Average Glasgow Coma Scale Score Research Articles

Platelet activation and function after trauma.

Abnormal hemostasis is associated with many of the complications of trauma-associated morbidity and mortality. Platelets are integral in the maintenance of hemostasis. Samples were obtained from 100 trauma patients on arrival at the emergency room (initial time) and at 24, 48, and 72 hours later. Samples were also obtained from 10 healthy controls at the same time intervals. Using flow cytometry, three parameters were used to measure platelet activation: platelet microparticles, expression of P-selectin (CD62P), and expression of the activated conformation of glycoprotein IIb-IIIa (PAC-1 binding). Platelet function was measured using a platelet function analyzer (PFA-100, Dade International Inc., Miami, FL). One hundred trauma patients were enrolled. The average age was 40 years, 75% were men, and 84% had blunt injuries. The mean Injury Severity Score was 22.3 +/- 10.9 (mean +/- SD) and the average Glasgow Coma Scale score was 11 +/- 4. All three platelet activation parameters were increased in trauma patients versus controls for all time periods (p < 0.001). Trauma patients had a trend toward a shorter initial collagen/epinephrine closure time versus controls (p = 0.096). Compared with the 24-, 48-, and 72-hour time intervals, initial collagen/epinephrine closure times were shortened (p < 0.001, p < 0.001, and p < 0.001). Platelet function returned to normal reference ranges within 24 hours but platelet activation parameters remained elevated at least 72 hours after initial trauma. In contrast, when trauma patients with and without brain injury were compared, brain injury patients had increased platelet activation but decreased platelet function (increased collagen/epinephrine closure times). In addition, there was a significant prolongation in collagen/epinephrine closure times for the 24-, 48-, and 72-hour time points in nonsurviving patients versus survivors. There was no association between platelet activation and function and other adverse outcomes including pulmonary embolism, deep venous thrombosis, and disseminated intravascular coagulation. Severe injury usually results in increased platelet activation and function. However, the combination of increased platelet activation with decreased function was associated with increased mortality.

NIHSS predicts outcome better than GCS in intracerebral hemorrhage

P96 Introduction: The National Institutes of Health Stroke Scale (NIHSS) score has been correlated with outcome in ischemic strokes but not intracerebral hemorrhage (ICH). We sought to validate the use of NIHSS in ICH patients by comparing it to outcomes using the Glasgow Coma Scale (GCS) score and volume of ICH. Use of the NIHSS will allow clinicians to follow the outcome of more specific parameters which may be used in clinical trials. Methods: We prospectively followed 61 ICH patients admitted to the Cleveland Clinic within 24 hours of onset. Age, NIHSS, GSC, Barthel index (BI), modified Rankin scale (mRs) were obtained on admission, discharge and at 3 months. An ICH volume was calculated using the AxBxC/2 method from the admission CT scan. Correlation was assessed using the Spearman correlation coefficient (SCC) and 95% CI, with a worst score given to deaths. Patients with a history of ischemic stroke were excluded. The maximum NIHSS for coma was 35. Results: The average age of the patients was 66 years old with 35 females and 26 males. On admission, the average NIHSS was 21 for all patients, 28 for those who died at 3 months and 10 for 3-month survivors. The average NIHSS for 3- month survivors was 3. On admission, the average GCS score was 9 for all patients, 7 for those who died and 12 for 3-month survivors. The average GCS of 3-month survivors was 15. The average BI and mRs were 98 and 0 on admission and 86 and 1 at 3 months for survivors. On admission, the average ICH volume was 49 cc for all patients, 66 cc for those who died at 3 months and 24 cc for 3-month survivors. For admission NIHSS of 18 or greater the 3-month mortality was 82% vs 9% for those with NIHSS &lt; 18 (P&lt;0.001). Admission NIHSS correlated strongly with admission GCS (SCC=0.82, CI 0.68, 0.97) and the two scores correlated similarly with volume (SCC=0.45, CI 0.22, 0.68; GCS SCC=0.40,CI 0.16, 0.63). Impressively, admission NIHSS correlated with the 3 month NIHSS (SCC=0.72, CI 0.53, 0.91), 3-month BI (SCC=0.74, CI 0.55, 0.92), 3-month mRs (SCC=0.72, CI 0.53, 0.91) significantly better than did the GCS (SCC=0.57,0.57 and 0.59 for the NIHSS, BI, and mRs, respectively). Conclusion: The admission NIHSS predicts 3-month survival in ICH patients better than the GCS.

Impaired dopaminergic neurotransmission in patients with traumatic brain injury: a SPET study using 123I-β-CIT and 123I-IBZM

Structural imaging suggests that traumatic brain injury (TBI) may be associated with disruption of neuronal networks, including the nigrostriatal dopaminergic pathway. However, to date deficits in pre- and/or postsynaptic dopaminergic neurotransmission have not been demonstrated in TBI using functional imaging. We therefore assessed dopaminergic function in ten TBI patients using [123I]2-beta-carbomethoxy-3-beta-(4-iodophenyl)tropane (beta-CIT) and [123I]iodobenzamide (IBZM) single-photon emission tomography (SPET). Average Glasgow Coma Scale score (+/-SD) at the time of head trauma was 5.8+/-4.2. SPET was performed on average 141 days (SD +/-92) after TBI. The SPET images were compared with structural images using cranial computerised tomography (CCT) and magnetic resonance imaging (MRI). SPET was performed with an ADAC Vertex dual-head camera. The activity ratios of striatal to cerebellar uptake were used as a semiquantitative parameter of striatal dopamine transporter (DAT) and D2 receptor (D2R) binding. Compared with age-matched controls, patients with TBI had significantly lower striatal/cerebellar beta-CIT and IBZM binding ratios (P< or =0.01). Overall, the DAT deficit was more marked than the D2R loss. CCT and MRI studies revealed varying cortical and subcortical lesions, with the frontal lobe being most frequently affected whereas the striatum appeared structurally normal in all but one patient. Our findings suggest that nigrostriatal dysfunction may be detected using SPET following TBI despite relative structural preservation of the striatum. Further investigations of possible clinical correlates and efficacy of dopaminergic therapy in patients with TBI seem justified.

Conversion of External Fixation to Intramedullary Nailing for Fractures of the Shaft of the Femur in Multiply Injured Patients*

From 1989 to 1997, 1507 fractures of the shaft of the femur were treated with intramedullary nailing at The R Adams Cowley Shock Trauma Center. Fifty-nine (4 percent) of those fractures were treated with early external fixation followed by planned conversion to intramedullary nail fixation. This two-stage stabilization protocol was selected for patients who were critically ill and poor candidates for an immediate intramedullary procedure or who required expedient femoral fixation followed by repair of an ipsilateral vascular injury. The purpose of the current investigation was to determine whether this protocol is an appropriate alternative for the management of fractures of the femur in patients who are poor candidates for immediate intramedullary nailing. Fifty-four multiply injured patients with a total of fifty-nine fractures of the shaft of the femur treated with external fixation followed by planned conversion to intramedullary nail fixation were evaluated in a retrospective review to gather demographic, injury, management, and fracture-healing data for analysis. The average Injury Severity Score for the fifty-four patients was 29 (range, 13 to 43); the average Glasgow Coma Scale score was 11 (range, 3 to 15). Most patients (forty-four) had additional orthopaedic injuries (average, three; range, zero to eight), and associated injuries such as severe brain injury, solid-organ rupture, chest trauma, and aortic tears were common. Forty fractures were closed, and nineteen fractures were open. According to the system of Gustilo and Anderson, three of the open fractures were type II, eight were type IIIA, and eight were type IIIC. Intramedullary nailing was delayed secondary to medical instability in forty-six patients and secondary to vascular injury in eight. All fractures of the shaft of the femur were stabilized with a unilateral external fixator within the first twenty-four hours after the injury; the average duration of the procedure was thirty minutes. The duration of external fixation averaged seven days (range, one to forty-nine days) before the fixation with the static interlocked intramedullary nail. Forty-nine of the nailing procedures were antegrade, and ten were retrograde. For fifty-five of the fifty-nine fractures, the external fixation was converted to intramedullary nail fixation in a one-stage procedure. The other four fractures were associated with draining pin sites, and skeletal traction to allow pin-site healing was used for an average of ten days (range, eight to fifteen days) after fixator removal and before intramedullary nailing. Follow-up averaged twelve months (range, six to eighty-seven months). Of the fifty-eight fractures available for follow-up until union, fifty-six (97 percent) healed within six months. There were three major complications: one patient died from a pulmonary embolism before union, one patient had a refractory infected nonunion, and one patient had a nonunion with nail failure, which was successfully treated with retrograde exchange nailing. The infection rate was 1.7 percent. Four other patients required a minor reoperation: two were managed with manipulation under anesthesia because of knee stiffness, and two underwent derotation and relocking of the nail because of rotational malalignment. The rate of unplanned reoperations was 11 percent. The average range of motion of the knee was 107 degrees (range, 60 to 140 degrees). We concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients.

NIHSS predicts outcome better than GCS in intracerebral hemorrhage

P96 Introduction: The National Institutes of Health Stroke Scale (NIHSS) score has been correlated with outcome in ischemic strokes but not intracerebral hemorrhage (ICH). We sought to validate the use of NIHSS in ICH patients by comparing it to outcomes using the Glasgow Coma Scale (GCS) score and volume of ICH. Use of the NIHSS will allow clinicians to follow the outcome of more specific parameters which may be used in clinical trials. Methods: We prospectively followed 61 ICH patients admitted to the Cleveland Clinic within 24 hours of onset. Age, NIHSS, GSC, Barthel index (BI), modified Rankin scale (mRs) were obtained on admission, discharge and at 3 months. An ICH volume was calculated using the AxBxC/2 method from the admission CT scan. Correlation was assessed using the Spearman correlation coefficient (SCC) and 95% CI, with a worst score given to deaths. Patients with a history of ischemic stroke were excluded. The maximum NIHSS for coma was 35. Results: The average age of the patients was 66 years old with 35 females and 26 males. On admission, the average NIHSS was 21 for all patients, 28 for those who died at 3 months and 10 for 3-month survivors. The average NIHSS for 3- month survivors was 3. On admission, the average GCS score was 9 for all patients, 7 for those who died and 12 for 3-month survivors. The average GCS of 3-month survivors was 15. The average BI and mRs were 98 and 0 on admission and 86 and 1 at 3 months for survivors. On admission, the average ICH volume was 49 cc for all patients, 66 cc for those who died at 3 months and 24 cc for 3-month survivors. For admission NIHSS of 18 or greater the 3-month mortality was 82% vs 9% for those with NIHSS Conclusion: The admission NIHSS predicts 3-month survival in ICH patients better than the GCS.

Prehospital treatment of head injuries ‐ can we do better?

AbstractAimsTo examine prehospital factors associated with head injuries.MethodPrehospital and outcome data were collected on a group of 123 patients with head injuries admitted to Waikato Hospital over 41 months.ResultsOver 80% of the head injuries were due to road trauma. Over 60% occurred &gt;30km from the first admission hospital, 35% were &gt;60km away and 43% took more than 90 minutes to arrive in hospital. Helicopter transport was used for 34% of patients. Hypoxia was present in 50% of the patients at the accident scene and 54% of the unintubated patients were breathing poorly on admission to hospital (64% unintubated). The average Glasgow Coma Scale score was 5.4. Glasgow Outcome Scores at six months were: dead (24), vegetative (0), severely disabled (25), moderately disabled (19), normal or mildly disabled (40), and not available (15). The presence of hypoxia and the worst Abbreviated Injury Scale scores occurred more commonly in those who died.ConclusionsMany New Zealanders suffer head injuries a long distance from hospital. The use of helicopter transport shortens admission times. Poor breathing patterns and hypoxia are still major problems. Facilitating early intubation by widening the skills of ambulance officers or utilising doctors in first response teams must be considered.

The acute management of hemodynamically unstable multiple trauma patients with pelvic ring fractures.

The management of hemodynamically unstable patients with displaced pelvic ring fractures and associated abdominal, thoracic, or head injuries is controversial. We studied 312 consecutive trauma patients with pelvic fractures admitted from July 1, 1989 through June 30, 1993: thirty-six of these patients were in shock (SBP < or = 90 mm Hg) and were treated by a protocol including volume resuscitation, and treatment of the associated injuries, without use of acute external fixation. Evaluation of the pelvic fractures revealed 39% to be rotationally unstable; 61% were both rotationally and vertically unstable. The mean injury Severity Score was 27 +/- 12, the average Glasgow Coma Scale score was 12 +/- 5, and the Abbreviated Injury Scale (AIS) scores stratified for the abdomen and the thorax were 1.9 +/- 1.7 and 1.6 +/- 1.8, respectively. Eighteen patients required thoracotomy, laparotomy, or both. The total blood requirement in the initial 24 hours postinjury was 4.0 +/- 4 Units. Deaths of four patients (11%) were a function of associated injuries and comorbid factors, not the result of uncontrolled pelvic hemorrhage. The data suggest that aggressive resuscitation of these patients and treatment of extrapelvic injuries in conjunction with early or delayed ORIF, without application of acute external fixation, resulted in a low overall mortality rate.

BASEBALL BAT ASSAULT INJURIES

The baseball bat, according to Baltimore City police crime statistics, is a commonly used weapon. To assess the severity of injuries inflicted by this modern-day club, we retrospectively reviewed 75 charts of patients treated at the University of Maryland Medical Systems Hospital for baseball bat injuries from January 1990 through July 1991. Multisystem trauma was documented, with craniocerebral injury being the most frequent and the most frequent cause of death. Of the victims struck on the head, 26% sustained an intracranial hemorrhage. In our series, the history of loss of consciousness and the Glasgow Coma Scale score failed to reliably identify the patients with serious injuries. Seventeen percent of our patients with intracranial hemorrhages had both a negative or uncertain history of loss of consciousness and a normal Glasgow Coma Scale score on arrival.

Functional outcome of low-level traumatically brain-injured admitted to an acute rehabilitation programme

A retrospective analysis of functional status at discharge, disposition, Glasgow Outcome Scale (GOS) score at 6 months and 1 year was undertaken for 23 consecutive 'low-level' traumatic brain injury victims admitted in a state of complete dependency to an acute rehabilitation programme. All patients met criteria for extremely severe traumatic brain injury, with an average Glasgow Coma Scale score of 8.7 at admission to the rehabilitation facility (an average of 44 days post-injury). All but three patients made significant functional gains during the acute rehabilitation stay. Almost half of the study patients (48%) were discharged at home while the rest went to sub-acute rehabilitation programmes. At 6 months post-injury eight (35%) met GOS criteria for 'good' outcome or 'moderate disability'. A review of clinical features, categories of functional progress, and relationships of outcome and disposition to variables known to have predictive value in such a patient population is described. Analysis of variables related to admission selection criteria that have been used in this rehabilitation programme is presented and the basis and implications of selection criteria discussed.

Cerebral blood flow and metabolism in severely head-injured children

The literature suggests that in children with severe head injury, cerebral hyperemia is common and related to high intracranial pressure (ICP). However, there are very few data on cerebral blood flow (CBF) after severe head injury in children. This paper presents 72 measurements of cerebral blood flow ("CBF15"), using the 133Xe inhalation method, with multiple detectors over both hemispheres in 32 children aged 3 to 18 years (mean 13.6 years) with severe closed head injury (average Glasgow Coma Scale (GCS) score 5.4). In 25 of the children, these were combined with measurements of arteriojugular venous oxygen difference (AVDO2) and of cerebral metabolic rate of oxygen (CMRO2). In 30 patients, the first measurement was taken approximately 12 hours postinjury. In 18 patients, an indication of brain stiffness was obtained by withdrawal and injection of ventricular cerebrospinal fluid and calculation of the pressure-volume index (PVI) of Marmarou. The CBF and CMRO2 data were correlated with the GCS score, outcome, ICP, and PVI. Early after injury, CBF tended to be lower with lower GCS scores, but this was not statistically significant. This trend was reversed 24 hours postinjury, as significantly more hyperemic values were recorded the lower the GCS score, with the exception of the most severely injured patients (GCS score 3). In contrast, mean CMRO2 correlated positively with the GCS score and outcome throughout the course, but large standard deviations preclude making predictions based on CMRO2 measurements in individual patients. Early after injury, there was mild uncoupling between CBF and CMRO2 (CBF above metabolic demands, low AVDO2) and, after 24 hours, flow and metabolism were completely uncoupled with an extremely low AVDO2. Consistently reduced flow as found in only four patients; 28 patients (88%) showed hyperemia at some point in their course. This very high percentage of patients with hyperemia, combined with the lowest values of AVDO2 found in the literature, indicates that hyperemia or luxury perfusion is more prevalent in this group of patients. The three patients with consistently the highest CBF had consistently the lowest PVI: thus, the patients with the most severe hyperemia also had the stiffest brains. Nevertheless, and in contrast to previous reports, no correlation could be established between the course of ICP or PVI and the occurrence of hyperemia, nor was there a correlation between the levels of CBF and ICP at the time of the measurements. The authors argue that this lack of correlation is due to: 1) a definition of hyperemia that is too generous, and 2) the lack of a systematic relationship between CBF and cerebral blood volume

Cerebral blood flow and metabolism in severely head-injured children

Autoregulation of cerebral blood flow ("CBF15") was tested in a series of 26 pediatric patients (mean age 13.2 years) with severe head injury (average Glasgow Coma Scale (GCS) score 5.5) in the acute stage. A baseline 133Xe CBF measurement was performed and then repeated, after blood pressure was increased by 29% with intravenous phenylephrine or decreased by 26% with intravenous trimethaphan camsylate. Correlations were made between CBF and clinical condition, outcome, time after injury, intracranial pressure (ICP), and pressure-volume index (PVI) changes, and the site of injury (hemispheres, diencephalon, or brain stem). The site of injury was determined with multimodality evoked potential measurements. Autoregulation was intact in 22 (59%) of 37 measurements. There was no correlation with GCS score, outcome, time after injury, site of injury, or way of testing (decreasing or increasing blood pressure). Autoregulation was statistically significantly more often impaired when CBF was either below normal -2 standard deviations (SD) (reduced flow) or above normal +2 SD (absolute hyperemia). In cases with intact autoregulation, mean ICP decreased from 17.5 to 15.0 mm Hg with higher blood pressure and increased from 19.0 to 21.3 mm Hg with lower blood pressure. When PVI was measured during the blood pressure manipulations, it was found to change in a direction opposite to the ICP change. The consequences of these findings in the management of ICP problems with blood pressure control are discussed.

Traumatic Intraventricular Hemorrhage

The authors studied 22 cases of traumatic IVH encountered during a recent 5-year period, with particular emphasis on factors related to outcome. There were 21 males and one female ranging in age from 3 to 76 years. These 22 cases constituted 7.2% of all severe head injuries (Types III and IV, according to Araki's classification) seen in the authors' institution during the study period. They were classified into four types on the basis of the CT findings: Type I, IVH with no other intracranial abnormality; Type II, IVH with other intracranial abnormalities; Type III, delayed IVH (after decompressive surgery) ; and Type IV, IVH due to penetration of an intracerebral hematoma. The incidence of Types II and IV IVH was high. The average Glasgow Coma Scale (GCS) score on admission was 7.0, with Type I patients having the lowest mean score (4.3). The direction of impact was most often anteroposterior in Type I and lateral in Type II. Associated intracranial lesions were observed in 95% of the patients. These were mostly brainstem injury in Type I and brain contusion or subdural hematoma in Types II and III. The overall mortality rate was 54.5%. It was 67% in Type I, 50% in Type II, 33% in Type III, and 63% in Type IV. The outcome appeared to have been determined largely by the severity of associated brain injury and the GCS score, which suggests that the severity of impact or brain injury causing the IVH is the most important factor in terms of prognosis.