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PubMed2006

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

BACKGROUND: Glasgow Coma Scale (GCS) scores are widely used to quantify level of consciousness in the prehospital environment. The predictive value of field versus arrival GCS is not well defined but has tremendous implications with regard to triage and therapeutic decisions as well as the use of various predictive scoring systems, such as Trauma Score and Injury Severity Score (TRISS). This study explores the predictive value of field GCS (fGCS) and arrival GCS (aGCS) as well as TRISS calculations using field (fTRISS) and arrival (aTRISS) data in patients with moderate-to-severe traumatic brain injury (TBI). METHODS: Major trauma victims with head Abbreviated Injury Scores of 3 or greater were identified from our county trauma registry over a 16-year period. The predictive ability of fGCS with regard to aGCS was explored using univariate statistics and linear regression modeling. The difference between aGCS and fGCS was also modeled against mortality and the composite endpoint using logistic regression, adjusting for fGCS. The predictive value of preadmission GCS (pGCS), defined as either fGCS or aGCS in nonintubated patients without a documented fGCS, with regard to mortality and a composite endpoint representing the need for neurosurgical care (death, craniotomy, invasive intracranial pressure monitoring, or intensive care unit care >48 hours) was determined using receiver-operator curve (ROC) analysis. Finally, fTRISS and aTRISS predicted survival values were compared with each other and to observed survival. RESULTS: A total of 12,882 patients were included. Mean values for fGCS and aGCS were similar (11.4 and 11.5, respectively, p = 0.336), and a strong correlation (r = 0.67, 95% CI 0.66-0.69, p < 0.0001) was observed between them. The difference between fGCS and aGCS was also predictive of outcome after adjusting for fGCS. Good predictive ability was observed for pGCS with regard to both mortality and neurosurgical intervention. Both fTRISS and aTRISS predicted survival values were nearly identical to observed survival. Observed and fTRISS predicted survival were nearly identical in patients undergoing prehospital intubation CONCLUSIONS: Values for fGCS are highly predictive of aGCS, and both are associated with outcome from TBI. A change in GCS from the field to arrival is highly predictive of outcome. The use of field data for TRISS calculations appears to be a valid methodological approach, even in severely injured TBI patients undergoing prehospital intubation.

Brain Injuries↗
PubMed2006

Waiting for the patient to "sober up": Effect of alcohol intoxication on glasgow coma scale score of brain injured patients.

BACKGROUND: Between 35% to 50% of traumatic brain injury (TBI) patients are under the influence of alcohol. Alcohol intoxication may limit the ability of the Glasgow Coma Scale (GCS) to accurately assess severity of TBI. We hypothesized that alcohol intoxication significantly depresses GCS scores of TBI patients. METHODS: A 10-year, retrospective analysis of a Level I trauma center registry was undertaken. The study population consisted of all blunt injured TBI patients tested for blood alcohol concentration (BAC, n = 1,075). Patients were divided into two groups; intoxicated (mean BAC 202 +/- 77 mg/dL, n = 504) and nonintoxicated (BAC = 0, n = 571). TBI was classified using ICD-9 codes as concussion alone (ICD-9 850, n = 90) and intracranial injury (ICI, ICD-9 851-854, n = 985). Severity was further classified using the Abbreviated Injury Score (AIS). Mean GCS score was compared between the two groups. Patients who were either intubated or hypotensive upon arrival were analyzed separately to rule out confounding effects on GCS score. Severely intoxicated patients (BAC >250 mg/dL, [mean +/- SD] 309 +/- 54 SD, n = 118) were similarly compared. Finally, multivariate linear regression analysis was undertaken to determine whether BAC level was an independent predictor of GCS score while controlling for confounding factors. RESULTS: Intoxicated and nonintoxicated TBI patients were clinically similar. Alcohol intoxication had little effect on GCS score, with less than a single point difference in all types of TBI, except the most severely injured (AIS 5 injuries, GCS score difference 1.4 points). These results were not altered by endotracheal intubation, systemic hypotension, or severe intoxication. Similarly, BAC was not a significant independent predictor of GCS score in a multivariate model. CONCLUSION: Alcohol intoxication does not result in clinically significant changes in GCS score for patients with blunt TBI. Hence, alterations in GCS score after TBI should not be attributed to alcohol intoxication, as doing so might result in inappropriate delays in monitoring and therapeutic interventions.

Adult↗
PubMed1988

The Traumatic Coma Data Bank: a nursing perspective, Part I.

The Traumatic Coma Data Bank (TCDB) was a collaborative project undertaken to study the nature and causes of severe head injury, allowing patients similar in age, severity of insults and neurological and physical symptoms to be compared in terms of outcome. Systematic uniform data were collected during the prehospital, acute and rehabilitative phases on 581 patients from 6 centers during the pilot phase of the TCDB, June 1, 1979 through May 31, 1982. The pilot phase successfully determined that a collaborative approach to studying head injury was feasible and additional information gained was incorporated into the main phase April, 1983 through April, 1988. A description of the TCDB population as of this writing (730 patients) is included here.

Adolescent↗
PubMed1988

The Traumatic Coma Data Bank: a nursing perspective, Part II.

The Traumatic Coma Data Bank (TCDB) was a collaborative project undertaken to study the nature and course of severe head injury. Evolution of nursing goals includes collection of data, communication, new clinical observations, designing future research projects, education and legislative impact. Management issues inherent in the collaborative research project are defining, collecting, entering, and analyzing and publishing results.

Brain Injuries↗
PubMed1995

Interrater reliability of the Glasgow Coma Scale.

The purpose of this study was to test the interrater reliability of the Glasgow Coma Scale (GCS) when used in assessing neurologically impaired patients. In order to control variables, a videotape was developed of seven patients with different neurological impairments. A total of 57 nurses and physicians with varying degrees of education and experience used the GCS to score the patient responses. These responses were then compared for consensus and against a criterion standard. The comparison showed a low disagreement rating and a moderate to high agreement rating demonstrating that this tool has good interrater reliability (p = 0.000). Nurses may use this tool with confidence as one measure of assessment in evaluating neurologically impaired patients.

Adult↗
PubMedDate not supplied

Myxoedema coma.

Myxoedema coma is a medical emergency, which must be treated immediately. Otherwise the mortality is high. It is important to administer L-triiodothyronine and corticosteroids early. If hypoventilation occurs, artificial respiration may be necessary. In the two cases of described here the outcome was successful, probably owing to quick substitution. The causes of myxoedema and the symptomatology are discussed.

Adult↗
PubMed1980

Hypoglycaemic coma following epidural analgesia.

A diabetic patient who was taking an intermediate-acting insulin preparation developed sudden hypoglycaemic coma after epidural analgesia between T5 and L1. Several diagnostic possibilities are discussed. It is concluded that prophylactic intravenous infusion of glucose and small doses of local anaesthetic are always advisable in diabetic patients having epidural analgesia.

Aged↗
PubMed1984

Postoperative myxoedema. A report of coma and upper airway obstruction.

The problems encountered in the immediate postoperative period in an undiagnosed myxoedematous patient are reported, the specific management of these problems discussed and the treatment of myxoedema coma outlined. The use of dopamine for cardiovascular support in this situation is commented upon.

Aged↗
PubMed2004

Simple bedside assessment of level of consciousness: comparison of two simple assessment scales with the Glasgow Coma scale.

Neurological assessment is an essential component of early warning scores used to identify seriously ill ward patients. We investigated how two simple scales (ACDU - Alert, Confused, Drowsy, Unresponsive; and AVPU - Alert, responds to Voice, responds to Pain, Unresponsive) compared to each other and also to the more complicated Glasgow Coma Scale (GCS). Neurosurgical nurses recorded patients' conscious level with each of the three scales. Over 7 months, 1020 analysable measurements were collected. Both simple scales identified distinct GCS ranges, although some overlap occurred (p < 0.001). Median GCS scores associated with AVPU were 15, 13, 8 and 6 and for ACDU were 15, 13, 10 and 6. The median values of ACDU were more evenly distributed than AVPU and may therefore be better at identifying early deteriorations in conscious level when they occur in critically ill ward patients.

Attitude of Health Personnel↗
PubMed1977

Serum octopamine, coma, and charcoal haemoperfusion in fulminant hepatic failure.

Serum octopamine levels were significantly higher in twenty patients with fulminant hepatic failure (FHF) during the first 48 h of grade IV coma than in health control subjects (3.38 +/- 0.20 ng/ml and 1.75 +/- 0.19 ng/ml respectively, P less than 0.001). Serial measurements in five patients who died without regaining consciousness showed serum octopamine to remain raised, and concentrations in the cerebrospinal fluid at death reflected serum levels. In five patients who regained consciousness, improvement in encephalopathy was associated with a significant reduction in serum octopamine. Renal failure in patients with FHF was found to contribute to raised serum octopamine but could not alone account for the observed levels. Patients given neomycin therapy did not have significantly lower serum octopamine levels than an untreated group. There was, however, a significant correlation between elevated serum octopamine and the occurrence of gestrointestinal bleeding during the previous 24 h. Charcoal haemoperfusion did not appreciably reduce serum octopamine levels.

Charcoal↗
PubMed1980

Coma and hypothermia in Wernicke's encephalopathy.

Two patients who developed Wernicke's Encephalopathy with subsequent hypothermia are described. Both patients responded rapidly to thiamine administration and one later had hypothalamic-pituitary function tests performed. This patient demonstrated depressed TSH response to TRH and a sluggish early cortisol response to adequate hypoglycaemia compared to 17 control subjects. These findings may suggest that previously described hypothalmic-pituitary abnormalties in chronic alcoholics may be mediated via thiamine deficiency and may also reflect hypothalamic damage contributing to the hypothermic state. The importance of intravenous thiamine administration in cases of coma of unknown aetiology is emphasised.

Coma↗
PubMedDate not supplied

Prolonged electrocerebral silent barbiturate coma in intractable seizure disorders.

Barbiturate coma (BC) is a known modality for terminating resistant convulsive status epilepticus. It is usually applied until seizure activity ends. We recently adopted a modified protocol of prolonged, electrocerebral silent BC to treat patients with chronic seizure activity resistant to multiple regimens of antiepileptic drugs. Four patients, aged 4 months to 10 years, with long-standing intractable generalized seizures were treated. Seizure frequency ranged from one to two to numerous times per day. Following BC, one patient has been seizure free during 8 months of follow-up, and another has had only two seizures in 18 months. A 4-month-old infant was seizure-free for 2 weeks after BC and then died from underlying CNS disease. A 10-year-old girl died during BC from shock and hyperpyrexia. The results obtained in our patients indicate that prolonged electrocerebral silent BC may exert a beneficial long-term effect in treatment of intractable seizure disorders. This procedure might also be beneficial in other forms of epilepsy.

Child↗
PubMed1997

Failure of the Miller criteria to predict significant intracranial injury in patients with a Glasgow Coma Scale score of 14 after minor head trauma.

OBJECTIVE: To determine the utility of the Miller criteria (presence of headache, nausea, vomiting, and signs of depressed skull fracture) for predicting the need for CT in patients with minor head trauma and a Glasgow Coma Scale score (GCS) of 14. METHODS: The study was a prospective, consecutive series of all patients undergoing head CT scans with a GCS of 14 following head trauma. A data sheet was completed for all patients prior to obtaining a head CT scan. RESULTS: 264 patients were entered into the study and 35 patients were found to have traumatic abnormalities on head CT scan. The use of the Miller criteria to select those patients who would require head CT scan would have resulted in missing 17 of the 35 abnormal scans, including 2 patients who required neurosurgical intervention. These 2 patients were markedly intoxicated upon presentation. CONCLUSION: The use of the Miller criteria as the only criteria for screening patients with a GCS of 14 after minor head trauma who require a head CT scan is not recommended. While the authors have identified ethanol intoxication as one confounding factor, further refinement of this risk-stratification tool is required.

Adult↗
PubMed1998

Intubation difficulty in poisoned patients: association with initial Glasgow Coma Scale score.

OBJECTIVE: To determine whether the initial Glasgow Coma Scale (GCS) score is predictive of intubation difficulty in out-of-hospital airway management of poisoned patients. METHODS: A prospective, observational study was performed in a toxicological intensive care unit of a university hospital and in a physician-based out-of-hospital care system. Subjects included consecutive poisoned patients intubated during their airway management by out-of-hospital medical teams before hospitalization. The intubating operator (emergency physician or nurse anesthetist) completed a 1-page checklist concerning the clinical parameters and circumstances (nature of sedation and difficulty) of endotracheal intubation upon hospital arrival. RESULTS: Forms were completed for all 394 consecutive out-of-hospital intubations. The patients ranged from 15 to 95 years of age (median age 38 years). Most (96%) of the intubations were via the oral route. Intubation difficulty was related to GCS values. Intubation difficulty was seen more often in patients with 7 < or = GCS < or = 9 (36%) than in patients with GCS < 7 (15%) or > 9 (10%). Not surprisingly, perceived intubation difficulty was least for those patients undergoing rapid-sequence intubation rather than administration of sedation alone. CONCLUSION: Maximum difficulty of intubation is encountered in poisoned patients with 7 < or = GCS < or = 9. Intubation of such patients appears to be facilitated by appropriate sedation and/or neuromuscular blockade.

Adolescent↗
PubMed2001

Hyperammonemia and coma without hepatic dysfunction induced by valproate therapy.

The authors report a case of a 41-year-old mentally disabled man with bipolar disorder who presented to the emergency department with altered mental status. He was found to have a significantly elevated ammonia level (377 microM/L) with no signs of hepatic insufficiency. His coma and hyperammonemia were attributed to his chronic valproate therapy. This patient had the highest serum ammonia level ever reported with a therapeutic valproate level in the absence of any other anticonvulsant therapy, metabolic abnormality, or hepatic dysfunction. The authors discuss this case and review the current literature on hyperammonemia in valproic acid therapy and the use of L-carnitine in these patients.

Adult↗
PubMed1984

Brainstem auditory evoked responses in coma due to meningoencephalitis.

Prognosticating the outcome of an unconscious patient continues to pose a serious challenge to the clinicians. BAERs are the latest addition to neurological diagnostic aids for predicting the outcome of coma. The relative value of BAERs in predicting the outcome of 15 comatosed meningoencephalitis patients has been studied. The results points to a rôle of BAERs in the detection of brain stem dysfunction in a large majority of patients. However, when used as a prognostic indicant, the traditional bed-side clinical assessment (GCS and vestibulo-ocular cold caloric response) still holds a slight advantage over advanced technology. BAERs may have a place in assessing brain stem dysfunction in neurologic conditions where an adequate clinical assessment may not be possible.

Adolescent↗
PubMed1977

Treatment of diabetic coma in children.

A short review is given on current aspects of the low-dose insulin therapy of diabetic ketoacidosis, and briefly on the other aspects of the treatment. Frequent intramuscular administration of low doses of regular insulin leads to plasma insulin concentrations, sufficient for maximal insulin biologic activity. The intravenous and subcutaneous routes of insulin administration are suitable as well in the low-dose insulin therapy. The author described results from a retrospective study comparing the efficacy of large and small insulin doses in the treatment of diabetic precoma and coma in children (1). The i.m. administration of insulin, 0.5 U/kg initially, followed by 0.25 U/kg at intervals of 1/2-3 hours led to as rapid disappearance of the signs and symptoms of ketoacidosis as with previously used larger insulin doses. The tendency to hypoglycemia and hypokalemia was milder with the smaller insulin dose. With such a modified low-dose insulin therapy it is essential to initiate i.v. glucose administration rather early. The responsiveness to insulin may vary from one child to another, and infections may increase the need for insulin. Therefore, careful individual monitoring of the treatment is important even when using the low-dose insulin therapy.

Child↗