Higher Glasgow Coma Scale Score Research Articles

Predictors of Intracranial Injury in Patients With Mild Head Trauma

Study objective: To determine the prevalence of abnormal computed tomography (CT) scans and define high-risk clinical variables in patients with mild head injury. Design: Retrospective descriptive study of patients with Glasgow Coma Scale (GCS) scores of 13 or greater who presented to the emergency department with blunt head trauma and who underwent cranial CT. Setting: Level I trauma center, university ED. Results: During the 15-month study period, 1,448 patients underwent CT scanning for mild head injury. Abnormalities resulting from the trauma were found in 119 (8.2%), and 11 patients (.76%) required neurosurgical intervention. Patients with higher GCS scores had a greater chance of having a solitary CT abnormality ( P =.004). Bicyclists and pedestrians struck by cars were more likely than others to sustain intracranial injury. High-risk clinical variables included the presence of cranial soft-tissue injury, a focal neurologic deficit, signs of basilar skull fracture and age older than 60 years. A strategy using those variables had a sensitivity of 91.6% and a specificity of 46.2% for detecting a CT abnormality. None of the patients missed by this strategy required medical or neurosurgical management for the CT finding. Conclusion: Abnormalities on CT scans in patients with mild head trauma are fairly common, although the need for neurosurgical intervention is rare. Clinical decision rules can be used to identify those patients with more serious intracranial pathology. Such strategies should be validated prospectively in various ED settings. [Borczuk P: Predictors of intracranial injury in patients with mild head trauma. Ann Emerg Med June 1995;25:731-736.]

Elective intubation for neurologic deterioration after stroke

To provide data to guide physicians and family when deciding whether a patient should be electively intubated after ischemic stroke. Chart review and patient interview. Clinical course, neurologic outcome, and financial and psychosocial effect of the decision to intubate were determined. Neurology/Neurosurgery critical care unit. Of our last 250 acute carotid territory ischemic stroke cases, we found 20 patients (8%) who were electively intubated, after CT and neurologic assessment, for neurologic deterioration. All patients received standard medical therapy. Intubation occurred 3 hours to 7 days (mean, 41 hours) after the onset of symptoms; six of 20 patients required intubation within the first 6 hours. Once clinical deterioration began, 10 of 20 patients required intubation within 1 hour. Six of 20 patients were discharged alive; two subsequently died, one is mostly dependent, two became mostly independent (one of these had a hemicraniectomy and is still improving, and the other died of an intercurrent illness 4 years after her stroke), and one is totally independent. The four "good" outcome survivors were distinguished by higher Glasgow Coma Scale scores (9.2 versus 5.9), and extubation was usually possible within 72 hours. For nonsurvivors, mean hospitalization after intubation was 6.4 days. In survivors, the monthly uninsured cost was $0 to $2,000, and caregivers experienced moderate stress. The same decision would be repeated by 76% of caregivers; 53% of caregivers would want intubation for themselves. Satisfactory outcome is possible in the 8% of ischemic stroke patients requiring elective intubation. Possible predictors of good outcome include less severe depression of consciousness at the time of intubation, extubation within 3 days, and hemicraniectomy. In retrospect, most families would repeat the decision to intubate. Further study in more patients of the cost/benefit of cerebral resuscitation after stroke is greatly needed.

Clinical predictors of post-traumatic seizures in children with head trauma

To determine the clinical characteristics associated with early post-traumatic seizures in children with head trauma. DESIGN, SETTING, AND TYPE OF PARTICIPANTS: Retrospective chart review; urban trauma center/pediatric emergency department. Trauma patients aged 3 months to 15 years given discharge diagnosis ICD-9-CM codes indicating head trauma and seen from 1988 to 1990 were eligible for the study. None. Of 194 patients, 96% suffered blunt trauma and 53% had a loss of consciousness. Fifty-one percent of 141 computed tomography (CT) scans of the head were abnormal, most frequently demonstrating skull fractures (34%), subdural hematomas (15%), and cerebral contusions (14%). Eighteen patients (9.3%) suffered post-traumatic seizures. A loss of consciousness, a low Glasgow Coma Scale (GCS) score (3 to 8), and an abnormal CT scan were associated with post-traumatic seizures (P < .02, .001, and .02, respectively). However, only a low GCS score was predictive of post-traumatic seizures when these factors were considered simultaneously (P < .001), with 38.7% of patients with low GCS scores suffering post-traumatic seizures and 3.8% of patients with high GCS scores suffering post-traumatic seizures. In children with low GCS scores, treatment with phenytoin was associated with a decrease in post-traumatic seizures. In the pediatric head trauma patient, a GCS score of 3 to 8 appears to be predictive of post-traumatic seizures. The data from this retrospective study are consistent with the hypothesis that prophylactic phenytoin reduces post-traumatic seizures in the pediatric head trauma patient with a low GCS score.

Injury patterns in motorcycle accident victims

An analysis of the injury patterns presented by inpatients of a government teaching hospital, known as one of the emergency centers of S. Paulo city, Brazil, is given the majority of victims are young, male adults and most of them were later discharged from the hospital. In relation to the injuries the majority of the patients were classified as being of minor injury grade (ISS between 1 and 9) and the most frequent injuries were extremity and pelvic fractures, surface trauma, traumatic brain injury and extremity and pelvic dislocations. Besides extremity and pelvic fractures, the victims who died showed abdominal organ injury and traumatic brain injury and the ISS was over 20. Head injury patients who had a high Glasgow Coma Scale score had a low ISS and vice-versa.

Propofol vs. Thiopental-Isoflurane for Neurosurgical Anesthesia

Sixty otherwise healthy patients with no clinical signs of intracranial hypertension who were undergoing elective intracranial surgery were randomly assigned to receive anesthesia with either thiopental, 3-6 mg/kg i.v., and isoflurane, 0.5-1.5% (group 1, N = 30) or propofol, 1-2.5 mg/kg i.v., and propofol infusion, 40-200 microg/kg/h (group 2, N = 30). Both groups received 50% nitrous oxide in O2 subsequent to dural opening. During induction, the changes in heart rate (HR), mean arterial pressure (MAP), cerebrospinal fluid pressure (CSFP), and cerebral perfusion pressure (CPP) were similar between the groups, except at 3 min when the findings (mean +/- SEM) for CPP (81 +/- 3.3 vs. 70.3 +/- 2.8 mm Hg, p <0.05) were significantly lower in group 2. At intubation, the highest level of MAP (103.1 +/- 3.3 vs. 88.9 +/- 2.7 mm Hg, p <0.05) was significantly greater in group 1. At pinhead-holder application, the highest values of HR (81.8 +/- 3 vs. 73.9 +/- 2.1 beats/min, p <0.05), MAP (112.2 +/- 3.6 vs. 98.3 +/- 3 mm Hg, p <0.05), CSFP (15.2 +/- 1.3 vs. 11.6 +/- 1.1 mm Hg, p <0.05), and CPP (97.0 +/- 3.9 vs. 86.7 +/- 3.3 mm Hg, p <0.05) were significantly greater in group 1. During early (20-30 min) recovery, group 2 had higher Glasgow Coma Scale scores and a greater percentage of patients in whom eye opening, response to commands, extubation, speech, and time/space orientation were present. In conclusion, when compared to thiopentalisoflurane for intracranial surgery, propofol produces similar HR, MAP, CSFP, and CPP responses during induction, adequate control of these responses during nociceptive stimulation, and faster recovery for cerebral function postoperatively.

A clinical study of head injuries in the aged : Inagawa T, Yano T, Kamiya K, et al. Jpn J Acute Med 1988;12: 1789–1795

We review 79 patients over 65 years old among 715 patients who underwent CT scans in the early period after head injuries, to study the characteristics of head injury in the aged. Among 79 aged patients, 24 developed posttraumatic subdural fluid collections, and in 13 of them chronic subdural hematomas developed subsequently. There were only three acute epidural hematomas. However, a high incidence of intracerebral lesions was noted, regardless of the presence of skull fracture. The pedestrian accident was the most frequent cause of head injury in the 36 aged patients admitted and the mortality rate of traffic accident in the aged was also highest. The relationship between Glasgow Coma Scale Score (GCS) on admission and the outcome was not parallel in the aged, because high GCS not rarely resulted in poor condition or death. Head injury is apt to occur and becomes severe in the aged pedestrian because of advancing carelessness and dull movements with age. The vulnerability of the brain to the injury and changes of intracranial environment in the aged tend to cause intracranial lesions much more than in the younger patients. Already-existing diseases and/or posttraumatic general complications also make clinical courses worse in the aged. It seems important for the improvement of the treatment that the characteristics described above are always taken into consideration throughout the period of the treatment in the aged, in order to eliminate worsening factors adequately. In addition, the social measures to cope with the suffering of the aged pedestrians from traffic accident should be considered and established in an aging society.

Glasgow Coma Scale Scores in the Patient Post Cardiopulmonary Resuscitation

This study was conducted to examine the difference in pre- and post-resuscitation Glasgow Coma Scale (GCS) scores in patients who suffered a cardiopulmonary arrest. Patients who arrested in an acute hospital setting were compared in terms of Glasgow Coma Scale scores with patients who arrested outside an acute hospital setting. The subjects for this study were 39 patients who arrested in the hospital and 16 patients who arrested outside the hospital setting. Data were collected over a period of one year using chart review. The data for this study included: GCS scores at one, two, four, twelve, and twenty-four hours post-arrest; age of the subjects; sex; site of arrest; and etiology of arrest. Results indicated that hospitalized arrest subjects had significantly higher GCS scores than out-of-hospital arrest subjects. Results further indicated that younger patients and those with myocardial infarctions had significantly higher GCS scores post-arrest. This study has implications for serial neurological assessment of the patient post-arrest.

ABSENT OR COMPRESSED BASAL CISTERNS ON FIRST CT SCAN

The relationship of outcome to the appearance of the basal cisterns as seen on initial computerized tomography (CT) scanning was assessed in 218 consecutive severely head-injured patients entered into the second phase of the National Pilot Traumatic Coma Data Bank. Outcome could be directly related to the status of the basal cisterns on the initial CT scan. The mortality rates were 77%, 39%, and 22% among those with absent, compressed, and normal basal cisterns, respectively. This association between cisterns and outcome was shown to be strong after adjusting for Glasgow Coma Scale (GCS) score (p less than 0.001). The state of the cisterns was more important for those with higher GCS scores (scores 6 to 8) than for those with lower scores (scores 3 to 5). Patients with GCS scores of 6 to 8, with cisterns absent or not visualized, suffered nearly a fourfold additional risk of poor outcome, compared to those with normal cisterns. This indicates that the status of the cisterns can be used as an early noninvasive method of identifying patients at high risk of death or severe disability, in whom the initial neurological examination would potentially suggest otherwise.

Absent or compressed basal cisterns on first CT scan: ominous predictors of outcome in severe head injury.

The relationship of outcome to the appearance of the basal cisterns as seen on initial computerized tomography (CT) scanning was assessed in 218 consecutive severely head-injured patients entered into the second phase of the National Pilot Traumatic Coma Data Bank. Outcome could be directly related to the status of the basal cisterns on the initial CT scan. The mortality rates were 77%, 39%, and 22% among those with absent, compressed, and normal basal cisterns, respectively. This association between cisterns and outcome was shown to be strong after adjusting for Glasgow Coma Scale (GCS) score (p less than 0.001). The state of the cisterns was more important for those with higher GCS scores (scores 6 to 8) than for those with lower scores (scores 3 to 5). Patients with GCS scores of 6 to 8, with cisterns absent or not visualized, suffered nearly a fourfold additional risk of poor outcome, compared to those with normal cisterns. This indicates that the status of the cisterns can be used as an early noninvasive method of identifying patients at high risk of death or severe disability, in whom the initial neurological examination would potentially suggest otherwise.