Higher Glasgow Coma Scale Research Articles

Determining the impact of timing and of clinical factors during end-of-life decision-making in potential controlled donation after circulatory death donors.

Controlled donation after circulatory death (cDCD) occurs after a decision to withdraw life‐sustaining treatment and subsequent family approach and approval for donation. We currently lack data on factors that impact the decision‐making process on withdraw life‐sustaining treatment and whether time from admission to family approach, influences family consent rates. Such insights could be important in improving the clinical practice of potential cDCD donors. In a prospective multicenter observational study, we evaluated the impact of timing and of the clinical factors during the end‐of‐life decision‐making process in potential cDCD donors. Characteristics and medication use of 409 potential cDCD donors admitted to the intensive care units (ICUs) were assessed. End‐of‐life decision‐making was made after a mean time of 97 hours after ICU admission and mostly during the day. Intracranial hemorrhage or ischemic stroke and a high APACHE IV score were associated with a short decision‐making process. Preserved brainstem reflexes, high Glasgow Coma Scale scores, or cerebral infections were associated with longer time to decision‐making. Our data also suggest that the organ donation request could be made shortly after the decision to stop active treatment and consent rates were not influenced by daytime or nighttime or by the duration of the ICU stay.

Clinical outcomes of different treatments and risk factors in patients with otogenic brain abscess, a real-world evidence-based retrospective study

Background Otogenic Brain Abscess (OBA) is a life-threatening complication secondary to otitis media, but its appropriate management remains controversial. Objectives To understand the demographic characteristics, management, and variables that affect the outcomes of patients with OBA based on our experiences over 11 years. Material and methods Clinical data were collected for 41 patients. Prognostic factors associated with mortality were assessed, and clinical outcomes compared among groups receiving different treatments. Results Among the 41 patients, 19.6% did not undergo surgery, 39.0% were treated with two-stage surgery (otological surgery and neurosurgery) and 41.4% were treated with single-stage surgery (otological surgery or neurosurgery). Overall mortality rate was 32.5%, and mortality was significantly higher in patients with invasion of the petrous apex (odds ratio [OR]: 7.81, 95% confidence interval [95% CI]: 1.26–48.36), and lower in those with appropriate surgical management (single otological surgery, OR: 0.07, 95% CI: 0–0.97; single neurosurgery, OR: 0.13, 95% CI: 0.02–1.0; two-stage surgery, OR: 0.08, 95% CI: 0.01–0.64) or a higher Glasgow Coma Scale (GCS) score at admission (OR: 0.64, 95% CI: 0.44–0.93). Conclusions and significance Data on invasiveness and pre-surgery GCS greatly aid in predicting the prognosis of OBA patients. Early evaluation will facilitate decision-making by physicians treating OBA patients.

Identifying Modifiable Predictors of Patient Outcomes After Intracerebral Hemorrhage with Machine Learning.

Demonstrating a benefit of acute treatment to patients with intracerebral hemorrhage (ICH) requires identifying which patients have a potentially modifiable outcome, where treatment could favorably shift a patient's expected outcome. A decision rule for which patients have a modifiable outcome could improve the targeting of treatments. We sought to determine which patients with ICH have a modifiable outcome. Patients with ICH were prospectively identified at two institutions. Data on hematoma volumes, medication histories, and other variables of interest were collected. ICH outcomes were evaluated using the modified Rankin Scale (mRS), assessed at 14 days and 3 months after ICH, with "good outcome" defined as 0-3 (independence or better) and "poor outcome" defined as 4-6 (dependence or worse). Supervised machine learning models identified the best predictors of good versus poor outcomes at Institution 1. Models were validated using repeated fivefold cross-validation as well as testing on the entirely independent sample at Institution 2. Model fit was assessed with area under the ROC curve (AUC). Model performance at Institution 1 was strong for both 14-day (AUC of 0.79 [0.77, 0.81] for decision tree, 0.85 [0.84, 0.87] for random forest) and 3 month (AUC of 0.75 [0.73, 0.77] for decision tree, 0.82 [0.80, 0.84] for random forest) outcomes. Independent predictors of functional outcome selected by the algorithms as important included hematoma volume at hospital admission, hematoma expansion, intraventricular hemorrhage, overall ICH Score, and Glasgow Coma Scale. Hematoma expansion was the only potentially modifiable independent predictor of outcome and was compatible with "good" or "poor" outcome in a subset of patients with low hematoma volumes, good Glasgow Coma scale and premorbid modified Rankin Scale scores. Models trained on harmonized data also predicted patient outcomes well at Institution 2 using decision tree (AUC 0.69 [0.63, 0.75]) and random forests (AUC 0.78 [0.72, 0.84]). Patient outcomes are predictable to a high level in patients with ICH, and hematoma expansion is the sole-modifiable predictor of these outcomes across two outcome types and modeling approaches. According to decision tree analyses predicting outcome at 3 months, patients with a high Glasgow Coma Scale score, less than 44.5mL hematoma volume at admission, and relatively low premorbid modified Rankin Score in particular have a modifiable outcome and appear to be candidates for future interventions to improve outcomes after ICH.

Putting a halt to unnecessary transfers: Do patients with isolated subarachnoid hemorrhage and Glasgow Coma Scale of 13 to 15 need a trauma center?

Trauma patients with isolated subarachnoid hemorrhage (iSAH) presenting to nontrauma centers are typically transferred to an institution with neurosurgical availability. However, recent studies suggest that iSAH is a benign clinical entity with an excellent prognosis. This investigation aims to evaluate the neurosurgical outcomes of traumatic iSAH with Glasgow Coma Scale (GCS) of 13 to 15 who were transferred to a higher level of care. The American College of Surgeon Trauma Quality Improvement Program was retrospectively analyzed from 2010 to 2015 for transferred patients 16 years and older with blunt trauma, iSAH, and GCS of 13 or greater. Those with any other body region Abbreviated Injury Scale of 3 or greater, positive or unknown alcohol/drug status, and requiring mechanical ventilation were excluded. The primary outcome was need for neurosurgical intervention (i.e., intracranial monitor or craniotomy/craniectomy). A total of 11,380 patients with blunt trauma, iSAH, and GCS of 13 to 15 were transferred to an American College of Surgeon level I/II from 2010 to 2015. These patients were 65 years and older (median, 72 [interquartile range (IQR), 59-81]) and white (83%) and had one or more comorbidities (72%). Eighteen percent reported a bleeding diathesis/chronic anticoagulation on admission. Most patients had fallen (80%), had a GCS of 15 (84%), and were mildly injured (median Injury Severity Score, 9 [IQR, 5-14]). Only 1.7% required neurosurgical intervention with 55% of patients being admitted to the intensive care unit for a median of 2 days (IQR, 1-3 days). Furthermore, 2.2% of the patients died. The median hospital length of stay was only 3 days (IQR, 2-5 days), and the most common discharge location was home with self-care (62%). Patient factors favoring neurosurgical intervention included high Injury Severity Score, low GCS, and chronic anticoagulation. Trauma patients transferred for iSAH with GCS of 13 to 15 are at very low risk for requiring neurosurgical intervention. Therapeutic/care management, Level IV.

Abstract TP349: Improving Utilization of ICU Care: Change in Intracerebral Hemorrhage Admission Protocol at a Comprehensive Stroke Center

Objectives: Non traumatic intracerebral hemorrhage (ICH) is responsible for 10-20% of acute stroke events and carries significant mortality concern. The protocol at our comprehensive stroke centers (CSC) is to admit all ICH patients to Neurosciences Intensive Care Unit (NSICU). We also have a stroke Intermediate Care Unit (IMCU) at our hospital which is a dedicated stroke unit where patients can be closely monitored and maintained on IV nicardipine. Optimal bed utilization is essential at our busy referral center. We aimed to develop criteria to identify ICH patients at low risk for clinical deterioration who could be admitted directly to our IMCU rather than the NSICU thereby improving overall utilization of monitored beds. Methods: Retrospective chart review for patients admitted between July 2018-Dec 2018 was performed. Age, sex, race, presenting Glasgow coma scale (GCS), ICH score, ICH volume, presence of IVH and location of the hemorrhage was documented. Patients who did not need any neurosurgical procedures (external ventricular drain, craniectomy or hematoma evacuation) and were not documented to have acute respiratory failure during their admission were considered appropriate for IMCU admission and were further assessed for hematoma expansion to determine stability throughout their hospital course. Results: 118 patients with ICH were included in the analysis, out of which 61 patients were suitable for IMCU admission. On univariable analysis, patients that had lower ICH scores (0.6±0.7 vs 2.5±0.9) and higher GCS score (14.1±1.4 vs 7.8±3.7) did not need any acute intervention. In this group of patients, only 9 (14.7%) patients had hematoma expansion documented out of which 6 (67%) patients had coagulation abnormalities on admission either due to medications or low platelet count. Conclusions: We conclude that the patients who had admission ICH score < 2, GCS ≥ 12 and no coagulation abnormalities on admission could have safely been admitted to our IMCU instead of the NSICU for further care and management. This would have led to a decrease in ICU admission rate. Application of such separate protocols for stroke IMCU admission vs ICU admission would lead to better utilization of resources at comprehensive stroke centers throughout the country.

Factors affecting outcomes of surgically treated patients with cranial extradural hematoma: A cross-sectional study

Objective: To evaluate the factors resulting in the poor outcomes in patients with extradural hematoma (EDH). Methods: The study was conducted at the Neurosurgery Teaching Hospital in Baghdad with a group of 100 surgically treated EDH patients and was carried prospectively from February 1st, 2015 to May 1st, 2017. The baseline information (gender, age, cause of injury, time interval between injury and reception, Glasgow coma scale, etc.) of the patients was recorded, and the variables affecting the outcomes were analyzed. Results: In the study, 80% of patients were male; 54% were between 10-29 years old; the commonest cause of injury was fall accounting for 51%; 78% of the patients got good functional recovery, and 10% had a residual disability; 12% died. Better functional recovery was found among patients with a shorter time interval (≤3 h) (P=0.001), while the longer time interval (>3 h) increased the residual disability (P=0.005). In addition, functional recovery increased six times with higher Glasgow coma scale (P=0.001), and inversely related to mortality (P=0.005). Conclusions: Age between 10 and 29 years, male gender, and depth of hematoma more than 5 cm are at higher risks of poor outcomes of patients with surgically treated EDH. Neurological conditions on admission and time interval between injury and reception are also important factors.

Vasospasm-related Sudden Cardiac Death Has Outcomes Comparable with Coronary Stenosis in Out-of-Hospital Cardiac Arrest.

BackgroundCharacteristics of coronary vasospasm-related sudden cardiac death are not well understood. We aimed to compare the characteristics and clinical outcomes between coronary vasospasm and stenosis, in out-of-hospital cardiac arrest (OHCA) survivors, who underwent coronary angiogram (CAG).MethodsWe conducted a multicenter retrospective observational registry-based study at 8 Korean tertiary care centers. Data of OHCA survivors undergoing CAG between 2010 and 2015 were extracted. Patients were divided into vasospasm and stenosis (stenosis > 50%) groups based on CAG findings. The primary and the secondary outcomes were survival and a good neurologic outcome at 30 days after OHCA. Patients in the vasospasm and stenosis groups were propensity score matched.ResultsOf the 413 included patients, vasospasm and stenosis groups comprised 87 and 326 patients, respectively. There were 279 (66.7%) survivors and 206 (49.3%) patients with good neurologic outcomes. The vasospasm group had better clinical characteristics for outcome (younger age, less diabetes and hypertension, more prehospital restoration of spontaneous circulation, higher Glasgow Coma Scale, less ST segment elevation, and less requirement of circulatory support). The vasospasm group had better survival (75/87 vs. 204/326, P < 0.001) and good neurologic outcomes (62/87 vs. 144/326, P < 0.001). However, vasospasm was not independently associated with survival (odds ratio [OR], 0.980; 95% confidence interval [CI], 0.400–2.406) or neurologic outcomes (OR, 0.870; 95% CI, 0.359–2.108) after adjustment and vasospasm was not associated with survival and neurologic outcome in propensity score-matched cohorts.ConclusionOur analysis of propensity score-matched cohorts finds that vasospasm OHCA survivors have survival and neurologic outcomes comparable with those of stenotic OHCA survivors.

Early tracheostomy is associated with better prognosis in patients with brainstem hemorrhage.

Brainstem hemorrhage is presumed to be invariably associated with a poor prognosis in people with spontaneous hypertensive cerebral hemorrhage. The optimal timing of tracheostomy placement in brainstem hemorrhage patients, who generally require endotracheal intubation for airway protection, remains uncertain. Our research aim was to analyze the impact of early tracheostomy versus late tracheostomy on brainstem hemorrhage patients related outcomes and prognostic factors at 30 days. We identified early tracheostomy and how it could benefit the patients with brainstem hemorrhage and ameliorate the predictors of functional recovery at 30 days. Data on 136 patients with brainstem hemorrhage and Glasgow Coma Scale score ≤ 8, were retrospectively collected from 2012 to 2019. Patients were divided into the early tracheostomy group and the late tracheostomy group. Patients in the early tracheostomy group had a significantly lower neurosurgical intensive care unit stay (both overall and survival) compared with the late tracheostomy group (15.6 days vs. 19.0 days, P = 0.041, overall and 14.5 vs. 19.5 days, P = 0.023, survival). Also, the good outcomes (modified Rankin Score ≤ 3) were higher in the early tracheostomy group (P = 0.036). Multivariate analysis demonstrated that less hemorrhagic volume, high Glasgow Coma Scale score on admission, young age, and early tracheostomy were significantly associated with a better 30-day functional outcome. In conclusion, an early tracheostomy in patients with brainstem hemorrhage can reduce neurosurgical intensive care unit stay, and in addition to improvements in prognosis at 30 days.

Risk Factors for Urinary Tract Infection or Pneumonia After Admission for Traumatic Subdural Hematoma at a Level I Trauma Center: Large Single-Institution Series

The development of infections such as urinary tract infections (UTIs) or pneumonia after a traumatic subdural hematoma (tSDH) can worsen patient outcomes and increase healthcare costs. We herein identify clinical parameters that influence the risk of infections after tSDH. This single-institution retrospective cohort study examined the incidence and risk factors for UTI and pneumonia among tSDH patients from 1990 to 2015. Multivariate logistic regression assessed the impact of various demographic and clinical variables on these outcomes. 3024 patients with tSDHs were identified (73.1% male); Of those, 208 (6.9%) experienced a UTI and 434 (14.4%) experienced pneumonia. Of the 559 patients (18.5%) who underwent a craniotomy and/or craniectomy for evacuation of a tSDH, 62 (11.1%) experienced a UTI and 222 (39.7%) experienced pneumonia. Risk factors for both pneumonia and UTI included length of stay (LOS) ≥7 days (odds ratio [OR]= 6.0, P < 0.001; OR= 11.2, P < 0.001), intensive care unit LOS ≥7 days (OR= 8.1, P < 0.001; OR= 1.7, P= 0.012), and mechanical ventilation ≥14 days (OR= 3.4, P < 0.001; OR= 1.8, P= 0.007). Craniotomy/craniectomy increased the risk of pneumonia (OR= 1.4, P= 0.019) but not UTI. Glasgow Coma Scale (GCS) ≥13 was associated with a decreased pneumonia risk (OR= 0.5, P= 0.003), and male gender (OR= 0.5, P < 0.001) and age <60 (OR= 0.6, P < 0.001) were associated with a decreased UTI risk. Patients with prolonged hospitalizations and/or intensive care unit stays were more likely to experience UTIs and pneumonia. Male gender and younger age were protective against UTI, and higher GCS was protective against pneumonia. These data may aid the identification and treatment of at-risk populations after admission for a tSDH.

Continuous EEG Monitoring Predicts a Clinically Meaningful Recovery Among Adult Inpatients.

Continuous EEG (cEEG) monitoring is primarily used for diagnosing seizures and status epilepticus, and for prognostication after cardiorespiratory arrest. The purpose of this study was to investigate whether cEEG could predict survival and meaningful recovery. The authors reviewed inpatient cEEG reports obtained between January 2013 and November 2015 and recorded demographics, preadmission modified Rankin Scale, history of preexisting epilepsy, Glasgow Coma Scale for those admitted to the intensive care unit, and EEG data (posterior dominant rhythm, reactivity, epileptiform discharges, seizures, and status epilepticus). Associations between clinical outcomes (death vs. survival or clinically meaningful recovery [inpatient rehabilitation, home-based rehabilitation, or home] vs. other [death, skilled nursing facility]) and cEEG findings were assessed with logistic regression models. P < 0.05 was considered significant. For 218 cEEG reports (197 intensive care unit admits), the presence of at least a unilateral posterior dominant rhythm was associated with survival (odds ratio for death, 0.38; 95% confidence interval, 0.19-0.77; P = 0.01) and with a clinically meaningful outcome (odds ratio, 3.26; 95% confidence interval, 1.79-5.93; P < 0.001); posterior dominant rhythm remained significant after adjusting for preadmission disability. Those with preexisting epilepsy had better odds of a meaningful recovery (odds ratio, 3.31; 95% CI, 1.34-8.17; P = 0.001). Treated seizures and status epilepticus were not associated with a worse mortality (P = 0.6) or disposition (P = 0.6). High Glasgow Coma Scale (≥12) at intensive care unit admission was associated with a clinically meaningful recovery (odds ratio, 16.40; 95% confidence interval, 1.58-170.19; P = 0.02). Continuous EEG findings can be used to prognosticate survival and functional recovery, and provide guidance in establishing goals of care.

Retrospective cohort study on factors associated with mortality in high-risk pediatric critical care patients in the Netherlands

BackgroundHigh-risk patients in the pediatric intensive care unit (PICU) contribute substantially to PICU-mortality. Complex chronic conditions (CCCs) are associated with death. However, it is unknown whether CCCs also increase mortality in the high-risk PICU-patient. The objective of this study is to determine if CCCs or other factors are associated with mortality in this group.MethodsRetrospective cohort study from a national PICU-database (2006–2012, n = 30,778). High-risk PICU-patients, defined as patients < 18 years with a predicted mortality risk > 30% according to either the recalibrated Pediatric Risk of Mortality-II (PRISM) or the Paediatric Index of Mortality 2 (PIM2), were included. Patients with a cardiac arrest before PICU-admission were excluded.ResultsIn total, 492 high-risk PICU patients with mean predicted risk of 24.8% (SD 22.8%) according to recalibrated PIM2 and 40.0% (SD 23.8%) according to recalibrated PRISM were included of which 39.6% died. No association was found between CCCs and non-survival (odds ratio 0.99; 95% CI 0.62–1.59). Higher Glasgow coma scale at PICU admission was associated with lower mortality (odds ratio 0.91; 95% CI 0.87–0.96).ConclusionsComplex chronic conditions are not associated with mortality in high-risk PICU patients.

Haplotype analysis of SERPINE1 gene: Risk for aneurysmal subarachnoid hemorrhage and clinical outcomes.

BackgroundAneurysmal subarachnoid hemorrhage (aSAH) has high fatality and permanent disability rates due to the severe damage to brain cells and inflammation. The SERPINE1 gene that encodes PAI‐1 for the regulation of tissue plasminogen activator is considered an important therapeutic target for aSAH.MethodsSix SNPs in the SERPINE1 gene (in order of rs2227631, rs1799889, rs6092, rs6090, rs2227684, rs7242) were investigated. Blood samples were genotyped with Taqman genotyping assays and pyrosequencing. The experiment‐wide statistically significant threshold for single marker analysis was set at p < 0.01 after evaluation of independent markers. Haplotype analysis was performed in Haplo.stats package with permutation tests. Bonferroni correction for multiple comparison in dominant, additive, and recessive model was applied.ResultsA total of 146 aSAH patients and 49 control subjects were involved in this study. The rs2227631 G allele is significant (p = 0.01) for aSAH compared to control. In aSAH group, haplotype analysis showed that G5GGGT homozygotes in recessive model were associated with delayed cerebral ischemia (p < 0.01, Odds Ratio = 5.14, 95% CI = 1.45–18.18), clinical vasospasm (p = 0.01, Odds Ratio = 4.58, 95% CI = 1.30–16.13), and longer intensive care unit stay (p = 0.01). By contrast, the G5GGAG carriers were associated with less incidence of cerebral edema (p < 0.01) and higher Glasgow Coma Scale (p < 0.01). The A4GGGT carriers were associated with less incidence of severe hypertension (>140/90) (p < 0.01).ConclusionThe results suggested an important regulatory role of the SERPINE1 gene polymorphism in clinical outcomes of aSAH.

Glasgow Coma Scale Score Fluctuations are Inversely Associated With a NIRS-based Index of Cerebral Autoregulation in Acutely Comatose Patients.

The Glasgow Coma Scale (GCS) is an essential coma scale in critical care for determining the neurological status of patients and for estimating their long-term prognosis. Similarly, cerebral autoregulation (CA) monitoring has shown to be an accurate technique for predicting clinical outcomes. However, little is known about the relationship between CA measurements and GCS scores among neurological critically ill patients. This study aimed to explore the association between noninvasive CA multimodal monitoring measurements and GCS scores. Acutely comatose patients with a variety of neurological injuries admitted to a neurocritical care unit were monitored using near-infrared spectroscopy-based multimodal monitoring for up to 72 hours. Regional cerebral oxygen saturation (rScO2), cerebral oximetry index (COx), GCS, and GCS motor data were measured hourly. COx was calculated as a Pearson correlation coefficient between low-frequency changes in rScO2 and mean arterial pressure. Mixed random effects models with random intercept was used to determine the relationship between hourly near-infrared spectroscopy-based measurements and GCS or GCS motor scores. A total of 871 observations (h) were analyzed from 57 patients with a variety of neurological conditions. Mean age was 58.7±14.2 years and the male to female ratio was 1:1.3. After adjusting for hemoglobin and partial pressure of carbon dioxide in arterial blood, COx was inversely associated with GCS (β=-1.12, 95% confidence interval [CI], -1.94 to -0.31, P=0.007) and GCS motor score (β=-1.06, 95% CI, -2.10 to -0.04, P=0.04). In contrast rScO2 was not associated with GCS (β=-0.002, 95% CI, -0.01 to 0.01, P=0.76) or GCS motor score (β=-0.001, 95% CI, -0.01 to 0.01, P=0.84). This study showed that fluctuations in GCS scores are inversely associated with fluctuations in COx; as COx increases (impaired autoregulation), more severe neurological impairment is observed. However, the difference in COx between high and low GCS is small and warrants further studies investigating this association. CA multimodal monitoring with COx may have the potential to be used as a surrogate of neurological status when the neurological examination is not reliable (ie, sedation and paralytic drug administration).

Cognition in patients with traumatic brain injury measured by the Montreal Cognitive Assessment-Basic

Patients with traumatic brain injury (TBI) undergo cognitive impairment. We aimed to explore the cognition level in patients of all severities with different lesion sites and the effect of demographic variables, lesion site, TBI severity, and the time since the TBI on their cognitive abilities using the Montreal Cognitive Assessment-Basic (MoCA-B). A total of 67 patients with TBI were recruited from the Department of Cerebral Surgery at No. 101 Hospital of the Chinese People’s Liberation Army (PLA) at out-patient follow up. A regression model was performed to assess the effect of these variables on cognition of TBI patients. As expected, age, education, and the Glasgow Coma Scale (GCS) score were found as predictors of cognition of TBI patients. Participants, who were younger, had more years of education, and a higher GCS score had better cognition, respectively. Thus, the results provide evidence for the early detection of possible different cognition impairment of TBI patients. Specifically, these findings can help predict early prognosis for patients in the course of clinical diagnosis and treatment and, thus, allow for early intervention to improve the patients’ quality of life and possible extend their life.

Outcomes of Decompressive Craniectomy for Spontaneous Deep Supratentorial Intracerebral Hemorrhage

AbstractBackground: Spontaneous Intracerebral Hemorrhage (ICH) is one of the most devastating forms of cerebrovascular disease and is associated with high mortality and morbidity rate. Mass-effects of hematoma and surrounding edema lead to increase intracranial pressure and subsequent brain herni-ation. Decompressive Craniectomy (DC) provide space for the edematous brain to expand away from the midline structures and reduce intracranial pressure.Aim of Study: The aim of this study was to evaluate the outcome of Outcomes of Decompressive Craniectomy for Spontaneous Deep Supratentorial Intracerebral Hemorrhage.Patient and Methods: We retrospectively reviewed the medical records of the patients with spontaneous deep su-pratentorial ICH who underwent DC without evacuation of hematoma within 24 hour of ictus. Outcome was assessed by the Glasgow Outcome Scale (GOS) 6 months after surgery.Results: A total of 12 patients were included in this study. The mean age was 45 years. Mean pre-operative Glasgow Coma Scale (GCS) score was 6.7. Mean hematoma volume was 68ml. At 6 months after surgery, 8 patients (67%) had favorable outcome while 4 (33%) had unfavorable outcome, 2 patients (17%) died. 83% of patients with pre-operative GCS score 8-9 compared to 50% with pre-operative GCS score 5-7 had favorable outcome. 71% of patients with he-matoma volume less than or equal to 70ml compared with 60% with hematoma volume more than 70ml had favorable outcome.Conclusions: Decompressive craniectomy can be benefi-cial in treatment of spontaneous deep supratentorial ICH in selected patient group. Patients with high pre-operative GCS score and small hematoma volume are more likely to have favorable outcome.

Safety of Peripheral Line Administration of 3% Hypertonic Saline and Mannitol in the Emergency Department.

Hypertonic saline (HTS) and mannitol are frequently utilized in the emergency department (ED) to manage elevations in intracranial pressure (ICP). The objective of this study was to compare the incidence of extravasation injury when HTS or mannitol was administered via peripheral i.v. line (PIV). This retrospective cohort study evaluated adult and pediatric patients given either 3% HTS or mannitol via PIV while in the ED. The primary outcome was extravasation incidence. One hundred and ninety-two patients were included, of which 85 (44%) received HTS and 107 (56%) received mannitol. Patients who received HTS were younger (27.5±24.3years vs. 53.9±22.3years; p<0.001); 55.3% of patients given HTS received it for traumatic brain injury (TBI) versus 38.3% of patients given mannitol (p=0.021); and 44.9% of patients given mannitol received it for intracerebral hemorrhage versus 21.2% of patients given HTS (p=0.001). There was no incidence of extravasation in either group. Patients who received HTS had lower ICP measurement 24h post admission (2.107±5.5mm Hg vs. 4.236±8.1mm Hg; p=0.047) and higher Glasgow Coma Scale (GCS) score upon discharge (GCS 14; interquartile range [IQR] 3-15 vs. GCS 3; IQR 3-14.2; p=0.004). In-hospital mortality was higher in the mannitol group (54.7% vs. 32.9%; p=0.003). Duration of mechanical ventilation was shorter in those patients who received HTS (1day; IQR 0-56days vs. 2days; IQR 0-56days; p=0.023). There were no incidences of extravasation among patients given 3% HTS or mannitol. Clinicians should reconsider recommendations to restrict HTS or mannitol to central lines.

Pre-hospital anaesthesia and assessment of head injured patients presenting to a UK Helicopter Emergency Medical Service with a high Glasgow Coma Scale: a cohort study

ObjectivesPatients who sustain a head injury but maintain a Glasgow Coma Scale (GCS) of 13–15 may still be suffering from a significant brain injury. We aimed to assess the appropriateness...

Effect of Auditory Stimulation on the Level of Consciousness in Comatose Patients Admitted to the Intensive Care Unit: A Randomized Controlled Trial.

Comatose patients are exposed to sensory deprivation in the intensive care units. Auditory stimulation of patients who are unconscious is a nonmedical procedure. This study examines the effect of organized voice, performed by a nurse, on the state of consciousness of comatose patients in intensive care units. This randomized controlled trial study of 60 patients was conducted fitting between August 2017 and February 2018. For 10 days, patients received the voice of a male nurse twice a day in the morning and night shifts, recorded on MP3 and repeated at least 3 to 4 times. Glasgow Coma Scale (GCS) scores were recorded by the researcher before and after auditory stimulation. Patient mean age was 69.2 years; 56.7% of the experimental group and 53.3% of the control group were male. On the first day in the morning and evening after auditory stimulation, the mean GCS was 4.8 in the experimental group and 4.7 in the control group. Before and after the intervention on the 10th day after auditory stimulation, the mean GCS of patients was 9.5 in the experimental group and 7.1 in the control group in the morning and 9.6 and 7.2, respectively, in the evening. No significant differences in mean GCS by group were observed for the first 3 days (P > .05). However, the difference in mean GCS scores of the 2 groups was statistically significant after the third day (P < .05). Auditory stimulation is associated with higher GCS in comatose patients.

The Effect of Cerebrovascular Stenosis on -Peri-Hematoma Cerebral Perfusion and Clinical Outcomes in Patients with Supratentorial Spontaneous Intracerebral Hemorrhage.

BackgroundMany factors are associated with the cerebral hypoperfusion after spontaneous intracerebral hemorrhage (sICH), however, the effect of cerebrovascular stenosis on peri-hematoma cerebral blood flow (CBF) and 90-day poor outcomes in patients with spontaneous intracerebral hemorrhage is still unclear.Material/MethodsFrom September 2016 to March 2017, we prospectively collected data on adults with supratentorial spontaneous intracerebral hemorrhages. Using the Propensity Score model, we compared the peri-hematoma CBF and 90-day poor outcomes (mRS ≥3) in the stenosis group and the control group.ResultsBefore matching, a total of 116 patients were included in this study, 25 patients in the stenosis group and 91 patients in the control group. After matching, the patients in the stenosis group had a higher absolute decrease of CBF (p=0.003), higher relative decrease of CBF (p=0.016), and higher incidence of 90-day poor outcomes (p=0.041) than the control group. With subgroup analysis, the patients with Glasgow Coma Scale from 13 to 15 (p=0.035), hematoma in the cerebral lobe (p=0.003), mean arterial pressure lower than 120 mm Hg (p=0.003), absolute decrease of CBF higher than 15 mL/100 g per minute (p=0.007), and relative decrease of CBF higher than 30% (p=0.020) had poorer outcomes.ConclusionsIn our series, the stenosis of main cerebral vessels decreased the peri-hematoma CBF and increased the rate of 90-day poor outcomes. Despite higher Glasgow Coma Scale, the evaluation of cerebral perfusion in patients with sICH is needed, especially for the patients with hematoma in the cerebral lobe and lower mean arterial pressure; and treatments to keep adequate cerebral perfusion are needed.

Potential Risk Factors for In-Hospital Mortality in Patients with Moderate-to-Severe Blunt Multiple Trauma Who Survive Initial Resuscitation.

Introduction The aim was to identify risk factors that influence in-hospital mortality for patients with moderate-to-severe blunt multiple trauma (BMT) who survive initial resuscitation. Methods The prospective study involved 195 adult patients with BMT who were admitted to a referral hospital's emergency department (ED) between May 1, 2015, and May 31, 2016. Results Forty-three (22%) of the 195 patients died in hospital. Multivariate analysis identified low blood pH (odds ratio [OR] 6.580, 95% confidence interval [CI] 1.12-38.51), high serum lactate level (OR 1.041, 95% CI 1.01-1.07), high ISS (OR 1.109, 95% CI 1.06-1.16), high APACHE II score (OR 1.189, 95% CI 1.07-1.33), traumatic brain injury (TBI) (OR 4.358, 95% CI 0.76-24.86), severe hemorrhage (OR 5.314, 95% CI 1.07-26.49), and coagulopathy (OR 5.916, 95% CI 1.17-29.90) as useful predictors of acute in-hospital mortality. High ISS (OR 1.047, 95% CI 1.02-1.08), TBI (OR 8.922, 95% CI 2.57-31.00), sepsis (OR 4.956, 95% CI 1.99-12.36), acute respiratory distress syndrome (ARDS) (OR 8.036, 95% CI 1.85-34.84), respiratory failure (OR 9.630, 95% CI 2.64-35.14), renal failure (OR 74.803, 95% CI 11.34-493.43), and multiple organ failure [MOF] (OR 10.415, 95% CI 4.48-24.24) were risk factors for late in-hospital mortality. High Glasgow Coma Scale (GCS) was a good predictor for survival at 2, 7, and 28 or more days of hospitalization (OR 0.708 and 95% CI 0.56-0.09; OR 0.835 and 95% CI 0.73-0.95; OR 0.798 and 95% CI 0.71-0.90, resp.). Conclusion Several factors signal poor short-term outcome for patients who present to the ED with moderate-to-severe BMT: low blood pH, high serum lactate level, presence of TBI, severe hemorrhage, coagulopathy, organ failure (respiratory, renal, and MOF), and ARDS. For this patient group, ISS and APACHE II scores might be helpful for stratifying by mortality risk, and GCS might be a good predictor for survival.