Glasgow Coma Scale Research Articles

Predictors of polytrauma outcome in children on the first day of treatment in ICU

The objective was to identify predictors of polytrauma outcome in children on the first day of treatment in ICU.Materials and methods. Design – multicenter, cohort, retrospective, observational study. 225 children with polytrauma were examined. The average age of children was 10 (4–14) years. There were 148 (65.8%) boys. In 65.2% of cases, the injury was received as a result of a traffic accident, catatrauma occurred in 32.6% of polytrauma. The AIS score was 34 (25–48) and the PTS score was 5 (2.0–8.0). The duration of artificial lung ventilation was 12 (0–97) hours, and treatment in ICU – 5 (2–8) days. Death was in 14.2% of cases. Results. An increase in Glasgow Coma Scale (GCS) and SpO2 by one unit (1 point, 1%) was found to reduce the risk of adverse outcome by 44% and 9%, respectively, and an increase in creatinine concentration and international normalized ratio by one unit increased the probability of patient death by 4.3 and 15.8 times, respectively. A mathematical formula was developed to assess the risk of an unfavorable outcome of polytrauma in children at the time of admission to the ICU: OR = exp (3.74–0.58 · [GCS score] – 0.09 · [SpO2] + 0.06 · [Creatinine] + 2.62 · [INR]. Its accuracy is 96.4%; sensitivity 83.4%; specificity 98.7%.Conclusion. Predictors of unfavorable outcome of polytrauma in children at admission to ICU are low scores on the Glasgow Coma Scale, severe hypoxemia, coagulopathy and kidney damage.

Development of a risk predication model for critical care needs in patients with intracerebral hemorrhage: a retrospective cohort.

It is very important to provide the correct nursing care for patients with intracerebral hemorrhage (ICH), but the level of critical care needs in patients with intracerebral hemorrhage is not clear. The purpose of this study is to establish a risk model based on the epidemiological and clinical characteristics of ICH patients, to help identify the critical care needs of ICH patients. The clinical data of ICH patients from January 2018 to September 2023 were analyzed retrospectively. The full cohort was used to derive the clinical prediction model and the model was internally validated with bootstrapping. Discrimination and calibration were assessed using the area under curve (AUC) and the Hosmer-Lemeshow tests, respectively. 611 patients with ICH were included for model development. 61.21% (374/611) ICH patients had received critical care interventions. The influencing factors included in the model were Glasgow Coma Scale (GCS) score, intraventricular hemorrhage, past blood pressure control, systolic blood pressure on admission and bleeding volume. The model's goodness-of-fit was evaluated, which yielded a high area under the curve (AUC) value of 0.943, indicating a good fit. For the purpose of model validation, a cohort of 260 patients with ICH was utilized. The model demonstrated a Youden's index of 0.750, with a sensitivity of 90.56% and a specificity of 78.22%. GCS, systolic blood pressure, intraventricular hemorrhage, bleeding volume and past blood pressure control are the main factors affecting the critical care needs of patients with ICH. This study has deduced a clinical predictive model with good discrimination and calibration to provide scoring criteria for clinical health care providers to accurately evaluate and identify the critical care needs of ICH patients, to improve the rational integration and allocation of medical resources.

Association between serum calcium and in-hospital mortality in intensive care unit patients with cerebral infarction: a cohort study.

The relationship between serum calcium levels and the prognosis of cerebral infarction remains controversial. This study aims to investigate the correlation between serum calcium levels and in-hospital mortality in critically ill patients with ischemic stroke admitted to the intensive care unit (ICU). A retrospective cohort study was conducted using data from the MIMIC-IV database. Demographic and clinical data of all participants were collected including gender, age, hypertension, diabetes, myocardial infarction, heart failure, chronic obstructive pulmonary disease, hemoglobin, potassium, sodium, anion gap, platelets, white blood cells, glucose, creatinine, Glasgow coma score (GCS), IV-tPA administration (rt-PA), and mechanical thrombectomy (MT). The outcome measure was in-hospital death. Multivariable-adjusted logistic regression analysis, curve fitting, interaction analysis, and threshold effect analysis were employed to evaluate the relationship between serum calcium levels and in-hospital mortality among ICU patients with cerebral infarction. A total of 2,680 critically ill patients with cerebral infarction were enrolled, with a mean serum calcium level of 8.6 ± 0.8 mg/dL. The overall in-hospital mortality rate was 19.5%, where Group 1 (serum calcium < 8.0 mg/dL) had a mortality rate of 27.7%, Group 2 (serum calcium 8-9 mg/dL) had a rate of 19.8%, and Group 3 (serum calcium ≥ 9 mg/dL) had a rate of 13.9%. There was a non-linear, S-shaped relationship between serum calcium levels and in-hospital mortality. Serum calcium levels within the range of 7.70-9.50 mg/dL were found to be independently associated with increased in-hospital mortality in ICU patients with cerebral infarction. No significant interactions were detected in subgroup analyses, and the results of sensitivity analyses remained stable. Serum calcium levels are independently associated with in-hospital mortality in critically ill patients with cerebral infarction in the ICU setting. Within the range of 7.70-9.50 mg/dL, lower serum calcium levels increase the risk of in-hospital death among these patients, emphasizing the importance of close monitoring by ICU physicians.

Analysis of Factors and Clinical Outcomes of Planned Tracheal Extubation Failure in Neurosurgical Intensive Care Unit Patients.

BACKGROUND: Planned tracheal extubation failure is a common occurrence among patients in the neurosurgical intensive care unit (NICU) because of the complex nature of neurocritical injuries, and the failure could result in a poor prognosis. METHODS: We observed and recorded the patients with tracheal intubation in the NICU of a hospital in Shanghai from June 2021 to December 2022 and analyzed data from planned tracheal extubation, categorizing patients by success or failure, and compared outcomes between the two groups while investigating contributing factors. RESULTS: A total of 156 patients were included, 133 (85.3%) of whom were successfully extubated and 23 (14.7%) were not. The results of logistic regression analysis demonstrated that the Glasgow Coma Scale score before extubation (OR, 0.643; 95% CI, 0.444-0.931; P = .020) and the frequency of respiratory secretions suctioning before tracheal extubation (OR, 0.098; 95% CI, 0.027-0.354; P < .001) were independent risk factors for extubation failure. We also found that the extubation failure group experienced a significantly longer ICU stay and incurred higher hospitalization costs. CONCLUSIONS: Poor Glasgow Coma Scale scores and a high frequency of respiratory secretions suctioning before tracheal extubation were the main factors contributing to tracheal extubation failure in NICU patients. To avoid tracheal extubation failure and adverse outcomes, these two factors should be carefully assessed before tracheal extubation.

Development of a Nomogram for Predicting ICU Readmission.

Background This study aims to develop and validate a comprehensive prediction model for ICU readmissions. Readmission following ICU discharge is associated with adverse outcomes such as increased mortality, prolonged hospital stays, and elevated healthcare costs. Consequently, predicting and preventing readmissions is crucial. Previous models for predicting ICU readmissions were primarily based on physiological indices; however, these indices fail to capture the complete nature of treatment or patient conditions beyond physiological measures, thereby limiting the accuracy of these predictions. Methodology A total of 1,400 patients who had an unplanned ICU admission at Sapporo Medical University Hospital from January 2015 to October 2022 were included; a single regression analysis was performed using unplanned ICU readmission as the dependent variable. After performing a single regression analysis, logistic regression analysis using the stepwise method was performed using variables with significant differences, and a predictive nomogram was created using the variables that remained in the final model. To internally validate the predictive nomogram model, nonparametric bootstrapping (1,000 replications) was performed on the original model. Results Of the 1,400 patients who had an unplanned admission to the ICU, 114 (8.1%) were readmitted to the ICU unplanned. Seven main variables (Sequential Organ Failure Assessment score, respiratory rate, Glasgow Coma Scale, sleep disturbance, Continuous Kidney Replacement Therapy, presence of tracheal suctioning, and Oxygen Saturation) were selected to be associated with ICU readmission. The evaluation of the models showed excellent discrimination with an area under the receiver operating characteristic of 0.805 (original model) and 0.796 (bootstrap model). Calibration plots also confirmed good agreement between observed and predicted reentry. Conclusions This new predictive model is more accurate than previous models because it includes physiological indicators as well as other patient conditions and procedures needed and is expected to be used in clinical practice. In particular, the inclusion of new factors, such as sleep disturbance and the need for tracheal suctioning, enabled a more comprehensive patient assessment. The use of this predictive nomogram as a criterion for discharging ICU patients may prevent unplanned ICU readmission.

Percheron Artery Stroke and Reperfusive therapies: A systematic review and meta-analysis

Background and AimsPercheron Artery Stroke, affecting bilateral paramedian thalamic structures, accounts for 0.1–0.4 % of all acute ischemic strokes. Little is known about disability or mortality outcomes in patients receiving intravenous thrombolysis (IVT) or endovascular treatment (EVT), therefore a systematic review was carried out. MethodsA systematic search of Pubmed, Embase and Scopus databases for all kind of studies regarding Percheron Artery Stroke was performed. The review is registered in INPLASY (202410059). In total, 1895 papers were screened; 197 studies were included, consisting exclusively in case reports, retrospective series and conference abstracts. Data from 448 patients were analyzed in logistic regression. ResultsBoth IVT (ORIVT = 3.08; 95 % CI 1.4 – 6.7; p = 0.005) and EVT (OREVT = 5.77; 95 % CI 1.69 – 19.7; p = 0.005) were associated with reduced disability, as well as exclusive thalamic involvement (OR = 3.24; CI 2.1 – 5.1; p < 0.001) and higher Glasgow Coma Scale score (GCS) on admission (OR = 1.2; 95 % CI 1.12 – 1.28; p < 0.001). GCS (OR = 0.73, 95 % CI 0.63 – 0.82; p < 0.001) and exclusive thalamic involvement (OR = 0.36; 95 % CI 0.16 – 0.74; p = 0.005) were associated with lesser mortality, while IVT displayed a non-significant trend towards reduced mortality (ORIVT = 0.13; 95 % CI 0.01 – 1.04; p = 0.056). ConclusionThe present work, albeit summarizing data coming from low quality sources, suggests an association between both EVT/IVT and better outcomes in paramedian bilateral thalamic strokes.

Postoperative fever and clinical outcomes after endoscopic surgery for spontaneous intracerebral hemorrhage: a retrospective database study

BackgroundSpontaneous intracerebral hemorrhage (SICH) is a severe stroke with high mortality and disability rates. Endoscopic surgery is an increasingly widely used minimally invasive method for the treatment of SICH. However, the impact of fever on patient outcomes remains unclear.MethodsWe retrospectively included patients aged 18 years or older with supratentorial SICH confirmed by CT, who underwent endoscopic hematoma evacuation within 48 h of symptom onset. The primary outcome was the modified Rankin Scale (mRS) score at 3 months. Secondary outcomes included hospital and neurosurgical intensive care unit (NSICU) stays, and perioperative complications. We analyzed the association between postoperative fever (highest temperature within 24 h after surgery) and these outcomes using multivariate analysis, generalized additive models, and segmented regression analysis.ResultsOf the 56 patients, 38 had favorable outcomes (mRS ≤ 3) and 18 had unfavorable outcomes (mRS > 3) at 3 months. A threshold effect at 38.2 °C was observed between postoperative body temperature and clinical outcomes. The mean age was 56 years (SD = 9) for the > 38.2 °C group and 58 years (SD = 8) for the ≤ 38.2 °C group, with a similar proportion of male patients (63% vs. 69%, P = 0.635). Patients with postoperative fever had larger hematoma volumes (65 vs. 56 mL; P = 0.008). Other characteristics were similar between the groups. Postoperative fever (> 38.2 °C) was independently associated with a 4.99-fold increased risk of unfavorable outcomes (95% CI = [1.13 to 25.90]; P = 0.040), which remained significant after excluding patients with postoperative complications (adjusted RR = 16.03, 95% CI = [1.69 to 417.24]; P = 0.033). The association was consistent across subgroups with different Glasgow Coma Scale scores, hematoma volumes, and intraventricular extension. Postoperative fever was also associated with longer NSICU stays (3.1 vs. 2.3 days; P = 0.023), longer hospital stays (17.2 vs. 13.6 days; P = 0.010), more residual hematoma, and greater edema volume. Different antipyretic therapies did not affect outcomes.ConclusionsThis study identifies a temperature threshold (38.2 °C) associated with poor outcomes in SICH patients undergoing endoscopic surgery. Further research is needed to mitigate postoperative fever and improve patient outcomes.

Comprehensive risk factor-based nomogram for predicting one-year mortality in patients with sepsis-associated encephalopathy

Sepsis-associated encephalopathy (SAE) is a frequent and severe complication in septic patients, characterized by diffuse brain dysfunction resulting from systemic inflammation. Accurate prediction of long-term mortality in these patients is critical for improving clinical outcomes and guiding treatment strategies. We conducted a retrospective cohort study using the MIMIC IV database to identify adult patients diagnosed with SAE. Patients were randomly divided into a training set (70%) and a validation set (30%). Least absolute shrinkage and selection operator regression and multivariate logistic regression were employed to identify significant predictors of 1-year mortality, which were then used to develop a prognostic nomogram. The model’s discrimination, calibration, and clinical utility were assessed using the area under the receiver operating characteristic curve (AUC), calibration plots, and decision curve analysis, respectively. A total of 3,882 SAE patients were included in the analysis. The nomogram demonstrated strong predictive performance with AUCs of 0.881 (95% CI: 0.865, 0.896) in the training set and 0.859 (95% CI: 0.830, 0.888) in the validation set. Calibration plots indicated good agreement between predicted and observed 1-year mortality rates. The decision curve analysis showed that the nomogram provided greater net benefit across a range of threshold probabilities compared to traditional scoring systems such as Glasgow Coma Scale and Sequential Organ Failure Assessment. Our study presents a robust and clinically applicable nomogram for predicting 1-year mortality in SAE patients. This tool offers superior predictive performance compared to existing severity scoring systems and has significant potential to enhance clinical decision-making and patient management in critical care settings.

Correlation of Serum Albumin Levels With the Severity of Sepsis Among Intensive Care Unit Patients.

Background Sepsis is a critical and potentially fatal medical condition characterized by significant illness and death rates. Early recognition and assessment of sepsis severity are vital for its optimal management. Determination of its severity by Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation (APACHE) II, is quite a complex process as these score systems require complex and costly investigations. Therefore, this study was designed to determine the predictive capacity of serum albumin levels for the severity of sepsis in intensive care unit (ICU) patients. Methods This cross-sectional study was carried out on 201 ICU-admitted patients with diagnosed sepsis at Benazir Bhutto Hospital (BBH), Rawalpindi, Pakistan from March 2022 to April 2023. Recruitment of patients was performed through consecutive sampling and predefined inclusion and exclusion criteria. Prior to the data collection, ethical approval and informed consent were obtained. Data was gathered via a self-designed proforma. SOFA score was applied for the determination of the severity of sepsis. Patients were categorized into three groups based on sepsis severity (SOFA score). Data analysis was done in the Statistical Package for the Social Sciences (SPSS) version 25. Descriptive and inferential statistics compared study variables. Pearson's correlation and a simple linear regression model were used to assessthe relationship between serum albumin levels and sepsis severity and the predictive capacity of serum albumin levels for sepsis severity respectively. The statistical significance of the p-value was set at less than 0.05. Results Among the 201 patients, 64 (31.84%) had sepsis, 98 (48.75%) had severe sepsis, and 39 (19.41%) had septic shock. Hypoalbuminemia was present among 119 (59.20%) patients while 82 (40.80%) patients had normal albumin levels. Significant differences were found in the total bilirubin, serum creatinine, platelet count, PaO2/FiO2 ratio, mean arterial pressure, Glasgow Coma Scale score, SOFA score, serum albumin level, and the prevalence of normal and low albumin levels across three study groups (p < 0.05). Pearson's correlation analysis showed a strong negative correlation between serum albumin level and SOFA score (correlation coefficient (r) = -0.78, p = 0.001). Linear regression analysis confirmed an inverse relationship between serum albumin levels and SOFA scores (beta coefficient = -2.70, p = 0.002). Conclusions In the present study, serum albumin level was noted as a reliable predictor of sepsis severity in ICU patients. Lower serum albumin levels were associated with higher SOFA scores, indicating more severe sepsis. This study supports the use of serum albumin as a simple and cost-effective biomarker for early identification of sepsis severity, particularly in resource-limited settings.

Prognostic role of serum copeptin levels in adults with graded traumatic brain injury.

The efficacy of copeptin in patients with severe head injuries remains unclear. To investigate the role of serum copeptin levels in detecting intracranial injury, assessing trauma severity, and predicting outcomes in adults with graded traumatic brain injury (TBI). This prospective non-randomized controlled study enrolled 78 adults with isolated head trauma, as well as 59 age- and sex-matched controls. Baseline serum copeptin levels were measured in both groups. Patients were categorized by head trauma severity using Glasgow Coma Scale (GCS) scores (severe GCS 3-8, moderate GCS 9-13, mild GCS 14-15) and by the presence of intracerebral or extracerebral lesions on cranial computed tomography (CCT). Patients were also classified as survivors or non-survivors. Serum copeptin levels were compared among these. Mean serum copeptin levels were significantly higher in patients with graded TBI than in controls. Furthermore, patients with severe and moderate head trauma had significantly higher copeptin levels compared with patients exhibiting mild trauma. An optimal copeptin cutoff value of > 1147pg/mL was identified, indicating the presence of moderate or severe trauma in TBI patients. Patients with abnormal CCT findings had significantly higher mean serum copeptin levels compared with patients exhibiting normal CCT scans. Non-survivors also showed significantly higher serum copeptin levels compared with survivors. Serum copeptin levels rise after graded TBI and can distinguish between patients with and without intracranial or extracranial lesions evident on CCT. Copeptin levels also aid in identifying moderate or severe TBI and in predicting 28-day mortality.

Association Between Cerebral Microbleeds and Neurological Outcomes in Patients Who Underwent Extracorporeal Membrane Oxygenation.

Cerebral microbleeds (CMBs) are common and varied in patients receiving extracorporeal membrane oxygenation (ECMO). Here, the authors describe CMB findings in patients receiving ECMO and their association with clinical factors. A total of 138 patients receiving ECMO were enrolled and categorized as venovenous and venoarterial. Blood coagulation profiles during ECMO support and Glasgow Coma Scale (GCS) scores within 7 days were recorded. Patients with CMBs exhibited prolonged activated clotting time (P<0.001), decreased fibrinogen levels (P<0.001), reduced platelet counts (P<0.001), and extended prothrombin time (P<0.001). A significant correlation (P<0.05) was observed between the presence of CMBs and most coagulation parameters among all patients. Patients with venoarterial ECMO had significantly higher activated partial thromboplastin time, activated clotting time, and prothrombin time compared with those with venovenous ECMO (all P<0.05). Patients with a less severe CMB burden exhibited higher GCS scores and better neurological injury outcomes at both 7 and 90 days. CMB burden in all patients with ECMO was significantly correlated (P<0.05) with most blood coagulation profiles and neurological injury. CMB burdens after ECMO are common, varied, and associated with a variety of clinical conditions. These findings may guide ECMO management.

Ambulance Transports from NCAA Division 1 Football Games.

There is significant public health interest towards providing medical care at mass-gathering events. Furthermore, mass gatherings have the potential to have a detrimental impact on the availability of already-limited municipal Emergency Medical Services (EMS) resources. This study presents a cross-sectional descriptive analysis to report broad trends regarding patients who were transported from National Collegiate Athletic Association (NCAA) Division 1 collegiate football games at a major public university in order to better inform emergency preparedness and resource planning for mass gatherings. Patient care reports (PCRs) from ambulance transports originating from varsity collegiate football games at the University of Minnesota across six years were examined. Pertinent information was abstracted from each PCR. Across the six years of data, there were a total of 73 patient transports originating from NCAA collegiate football games: 45.2% (n = 33) were male, and the median age was 22 years. Alcohol-related chief complaints were involved in 50.7% (n = 37) of transports. In total, 31.5% of patients had an initial Glasgow Coma Scale (GCS) of less than 15. The majority (65.8%; n = 48; 0.11 per 10,000 attendees) were transported by Basic Life Support (BLS) ambulances. The remaining patients (34.2%; n = 25; 0.06 per 10,000 attendees) were transported by Advanced Life Support (ALS) ambulances and were more likely to be older, have abnormal vital signs, and have a lower GCS. This analysis of ambulance transports from NCAA Division 1 collegiate football games emphasizes the prevalence of alcohol-related chief complaints, but also underscores the likelihood of more life-threatening conditions at mass gatherings. These results and additional research will help inform emergency preparedness at mass-gathering events.

Increased serum phenylalanine/tyrosine ratio associated with the psychiatric symptom of anti-NMDAR encephalitis.

Encephalitis associated with antibodies against the N-methyl-D-aspartate receptor (NMDAR) results in a distinctive neuro-psychiatric syndrome. It has been reported that the serum phenylalanine-tyrosine (Phe/Tyr) ratio increases during infection. However, the connection between phenylalanine-tyrosine metabolism and psychiatric symptoms remains unclear. We enrolled 24 individuals with anti-NMDAR encephalitis and 18 individuals with non-inflammatory neurological diseases (OND). Chromatography was used to measure serum levels of phenylalanine and tyrosine. Serum and cerebrospinal fluid (CSF) TNF-α levels were obtained from the clinical database. The modified Rankin Scale (mRS) score and Glasgow Coma Scale (GCS) score were recorded during the acute phase. The area under the curve (AUC) of the receiver operating characteristic curve was used to assess prediction efficacy. In NMDAR patients, levels of serum Phe and the ratio of serum Phe/Tyr were higher compared to OND patients. The serum Phe/Tyr ratio was also elevated in NMDAR patients with psychiatric syndrome. Furthermore, serum Phe and Tyr levels were correlated with inflammatory indexes. The serum Phe/Tyr ratio is elevated in NMDAR patients with psychiatric syndrome and is associated with severity. Therefore, the serum Phe/Tyr ratio may serve as a potential prognostic biomarker.

Characteristics and Outcomes of Patients Admitted to Intensive Care Units in an Academic Hospital Northern Iran

Background: Identifying risk factors that predict mortality in the intensive care unit (ICU) can lead to improved management of critically ill patients and help reduce mortality rates. Objectives: This study aimed to identify the prevalence and risk factors that potentially contribute to predicting mortality in the ICU. Methods: This cross-sectional study was conducted in the general ICU of an academic hospital in northeastern Iran from April 2019 to March 2023. Demographic and clinical data were retrieved from medical records, including age, gender, marital status, residency, length of stay in the ICU, level of consciousness, duration of mechanical ventilation (MV), and co-morbidities. The outcomes were categorized as death or discharge. Results: Out of 8,650 admitted patients, 62.8% were discharged, and 37.2% died. The factors significantly associated with death included age (59.24 ± 21.9 years vs. 49.63 ± 23.32 years, P &lt; 0.0001), female gender (42.7% vs. 57.3%, P &lt; 0.0001), marital status (41.1% married vs. 58.9% unmarried, P &lt; 0.0001), length of stay in the ICU (5.99 ± 9.09 days vs. 4.13 ± 6.55 days, P &lt; 0.0001), Glasgow Coma Scale (GCS) of 3 - 5 (87.9% vs. 12.1%, P &lt; 0.0001), duration of MV (4.86 ± 8.69 days vs. 1.09 ± 4.85 days, P &lt; 0.0001), and co-morbidities (44.7% vs. 55.3%, P &lt; 0.0001), which were confirmed by logistic regression analysis. Conclusions: The prevalence of death in the ICU was 37.2%. Age, co-morbidities, cerebral vascular accident (CVA), GCS, duration of MV, and marital status were significantly associated with mortality.

Scandinavian Neurotrauma Guidelines: Frequency of intracranial hemorrhage in patients over 65 years old and on anti-platelet medication

PurposeIn 2013, the Scandinavian Neurotrauma Committee, produced an evidence-based guideline for the use of Computed Tomography (CT) in patients presenting following recent (<24 h) head injury (HI). A head CT scan is recommended for medium-risk patients with a Glasgow Coma Scale (GCS) score of 14–15, who are > 65 years old and on anti-platelet medication. The aim of this study was to determine the prevalence of intracranial hemorrhage (ICH) on head CT scans in this population, and to test for associations between ICH and baseline characteristics, symptoms and objective clinical findings. MethodsThis register-based retrospective study determined the prevalence of ICH on head CT scans performed over a 1-year period based on written CT-reports. Patient medical charts and imaging records were examined for data on symptomatology, objective findings and comorbidities. ResultsThe study population included 325 unique head CT scans with a 5.2% prevalence of ICH. Risk ratios (RR’s) signified higher risk of ICH with a GCS score of 14 compared to a GCS score of 15 (RR 5.35, 95%CI 2.14–13.47). ICH risk was lower in patients on Clopidogrel medication compared to Acetylsalicylic Acid medication (RR 0.33, 95%CI 0.12–0.93). ConclusionsThe associations between ICH and the GCS score call attention to the importance of comprehensive clinical examination of HI patients to minimize CT overuse. The implications for patients and healthcare resources in scanning patients > 65 years on anti-platelet medication should be determined by future prospective studies.

12264 Myxedema Coma And The Impact Of Treatment Noncompliance

Abstract Disclosure: R. Subramani: None. H. Marasandra Ramesh: None. S. Yavuz: None. Introduction: Myxedema coma represents a critical medical condition marked by a heightened risk of both morbidity and mortality. It manifests as severe hypothyroidism, typically presenting with symptoms like lethargy, altered mental status, or potential obtundation. Various triggering factors, including infections, hypothermia, metabolic imbalances, surgery, and specific medications like amiodarone, lithium, and anesthetics, can precipitate this emergency. Here we outline a classic instance of myxedema coma stemming from non-adherence to levothyroxine treatment in the context of primary hypothyroidism. Case Summary: A 56-year-old woman with a medical history significant for primary hypothyroidism, hyperlipidemia, and mood disorder presented to the hospital exhibiting symptoms suggestive of a stroke. Upon arrival, she had a seizure episode and eventual unresponsiveness. Emergency intubation was performed due to a low Glasgow Coma Scale score and concern for airway protection. Further history revealed non-compliance with levothyroxine therapy. Laboratory findings included TSH of 150 uIu/ml, T4 of 1.1 ng/dl, T3 of 1.17 ng/dl, and cortisol of 21.9 ug/dl. Chest x-ray revealed complete atelectasis of the left lung with mediastinal shift initially before intubation. CT head and neck were unremarkable. A diagnosis of myxedema coma was made based on clinical presentation and a myxedema score of 75. Treatment included IV levothyroxine 50 mcg, increased to 100 mcg, nor-epinephrine drip for hypotension and 1000 mg of levetiracetam for seizures management. Pulmonary edema resolved following levothyroxine initiation. The patient was successfully extubated on day 3, weaned off oxygen, and discharged home after 8 days with counseling on medication adherence. Discussion: While encountering a case of myxedema coma is rare, it is crucial to maintain a low threshold for diagnosing this potentially fatal emergency. Early recognition, facilitated by a comprehensive history, physical examination, and prompt initiation of treatment, is essential for effective management. Despite early intervention, the mortality rate remains high, ranging from 50% to 60%. Wartofsky et al. advocate for the primary treatment approach with T4 alone, emphasizing its efficacy. Supportive measures such as warming, fluid resuscitation, mechanical ventilation, administration of antibiotics, vasopressors, and corticosteroids are also integral components of management. This case report underscores the considerable morbidity and mortality associated with myxedema coma. The most common trigger precipitating myxedema coma is non-compliance with levothyroxine therapy, particularly in elderly females with longstanding hypothyroidism. Therefore, counseling regarding strict adherence to levothyroxine is of paramount importance. Presentation: 6/1/2024

Assessing consciousness in acute coma using name-evoked responses

Detecting consciousness in clinically unresponsive patients remains a significant challenge. Existing studies demonstrate that electroencephalography (EEG) can detect brain responses in behaviorally unresponsive patients, indicating potential for consciousness detection. However, most of this evidence is based on chronic patients, and there is a lack of studies focusing on acute coma cases. This study aims to detect signs of residual consciousness in patients with acute coma by using bedside EEG and electromyography (EMG) during an auditory oddball paradigm. We recruited patients with acute brain injury (either traumatic brain injury or cardiac arrest) who were admitted to the intensive care unit within two weeks after injury, with a Glasgow Coma Scale (GCS) score of 8 or below. Auditory stimuli included the patients' own names and other common names (referred to as standard names), spoken by the patients’ relatives, delivered under two conditions: passive listening (where patients were instructed that sounds would be played) and active listening (where patients were asked to move hands when heard their own names). Brain and muscle activity were recorded using EEG and EMG during the auditory paradigm. Event-related potentials (ERP) and EMG spectra were analyzed and compared between responses to the subject’s own name and other standard names in both passive and active listening conditions. A total of 22 patients were included in the final analysis. Subjects exhibited enhanced ERP responses when exposed to their own names, particularly during the active listening task. Compared to standard names or passive listening, distinct differences in brain network connectivity and increased EMG responses were detected during active listening to their own names. These findings suggest the presence of residual consciousness, offering the potential for assessing consciousness in behaviorally unresponsive patients.

Associations of arterial oxygen partial pressure with all‑cause mortality in critically ill ischemic stroke patients: a retrospective cohort study from MIMIC IV 2.2

BackgroundAs a supportive treatment, the effectiveness of oxygen therapy in ischemic stroke (IS) patients remains unclear. This study aimed to evaluate the relationships between arterial partial pressure of oxygen (PaO2) and both consciousness at discharge and all-cause mortality risk in ICU IS patients.MethodsBlood gas measurements for all patients diagnosed with IS were extracted from the MIMIC-IV database. Patients were classified into four groups based on their average PaO2 during the first ICU day: hypoxemia (PaO2 < 80 mmHg), normoxemia (PaO2 80–120 mmHg), mild hyperoxemia (PaO2 121–199 mmHg), and moderate/severe hyperoxemia (PaO2 ≥ 200 mmHg). The primary endpoint was 90-day all-cause mortality. Secondary outcomes included the level of consciousness at discharge, assessed by the Glasgow Coma Scale (GCS), and 30-day all-cause mortality. Multivariate Cox regression and Restricted cubic spline (RCS) analysis were used to investigate the relationship between mean PaO2 and mortality, and to assess the nonlinear association between exposure and outcomes.ResultsThis study included a total of 946 IS patients. The cumulative incidence of 30-day and 90-day all-cause mortality increased with decreasing PaO2 levels. RCS analysis revealed a nonlinear relationship between PaO2 and the risk of 30-day all-cause mortality (nonlinear P < 0.0001, overall P < 0.0001), as well as a nonlinear association between PaO2 and 90-day all-cause mortality (nonlinear P < 0.0001, overall P < 0.0001). The results remained consistent after excluding the small subset of patients who received reperfusion therapy. Sensitivity analysis indicated that the favorable impact on survival tends to increase with the extended duration of elevated PaO2.ConclusionsFor IS patients who do not receive reperfusion therapy or whose recanalization status is unknown, a lower PaO2 early during ICU admission is considered an independent risk factor for short-term and recent mortality. Adjusting respiratory parameters to maintain supraphysiological levels of PaO2 appears to be beneficial for survival, although this finding requires further validation through additional studies.Trial registrationNot applicable.

A Case Report of Bacterial Meningoencephalitis with Altered Sensorium in a 50-Year-Old Male

Bacterial meningoencephalitis remains a significant cause of morbidity and mortality worldwide, requiring prompt diagnosis and treatment. We present a case of a 50-year-old male who presented to the emergency room with a three-day history of low-grade fever, chills, altered sensorium, and recent episodes of seizures. Upon admission, the patient demonstrated positive Kernig's sign, bilateral pinpoint pupils, incomprehensible speech, and drowsiness, with a Glasgow Coma Scale score of E3M5V2. The patient had a significant history of chronic alcohol consumption spanning 32 years. Cerebrospinal fluid analysis revealed elevated protein levels (79.7 mg/dL) and the presence of Streptococcus pyogenes in culture, confirming the diagnosis of bacterial meningoencephalitis. While neuroimaging studies, including MRI and CT scan, showed no significant abnormalities, other diagnostic tests helped rule out concurrent infections. The patient received empirical antibiotic therapy with intravenous ceftriaxone, along with acyclovir, vancomycin, and supportive medications. Treatment also included management of increased intracranial pressure, seizure control, and careful monitoring of neurological status. Following a comprehensive 16-day treatment regimen, the patient showed significant improvement and was discharged in stable condition. This case shows the importance of early recognition of symptoms, prompt initiation of appropriate antimicrobial therapy, and the need for a multidisciplinary approach in managing bacterial meningoencephalitis. Regular follow-up was recommended due to the risk of relapse and potential long-term complications

Clinical importance of cerebrospinal fluid protein levels in HIV-associated cryptococcal meningitis: Insights from a prospective cohort study in Uganda.

Cerebrospinal fluid (CSF) protein levels exhibit high variability in HIV-associated cryptococcal meningitis; however, its clinical implications remain unclear. We analyzed data from 890 adults with HIV-associated cryptococcal meningitis randomized into two clinical trials in Uganda between 2015 and 2021. CSF protein was grouped into < 100mg/dl (72%, n =641) and ≥ 100mg/dl (28%, n =249). We described baseline clinical variables and 18-week mortality by CSF protein groups. Those with CSF protein ≥ 100mg/dl were more likely to present with Glasgow coma scale score<15 (P < .01), self-reported seizures at baseline (P = .02), higher CD4 T-cell count (P < .001), and higher CSF white blood cells (P < .001). Moreover, those with a baseline CSF protein ≥ 100mg/dl also had a lower baseline CSF fungal burden (P < .001) and a higher percentage of sterile CSF cultures at day 14 (P = .02). Individuals with CSF protein ≥ 100mg/dl demonstrated a more pronounced immune response consisting of upregulation of immune effector molecules, pro-inflammatory cytokines, T-helper cell type 1 and 17 cytokines, and immune-exhaustion marker (P < .05). 18-week mortality risk in individuals with a CSF protein < 100mg/dl was 34% higher (unadjusted Hazard Ratio 1.34; 95% Confidence Interval, 1.05-1.70; P = .02) than those with CSF protein ≥ 100mg/dl. In HIV-associated cryptococcal meningitis, individuals with baseline CSF protein ≥ 100mg/dl more frequently presented with neurological symptoms, higher CSF inflammatory cytokines, reduced fungal burden, and lower mortality risk. The findings underscore the prognostic significance of baseline CSF protein levels in predicting disease severity and mortality risk in cryptococcal meningitis.