICU. The poisoning severity scores of the admitted patients were none to mild in 38%, moderate to severe in 59%, and fatal in 2%. Upon admission, 60% of the patients received treatment. In retrospect, 77% of the admitted patients had a moderate, severe or fatal poisoning and/or required treatment. However, 23% of the admitted patients had a mild poisoning and required no treatment. This group involved younger patients (median age of 23 versus 42 years) and a higher proportion of patients reporting exposure to only one substance (65% versus 51%). CONCLUSIONS The majority of poisoned patients presented to the ED was admitted, while in retrospect, a quarter of these admissions were uneventful. Predictive parameters should be sought to identify patients who can be sent home safely.
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Affiliation(s)
- Laura Hondebrink
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, the Netherlands.
| | - Saskia J Rietjens
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Dirk W Donker
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Claudine C Hunault
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Irma van den Hengel-Koot
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Pauline M Verputten
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Irma de Vries
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Karin A H Kaasjager
- Department of Internal Medicine, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Douwe Dekker
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, the Netherlands; Department of Internal Medicine, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Dylan W de Lange
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, the Netherlands; Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, the Netherlands
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10
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Chalela R, Gallart L, Pascual-Guardia S, Sancho-Muñoz A, Gea J, Orozco-Levi M. Bispectral index in hypercapnic encephalopathy associated with COPD exacerbation: a pilot study. Int J Chron Obstruct Pulmon Dis 2019; 13:2961. [PMID: 30310272 PMCID: PMC6167126 DOI: 10.2147/copd.s167020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Hypercapnic encephalopathy is relatively frequent in severe exacerbations of COPD (ECOPDs), with its intensity usually being evaluated through clinical scales. Bispectral index (BIS) is a relatively new technique, based on the analysis of the electroencephalographic signal, which provides a good approximation to the level of consciousness, having already been validated in anesthesia. OBJECTIVE The objective of the study was to evaluate the utility of BIS in the assessment of the intensity of hypercapnic encephalopathy in ECOPD patients. PATIENTS AND METHODS A total of ten ECOPD patients were included, and the level of brain activity was assessed using BIS and different scales: Glasgow Coma Scale, Ramsay Sedation Scale (RSS), and Richmond Agitation-Sedation Scale. The evaluation was performed both in the acute phase and 3 months after discharge. RESULTS BIS was recorded for a total of about 600 minutes. During ECOPD, BIS values ranged from 58.8 (95% CI: 48.6-69) for RSS score of 4 to 92.2 (95% CI: 90.1-94.3) for RSS score of 2. A significant correlation was observed between values obtained with BIS and those from the three scales, although the best fit was for RSS, followed by Glasgow and Richmond (r=-0.757, r=0.701, and r=0.615, respectively; P<0.001 for all). In the stable phase after discharge, BIS showed values considered as normal for a wake state (94.6; 95% CI: 91.7-97.9). CONCLUSION BIS may be useful for the objective early detection and automatic monitoring of the intensity of hypercapnic encephalopathy in ECOPD, facilitating the early detection and follow-up of this condition, which may avoid management problems in these patients.
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Affiliation(s)
- Roberto Chalela
- Respiratory Medicine Department, Hospital del Mar-IMIM, Barcelona, Spain, .,Department CEXS, Universitat Pompeu Fabra, Barcelona, Spain, .,CIBERES, ISCIII, Barcelona, Spain,
| | - Lluis Gallart
- Department of Anesthesia, Hospital del Mar-IMIM, Barcelona, Spain.,Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Sergi Pascual-Guardia
- Respiratory Medicine Department, Hospital del Mar-IMIM, Barcelona, Spain, .,Department CEXS, Universitat Pompeu Fabra, Barcelona, Spain, .,CIBERES, ISCIII, Barcelona, Spain,
| | - Antonio Sancho-Muñoz
- Respiratory Medicine Department, Hospital del Mar-IMIM, Barcelona, Spain, .,Department CEXS, Universitat Pompeu Fabra, Barcelona, Spain,
| | - Joaquim Gea
- Respiratory Medicine Department, Hospital del Mar-IMIM, Barcelona, Spain, .,Department CEXS, Universitat Pompeu Fabra, Barcelona, Spain, .,CIBERES, ISCIII, Barcelona, Spain,
| | - Mauricio Orozco-Levi
- Respiratory Medicine Department, Hospital del Mar-IMIM, Barcelona, Spain, .,Department CEXS, Universitat Pompeu Fabra, Barcelona, Spain, .,CIBERES, ISCIII, Barcelona, Spain,
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11
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Sanello A, Gausche-Hill M, Mulkerin W, Sporer KA, Brown JF, Koenig KL, Rudnick EM, Salvucci AA, Gilbert GH. Altered Mental Status: Current Evidence-based Recommendations for Prehospital Care. West J Emerg Med 2018; 19:527-541. [PMID: 29760852 PMCID: PMC5942021 DOI: 10.5811/westjem.2018.1.36559] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 11/15/2017] [Accepted: 01/04/2018] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
- Ashley Sanello
- Los Angeles County Emergency Medical Services (EMS) Agency, Santa Fe Springs, California.,David Geffen School of Medicine, Department of Emergency Medicine, Los Angeles, California
| | - Marianne Gausche-Hill
- Los Angeles County Emergency Medical Services (EMS) Agency, Santa Fe Springs, California.,Harbor UCLA, Department of Emergency Medicine, Torrance, California.,David Geffen School of Medicine, Department of Emergency Medicine, Los Angeles, California.,EMS Medical Directors Association of California
| | - William Mulkerin
- Stanford University, Department of Emergency Medicine, Stanford, California
| | - Karl A Sporer
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California.,EMS Medical Directors Association of California
| | - John F Brown
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California.,EMS Medical Directors Association of California
| | - Kristi L Koenig
- EMS Medical Directors Association of California.,County of San Diego, Health & Human Services Agency, Emergency Medical Services, San Diego, California.,University of California, Irvine, Department of Emergency Medicine, Orange, California
| | - Eric M Rudnick
- EMS Medical Directors Association of California.,NorCal EMS Agency, Redding, California
| | - Angelo A Salvucci
- EMS Medical Directors Association of California.,Ventura County EMS Agency, Oxnard, California
| | - Gregory H Gilbert
- EMS Medical Directors Association of California.,Stanford University, Department of Emergency Medicine, Stanford, California
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12
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Reith FC, Synnot A, van den Brande R, Gruen RL, Maas AI. Factors Influencing the Reliability of the Glasgow Coma Scale: A Systematic Review. Neurosurgery 2018; 80:829-839. [PMID: 28327922 DOI: 10.1093/neuros/nyw178] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 12/23/2016] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Florence Cm Reith
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Anneliese Synnot
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Preventive Medicine and Public Health, Monash University, Melbourne, Australia.,Cochrane Consumers and Communication Group, Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Melbourne, Australia.,National Trauma Institute, Melbourne, Australia
| | - Ruben van den Brande
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Russell L Gruen
- Lee Kong Chian School of Medicine, Nanyang Institute of Technology in Health and Medicine (NITHM), Nanyang Technological University, 637553, Singapore
| | - Andrew Ir Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
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13
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Schwarz ES, Kopec KT, Wiegand TJ, Wax PM, Brent J. Should We Be Using the Poisoning Severity Score? J Med Toxicol 2017; 13:135-145. [PMID: 28283941 DOI: 10.1007/s13181-017-0609-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Revised: 02/18/2017] [Accepted: 02/22/2017] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Despite the existence of a number of severity-of-illness classifications for other areas of medicine, toxicology research lacks a well-accepted method for assessing the severity of poisoning. The Poisoning Severity Score (PSS) was developed in the 1990s in Europe as a scoring system for poisonings reported to a poison center in order to describe a patient's most severe symptomatology. We reviewed the literature to describe how the PSS is utilized and describe its limitations. DISCUSSION We searched the medical literature in all languages using PUBMED, EMBASE, and SCOPUS from inception through August 2013 using predefined search terms. Out of 204 eligible publications, 40 met our criteria for inclusion in this review. There has been a paucity of published studies from North America that used the PSS. In some cases, the PSS was misapplied or modified from standard scoring, making a bottom line appraisal of the validity or reliability of the original version of the instrument challenging. The PSS has several subjective criteria, is time consuming to score, and is likely to be of little use with some types of poisonings, limiting its clinical utility. CONCLUSION The PSS was developed as a tool to document encounters with poisoned patients. However, it is used infrequently and, when applied, has been misused or modified from its original form. In its current form, it has limited clinical utility and likely cannot be broadly applied to many exposures due to their unique clinical circumstances. With better global collaboration among medical toxicologists, it is possible that a modified score could be developed for use clinically or as a research instrument.
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Affiliation(s)
- Evan S Schwarz
- Division of Emergency Medicine, Washington University School of Medicine, 660 South Euclid, Campus Box 8072, Saint Louis, MO, 63110, USA.
| | - Kathryn T Kopec
- Department of Emergency Medicine, Carolinas Medical Center, Medical Education Building, Third Floor 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Timothy J Wiegand
- Department of Emergency Medicine, University of Rochester Medical Center, 601 Elmwood Ave, Box 655, Rochester, NY, 14642, USA
| | - Paul M Wax
- Department of Emergency Medicine, University of Texas Southwestern School of Medicine, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Jeffrey Brent
- University of Colorado School of Medicine, 12605 E. 16th Ave, Aurora, CO, 80045, USA
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Abstract
CONTEXT The sideline assessment of concussion is challenging, given its variable presentations, the limited sensitivity and specificity of sideline assessment tools, and how the presentation of the injury evolves over time. In addition, the diagnostic process, as well as the tools used to assess and manage concussion, continue to progress as research and what we know about concussion advance. This paper focuses on the initial assessment on the sideline by reviewing the concussion-evaluation literature, drawing from clinical experience to emphasize a standardized approach, and underscoring the importance of both familiarity with the athlete and clinical judgment. OBJECTIVE To review the evidence regarding the clinical assessment of sport-related concussion on the sideline. Additional considerations included making same-day return-to-play decisions, the sensitivity and specificity of sideline testing, and the importance of ongoing assessment and follow-up of injured athletes. DATA SOURCES I conducted a systematic literature review of the assessment of concussion on the sideline. The PubMed and MEDLINE databases were searched using the key term athletic injuries with concussion and mild traumatic brain injury. The search was refined by adding the key terms sideline assessment and on-field assessment. In addition, select additional position statements and guidelines on concussion were included in the review. RESULTS The PubMed search using athletic injuries and concussion as key terms produced 1492 results. Refining the search by sideline assessment and on-field assessment produced 29 and 35 results, respectively. When athletic injuries and traumatic brain injury were combined, 1912 results were identified. Refining the search by sideline assessment and on-field assessment led to 28 and 35 results, respectively. Only papers that were English-language titles, original work, and limited to human participants and included sideline assessments of sport-related concussion in athletes older than 13 years were considered for this discussion. A total of 96 papers were reviewed, including systematic reviews, consensus guidelines, and position statements. CONCLUSIONS The sideline assessment of sport-related concussion is challenging given the elusiveness and variability of presentation, reliance on athlete-reported symptoms, and the varying specificity and sensitivity values of sideline assessment tools. In addition, the recognition of injury and assessment often occur in a time-pressured environment, requiring rapid disposition and decision making. Clinicians should begin the evaluation by assessing for cervical spine injury, intracranial bleeding, and other injuries that can present in a similar fashion or in addition to concussion. The sideline concussion evaluation should consist of a symptom assessment and a neurologic examination that addresses cognition (briefly), cranial nerve function, and balance. Emerging tools that assess visual tracking may provide additional information. The sensitivity and specificity of commonly implemented sideline assessment tools are generally good to very good, especially for symptom scores and cognitive evaluations performed within 48 hours of injury, and they are improved when a baseline evaluation is available for comparison. Serial assessments are often necessary as objective signs and symptoms may be delayed. A standardized assessment is paramount in evaluating the athlete with a suspected concussion, but there is no replacement for being familiar with the athlete and using clinical judgment when the athlete seems "not right" despite a "normal" sideline assessment. Ultimately, the clinician should err on the side of caution when making a return-to-play decision.
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Affiliation(s)
- Margot Putukian
- University Health Services, Princeton University, NJ, and Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ
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15
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El-Sarnagawy GN, Hafez ASAF. Comparison of different scores as predictors of mechanical ventilation in drug overdose patients. Hum Exp Toxicol 2016; 36:539-546. [DOI: 10.1177/0960327116655389] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Ghada N El-Sarnagawy
- Department of Forensic Medicine and Clinical Toxicology, Tanta Faculty of Medicine, Tanta University, Egypt
| | - Amal SAF Hafez
- Department of Forensic Medicine and Clinical Toxicology, Tanta Faculty of Medicine, Tanta University, Egypt
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16
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Mick I, Gross C, Lachnit A, Kalkbrenner M, Hoppe L, Reichert J, Zimmermann US. Alcohol-induced impairment in adolescents admitted to inpatient treatment after heavy episodic drinking: effects of age and gender. J Stud Alcohol Drugs 2016; 76:493-7. [PMID: 25978837 DOI: 10.15288/jsad.2015.76.493] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE In Germany and many other countries, the number of adolescent heavy episodic drinking-induced hospital admissions (HEDHA) in pediatric units markedly increased during the past decade. A low level of response to alcohol in young adults is associated with high risk for later development of alcohol use disorders (AUDs). METHOD We performed a retrospective chart review of all 1,123 HEDHA cases in adolescents aged 11-17 years who were admitted to one of the pediatric inpatient units covering the cities of Dresden, Pirna, and Rostock, Germany, between 2000 and 2008. Blood alcohol concentration (BAC) and Glasgow Coma Scale (GCS) measures on admission were documented in 846 cases. RESULTS The mean (SD) BAC was 155 (50) mg/100 ml full blood, and M (SD) GCS was 12.21 (3.02). These parameters were negatively correlated with each other (r = -.256, p < .001), indicating more impairment at higher BACs. To describe a numerical estimate of how severely a subject was compromised relative to his BAC, the GCS scores were inverted (making high scores indicate severe impairment) and divided by BAC. The resulting alcohol-induced impairment index (AIII) was significantly influenced by an interaction between age and gender, decreasing with age in boys but increasing in girls. CONCLUSIONS During adolescence, alcohol-induced impairment develops differently in boys and girls, which may be because of the girls' developmental edge. The high variability of observed AIII might help to predict the risk for later AUDs in the emergency department, simply by measuring BAC and GCS.
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Affiliation(s)
- Inge Mick
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus, Technische Universität, Dresden, Germany.,Centre for Neuropsychopharmacology, Division of Brain Science, Faculty of Medicine, Imperial College London, United Kingdom
| | - Cornelius Gross
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus, Technische Universität, Dresden, Germany
| | - Andreas Lachnit
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus, Technische Universität, Dresden, Germany.,Department of Child and Adolescent Medicine, Municipal Hospital Dresden-Neustadt, Dresden, Germany
| | - Manja Kalkbrenner
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus, Technische Universität, Dresden, Germany
| | - Linda Hoppe
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus, Technische Universität, Dresden, Germany
| | - Jörg Reichert
- Department of Child and Adolescent Medicine, University Hospital Carl Gustav Carus, Technische Universität, Dresden, Germany
| | - Ulrich S Zimmermann
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus, Technische Universität, Dresden, Germany
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17
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18
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Reith FCM, Van den Brande R, Synnot A, Gruen R, Maas AIR. The reliability of the Glasgow Coma Scale: a systematic review. Intensive Care Med 2015; 42:3-15. [PMID: 26564211 DOI: 10.1007/s00134-015-4124-3] [Citation(s) in RCA: 129] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 10/26/2015] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The Glasgow Coma Scale (GCS) provides a structured method for assessment of the level of consciousness. Its derived sum score is applied in research and adopted in intensive care unit scoring systems. Controversy exists on the reliability of the GCS. The aim of this systematic review was to summarize evidence on the reliability of the GCS. METHODS A literature search was undertaken in MEDLINE, EMBASE and CINAHL. Observational studies that assessed the reliability of the GCS, expressed by a statistical measure, were included. Methodological quality was evaluated with the consensus-based standards for the selection of health measurement instruments checklist and its influence on results considered. Reliability estimates were synthesized narratively. RESULTS We identified 52 relevant studies that showed significant heterogeneity in the type of reliability estimates used, patients studied, setting and characteristics of observers. Methodological quality was good (n = 7), fair (n = 18) or poor (n = 27). In good quality studies, kappa values were ≥0.6 in 85%, and all intraclass correlation coefficients indicated excellent reliability. Poor quality studies showed lower reliability estimates. Reliability for the GCS components was higher than for the sum score. Factors that may influence reliability include education and training, the level of consciousness and type of stimuli used. CONCLUSIONS Only 13% of studies were of good quality and inconsistency in reported reliability estimates was found. Although the reliability was adequate in good quality studies, further improvement is desirable. From a methodological perspective, the quality of reliability studies needs to be improved. From a clinical perspective, a renewed focus on training/education and standardization of assessment is required.
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Affiliation(s)
- Florence C M Reith
- Department of Neurosurgery, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium. .,University of Antwerp, Edegem, Belgium.
| | - Ruben Van den Brande
- Department of Neurosurgery, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium.,University of Antwerp, Edegem, Belgium
| | - Anneliese Synnot
- Australian & New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Cochrane Consumers and Communication Review Group, Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Melbourne, Australia.,ANZIC-RC, Department of Epidemiology and Preventive Medicine, Monash University, The Alfred Hospital, Level 6, 99 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Russell Gruen
- Central Clinical School, Monash University, Melbourne, Australia.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.,Central Clinical School, Level 6, The Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium.,University of Antwerp, Edegem, Belgium
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19
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Badreldin AMA, Doerr F, Putensen C, Bayer O, Noutsias M, Hekmat K. Glasgow Coma Scale for outcome prediction after cardiac surgery: is it applicable? J Cardiothorac Vasc Anesth 2014; 28:1257-63. [PMID: 25281043 DOI: 10.1053/j.jvca.2014.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The Glasgow Coma Scale (GCS) is used commonly for assessing patients' neurologic condition and outcome in intensive care units (ICUs); however, its reliability in cardiac surgical patients has been questioned. It has been claimed that active sedation is the cause of its unsuitability for these patients. This study aimed to compare the accuracy of GCS in cardiac surgical patients with and without active sedation to find out if the inapplicability of GCS in surgical patients is related to active sedation. DESIGN This was an observational cohort study. SETTING The study was conducted in a cardiac surgical intensive care unit between January 1, 2007 and December 31, 2009. PARTICIPANTS All consecutive adult cardiac surgical patients were included in this study. INTERVENTIONS All types of cardiac surgical procedures performed during the study period were included without any exceptions. The study population was divided into 2 groups: sedated and non-sedated. MEASUREMENTS AND MAIN RESULTS GCS was calculated daily for the first 7 postoperative days. The authors developed a new 4-point neurologic descriptor (ND): (1) neurologically free, (2) ICU psychosis, (3) actively sedated, and (4) documented focal neurologic deficits. The accuracy of both scales (GCS and ND) at predicting ICU mortality was compared by replacing the GCS in the Sequential Organ Failure Assessment (SOFA) score with the new ND, producing a modified SOFA. GCS was not an accurate outcome predictor in non-sedated or sedated patients. The ND was superior to GCS. Correspondingly, the modified SOFA showed a significantly higher accuracy of ICU-mortality prediction than the original SOFA. CONCLUSIONS Regardless of active sedation, GCS is not accurate at outcome prediction for cardiac surgical patients. The suggested ND is a simple and more accurate risk stratification variable in cardiac surgical ICUs.
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Affiliation(s)
- Akmal M A Badreldin
- Department of Anesthesia and Operative Intensive Care Medicine, Friedrich-Wilhelms-University of Bonn, Bonn, Germany.
| | - Fabian Doerr
- School of Medicine, University of Cologne, Cologne, Germany
| | - Christian Putensen
- Department of Anesthesia and Operative Intensive Care Medicine, Friedrich-Wilhelms-University of Bonn, Bonn, Germany
| | - Ole Bayer
- Department of Anaesthesia and Intensive Care Medicine, Friedrich-Schiller-University of Jena, Jena, Germany
| | - Michel Noutsias
- Department of Cardiology, Friedrich-Schiller-University of Jena, Jena, Germany
| | - Khosro Hekmat
- Department of Cardiothoracic Surgery, University of Cologne, Cologne, Germany
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Teasdale G, Maas A, Lecky F, Manley G, Stocchetti N, Murray G. The Glasgow Coma Scale at 40 years: standing the test of time. Lancet Neurol 2014; 13:844-54. [PMID: 25030516 DOI: 10.1016/s1474-4422(14)70120-6] [Citation(s) in RCA: 514] [Impact Index Per Article: 51.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Since 1974, the Glasgow Coma Scale has provided a practical method for bedside assessment of impairment of conscious level, the clinical hallmark of acute brain injury. The scale was designed to be easy to use in clinical practice in general and specialist units and to replace previous ill-defined and inconsistent methods. 40 years later, the Glasgow Coma Scale has become an integral part of clinical practice and research worldwide. Findings using the scale have shown strong associations with those obtained by use of other early indices of severity and outcome. However, predictive statements should only be made in combination with other variables in a multivariate model. Individual patients are best described by the three components of the coma scale; whereas the derived total coma score should be used to characterise groups. Adherence to this principle and enhancement of the reliable practical use of the scale through continuing education of health professionals, standardisation across different settings, and consensus on methods to address confounders will maintain its role in clinical practice and research in the future.
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Affiliation(s)
- Graham Teasdale
- Mental Health and Wellbeing, Institute of Health and Wellbeing College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK.
| | - Andrew Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Fiona Lecky
- Emergency Medicine Research in Sheffield, Health Services Research Section, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Geoffrey Manley
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, Milan University, and Neuroscience ICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gordon Murray
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
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Eizadi Mood N, Sabzghabaee AM, Khalili-Dehkordi Z. Applicability of different scoring systems in outcome prediction of patients with mixed drug poisoning-induced coma. Indian J Anaesth 2013; 55:599-604. [PMID: 22223905 PMCID: PMC3249868 DOI: 10.4103/0019-5049.90616] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background: Mixed drugs poisoning (MDP) is common in the emergency departments. Because of the limited number of intensive care unit beds, recognition of risk factors to divide the patients into different survival groups is necessary. Poisoning due to ingestion of different medications may have additive or antagonistic effects on different parameters included in the scoring systems; therefore, the aim of the study was to compare applicability of the different scoring systems in outcomes prediction of patients admitted with MDP-induced coma. Methods: This prospective, observational study included 93 patients with MDP-induced coma. Clinical and laboratory data conforming to the Acute Physiology and Chronic Health Evaluation (APACHE II), Modified APACHE II Score (MAS), Mainz Emergency Evaluation Scores (MEES) and Glasgow Coma Scale (GCS) were recorded for all patients on admission (time0) and 24 h later (time24). The outcome was recorded in two categories: Survived with or without complication and non-survived. Discrimination was evaluated using receiver operating characteristic (ROC) curves and area under the ROC curve (AUC). Results: The mortality rate was 9.7%. Mean of each scoring system was statistically significant between time0 and time24 in the survivors. However, it was not significant in non-survivors. Discrimination was excellent for GCS24 (0.90±0.05), APACHE II24 (0.89±0.01), MAS24 (0.86±0.10), and APACHE II0 (0.83±0.11) AUC. Conclusion: The GCS24, APACHE II24, MAS24, and APACHE II0 scoring systems seem to predict the outcome in comatose patients due to MDP more accurately. GCS and MAS may have superiority over the others in being easy to perform and not requiring laboratory data.
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Affiliation(s)
- Nastaran Eizadi Mood
- Departments of Clinical Toxicology and Forensic Medicine, Noor and Ali Asghar (PBUH) Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
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Moon JM, Chun BJ, Lee BK. Glasgow coma scale score in the prognosis of acute carbamate insecticide intoxication. Clin Toxicol (Phila) 2012; 50:832-7. [PMID: 22995033 DOI: 10.3109/15563650.2012.727093] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Carbamate is a widely used insecticide, and fatality due to carbamate insecticide intoxication has been reported. However, no studies have addressed the factors associated with outcome of patients poisoned by carbamate insecticide. The present study sought to identify the independent factors that could help predict the development of medical complications as a result of carbamate intoxication. METHODS Fifty two patients presenting with acute carbamate insecticide ingestion at Chonnam National University Hospital were enrolled in this retrospective observational case series. The morbidities that needed intensive treatment such as hypotension, respiratory failure, and death were regarded as complications. To identify the associated factors to these complications, objective variables that are easily assessed at presentation, such as age, initial Glasgow coma scale (GSC) and corrected QT (QTc) prolongation, were analyzed by univariate and multivariate stepwise logistic regression analyses. RESULTS Of the 52 patients, 35 (67.3%) had medical complications within 24 hours after carbamate insecticide intoxication and seven (13.5%) died. Respiratory failure was the most common medical complication. The significant factors determined by univariate analysis were initial GCS, elevated lactate, and QTc prolongation. However, initial GCS (≤13) was the only independent factor determined by multivariate analysis that was associated with serious complications requiring intensive medical treatment. CONCLUSIONS Carbamate insecticide intoxication is not a mild disease, as previously thought, having a mortality rate of 13.8% and a morbidity rate of 67.3%. Initial GCS ≤ 13 can be used as a significant factor to identify carbamate insecticide-intoxicated patients who will experience complications.
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Affiliation(s)
- Jeong Mi Moon
- Department of Emergency medicine, Chonnam National University Hospital, Gwangju, South Korea.
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Adeleye AO, Owolabi MO, Rabiu TB, Orimadegun AE. Physicians' Knowledge of the Glasgow Coma Scale in a Nigerian University Hospital: Is the Simple GCS Still Too Complex? Front Neurol 2012; 3:28. [PMID: 22408634 PMCID: PMC3297815 DOI: 10.3389/fneur.2012.00028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Accepted: 02/16/2012] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE The Glasgow Coma Scale, GCS, is a universal clinical means of quantifying the level of impaired consciousness. Although physicians usually receive undergraduate and postgraduate training in the use of this scale in our university hospital we are aware of studies suggesting that the working knowledge of the GCS among practising physicians might not be adequate. METHODS We carried out a questionnaire-based survey across all specialties and levels of training of physicians in active patient care in a Nigerian university hospital. RESULTS Of the 100 physicians sampled, 98 correctly spelled out what the three-letter abbreviation, GCS, stands for. Ninety-three percent also conceded it to be an important clinical rating scale. However, only 55-89% of the participants correctly identified the three respective clinical variables, (eye opening, verbal response, and motor response), of the GCS. More particularly, the participants' ability to itemize and correctly score all the respective components of each of the three clinical variables ranged from 0 to 35% across specialties and levels of training. Performance was best for the four-item eye opening variable and, worst for the six-item motor response variable. CONCLUSION In our university hospital, practising physicians' working knowledge of the GCS is inadequate and is dependent on the degree of the complexity of each of the three clinical variables of the scale.
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Affiliation(s)
- Amos O Adeleye
- Division of Neurological Surgery, Department of Surgery, College Of Medicine, University of Ibadan Ibadan, Nigeria
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Thompson DO, Hurtado TR, Liao MM, Byyny RL, Gravitz C, Haukoos JS. Validation of the Simplified Motor Score in the Out-of-Hospital Setting for the Prediction of Outcomes After Traumatic Brain Injury. Ann Emerg Med 2011; 58:417-25. [DOI: 10.1016/j.annemergmed.2011.05.033] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2011] [Revised: 05/26/2011] [Accepted: 05/31/2011] [Indexed: 12/01/2022]
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Namiki J, Yamazaki M, Funabiki T, Hori S. Inaccuracy and misjudged factors of Glasgow Coma Scale scores when assessed by inexperienced physicians. Clin Neurol Neurosurg 2011; 113:393-8. [DOI: 10.1016/j.clineuro.2011.01.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2010] [Revised: 09/17/2010] [Accepted: 01/02/2011] [Indexed: 10/18/2022]
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Glasgow coma scale and its components on admission: are they valuable prognostic tools in acute mixed drug poisoning? Crit Care Res Pract 2011; 2011:952956. [PMID: 21559299 PMCID: PMC3087408 DOI: 10.1155/2011/952956] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2010] [Accepted: 01/26/2011] [Indexed: 12/02/2022] Open
Abstract
Introduction. The verbal, eye, and motor components of Glasgow coma scale (GCS) may be influenced by poisoned patients' behavior in an attempted suicide. So, the values of admission GCS and its components for outcomes prediction in mixed drugs poisoning were investigated. Materials and Methods. A followup study data was performed on patients with mixed drugs poisoning. Outcomes were recorded as without complications and with complications. Discrimination was evaluated by calculating the area under the receiver operating characteristic curves (AUC). Results. There was a significant difference between the mean value of each component of GCS as well as the total GCS between patients with and without complication. Discrimination was best for GCS (AUC: 0.933 ± 0.020) and verbal (0.932 ± 0.021), followed by motor (0.911 ± 0.025), then eye (0.89 ± 0.028). Conclusions. Admission GCS and its components seem to be valuable in outcome prediction of patients with mixed drug poisoning.
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Abstract
BACKGROUND Aspiration of gastric contents is a serious problem in critically ill, mechanically ventilated patients receiving tube feedings. OBJECTIVES The purpose of this study was to evaluate the effectiveness of a three-pronged intervention to reduce aspiration risk in a group of critically ill, mechanically ventilated patients receiving tube feedings. METHODS A two-group quasi-experimental design was used to compare outcomes of a usual care group (December 2002-September 2004) with those of an Aspiration Risk-Reduction Protocol (ARRP) group (January 2007-April 2008). The incidence of aspiration and pneumonia was compared between the usual care group (n = 329) and the ARRP group (n = 145). The ARRP had three components: maintaining head-of-bed elevation at 30 degrees or higher, unless contraindicated; inserting feeding tubes into distal small bowel, when indicated; and using an algorithmic approach for high gastric residual volumes. RESULTS Two of the three ARRP components were implemented successfully. Almost 90% of the ARRP group had mean head-of-bed elevations of 30 degrees or higher as compared to 38% in the usual care group. Almost three fourths of the ARRP group had feeding tubes placed in the small bowel as compared with less than 50% in the usual care group. Only three patients met the criteria for the high gastric residual volume algorithm. Aspiration was much lower in the ARRP group than that in the usual care group (39% vs. 88%, respectively). Similarly, pneumonia was much lower in the ARRP group than that in the usual care group (19% vs. 48%, respectively). DISCUSSION Findings from this study suggest that a combination of a head-of-bed position elevated to at least 30 degrees and use of a small-bowel feeding site can reduce the incidence of aspiration and aspiration-related pneumonia dramatically in critically ill, tube-fed patients.
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Abstract
OBJECTIVE Alcohol misuse by college students places resource demands on colleges and universities, including the provision of medical services for intoxicated students. We harvested archival data to document the prevalence of alcohol-related ambulance utilization and to explore factors associated with ambulance use. METHODS We reviewed 2 years of university ambulance records and determined which trips were alcohol related and their demographic, descriptive, and medical correlates. RESULTS Alcohol use was associated with 17 and 16 percent of all university-based ambulance trips in 2005 and 2006, respectively. When alcohol was involved, patients were more likely to be younger than 21 years, less alert, and more likely to receive advanced life support. Alcohol-related ambulance trips were more likely to occur on weekends, to involve transport from a residence hall, and to a hospital. CONCLUSION Alcohol misuse is associated with one out of every six campus-based ambulance runs, a hidden cost of student alcohol misuse.
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Eizadi-Mood N, Saghaei M, Alfred S, Zargarzadeh AH, Huynh C, Gheshlaghi F, Yaraghi A, Saad YS. Comparative evaluation of Glasgow Coma Score and gag reflex in predicting aspiration pneumonitis in acute poisoning. J Crit Care 2009; 24:470.e9-15. [PMID: 19327309 DOI: 10.1016/j.jcrc.2008.08.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2007] [Revised: 05/08/2008] [Accepted: 08/25/2008] [Indexed: 02/08/2023]
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Zuercher M, Ummenhofer W, Baltussen A, Walder B. The use of Glasgow Coma Scale in injury assessment: A critical review. Brain Inj 2009; 23:371-84. [DOI: 10.1080/02699050902926267] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Duncan R, Thakore S. Decreased Glasgow Coma Scale score does not mandate endotracheal intubation in the emergency department. J Emerg Med 2009; 37:451-5. [PMID: 19272743 DOI: 10.1016/j.jemermed.2008.11.026] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2008] [Revised: 09/30/2008] [Accepted: 11/08/2008] [Indexed: 11/25/2022]
Abstract
BACKGROUND Decreased consciousness is a common reason for presentation to the emergency department (ED) and admission to acute hospital beds. In trauma, a Glasgow Coma Scale score (GCS) of 8 or less indicates a need for endotracheal intubation. Some advocate a similar approach for other causes of decreased consciousness, however, the loss of airway reflexes and risk of aspiration cannot be reliably predicted using the GCS alone. STUDY OBJECTIVE A survey of all poisoned patients with a decreased GCS who were admitted to an ED short-stay ward staffed by experienced emergency physicians, to establish the incidence of clinically significant aspiration or other morbidities and endotracheal intubation. METHODS A prospective, observational study was conducted of all patients admitted to the ED short-stay ward with a decreased level of consciousness (GCS < 15). RESULTS The study included 73 patients with decreased consciousness as a result of drug or alcohol intoxication. The GCS ranged from 3 to 14, and 12 patients had a GCS of 8 or less. No patient with a GCS of 8 or less aspirated or required intubation. There was one patient who required intubation; this patient had a GCS of 12 on admission to the ward. CONCLUSIONS This study suggests that it can be safe to observe poisoned patients with decreased consciousness, even if they have a GCS of 8 or less, in the ED.
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Affiliation(s)
- Russell Duncan
- Department of Emergency Medicine, Ninewells Hospital and Medical School, Dundee, Scotland, UK
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Sam KG, Kondabolu K, Pati D, Kamath A, Pradeep Kumar G, Rao PGM. Poisoning severity score, APACHE II and GCS: effective clinical indices for estimating severity and predicting outcome of acute organophosphorus and carbamate poisoning. J Forensic Leg Med 2009; 16:239-47. [PMID: 19481704 DOI: 10.1016/j.jflm.2008.12.004] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2007] [Revised: 09/23/2008] [Accepted: 12/09/2008] [Indexed: 11/25/2022]
Abstract
Self-poisoning with organophosphorus (OP) compounds is a major cause of morbidity and mortality across South Asian countries. To develop uniform and effective management guidelines, the severity of acute OP poisoning should be assessed through scientific methods and a clinical database should be maintained. A prospective descriptive survey was carried out to assess the utility of severity scales in predicting the outcome of 71 organophosphate (OP) and carbamate poisoning patients admitted during a one year period at the Kasturba Hospital, Manipal, India. The Glasgow coma scale (GCS) scores, acute physiology and chronic health evaluation II (APACHE II) scores, predicted mortality rate (PMR) and Poisoning severity score (PSS) were estimated within 24h of admission. Significant correlation (P<0.05) between PSS and GCS and APACHE II and PMR scores were observed with the PSS scores predicting mortality significantly (P< or =0.001). A total of 84.5% patients improved after treatment while 8.5% of the patients were discharged with severe morbidity. The mortality rate was 7.0%. Suicidal poisoning was observed to be the major cause (80.2%), while other reasons attributed were occupational (9.1%), accidental (6.6%), homicidal (1.6%) and unknown (2.5%) reasons. This study highlights the application of clinical indices like GCS, APACHE, PMR and severity scores in predicting mortality and may be considered for planning standard treatment guidelines.
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Affiliation(s)
- Kishore Gnana Sam
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal, Karnataka, India.
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Criminal poisoning of commuters in Bangladesh: Prospective and retrospective study. Forensic Sci Int 2008; 180:10-6. [DOI: 10.1016/j.forsciint.2008.06.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2007] [Revised: 01/10/2008] [Accepted: 06/18/2008] [Indexed: 11/21/2022]
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Baker M. Reviewing the application of the Glasgow Coma Scale: Does it have interrater reliability? ACTA ACUST UNITED AC 2008. [DOI: 10.12968/bjnn.2008.4.7.30674] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Mark Baker
- Neurosciences Ward, West Wing, John Radcliffe Hospital, Oxford
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Rauen CA, Chulay M, Bridges E, Vollman KM, Arbour R. Seven Evidence-Based Practice Habits: Putting Some Sacred Cows Out to Pasture. Crit Care Nurse 2008. [DOI: 10.4037/ccn2008.28.2.98] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Carol A. Rauen
- Carol A. Rauen is an independent critical care clinical nurse specialist in Silver Spring, Maryland
| | - Marianne Chulay
- Marianne Chulay is a consultant in clinical research and critical care nursing in Gainesville, Florida
| | - Elizabeth Bridges
- Elizabeth Bridges is an assistant professor at the University of Washington School of Nursing in Seattle and a clinical nurse researcher at the University of Washington Medical Center in Seattle
| | - Kathleen M. Vollman
- Kathleen M. Vollman is a clinical nurse specialist, educator, and consultant at Advancing Nursing LLC in Northville, Michigan
| | - Richard Arbour
- Richard Arbour is a critical care clinical nurse specialist at Albert Einstein Medical Center in Philadelphia, Pennsylvania
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Verbrugge LB, van Wezel HB. Pathophysiology of Verapamil Overdose: New Insights in the Role of Insulin. J Cardiothorac Vasc Anesth 2007; 21:406-9. [PMID: 17544895 DOI: 10.1053/j.jvca.2007.01.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2006] [Indexed: 01/23/2023]
Affiliation(s)
- Lisette B Verbrugge
- Department of Anesthesiology, Academic Medical Center, Amsterdam, the Netherlands.
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Holdgate A, Ching N, Angonese L. Variability in agreement between physicians and nurses when measuring the Glasgow Coma Scale in the emergency department limits its clinical usefulness. Emerg Med Australas 2006; 18:379-84. [PMID: 16842308 DOI: 10.1111/j.1742-6723.2006.00867.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess the interrater reliability of the Glasgow Coma Scale (GCS) between nurses and senior doctors in the ED. METHODS This was a prospective observational study with a convenience sample of patients aged 18 or above who presented with a decreased level of consciousness to a tertiary hospital ED. A senior ED doctor (emergency physicians and trainees) and registered nurse each independently scored the patient's GCS in blinded fashion within 15 min of each other. The data were then analysed to determine interrater reliability using the weighted kappa statistic and the size and directions of differences between paired scores were examined. RESULTS A total of 108 eligible patients were enrolled, with GCS scores ranging from 3 to 14. Interrater agreement was excellent (weighted kappa > 0.75) for verbal scores and total GCS scores, and intermediate (weighted kappa 0.4-0.75) for motor and eye scores. Total GCS scores differed by more than two points in 10 of the 108 patients. Interrater agreement did not vary substantially across the range of actual numeric GCS scores. CONCLUSIONS Although the level of agreement for GCS scores was generally high, a significant proportion of patients had GCS scores which differed by two or more points. This degree of disagreement indicates that clinical decisions should not be based solely on single GCS scores.
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Affiliation(s)
- Anna Holdgate
- Department of Emergency Medicine, Emergency Medicine Research Unit, Liverpool Hospital, Liverpool BC, NSW, Australia.
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