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At least 1,063 records · Page 59Linked to original sources
PubMed2005

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

STUDY OBJECTIVE: The 15-point Glasgow Coma Scale (GCS) is extensively used in the initial evaluation of traumatic brain injury in emergency department (ED) settings. We hypothesized that the GCS might be unnecessarily complex and that a simpler scoring system might demonstrate similar accuracy in the prediction of traumatic brain injury outcomes. METHODS: We analyzed a prospectively maintained trauma registry of patients evaluated at our Level I trauma center from 1990 to 2002. We calculated the test performance of ED GCS scores relative to 4 clinically relevant traumatic brain injury outcomes (emergency intubation, neurosurgical intervention, brain injury, and mortality) using areas under their receiver operating characteristic (ROC) curves. We performed similar analyses for each of the 3 GCS components and for 2 simplified 3-point scores (simplified verbal score: oriented=2, confused conversation=1, inappropriate words or less=0; simplified motor score: obeys commands=2, localizes pain=1, withdrawal to pain or less=0). We then compared the test performance of each of these 5 to the total GCS score using a priori thresholds for clinically important differences. RESULTS: Each of the 3 GCS components alone and the 2 simplified 3-point scores demonstrated ROC areas within 9% of that of the GCS score for the 4 outcomes, with a median difference of 3.0% (interquartile range 1.6% to 4.5%). These differences were all below our a priori definitions of clinical importance. CONCLUSION: The 3 individual GCS components alone and two 3-point simplified scores demonstrated test performance similar to the total GCS score for the prediction of 4 clinically relevant traumatic brain injury outcomes. Despite the widespread use of the GCS for the initial evaluation of traumatic brain injury, this score may be unnecessarily complex for this indication.

Adolescent↗
PubMed2006

Clinical features of head injury patients presenting with a Glasgow Coma Scale score of 15 and who require neurosurgical intervention.

STUDY OBJECTIVE: Emergency physicians are concerned about minor head injury patients who present with a Glasgow Coma Scale (GCS) score of 15 yet require neurosurgical intervention. Our objectives are to determine the accuracy of the Canadian CT Head Rule (CCHR) in this important subset, the prevalence of patients requiring urgent intervention, and their clinical course and possible warning signs. METHODS: We conducted a secondary data analysis of the CCHR study cohorts from 10 hospital emergency departments (EDs). We included head trauma patients with witnessed loss of consciousness, disorientation, or definite amnesia and who presented with an initial GCS score of 15. Records were reviewed and specific variables added to the database. The primary outcome was need for urgent neurosurgical intervention. RESULTS: Among the 4,551 study patients, only 26 (0.6%; 95% confidence interval [CI] 0 to 1.0%) required neurosurgical intervention, and the CCHR identified all 26 cases with 100% sensitivity. Eleven patients required "urgent" craniotomy within 7 days, and of those, 2 patients deteriorated precipitously. These 11 (0.2%; 95% CI 0.1% to 0.3%) cases had additional signs: GCS score decrease within 6 hours (82%), GCS score decrease within 3 hours (73%), confusion (64%), any vomiting (36%), focal temporal blow (36%), restlessness (36%), and severe headache (45%). CONCLUSION: For patients with minor head injury and GCS score of 15, urgent neurosurgical intervention and precipitous deterioration are rare. The CCHR accurately identified all patients requiring neurosurgical intervention. Warning signs that may portend need for urgent intervention include any vomiting, restlessness, any GCS score decrease, severe headache, confusion, and focal temporal blow.

Adolescent↗
PubMed2004

[Auditive and somato-sensory event-related potentials in comas: prognostic value for awakening, social and professional reinstatement].

OBJECTIVE: To appreciate prognostical value of event-related potentials in comatose states and the influence of the stimulation's modality. PATIENTS AND METHODS: Thirty-five patients were recorded with the auditory modality whose thirteen were also recorded with the somesthetic modality. They were free of sedation except for five. For 21 patients out of coma, it was possible to get information about their social readaptation 14 months later. RESULTS: When present, cognitive components predict awakening in 100 % of the cases, but only 50 % of the patients who awake had these components. The somesthetic modality seemed to enlarge their detection, but did not improve short-term forecasts. We could not confirm their absence could hamper social reinstatement. CONCLUSION: Event-related potentials are strengthened as having excellent positive prognostic value. Further studies should clarify the interest of the somesthetic modality, and the possibility to get remote prognostic.

Adolescent↗
PubMed2004

Mortality prediction of head Abbreviated Injury Score and Glasgow Coma Scale: analysis of 7,764 head injuries.

BACKGROUND: We assessed the prognostic value and limitations of Glasgow Coma Scale (GCS) and head Abbreviated Injury Score (AIS) and correlated head AIS with GCS. STUDY DESIGN: We studied 7,764 patients with head injuries. Bivariate analysis was performed to examine the relationship of GCS, head AIS, age, gender, and mechanism of injury with mortality. Stepwise logistic regression analysis was used to identify the independent risk factors associated with mortality. RESULTS: The overall mortality in the group of head injury patients with no other major extracranial injuries and no hypotension on admission was 9.3%. Logistic regression analysis identified head AIS, GCS, age, and mechanism of injury as significant independent risk factors of death. The prognostic value of GCS and head AIS was significantly affected by the mechanism of injury and the age of the patient. Patients with similar GCS or head AIS but different mechanisms of injury or ages had significantly different outcomes. The adjusted odds ratio of death in penetrating trauma was 5.2 (3.9, 7.0), p < 0.0001, and in the age group > or = 55 years the adjusted odds ratio was 3.4 (2.6, 4.6), p < 0.0001. There was no correlation between head AIS and GCS (correlation coefficient -0.31). CONCLUSIONS: Mechanism of injury and age have a major effect in the predictive value of GCS and head AIS. There is no good correlation between GCS and head AIS.

Adult↗
PubMed2005

The association between field Glasgow Coma Scale score and outcome in patients undergoing paramedic rapid sequence intubation.

Early intubation is standard for treating severe traumatic brain injury (TBI). Aeromedical crews and select paramedic agencies use rapid sequence intubation (RSI) to facilitate intubation after TBI, with Glasgow Coma Scale (GCS) score commonly used as a screening tool. To explore the association between paramedic GCS and outcome in patients with TBI undergoing prehospital RSI, paramedics prospectively enrolled adult major trauma victims with GCS 3-8 and clinical suspicion for head trauma to undergo succinylcholine-assisted intubation as part of the San Diego Paramedic RSI Trial. The following data were abstracted from paramedic debriefing interviews and the county trauma registry: demographics, mechanism, vital signs including GCS score, clinical evidence of aspiration before RSI, arrival laboratory values, hospital course, and outcome. Paramedic GCS calculations were confirmed during debriefing interviews. Patients were stratified by GCS score, with chi-square and receiver-operator-curve (ROC) analysis used to explore the relationship between GCS and hypoxia, head injury severity, aspiration, intensive care unit (ICU) length of stay, and outcome. Cohort analysis was used to explore potential reasons for early extubation and discharge from the ICU in some patients. A total of 412 patients were included in this analysis. A total of 81 patients (20%) were extubated and discharged from the ICU in 48 h or less; these patients had higher pre-RSI oxygen saturation (SaO(2)) values and higher arrival serum ethanol levels. Paramedic and physician GCS calculations had high agreement (kappa=0.995). A statistically significant relationship was observed between GCS score and Head Abbreviated Injury Score (AIS), survival, and pre-RSI SaO(2) values. However, ROC analysis revealed a limited ability of GCS to predict the presence of severe TBI, injury severity, desaturation, aspiration, ICU length of stay, or ultimate survival. In conclusion, paramedics seem to accurately calculate GCS values before prehospital RSI. Although a relationship between paramedic GCS and outcome exists, the ability to predict the severity of injury, airway-related complications, ICU length of stay, and overall survival is limited using this single variable. Other factors should be considered to screen TBI patients for prehospital RSI.

Adult↗
PubMed2005

Pediatric trauma patients with isolated airway compromise or Glasgow Coma Scale less than 8: does immediate attending surgeon's presence upon arrival make a difference?

BACKGROUND/PURPOSE: Optimal trauma care requires an attending pediatric surgeon to head a trauma team for the most severely injured patients. Recently, the American College of Surgeons-Committee on Trauma has added "Glasgow Coma Scale (GCS) <8" and "airway compromise" to the existing anatomical and physiological criteria for immediate attending presence. This report analyzes the outcome of children who met these isolated criteria and were treated before the change in guidelines was made. METHODS: The trauma registry of this level I trauma center was queried for all pediatric patients with GCS <8 or airway compromise. Age, sex, initial GCS, Revised Trauma Score, Injury Severity Score, outcome, and probability of survival (TRISS methodology) were recorded. The subgroup of patients for whom an attending surgeon was not immediately present was further analyzed. RESULTS: Over a 5-year period, 2895 trauma patients (aged 0-16 years) were admitted. One hundred fifteen patients had a GCS <8 and/or airway compromise. In 61 cases, an attending surgeon was not present upon patient arrival. Of these patients, 24 died (group D), 15 were discharged to a rehabilitation facility (group R), and 22 were discharged home (group H). Ten patients with a probability of survival of lower than 0.5 survived. Only 4 of the 24 patients who died had a probability of survival of >0.5 (mean, 0.697). All 4 had an Injury Severity Score >25 and a GCS < or =4. All deaths were reviewed through a quality improvement program and were deemed nonpreventable by objective reviewers. Patient outcome was not affected by the presence or absence of an attending surgeon upon patient arrival. CONCLUSIONS: Outcome of severely injured children with GCS <8 or airway compromise met and, in some cases, exceeded expectations of survival according to the TRISS methodology. The lack of immediate attending surgeon's presence does not appear to have negatively influenced the outcome in these children. Based on this series, there is no evidence to justify mandatory immediate presence of an attending surgeon for these 2 criteria alone.

Adolescent↗
PubMed2006

Factors influencing pediatric Injury Severity Score and Glasgow Coma Scale in pediatric automobile crashes: results from the Crash Injury Research Engineering Network.

BACKGROUND/PURPOSE: Motor vehicle crashes account for more than 50% of pediatric injuries. Triage of pediatric patients to appropriate centers can be based on the crash/injury characteristics. Pediatric motor vehicle crash/injury characteristics can be determined from an in vitro laboratory using child crash dummies. However, to date, no detailed data with respect to outcomes and crash mechanism have been presented with a pediatric in vivo model. METHODS: The Crash Injury Research Engineering Network is comprised of 10 level 1 trauma centers. Crashes were examined with regard to age, crash severity (DeltaV), crash direction, restraint use, and airbag deployment. Multiple logistic regression analysis was performed with Injury Severity Score (ISS) and Glasgow Coma Scale (GCS) as outcomes. Standard age groupings (0-4, 5-9, 10-14, and 15-18) were used. The database is biases toward a survivor population with few fatalities. RESULTS: Four hundred sixty-one motor vehicle crashes with 2500 injuries were analyzed (242 boys, 219 girls). Irrespective of age, DeltaV > 30 mph resulted in increased ISS and decreased GCS (eg, for 0-4 years, DeltaV < 30: ISS = 10, GCS = 13.5 vs DeltaV > 30: ISS = 19.5, GCS = 10.6; P < .007, < .002, respectively). Controlling for DeltaV, children in lateral crashes had increased ISS and decreased GCS versus those in frontal crashes. Airbag deployment was protective for children 15 to 18 years old and resulted in a lower ISS and higher GCS (odds ratio, 2.1; 95% confidence interval, 0.9-4.6). Front-seat passengers suffered more severe (ISS > 15) injuries than did backseat passengers (odds ratio, 1.7; 95% confidence interval, 0.7-3.4). A trend was noted for children younger than 12 years sitting in the front seat to have increased ISS and decreased GCS with airbag deployment but was limited by case number. CONCLUSION: A reproducible pattern of increased ISS and lower GCS characterized by high severity, lateral crashes in children was noted. Further analysis of the specific injuries as a function and the crash characteristic can help guide management and prevention strategies.

Accidents, Traffic↗
PubMed2005

Reactive EEG patterns in pediatric coma.

This study was designed to determine whether the observed reactive electroencephalographic patterns in comatose children were associated with a better outcome. All electroencephalograms performed in comatose children aged 2 months to 18 years during the period 1996-2003 were retrospectively analyzed and classified according to modified Young's classification. Reactivity to painful/auditory stimuli and passive eye closure (at least two modalities) was checked in all electroencephalograms. The clinical outcome at 1 year or during the last clinic/inpatient follow-up was scored according to the Pediatric Cerebral and Overall Performance Category Scale. Outcomes were then compared using Fisher exact test and the Mann-Whitney test. Thirty-three patients had electroencephalography within 72 hours after the onset of coma. Fourteen of 33 electroencephalograms revealed reactive patterns. Outcome was unfavorable in 4 (28.6%) of these patients. Three children had no residual neurologic impairment. Among the 19 children with nonreactive electroencephalogram, 13 (65%) had unfavorable outcome, which included 10 deaths. All the survivors had residual neurologic impairment. Outcome was better in children with reactive electroencephalographic patterns (Fisher exact test; P = 0.023). Comatose children with reactive electroencephalographic patterns have better clinical outcome in terms of morbidity and mortality. A careful assessment of electroencephalographic reactive patterns in all comatose children is required for better understanding of the clinical outcome.

Adolescent↗
PubMed2006

Magnetic resonance spectroscopy and electroencephalography in baclofen coma.

This report describes a 14-year-old female who presented with coma and seizures. Continuous electroencephalographic monitoring revealed suppression and semiperiodic sharp waves. Magnetic resonance spectroscopy performed 1 day after admission suggested a good outcome despite her clinical examination and electroencephalogram. She was subsequently found to have elevated serum baclofen levels after an intentional overdose. At the time of her discharge from the pediatric intensive care unit, she manifested no neurologic deficits, and on telephone follow-up 2 years after the ingestion the patient had no complaints of any cognitive problems or neurologic dysfunction.

Adolescent↗
PubMed2004

Evaluation of coma and brain death.

Coma is a nonspecific sign of widespread central nervous system impairment resulting from various metabolic and structural etiologies. The rapid recognition of this neurologic emergency and results from the history, physical examination, and early investigative studies are key to the identification and treatment of its underlying cause. The prognosis for recovery depends greatly on the underlying etiology as well as on its optimal treatment, which seeks to preserve neurologic function and maximize the potential for recovery by reversing the primary cause of brain injury, if known, and preventing secondary brain injury from anoxia, ischemia, hypoglycemia, cerebral edema, seizures, infections, and electrolyte and temperature disturbances. Brain death must be diagnosed with similar care and precision, and families approached compassionately about the diagnosis and their decisions regarding organ donation.

Brain Death↗
PubMed2004

Now we lay them down to sleep: ethical issues with the use of pharmacologic coma for adult status epilepticus.

The use of pharmacologic coma (PC) to treat status epilepticus (SE) is not always successful, and there are no guidelines for the duration of PC in an attempt to achieve seizure control. Using clinical cases, we explore three concepts: (1) SE as a terminal condition; (2) PC resulting in permanent unconsciousness; and (3) use of PC for extended periods. Regarding a patient's Advance Directive/Living Will, these three concepts can pose ethical complexities for the medical team due to the notions of unconsciousness, cognitive appreciation, and life support being relevant to both PC therapy as well as these documents. We argue that when PC therapy is not reversing the patient's clinical course and only offering to sustain organic life, it is ethically appropriate to discontinue such therapy and provide the patient comfort care. If PC therapy is only expected to sustain organic life, it is ethically appropriate not to offer it.

Adult↗
PubMed2000

An extended Glasgow Coma Scale (GCS-E) with enhanced sensitivity to mild brain injury.

OBJECTIVE: The Glasgow Coma Scale-Extended (GCS-E) was developed to flag mild cases of concussion (corresponding to Grades I and II concussion as defined by the American Academy of Neurology) at the time of first contact with the health care system. SUBJECTS AND SETTING: The GCS-E was applied to 561 consecutive admissions with GCS scores of 13 to 15 at two hospitals in South Africa and two in the United Kingdom (UK). RESULTS: The amnesia scale was readily learned and reliably applied by emergency department staff without affecting the standard scoring of the GCS itself. Among patients with an admitting GCS of 15, 27% in the UK and 31% in South Africa reported amnesia of some duration. CONCLUSIONS: Wide use of the GCS-E would hold mild traumatic brain injury cases in the treatment loop, improve access to counselling, rehabilitation services, and personal injury compensation, and reduce the "cognitive dissonance" between victims of mild traumatic brain injury and treating professionals.

Adult↗
PubMed2000

Differential phosphorylation at Ser473 and Thr308 of Akt-1 in rat brain following hypoglycemic coma.

We analyzed both total Akt-1 and phosphorylation of Akt-1 at residues Ser473 and Thr308 (phospho-Akt-1(Ser474) and phospho-Akt-1(Thr308), respectively) in the outer and inner layers of cortex following 30 min of hypoglycemic coma by Western blot analyses and confocal microscopy. The total amount of Akt-1 was not altered in any area examined. Phospho-Akt-1(Ser474), however, increased significantly in both layers of cortex at 0 and 30 min of recovery, but returned to control level at 3 h of recovery. In the vulnerable area (outer layer of cortex), no upregulation of phospho-Akt-1(Thr308) was observed at any time points examined. In the resistant area like inner layer of cortex, however, phospho-Akt-1(Thr308) was significantly over the control level at 3 h of recovery. Confocal microscopy result indicates that most of phospho-Akt-1(Thr308) had already moved into nucleus at 3 h of recovery. Our results suggest that Akt-1, when phosphorylated at Thr308, may play a protective role for neurons in the resistant regions of the brain.

Amino Acid Sequence↗
PubMed1998

Evaluation and prognostication in coma.

Electroencephalography (EEG) and evoked potential (EP) studies are neurophysiologic techniques which provide information on physiological state and response to therapy, and may aid diagnosis and prognosis. Serial studies or continuous monitoring may enable changes to be detected prior to irreversible deterioration in the patient's condition. Current computer technology allows simultaneous display and correlation of electrophysiologic parameters, cardiovascular state and ICP. Continuous EEG monitoring in the ICU has been shown to have a decisive or contributing impact on medical decision making in more than three-quarters of patients. In addition, continuous EEG monitoring has revealed previously unsuspected non-convulsive seizures in two-thirds of patients. Somatosensory and auditory EPs can provide useful prognostic information in coma patients, however, these tests are etiologically non-specific and must be carefully integrated into the clinical situation. Motor EPs offer a potentially useful tool for evaluating motor system abnormalities in the ICU. Thus, neurophysiologic tests are established monitoring tools in the neurological intensive care unit.

Coma↗
PubMed1998

The Glasgow Coma Score: reliable evidence?

The Glasgow Coma Score (GCS) is an important factor in the management and prognosis of a patient with neurosurgical pathology. We have found that there is often a disparity between the quoted and actual GCS of patients referred to this unit. We performed a prospective observational study to determine the proportion of patients referred with a correct GCS. Forty-two (51%) out of a total of 82 patients had a correct GCS on referral. The proportion of patients referred with a correct GCS did not vary with either the grade or speciality of the referring doctor.

Clinical Competence↗
PubMed1992

Coma associated with intense bursts of abnormal movements and long-lasting cognitive disturbances: an acute encephalopathy of obscure origin.

We report six previously healthy children who several days after a prodromal illness had an acute encephalopathy that ran a biphasic course. It appears to constitute a recognizable syndrome with a good prognosis that can be differentiated from other encephalopathies of obscure origin as previously defined by Lyon et al. The active phase was dominated by coma or confusion and by abnormal movements, including disordered gesticulation and attacks of orofacial dyskinesia or limb dystonia associated with permanent rigidity and culminating in opisthotonic posturing. Repeated seizures were observed in only two patients. Permanent slow waves were recorded on the electroencephalogram in all patients, even during bursts of abnormal movements. Cerebrospinal fluid and results of serologic studies were normal throughout the course of the disease, and attempts at viral isolation and antiviral antibody detection yielded negative results. Brain imaging either showed no abnormalities or suggested a moderate degree of brain edema. The recovery phase, which extended for several weeks, was characterized by a rapid return of motor function and persistent behavioral and cognitive disturbances. Nonverbal reasoning recovered long before verbal expression returned to normal. Four patients eventually recovered fully, whereas two had mild sequelae.

Acute Disease↗
PubMed1995

Myxedema coma. Pathophysiology, therapy, and factors affecting prognosis.

Myxedema coma is a fatal condition when left unrecognized. With the advent of intensive supportive therapy and the use of intravenous thyroxine, however, mortality for this disorder is declining. Further insights into the pathophysiology of hypothyroidism should lead to more rational approaches to therapy and result in improved survival.

Coma↗