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Ulderich Williams SC, Qaddoumi AI, Meghreblian JT, McBride ME, King SA, Elahi MA, Tuggle D, Heidel RE, Smith LM. Incidence and Risk Factors for ICU-Associated Delirium in the Alert Geriatric Trauma Population. Am Surg 2024:31348241241707. [PMID: 38520278 DOI: 10.1177/00031348241241707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2024]
Abstract
BACKGROUND This study analyzed the overall incidence of delirium, comorbid conditions, injury patterns, and pharmacological risk factors for the development of delirium in an alert, geriatric trauma population. METHODS IRB-approved, prospective, consecutive cohort series at two Southeastern Level 1 trauma centers from June 11 to August 15, 2023. Delirium was assessed using the Confusion Assessment Method (CAM) score. Comorbidities and medications were detailed from electronic medical records. Inclusion criteria: age ≥55, GCS ≥14, and ICU admission for trauma. Patients on a ventilator were excluded. Data was analyzed using SPSS version 28 (Armonk, NY: IBM Corp). RESULTS In total, 196 patients met inclusion criteria. Incidences of delirium for Hospital 1 (n = 103) and Hospital 2 (n = 93) were 15.5% and 12.9%, respectively, with an overall incidence of 14.3% and with no statistical differences between hospitals (P = .599). CAD, CKD, dementia, stroke history, and depression were statistically significant risk factors for developing delirium during ICU admission. Inpatient SSRI/SNRIs, epinephrine/norepinephrine, and lorazepam were significant risk factors. Injury patterns, operative intervention, and use of lidocaine infusions and gabapentin were not statistically significant in delirium development. Using binary linear regression (BLR) analysis, independent risk factors for delirium were dementia, any stage CKD, home SSRI/SRNI prescription, any spine injury and cerebrovascular disease, or injury. DISCUSSION Comorbidities of CAD, CHF, CKD, and depression, and these medications: home lorazepam and ICU epinephrine/norepinephrine statistically are more common in patients developing delirium. Dementia, CKD, home SSRI/SRNI and stroke/cerebrovascular disease/injury, and spine injuries are independent predictors by BLR.
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Affiliation(s)
| | - Ansam I Qaddoumi
- Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
| | - John T Meghreblian
- Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Mary E McBride
- Department of Surgery, East Tennessee State University, Johnson City, TN, USA
| | - Sarah A King
- Department of Surgery, University of Tennessee Medical Center Knoxville, Knoxville, TN, USA
| | - Muhammad A Elahi
- Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Debbie Tuggle
- Department of Surgery, University of Tennessee Medical Center Knoxville, Knoxville, TN, USA
| | - R Eric Heidel
- Department of Surgery, University of Tennessee Medical Center Knoxville, Knoxville, TN, USA
| | - Lou M Smith
- Department of Surgery, East Tennessee State University, Johnson City, TN, USA
- Department of Surgery, University of Tennessee Medical Center Knoxville, Knoxville, TN, USA
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Zhang JK, Dinh TU, Teasdale G, Mercier P, Mattei TA. The message of the Glasgow Coma Scale: a comprehensive bibliometric analysis and systematic review of clinical practice guidelines spanning the past 50 years. World Neurosurg 2024:S1878-8750(24)00352-8. [PMID: 38437980 DOI: 10.1016/j.wneu.2024.02.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 02/25/2024] [Accepted: 02/26/2024] [Indexed: 03/06/2024]
Abstract
BACKGROUND Despite the ubiquitous use and profound impact of the Glasgow Coma Scale (GCS), no study to date has quantitatively assessed its impact on scientific literature and clinical practice. Therefore, we comprehensively analyze scientific publications and clinical practice guidelines employing the GCS to gauge its clinical and academic impact, identify research hotspots, and inform future research. METHODS A cross-sectional bibliometric analysis was performed on Scopus to obtain relevant publications incorporating the GCS from 1974 to 2022. In addition, a systematic review of existing clinical practice guidelines in PubMed, Scopus, Web of Science, and Trip Database was performed. Validated bibliometric parameters including article title, journal, publication year, authors, citation count, country, institution, keywords, impact factor, and references were assessed. When evaluating clinical practice guidelines, the sponsoring organization, country of origin, specialty, and publication year were assessed. RESULTS A total of 37,633 articles originating from 3,924 different scientific journals spanning 1974 to 2022 were included in the final analysis. The compound annual growth rate was 16.7%. Of 104 countries, the United States had the highest total number of publications (n=8,517). World Neurosurgery was the scientific periodical with the highest number of publications (n=798). The top trending author-supplied keyword was "traumatic brain injury" (n=3,408). The 97 included clinical practice guidelines most commonly employed the GCS in the fields of internal medicine (n=22, 23%), critical care (n=21, 22%), and neurotrauma (n=19, 20%). CONCLUSION At the turn of the 50th anniversary of the GCS, we provided an objective description of the "path to success" of the GCS both in terms of its scientific and clinical impact. These results hold not only a historical but also a didactic value. Our analysis of some of the factors that led the GCS to become such a widespread and highly influential score may assist future researchers in their development of future outcome measures and clinical scores, especially as they become increasingly relevant in an evidence-based, data-driven age.
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Affiliation(s)
- Justin K Zhang
- Division of Neurological Surgery, Department of Neurosurgery, Saint Louis University School of Medicine, St. Louis, MO, 63104, USA;; Department of Neurological Surgery, University of Utah, Salt Lake City, MO, 84102, USA
| | - Thai Uyen Dinh
- Division of Neurological Surgery, Department of Neurosurgery, Saint Louis University School of Medicine, St. Louis, MO, 63104, USA
| | - Graham Teasdale
- Emeritus Professor of Neurosurgery, University of Glasgow, Glasgow, United Kingdom
| | - Philippe Mercier
- Division of Neurological Surgery, Department of Neurosurgery, Saint Louis University School of Medicine, St. Louis, MO, 63104, USA
| | - Tobias A Mattei
- Division of Neurological Surgery, Department of Neurosurgery, Saint Louis University School of Medicine, St. Louis, MO, 63104, USA;.
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Caruana M, Hackenbruch SN, Grech V, Farrugia R. Inconsistency in the Application of Glasgow Coma Scale in Pediatric Patients. Med Princ Pract 2023; 33:41-46. [PMID: 37899031 PMCID: PMC10896613 DOI: 10.1159/000534797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 10/24/2023] [Indexed: 10/31/2023] Open
Abstract
OBJECTIVE The Glasgow Coma Scale (GCS) is widely used to objectively describe the extent of patients' impaired consciousness. However, there are known variations in scoring GCS both in adults and children which may impact patient management. The aim of this audit was to assess the application of GCS by medical and nursing staff in pediatric medical patients. SUBJECT AND METHODS An online questionnaire was distributed amongst doctors and nurses working in the Department of Child and Adolescent Health at Mater Dei Hospital in Malta. The participants assigned GCS for 8 case scenarios involving children of different ages with varying levels of consciousness. Results were analyzed by calculating percentage agreement and by Cronbach's alpha. RESULTS Sixty-six participants were studied, with a response rate of 52%. Performance was poor overall, with Cronbach alpha 0.53. Correlation was better at the upper and lower ends of the scale and the worst performance was for verbal response. Only respondents with 5-10 years of experience achieved acceptable consistency in the application of the GCS (Cronbach alpha 0.78). CONCLUSION There is considerable variation in application of GCS in pediatric patients, highlighting the need for education and training to improve consistency for this commonly used neurological assessment tool.
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Affiliation(s)
- Maria Caruana
- Department of Child and Adolescent Health, Mater Dei Hospital, Msida, Malta
| | | | - Victor Grech
- Department of Child and Adolescent Health, Mater Dei Hospital, Msida, Malta
| | - Ruth Farrugia
- Department of Child and Adolescent Health, Mater Dei Hospital, Msida, Malta
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Abstract
BACKGROUND Undertriage of older trauma patients is implicated as a cause for outcome disparities. Undertriage is defined by an Injury Severity Score (ISS) ≥16 without full trauma activation. We hypothesized that in patients ≥65 years, undertriage is associated with unfavorable discharge. METHODS This is a retrospective study of patients ≥65 years admitted at a Level 1 Trauma Center between July 2016 and June 2018 with blunt trauma. The Matrix method was used to determine the undertriage rate, and outcomes were compared between undertriaged and fully activated patients with ISS ≥16. Favorable outcomes in undertriaged patients instigated further analyses to determine factors that predicted unfavorable discharge condition, defined by discharge from the hospital with severe disability, persistent vegetative state, and in-hospital death. RESULTS The undertriage rate was 7.9%. When compared to fully activated patients with ISS ≥16, a lower percentage of undertriaged patients were discharged in an unfavorable condition (16.6% vs 64.7%, P < .001). On the multivariate analysis, male sex (OR = 1.52), preexisting coronary artery disease (OR = 1.86), age >90 years (OR = 2.31), ISS 16-25 (OR = 3.50), Glasgow Coma Score (GCS) ≤14 (OR = 6.34), and ISS >25 (OR = 9.64) were significant independent risk factors for unfavorable discharge. DISCUSSION The undertriage rate in patients ≥65 years was higher than the accepted standard (5%). However, undertriaged patients had better outcomes than those fully activated with ISS ≥16. Factors more predictive of unfavorable discharge condition were GCS ≤14 and ISS >25. These data suggest that ISS alone is a poor marker for assessing undertriage in older patients. Additional parameters established in this study should be considered as potential markers for better predicting outcomes in older trauma patients.
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Affiliation(s)
- Chelsea M Knotts
- 20205 Department of Surgery, West Virginia University School of Medicine-Charleston Division, WV, USA.,Department of Surgery, Charleston Area Medical Center, WV, USA
| | | | - Damayanti Samanta
- Trauma Research, General Hospital, Charleston Area Medical Center Health Education and Research Institute, WV, USA
| | - Bryan K Richmond
- 20205 Department of Surgery, West Virginia University School of Medicine-Charleston Division, WV, USA.,Department of Surgery, Charleston Area Medical Center, WV, USA
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Abstract
Pasquier, Mathieu, Evelien Cools, Ken Zafren, Pierre-Nicolas Carron, Vincent Frochaux, and Valentin Rousson. Vital signs in accidental hypothermia. High Alt Med Biol. 22: 142-147, 2021. Background: Clinical indicators are used to stage hypothermia and to guide management of hypothermic patients. We sought to better characterize the influence of hypothermia on vital signs, including level of consciousness, by studying cases of patients suffering from accidental hypothermia. Materials and Methods: We retrospectively included patients aged ≥18 years admitted to the hospital with a core temperature below 35°C. We identified the cases from a literature review and from a retrospective case series of hypothermic patients admitted to the hospital between 1994 and 2016. Patients who experienced cardiac arrest, as well as those with potential confounders such as concomitant diseases or intoxications, were excluded. Relationships between core temperature and heart rate, systolic blood pressure, respiratory rate, and level of consciousness were explored via correlations and regression. Results: Of the 305 cases reviewed, 216 met the criteria for inclusion. The mean temperature was 29.7°C ± 4.2°C (range 19.3°C-34.9°C). The relationships between temperature and each of the four vital signs were generally linear and significantly positive, with Spearman correlations for respiratory rate, heart rate, systolic blood pressure, and Glasgow Coma Score (GCS) of 0.29 (p = 0.024), 0.44 (p < 0.001), 0.47 (p < 0.001), and 0.78 (p < 0.001), respectively. Based on linear regression, the mean decrease of a vital sign associated with a 1°C decrease of temperature was estimated to be 0.50 minute-1 for respiratory rate, 2.54 minutes-1 for heart rate, 4.36 mmHg for systolic blood pressure, and 0.88 for GCS. Conclusions: There is a significant positive correlation between core temperature and heart rate, systolic blood pressure, respiratory rate, and GCS. The relationship between vital signs and temperature is generally linear. This knowledge might help clinicians make appropriate decisions when determining whether the clinical condition of a patient should be attributed to hypothermia. This could enhance clinical care and help to guide future research.
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Affiliation(s)
- Mathieu Pasquier
- Emergency Department, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland.,University of Lausanne, Lausanne, Switzerland
| | - Evelien Cools
- Department of Anaesthesiology, University Hospital of Geneva, Geneva, Switzerland
| | - Ken Zafren
- Department of Emergency Medicine, Stanford University Medical Center, Stanford, California, USA
| | - Pierre-Nicolas Carron
- Emergency Department, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland.,University of Lausanne, Lausanne, Switzerland
| | | | - Valentin Rousson
- University of Lausanne, Lausanne, Switzerland.,Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland
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Abstract
Context Head injury causes disseminated intravascular coagulation as the most severe complication which is associated with high mortality. Elevated levels of markers of fibrinolysis such as D-dimer and fibrinopeptide A (FPA) have been correlated with poor outcome in these patients. Aim The study aimed to correlate the levels of plasma fibrinogen, D-dimer, and FPA with outcome in patients with isolated head trauma. Settings and Design This cross-sectional descriptive study was conducted in the Departments of Pathology and Neurosurgery, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, on 100 patients admitted within 12 h of isolated head trauma. Subjects and Methods Plasma fibrinogen, D-dimer, and FPA were measured in 100 patients admitted within 12 h of isolated head trauma. While plasma fibrinogen and D-dimer were estimated in all patients, FPA was measured in 45 patients. Statistical Analysis SPSS (20.2) software was used for mean, standard deviation, and median values of the quantitative parameters, and for all qualitative parameters, their frequencies were obtained. P < 0.05 was considered significant. Results Elevated D-dimer (>250 ng/ml) and FPA (>3 ng/ml) were observed in 64% and 91.1% patients, respectively. Both D-dimer and FPA were elevated in 66.6% of patients. Disseminated intravascular coagulation (DIC) score, calculated using standard criteria, was ≥5 in 28% of patients indicating overt DIC. Hypofibrinogenemia was observed in 48% of patients. D-dimer, FPA, and DIC score was significantly (P < 0.001) higher and plasma fibrinogen significantly (P < 0.001) lower in nonsurvivors as compared to survivors. Elevated D-dimer and FPA and low fibrinogen levels were seen in patients irrespective of severity of injury. Conclusions Elevated D-dimer and FPA were frequently observed in patients with isolated head trauma. As these markers rise soon after injury and indicate poor outcome, their measurement will help identify patients who will benefit with additional therapy, thus reducing morbidity and mortality.
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Affiliation(s)
- Meera Sikka
- Department of Pathology, University College of Medical Sciences and Guru Teg Bahadur Hospital Hospital, New Delhi, India
| | - Ruchika Sodhi
- Department of Pathology, University College of Medical Sciences and Guru Teg Bahadur Hospital Hospital, New Delhi, India
| | - Mrinalini Kotru
- Department of Pathology, University College of Medical Sciences and Guru Teg Bahadur Hospital Hospital, New Delhi, India
| | - Gurubachan Singh
- Department of Neurosurgery, University College of Medical Sciences and Guru Teg Bahadur Hospital Hospital, New Delhi, India
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Nuttall AG, Paton KM, Kemp AM. To what extent are GCS and AVPU equivalent to each other when assessing the level of consciousness of children with head injury? A cross-sectional study of UK hospital admissions. BMJ Open 2018; 8:e023216. [PMID: 30498041 PMCID: PMC6278791 DOI: 10.1136/bmjopen-2018-023216] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 07/09/2018] [Accepted: 09/19/2018] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To evaluate utility and equivalence of Glasgow Coma Scale (GCS) and the Alert, Voice, Pain, Unresponsive (AVPU) scale in children with head injury. DESIGN Cross sectional study. SETTING UK hospital admissions: September 2009-February 2010. PATIENTS <15 years with head injury. INTERVENTIONS GCS and/or AVPU at injury scene and in emergency departments (ED). MAIN OUTCOME Measures used, the equivalence of AVPU to GCS, GCS at the scene predicting GCS in ED, CT results by age, hospital type. RESULTS Level of consciousness was recorded in 91% (5168/5700) in ED (43%: GCS/30.5%: GCS+AVPU/17.3%: AVPU) and 66.1% (1190/1801) prehospital (33%: GCS/26%GCS+AVPU/7%: AVPU). Failure to record level of consciousness and the use of AVPU were greatest for infants. Correlation between AVPU and median GCS in 1147 children <5 years: A=15, V=14, P=8, U=3, for 1163 children ≥5 years: A=15, V=13, P=11, U=3. There was no significant difference in the proportion of infants who had a CT whether AVPU=V/P/U or GCS<15. However diagnostic yield of intracranial injury or depressed fracture was significantly greater for V/P/U than GCS<15 :7/7: 100% (95% CI 64.6% to 100%) versus 5/17: 29.4% (95% CI 13.3% to 53.1%). For children >1 year significantly more had a CT scan when GCS<14 was recorded than 'V/P/U only' and the diagnostic yield was greater. Prehospital GCS and GCS in the ED were the same for 77.4% (705/911). CONCLUSION There was a clear correlation between Alert and GCS=15 and between Unresponsive and GCS=3 but a wider range of GCS scores for responsive to Pain or Voice that varied with age. AVPU was valuable at initial assessment of infants and did not adversely affect the proportion of infants who had head CT or the diagnostic yield.
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Affiliation(s)
- Amy Gl Nuttall
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Katie M Paton
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Alison M Kemp
- Division of Population Medicine, Cardiff University, Cardiff, UK
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Sterkel S, Akinyemi A, Sanchez-Gonzalez MA, Michel G. Preserving brain function in a comatose patient with septic hyperpyrexia (41.6 °C): a case report. J Med Case Rep 2017; 11:40. [PMID: 28190402 PMCID: PMC5304390 DOI: 10.1186/s13256-017-1204-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 01/06/2017] [Indexed: 11/12/2022] Open
Abstract
Background Pyrexia is a physiological response through which the immune system responds to infectious processes. Hyperpyrexia is known to be neurodegenerative leading to brain damage. Some of the neurotoxic effects of hyperpyrexia on the brain include seizures, decreased cognitive speed, mental status changes, coma, and even death. In the clinical management of hyperpyrexia, the goal is to treat the underlying cause of elevated temperature and prevent end organ damage. Case presentation This case illustrates a 39-year-old white American man referred from another medical facility where he had undergone an upper gastrointestinal tract diagnostic procedure which became complicated by blood aspiration and respiratory distress. During hospitalization, he developed a core body temperature of 41.6 °C (106.9 °F) leading to cognitive decline and coma with a Glasgow Coma Score of 3. Levetiracetam and amantadine were utilized effectively for preserving and restoring neurocognitive function. Prior studies have shown that glutamate levels can increase during an infectious process. Glutamate is an excitatory neurotransmitter that is utilized by the organum vasculosum laminae terminalis through the neuronal excitatory system and causes an increase in body temperature which can lead to hyperpyrexia. Similar to neurogenic fevers, hyperpyrexia can lead to neurological decline and irreversible cognitive dysfunction. Inhibition of the glutamate aids a decrease in excitatory states, and improves the brain’s regulatory mechanism, including temperature control. To further improve cognitive function, dopamine levels were increased with a dopamine agonist. Conclusions We propose that a combination of levetiracetam and amantadine may provide neuroprotective and neurorestorative properties when administered during a period of hyperpyrexia accompanied by any form of mental status changes, particularly if there is a decline in Glasgow Coma Score.
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Affiliation(s)
- Samantha Sterkel
- Department of Internal Medicine, Larkin Community Hospital, Graduate Medical Education, 7000 SW 62nd Avenue, Suite 401, South Miami, FL, 33142, USA
| | - Akinboyede Akinyemi
- Department of Psychiatry, Larkin Community Hospital, Graduate Medical Education, 7000 SW 62nd Avenue, Suite 401, South Miami, FL, 33142, USA.
| | | | - George Michel
- Department of Internal Medicine, Larkin Community Hospital, Graduate Medical Education, 7000 SW 62nd Avenue, Suite 401, South Miami, FL, 33142, USA
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Sterkel S, Akinyemi A, Sanchez-Gonzalez MA, Michel G. Preserving brain function in a comatose patient with septic hyperpyrexia (41.6 °C): a case report. J Med Case Rep 2017. [PMID: 28190402 DOI: 10.1186/s13256--017--1204--8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2022] Open
Abstract
BACKGROUND Pyrexia is a physiological response through which the immune system responds to infectious processes. Hyperpyrexia is known to be neurodegenerative leading to brain damage. Some of the neurotoxic effects of hyperpyrexia on the brain include seizures, decreased cognitive speed, mental status changes, coma, and even death. In the clinical management of hyperpyrexia, the goal is to treat the underlying cause of elevated temperature and prevent end organ damage. CASE PRESENTATION This case illustrates a 39-year-old white American man referred from another medical facility where he had undergone an upper gastrointestinal tract diagnostic procedure which became complicated by blood aspiration and respiratory distress. During hospitalization, he developed a core body temperature of 41.6 °C (106.9 °F) leading to cognitive decline and coma with a Glasgow Coma Score of 3. Levetiracetam and amantadine were utilized effectively for preserving and restoring neurocognitive function. Prior studies have shown that glutamate levels can increase during an infectious process. Glutamate is an excitatory neurotransmitter that is utilized by the organum vasculosum laminae terminalis through the neuronal excitatory system and causes an increase in body temperature which can lead to hyperpyrexia. Similar to neurogenic fevers, hyperpyrexia can lead to neurological decline and irreversible cognitive dysfunction. Inhibition of the glutamate aids a decrease in excitatory states, and improves the brain's regulatory mechanism, including temperature control. To further improve cognitive function, dopamine levels were increased with a dopamine agonist. CONCLUSIONS We propose that a combination of levetiracetam and amantadine may provide neuroprotective and neurorestorative properties when administered during a period of hyperpyrexia accompanied by any form of mental status changes, particularly if there is a decline in Glasgow Coma Score.
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Affiliation(s)
- Samantha Sterkel
- Department of Internal Medicine, Larkin Community Hospital, Graduate Medical Education, 7000 SW 62nd Avenue, Suite 401, South Miami, FL, 33142, USA
| | - Akinboyede Akinyemi
- Department of Psychiatry, Larkin Community Hospital, Graduate Medical Education, 7000 SW 62nd Avenue, Suite 401, South Miami, FL, 33142, USA.
| | | | - George Michel
- Department of Internal Medicine, Larkin Community Hospital, Graduate Medical Education, 7000 SW 62nd Avenue, Suite 401, South Miami, FL, 33142, USA
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Osler T, Cook A, Glance LG, Lecky F, Bouamra O, Garrett M, Buzas JS, Hosmer DW. The differential mortality of Glasgow Coma Score in patients with and without head injury. Injury 2016; 47:1879-85. [PMID: 27129906 DOI: 10.1016/j.injury.2016.04.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 03/25/2016] [Accepted: 04/13/2016] [Indexed: 02/02/2023]
Abstract
IMPORTANCE The GCS was created forty years ago as a measure of impaired consciousness following head injury and thus the association of GCS with mortality in patients with traumatic brain injury (TBI) is expected. The association of GCS with mortality in patients without TBI (non-TBI) has been assumed to be similar. However, if this assumption is incorrect mortality prediction models incorporating GCS as a predictor will need to be revised. OBJECTIVE To determine if the association of GCS with mortality is influenced by the presence of TBI. DESIGN/SETTING/PARTICIPANTS Using the National Trauma Data Bank (2012; N=639,549) we categorized patients as isolated TBI (12.8%), isolated non-TBI (33%), both (4.8%), or neither (49.4%) based on the presence of AIS codes of severity 3 or greater. We compared the ability GCS to discriminate survivors from non-survivors in TBI and in non-TBI patients using logistic models. We also estimated the odds ratios of death for TBI and non-TBI patients at each value of GCS using linear combinations of coefficients. MAIN OUTCOME MEASURE Death during hospital admission. RESULTS As the sole predictor in a logistic model GCS discriminated survivors from non-survivors at an acceptable level (c-statistic=0.76), but discriminated better in the case of TBI patients (c-statistic=0.81) than non-TBI patients (c-statistic=0.70). In both unadjusted and covariate adjusted models TBI patients were about twice as likely to die as non-TBI patients with the same GCS for GCS values<8; for GCS values>8 TBI and non-TBI patients were at similar risk of dying. CONCLUSIONS A depressed GCS predicts death better in TBI patients than non-TBI patients, likely because in non-TBI patients a depressed GCS may simply be the result of entirely reversible intoxication by alcohol or drugs; in TBI patients, by contrast, a depressed GCS is more ominous because it is likely due to a head injury with its attendant threat to survival. Accounting for this observation into trauma mortality datasets and models may improve the accuracy of outcome prediction.
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Affiliation(s)
- Turner Osler
- Department of Surgery, University of Vermont, 789 Orchard Shore Road, Colchester, VT 05446, United States.
| | - Alan Cook
- Trauma Research Program, Chandler Regional Medical Center, United States; Department of Surgery University of Arizona College of Medicine, Phoenix, United States.
| | - Laurent G Glance
- Department of Anesthesiology, University of Rochester, United States.
| | - Fiona Lecky
- Emergency Medicine, University of Sheffield, United Kingdom; Trauma Audit and Research Network, United Kingdom.
| | - Omar Bouamra
- Trauma Audit and Research Network, United Kingdom.
| | - Mark Garrett
- Chandler Regional Medical Center, United States.
| | - Jeffery S Buzas
- Department of Mathematics and Statistics, University of Vermont, United States.
| | - David W Hosmer
- School of Public Health and Health Sciences, University of Massachusetts, United States.
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Salottolo K, Carrick M, Levy AS, Morgan BC, Mains CW, Slone DS, Bar-Or D. Aggressive operative neurosurgical management in patients with extra-axial mass lesion and Glasgow Coma Scale of 3 is associated with survival benefit: A propensity matched analysis. Injury 2016; 47:70-6. [PMID: 26499227 DOI: 10.1016/j.injury.2015.10.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 10/01/2015] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Prognosis in patients with traumatic brain injury (TBI) and Glasgow Coma Scale (GCS) score of 3 is poor, raising concern regarding the utility of aggressive operative neurosurgical management. Our purpose was to describe outcomes in a propensity matched population with TBI and GCS3 treated with operative neurosurgical procedures of craniotomy or craniectomy (CRANI). METHODS We conducted a five-year, multicenter retrospective cohort study of patients with an ED GCS 3 and a positive head CT identified by ICD-9CM diagnosis codes. Two populations were examined: (1) patients with extra-axial mass lesion (subdural or epidural haematoma), (2) patients without mass lesion (subarachnoid and intraparenchymal haemorrhage including contusion, other intracerebral haemorrhage or intracranial injury including diffuse axonal injury). In patients with extra-axial mass lesion, propensity score techniques were used to match patients 1:1 by CRANI, and the following outcomes were analysed with conditional logistic regression: survival, favourable hospital disposition to home or rehabilitation, and development of complications. RESULTS There were 541 patients with TBI and GCS3; 19% had a CRANI, 83% were initiated within 4h. In those with mass lesion, 27% (91/338) had a CRANI; after matching, a significant survival benefit was observed with CRANI vs. without CRANI (65% vs. 34% survival, OR: 3.9 (1.6-10.5) p<0.001). There was borderline increased odds of favourable disposition (43% vs. 26%, OR: 2.4 (0.99-6.3, p=0.052) with CRANI vs. without CRANI, and no difference in developing a complication (58% vs. 48%, OR: 1.5 (0.7-3.4), p=0.30). CONCLUSIONS Survival was achieved in 65% of patients that underwent surgical intervention for subdural and epidural haematoma, despite a presenting GCS of 3. These results demonstrate prompt operative neurosurgical management of mass lesion is warranted for selected patients with a GCS of 3, contributing to a significant 4-fold survival benefit. In the absence of mass lesion the effect of immediate neurosurgery on outcomes is inconclusive.
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Affiliation(s)
- Kristin Salottolo
- Department of Trauma Research, Medical Center of Plano, 3901 West 15th Street, Plano, TX 75075, United States; Department of Trauma Research, Swedish Medical Center, 501 E. Hampden Ave, Englewood, CO 80113, United States; Department of Trauma Research, St. Anthony Hospital, 11600 W. 2nd Place, Lakewood, CO 80228, United States.
| | - Matthew Carrick
- Department of Trauma Research, Medical Center of Plano, 3901 West 15th Street, Plano, TX 75075, United States; Trauma Services Department, Medical Center of Plano, 3901 W. 15th St, Plano, TX 75075, United States.
| | - A Stewart Levy
- Trauma Services Department, St. Anthony Hospital, 11600 West 2nd Place, Lakewood, CO 80228, United States; Trauma Services Department, Intermountain Neurosurgery, 11700 W. 2nd Place, Lakewood, CO 80228, United States.
| | - Brent C Morgan
- Trauma Services Department, Medical Center of Plano, 3901 W. 15th St, Plano, TX 75075, United States.
| | - Charles W Mains
- Trauma Services Department, St. Anthony Hospital, 11600 West 2nd Place, Lakewood, CO 80228, United States.
| | - Denetta S Slone
- Department of Trauma Research, St. Anthony Hospital, 11600 W. 2nd Place, Lakewood, CO 80228, United States; Trauma Services Department, Swedish Medical Center, 499 E. Hampden Ave, Englewood, CO 80113, United States; Trauma Services Department, Rocky Vista University, 8401 S. Chambers Rd, Parker, CO 80134, United States.
| | - David Bar-Or
- Department of Trauma Research, Medical Center of Plano, 3901 West 15th Street, Plano, TX 75075, United States; Department of Trauma Research, Swedish Medical Center, 501 E. Hampden Ave, Englewood, CO 80113, United States; Department of Trauma Research, St. Anthony Hospital, 11600 W. 2nd Place, Lakewood, CO 80228, United States; Trauma Services Department, Rocky Vista University, 8401 S. Chambers Rd, Parker, CO 80134, United States.
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Kirmani AR, Sarmast AH, Bhat AR. Role of external ventricular drainage in the management of intraventricular hemorrhage; its complications and management. Surg Neurol Int 2015; 6:188. [PMID: 26759733 PMCID: PMC4697206 DOI: 10.4103/2152-7806.172533] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 09/30/2015] [Indexed: 11/23/2022] Open
Abstract
Background: External ventricular drainage (EVD) is the procedure of choice for the treatment of acute hydrocephalus and increased intracranial pressure in patients of subarachnoid hemorrhage (SAH) and intracerebral hemorrhage with hydrocephalus and its sequelae. We evaluated the use of EVD in patients of SAHs (spontaneous/posttraumatic with/without hydrocephalus), hypertensive intracerebral bleeds with interventricular extensions, along with evaluation of the frequency of occurrence of complications of the procedure, infectious and noninfectious, and their management. Methods: During the period of 2½ years, between September 2012 and February 2015, 130 patients were subjected to external drainage procedure and were prospectively enrolled in this study. Information was collected on each patient regarding age, sex, diagnosis, underlying illness, secondary complications, other coexisting infections, use of systemic steroids, antibiotic treatment (systemic and intraventricular), and whether any other neurosurgical procedures were performed within 2 weeks of EVD insertion or any time the duration of ventriculostomy. Results: The study population of 130 patients underwent a total of 193 ventriculostomies. Thirty-six patients had ventriculostomy infection (27.6%). Evaluation of the use of EVD was done by comparing preoperative and postoperative grading scores. Forty-nine patients survived and improved their score from Grade 3–5 to Grade 2–4. Twenty-nine patients were moderately disable, 16 were severely disable, and 5 were left in the vegetative state. Evaluation of outcome of patients revealed that there was an overall mortality of 61 (46.9%) patients both in the acute phase and later. 33 of the 39 patients having Glasgow Coma Score (GCS) 3–5 at the time of EVD insertion expired, as against 20 of the 51 patients in GCS 6–8. Patients in GCS 9–12 had an even better outcome, with 8 of the 35 patients in this group expiring. Conclusions: The use of EVD should be undertaken only in situation where it is absolutely necessary and ventriculostomy should be kept only for the duration required, and this should be monitored on a daily basis, given the exponential increase in infection after 5 days.
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Affiliation(s)
- Altaf Rehman Kirmani
- Department of Neurosurgery, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Arif Hussain Sarmast
- Department of Neurosurgery, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Abdul Rashid Bhat
- Department of Neurosurgery, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Popernack ML, Gray N, Reuter-Rice K. Moderate-to-Severe Traumatic Brain Injury in Children: Complications and Rehabilitation Strategies. J Pediatr Health Care 2015; 29:e1-7. [PMID: 25449002 PMCID: PMC4409446 DOI: 10.1016/j.pedhc.2014.09.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 09/17/2014] [Accepted: 09/20/2014] [Indexed: 10/24/2022]
Abstract
Traumatic brain injury (TBI) is the leading cause of death in children in the United States. Each year 37,200 children sustain a severe TBI, with up to 1.3 million life-years potentially adversely affected. Severe pediatric TBI is associated with significant mortality and morbidity. Of the children who survive their injury, more than 50% experience unfavorable outcomes 6 months after the injury. Although TBI-associated death rates decreased between 1997-2007, disabilities for TBI survivors continue to have both a direct and indirect impact on the economic and human integrity of our society. The degree of disability varies with the severity and mechanism of the injury, but a realm of physical and emotional deficits may be evident for years after the injury occurs. This article describes the pathophysiology of moderate to severe TBI, its associated complications, and opportunities to improve patient outcomes through use of acute management and rehabilitation strategies. To address the many challenges for TBI survivors and their families, including significant financial and emotional burdens, a collaborative effort is necessary to help affected children transition seamlessly from acute care through long-term rehabilitation.
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Hosseini M, Ramazani J. Comparison of acute physiology and chronic health evaluation II and Glasgow Coma Score in predicting the outcomes of Post Anesthesia Care Unit's patients. Saudi J Anaesth 2015; 9:136-41. [PMID: 25829900 PMCID: PMC4374217 DOI: 10.4103/1658-354x.152839] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Context: Acute physiology and chronic health evaluation II (APACHE II) is one of the most general classification systems of disease severity in Intensive Care Units and Glasgow Coma Score (GCS) is one of the most specific ones. Aims: The aim of the current study was to assess APACHE II and GCS ability in predicting the outcomes (survivors, non-survivors) in the Post Anesthesia Care Unit's (PACU). Settings and Design: This was an observational and prospective study of 150 consecutive patients admitted in the PACU during 6-month period. Materials and Methods: Demographic information recorded on a checklist, also information about severity of disease calculated based on APACHE II scoring system in the first admission 24 h and GCS scale. Statistical Analysis Used: Logistic regression, Hosmer-Lemeshow test and receiver operator characteristic (ROC) curves were used in statistical analysis (95% confidence interval). Results: Data analysis showed a significant statistical difference between outcomes and both APACHE II and Glasgow Coma Score (GCS) (P < 0.0001). The ROC-curve analysis suggested that the predictive ability of GCS is slightly better than APACHE II in this study. For GCS the area under the ROC curve was 86.1% (standard error [SE]: 3.8%), and for APACHE II it was 85.7% (SE: 3.5%), also the Hosmer-Lemeshow statistic revealed better calibration for GCS (χ2 = 5.177, P = 0.521), than APACHE II (χ2 = 10.203, P = 0.251). Conclusions: The survivors had significantly lower APACHE II and higher GCS compared with non-survivors, also GCS showed more predictive accuracy than APACHE II in prognosticating the outcomes in PACU.
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Affiliation(s)
- Mohammad Hosseini
- Department of Nursing, North Khorasan University of Medical Sciences, Bojnourd, Iran
| | - Jamileh Ramazani
- Department of Nursing, Islamic Azad University, Bojnourd Branch, Bojnourd, Iran
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Whyte J, Nakase-Richardson R, Hammond FM, McNamee S, Giacino JT, Kalmar K, Greenwald BD, Yablon SA, Horn LJ. Functional outcomes in traumatic disorders of consciousness: 5-year outcomes from the National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems. Arch Phys Med Rehabil 2013; 94:1855-60. [PMID: 23732164 DOI: 10.1016/j.apmr.2012.10.041] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Revised: 10/05/2012] [Accepted: 10/26/2012] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To characterize the 5-year outcomes of patients with traumatic brain injury (TBI) not following commands when admitted to acute inpatient rehabilitation. DESIGN Secondary analysis of prospectively collected data from the National Institute on Disability and Rehabilitation Research-funded Traumatic Brain Injury Model Systems (TBIMS). SETTING Inpatient rehabilitation hospitals participating in the TBIMS program. PARTICIPANTS Patients (N=108) with TBI not following commands at admission to acute inpatient rehabilitation were divided into 2 groups (early recovery: followed commands before discharge [n=72]; late recovery: did not follow commands before discharge [n=36]). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES FIM items. RESULTS For the early recovery group, depending on the FIM item, 8% to 21% of patients were functioning independently at discharge, increasing to 56% to 85% by 5 years postinjury. The proportion functioning independently increased from discharge to 1 year, 1 to 2 years, and 2 to 5 years. In the late recovery group, depending on the FIM item, 19% to 36% of patients were functioning independently by 5 years postinjury. The proportion of independent patients increased significantly from discharge to 1 year and from 1 to 2 years, but not from 2 to 5 years. CONCLUSIONS Substantial proportions of patients admitted to acute inpatient rehabilitation before following commands recover independent functioning over as long as 5 years, particularly if they begin to follow commands before hospital discharge.
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Affiliation(s)
- John Whyte
- Moss Rehabilitation Research Institute, Elkins Park, PA.
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