Initial Glasgow Coma Scale Research Articles

Impact of timing of preoperative gabapentin administration on postoperative somnolence.

Enhanced Recovery After Surgery (ERAS) is a multimodal protocol aimed to improve quality of postoperative recovery, minimize complications, and optimize overall self-regulation. Preoperative gabapentin decreases postoperative pain but can be associated with prolonged postoperative somnolence and respiratory depression risk. Although it is known that gabapentin affects the postoperative course, it is unclear if the timing of preoperative administration affects this finding. This study aims to assess the optimal preoperative timing for gabapentin administration in patients undergoing gynecologic surgery to minimize postoperative somnolence risk. A retrospective cohort study evaluated patients who underwent major gynecologic surgery and received preoperative gabapentin. Patients were grouped based on timing from gabapentin administration to surgical incision (<4h group vs.≥4h group). Preoperative, intraoperative, and postoperative data were abstracted and compared. Univariate associations between the timing of gabapentin administration and the patient and surgical characteristics and outcomes were tested utilizing two-sample equal-variance t-tests, linear model ANOVA, or Fisher's exact tests. Associations between the timing of gabapentin administration and the time until the Richmond Agitation Sedation Scale (RASS) score of 0 were modeled utilizing linear regression, adjusted for age, initial postoperative anesthesia care unit (PACU), RASS score, and postoperative narcotics. Each group contained 127 patients. Demographics were similar except for age (<4h group mean=44.2 years;≥4h group mean=40.5 years; p=0.021), chronic pain (<4h group=17.6%;≥4h group=43.3%; p<0.001), and surgical indication (<4h group=pelvic pain [29.1%];≥4h group=pelvic pain [51.2%]; p=0.007). The <4h group had a similar postoperative narcotic administration (<4h group mean morphine milligram equivalents [MME]=3.667;≥4h group mean MME=4.833; p=0.185). The minutes from surgical closure until the patient received a RASS score of 0 and initial PACU pain score (Visual Analogue Scale [VAS]) were similar. The initial PACU oxygen administration volume, hours from surgical closure until the patient transitioned to room air, and initial PACU respiratory rate were similar. The PACU duration, admission secondary to somnolence, and initial PACU Glasgow Coma Scale (GCS) score showed no difference. Postoperative nausea/vomiting was decreased in the≥4h group (<4h group=24.4%;≥4h group=13.4%; p-value=0.036), and urinary retention (<4h group=14.2%;≥4h group=5.5%; p-value=0.033) was decreased in the≥4h group. The timing of gabapentin administration less than or more than 4h preoperatively in patients ≥18 years does not significantly affect postoperative somnolence or respiratory depression. Further, it does not have a significant effect on GCS scores or VAS scores.

Predictors of Prolonged Mechanical Ventilation Among Patients with Aneurysmal Subarachnoid Hemorrhage After Microsurgical Clipping.

IntroductionAneurysmal subarachnoid hemorrhage (aSAH) is a fatal event with high mortality and morbidity rates. Survivors may require prolonged intubation with mechanical ventilation (MV). However, the risk factors for prolonged intubation in these patients remain unclear. The aim of this study was to determine the predictors of prolonged MV in aSAH patients who underwent surgical clipping.MethodsIn total, 108 adult patients with a primary diagnosis of aSAH who were on MV > 48 h and survived > 14 days after surgery were included. Clinicodemographic and radiological characteristics, laboratory tests on admission, and initial Glasgow Coma Scale (GCS) and its components were analyzed.ResultsThe average age of the patients included in the analysis was 59.1 ± 12.5 years. Overall, 32 patients (29.6%) had prolonged MV. The group with prolonged MV showed a higher prevalence of diabetes mellitus and hypertension, lower initial GCS and its components, higher World Federation of Neurosurgeons (WFNS) and Hunt and Hess grades, and higher initial white cell counts. The independent factors associated with prolonged MV were a history of diabetes mellitus (odds ratio [OR] 5.799, 95% confidence interval [CI] 1.109–30.334; P = 0.037) and Hunt and Hess grade 3–5 (OR 7.217, 95% CI 1.090–47.770; P = 0.040).ConclusionA history of diabetes mellitus and Hunt and Hess grade 3–5 independently predict prolonged MV after microsurgical clipping in patients with aSAH. Thus, knowledge of potential predictors for prolonged MV is essential to improve the early initiation of adequate treatment in the early stages of treatment and provide useful information for communication between caregivers and families.

Critical care for concomitant severe traumatic brain injury and acute spinal cord injury in the polytrauma patient: illustrative case

BACKGROUNDThe occurrence of traumatic brain injury with spinal cord injury (SCI) in polytrauma patients is associated with significant morbidity. Clinicians face challenges from a decision-making and rehabilitative perspective. Management is complex and understudied. Treatment should be systematic beginning at the scene, focusing on airway resuscitation and hemodynamic stabilization, immobilization, and timely transport. Early operative interventions should be provided, followed by minimizing secondary pathophysiology. The authors present a case to delineate decision-making in the treatment of combined cranial and spinal trauma.OBSERVATIONSA 19-year-old man presented as a level I trauma patient after falling 30 feet as the result of scaffolding collapse. The patient was unresponsive and was intubated; he had an initial Glasgow Coma Scale score of 4. Computed tomography revealed multicompartmental bleeding and herniation, for which supra- and infratentorial decompressive craniectomies were performed. The patient also suffered from thoracic SCI that resulted in complete paraplegia. Multimodality monitoring was used. After stabilization and lengthy rehabilitation, the patient obtained significant functional improvement.LESSONSThe approach to initial management of concomitant head and spine trauma is to establish intracranial stability followed by intraspinal stability. Patients can make considerable recovery, particularly younger patients, who are more likely to benefit from early aggressive interventions and medical treatment.

Role of Decompressive Craniectomy in severe Traumatic Brain Injury: An Institutional Experience

Objective: The present study was designed to assess the outcome following the Decompressive Craniectomy procedures performed in our setup for patients presenting with severe traumatic brain injury.&#x0D; Materials and Methods: This was a retrospective study wherein the medical records of adult patients that presented with an initial Glasgow Coma Scale (GCS) ? 8 and in whom decompressive craniectomy had been carried out for severe traumatic brain injury were retrospectively analyzed. Patients in whom decompressive craniectomy had been carried out for causes other than trauma and patients with initial GCS ? 9 were excluded from the study. The studied parameters included age, sex, initial GCS, computed tomography (CT) brain diagnosis, and the outcome according to the Glasgow coma outcome scale (GOS).&#x0D; Results: The study included 12 patients, and of these 12 patients operated with Decompressive Craniectomy for severe traumatic brain injury only 2 survived. The mortality was 83.3%. The initial GCS and age were not statistically different between the survivors and the non-survivors. Based on the Glasgow Outcome Scale (GOS) only 1 patient had a good outcome. Overall, an unfavorable outcome based on the GOS score was seen in 91.7% of patients.&#x0D; Conclusion: Our study concludes that Decompressive Craniectomy is associated with high mortality in patients presenting with severe traumatic brain injury and does not seem to offer a better alternative to standard medical management.

Hyperglycemia as a positive predictor of mortality in major trauma

Background:Hyperglycemia in the acute phase after trauma is a stress response and a metabolic reflection in humans with injury, which could adversely affect outcome in trauma patients. In this study, we attempted to identify if hyperglycemia a reliable predictor for mortality in major trauma patients.Objectives:In order to identify if hyperglycemia a reliable predictor for mortality in major trauma, we designed and proformed a prospective observational study in a tertiary hospital.Method:We performed a prospective observational study to review the records of 601 patients with major trauma (injury severity scores &gt;15) who visited our hospital's emergency department from August 2012 to July 2015. Logistic regression was performed to assess the effect of hyperglycemia on mortality.Result:Major trauma patients in the hyperglycemia group had low systolic/diastolic blood pressure at triage, low initial Glasgow Coma Scale score, high incidence of hypotension episodes, coagulopathy, acidosis, and anemia. Hyperglycemia was significantly correlated with mortality in major trauma patients in this study (odds ratio: 1.97, 95% confidence interval: 1.04–3.74).Conclusion:In major trauma patients with injury severity scores &gt;15, hyperglycemia has a positive correlation with mortality, which could be a predictor of mortality in clinical practice.

Surgical Outcomes in Patients with Simultaneous Traumatic Brain and Torso Injuries in a Single Regional Trauma Center over a 5-Year Period

Purpose The purpose of the study is to analyze the results of surgical treatment of patients with brain and torso injury for 5 years in a single regional trauma center. Methods We analyzed multiple trauma patients who underwent brain surgery and torso surgery for chest or abdominal injury simultaneously or sequentially among all 14,175 trauma patients who visited Dankook University Hospital Regional Trauma Center from January 2015 to December 2019. Results A total of 25 patients underwent brain surgery and chest or abdominal surgery, with an average age of 55.4 years, 17 men and eight women. As a result of surgical treatment, there were 14 patients who underwent the surgery on the same day (resuscitative surgery), of which five patients underwent surgery simultaneously, four patients underwent brain surgery first, and one patient underwent chest surgery first, four patients underwent abdominal surgery first. Among the 25 treated patients, the 10 patients died, which the cause of death was five severe brain injuries and four hemorrhagic shocks. Conclusions In multiple damaged patients require both torso surgery and head surgery, poor prognosis was associated with low initial Glasgow Coma Scale and high Injury Severity Score. On the other hand, patients had good prognosis when blood pressure was maintained and operation for traumatic brain injury was performed first. At the same time, patients who had operation on head and torso simultaneously had extremely low survival rates. This may be associated with secondary brain injury due to low perfusion pressure or continuous hypotension and the traumatic coagulopathy caused by massive bleeding.

TRAUMATIC BRAIN INJURY ASSESSMENT USING GLASGOW COMA SCALE: A LITERATURE REVIEW

Objective: The objective of this study was to analyse the Glasgow Coma Scale (GCS) reporting and recognize causes for inaccuracy of GCS implications. Literature selection and critical appraisal: Literature search was carried out by using specific keywords on PubMed, Google Scholar, and Science Direct. The GCS definitions, present status of GCS reporting, frequency and time of assessment, assessment schemes and confounders were critically analysed. Results: More than 90% of the publications using GCS scoring cite the 14-item GCS rather than the 15-item GCS. The timing of the initial GCS assessment is inconstant. GCS components are seldom utilized, contributing to the loss of information. Confounders are often not reported and, if they are, not in a standardized manner. The order of the GCS components is not consistent. Conclusion: The current inconsistent and inappropriate use of GCS diminishes its reliability in both clinical and scientific context. A consensus statement is needed to correct this situation. Citing the correct references, early and repeated GCS assessments at defined intervals, standardized reporting of confounders and GCS component and scores. Utilization of a uniform assessment scheme is recommended. Pak J Physiol 2021;17(4):75–80

Comparison of the predictive value of two international guidelines for safe discharge of patients with mild traumatic brain injuries and associated intracranial pathology

PurposeTo determine and compare the sensitivity, specificity, and proportion of patients eligible for discharge by the Brain Injury Guidelines and the Mild TBI Risk Score in patients with mild traumatic brain injury and concomitant intracranial injury.MethodsRetrospective review of the medical records of adult patients with traumatic intracranial injuries and an initial Glasgow Coma Scale score of 14–15, who sought care at Helsingborg Hospital between 2014/01/01 and 2019/12/31. Both guidelines were theoretically applied. The sensitivity, specificity, and percentage of the cohort that theoretically could have been discharged by either guideline were calculated. The outcome was defined as death, in-hospital intervention, admission to the intensive care unit, requiring emergency intubation due to intracranial injury, decreased consciousness, or seizure within 30 days of presentation.ResultsOf the 538 patients included, 8 (1.5%) and 10 (1.9%) were eligible for discharge according to the Brain Injury Guidelines and the Mild TBI Risk Score, respectively. Both guidelines had a sensitivity of 100%. The Brain Injury Guidelines had a specificity of 2.3% and the Mild TBI Risk Score had a specificity of 2.9%.ConclusionThere was no difference between the two guidelines in sensitivity, specificity, or proportion of the cohort eligible for discharge. Specificity and proportion of cohort eligible for discharge were lower than each guideline’s original study. At present, neither guideline can be recommended for implementation in the current or similar settings.

Rearrest during hospitalisation in adult comatose out-of-hospital cardiac arrest patients: Risk factors and prognostic impact, and predictors of favourable long-term outcomes

BackgroundRearrest occurs commonly after initial resuscitation following out-of-hospital cardiac arrest (OHCA). We determined (1) the predictors of rearrest during hospitalisation that can be identified in the hours immediately after OHCA, (2) the association between rearrest and favourable long-term outcomes, and (3) the predictors of favourable long-term outcomes in rearrest patients. MethodsConditional multivariable logistic regression analyses were performed using the Korean Hypothermia Network prospective registry data, which included details of adult OHCA patients treated with targeted temperature management at 22 teaching hospitals in South Korea. ResultsAmong the 1,233 patients, 260 (21.1%) experienced rearrest. Of the 192 patients resuscitated from first rearrest, 33 (17.2%) achieved 6-month favourable outcomes. Arrhythmia, heart failure, ST-segment elevation, lower initial Glasgow coma scale (GCS) motor score, higher initial lactate level, and antiarrhythmic drug use within 1 h were independently associated with rearrest. Higher lactate level and antiarrhythmic drug use were associated with shockable first rearrest, while arrhythmia, heart failure, ST-segment elevation, and lower GCS motor score were associated with non-shockable first rearrest. Rearrest was independently associated with a lower likelihood of 6-month favourable outcomes (P = 0.003). Initial shockable rhythm after OHCA, absence of diabetes, shorter cumulative time to restoration of spontaneous circulation, coronary angiography, and hypophosphataemia within 7 d were independently associated with 6-month favourable outcomes in the patients resuscitated from first rearrest. ConclusionsRearrest during hospitalisation after OHCA was inversely associated with 6-month favourable outcomes. We identified several risk factors for rearrest and prognostic factors for patients resuscitated from first rearrest.

Prediction models of methicillin sensitive Staphylococcus aureus ventilator associated pneumonia relapse in trauma and brain injury patients: A retrospective analysis.

To describe the incidence and risk factors of methicillin sensitive Staphylococcus aureus ventilator associated pneumonia (MSSA-VAP) relapse in trauma and non-traumatic brain injury patients. Retrospective observational monocentric cohort study of consecutive ICU patients who developed a first episode of MSSA-VAP after trauma and non-traumatic brain injury. MSSA-VAP relapse encompass MSSA-VAP treatment failure (persistence or recurrence of MSSA) or other pathogen - VAP. A total of 165 patients (71% of trauma and 29% of non-traumatic brain injury) with MSSA-VAP were included. MSSA-VAP relapse occurred in 54 (33%) patients, including 28 (17%) MSSA-VAP treatment failure and 46 (28%) other pathogen-VAP. Empirical first-line antibiotic therapy was appropriate in 96% of cases. In multivariate analysis, the presence of Streptococcus species (Odds ratio [OR] 7.37) and oropharyngeal flora (OR 3.64) as initial MSSA co-pathogen, suggested aspiration at the time of admission and independently predicted MSSA-VAP treatment failure. Initial Glasgow coma scale (OR 0.89), need for emergent surgery (OR 5.71) and the presence of an acute respiratory distress syndrome at the time of the first MSSA-VAP (3.99), independently predicted the onset of other pathogen - VAP. Early and simple factors may help to identify patients with high-risk of MSSA-VAP relapse.

Pediatric Gunshot Head Injury: Prevalence of Prognostic Factors in Surgical Patients: An Institutional Experience in Ten Years.

This article aims to evaluate the predictive factors of morbidity and mortality in pediatric patients who suffered gunshot wounds to the head. We reviewed a series of 43 patients who were admitted to a referential neurosurgical hospital between 2010 and 2019. Data from 43 patients who underwent a surgical treatment in our institution were collected, and the following parameters were considered in the analysis: the initial Glasgow Coma Scale (GCS), age, sex, bullet entry site, and bullet trajectory. Computed tomography (CT) scans at admission, complications, midline crossing, and Glasgow score scale at the time of discharge (Glasgow Outcome Scale; GOS) were also factored in. Male sex corresponded to 90.7% of cases (N = 39), and 16–17 years of age was the most common age (60.5%). The frontal region was the most common entry site (41.9%), followed by the parietal wall and occipital entry. Penetrating trajectory was shown in 48.8% of cases, perforation/transfixing in 39.5%, and tangential in 11.6%. CT showed that sinking is the most common alteration (74.4%), followed by cerebral contusion (44.2%). According to the GOS, 23.3% died, 23.3% were classified by an unfavorable outcome (GOS, 2–3), and 53.5% a favorable outcome (GOS, 4 and 5). In our study, there was a significant association between the low GCS scores on admission and low GOS (1–3; p = 0.001) at time of discharge. Patients with wounds that crossed the midline also had a significant association with low GOS (p = 0.014) in our clinical experience. We concluded that low GCS scores at admission and children with a wound that crosses the midline are predictive factors of high mortality and morbidity, in our clinical experience.

Relation of Volume of Hemorrhage With Mortality Within First 48 Hours in Hemorrhagic Stroke

Background: Hemorrhagic stroke accounts for 10-15% of all strokes with higher mortality rates than cerebral infarction. Intracerebral hemorrhage has a reported 30-day mortality of 44% to 51%, with almost half of the death occurs within the first 48 hours. Advanced age, low level of consciousness, large volume of hemorrhage has been linked with poor outcome. Objectives: To predict early outcome of hemorrhagic stroke patient in relation with age, Glasgow Coma Scale, volume of hemorrhage and ventricular extension. Materials and Methods: Hospital based prospective study carried out in hundred hemorrhagic stroke patients. The formula of ABC/2 was used to calculate hemorrhage volume in bedside by using CT scan. Results: 1st month mortality rates of hemorrhagic stroke was 44% with 45.45% of patients died within the first 48 hours of onset. Mean age of patients of hemorrhagic stroke was 61.2 ± 13.88 years. Mortality rate of intracerebral hemorrhage after age of 60 was 51.06% in 1st month. Volume of intracerebral hemorrhage was the strongest predictor of both 48 hours and 30 days mortality. Using three categories of intracerebral hemorrhage (X for &lt; 30 ml, Y for 30 - 50 ml and Z for &gt; 50 ml group) calculated by ABC/2 formula showed 100% mortality rate in Z group, 50% in Y group and only 12% mortality rate in X group in 1st month. Among all death, 61.5% of Z group 25% of Y group and 16.67% of patients of X group died within 48 hours. Two categories of Glasgow Coma Scale (≤ 8 and ≥ 9) were used and shown death rates 80.77% in GCS ≤ 8 and 4.55% in GCS ≥ 9 in 1st month. Conclusion: Volume of intracerebral hemorrhage in combination with advanced age, initial Glasgow Coma Scale is a powerful and easy to use in both 48 hours and 1st month mortality in patients with spontaneous intracerebral hemorrhage. KYAMC Journal. 2021;12(3): 127-132

Cerebral vasospasm in children with subarachnoid hemorrhage: frequency, diagnosis, and therapeutic management.

The present study explores the frequency, diagnostic approach, and therapeutic management of cerebral vasospasm in a cohort of children with moderate-to-severe traumatic and nontraumatic subarachnoid hemorrhage (SAH). This was a single-center retrospective study performed over a 10-year period, from January 2010 to December 2019. Children aged from one month to 18years who were admitted to the pediatric or adult intensive care unit with a diagnosis of SAH were eligible. Cerebral vasospasm could be suspected by clinical signs or transcranial Doppler (TCD) criteria (mean blood flow velocity > 120cm/s or an increase in mean blood flow velocity by > 50cm/s within 24h) and then confirmed on cerebral imaging (with a reduction to less than 50% of the caliber of the cerebral artery). Eighty patients aged 8.6years (3.3-14.8years, 25-75th centiles) were admitted with an initial Glasgow Coma Scale score of 8 (4-12). SAH was nontraumatic in 21 (26%) patients. A total of 14/80 patients (18%) developed cerebral vasospasm on brain imaging on day 6 (5-10) after admission, with a predominance of nontraumatic SAH (12/14). The diagnosis of cerebral vasospasm was suspected on clinical signs and/or significant temporal changes in TCD monitoring (7 patients) and then confirmed on cerebral imaging. Thirteen of 14 patients with vasospasm were successfully treated using a continuous intravenous infusion of milrinone. The Pediatric Cerebral Performance Category score at discharge from the intensive care unit was comparable between children with vasospasm (score of 2 [1-4]) vs. children without vasospasm (score of 4 [2-4]) (p = 0.09). These findings indicate that cerebral vasospasm exists in pediatrics, particularly after nontraumatic SAH. The use of TCD and milrinone may help in the diagnostic and therapeutic management of cerebral vasospasm.

Readmission into intensive care unit in patients with aneurysmal subarachnoid hemorrhage.

ObjectiveAneurysmal subarachnoid hemorrhage (aSAH) is a devastating cerebrovascular event; patients are routinely admitted to the intensive care unit (ICU) for initial management. Because complications may be delayed, unplanned ICU readmissions can occur. Therefore, in this study we evaluate the rate of and factors associated with readmission after aSAH and identify if readmission is associated with poor clinical outcomes.MethodsWe retrospectively reviewed the medical records of all patients receiving surgical or endovascular treatment for aSAH and admitted to the ICU between January 2008 and December 2019. We categorized patients by readmission and analyzed their clinical parameters.ResultsOf the 345 patients who transferred to ward-level care after an initial ICU stay (Group 2), 27 (7.3%) were readmitted to the ICU (Group 1). History of hypertension (HTN), initial Glasgow Coma Scale (GCS) score, modified Fisher grade, and vasospasm therapy during first ICU stay were significantly different between the groups. The most common reason for readmission was delayed cerebral ischemia (DCI; 70.3%; OR 5.545; 95% CI 1.25−24.52; p=0.024). Comorbid HTN (OR 5.311; 95% CI 1.75−16.12; p=0.03) and vasospasm therapy during first ICU stay (OR 7.234; 95% CI 2.41−21.7; p＜0.01) also were associated with readmission. Readmitted patients had longer hospital stay and lower GCS scores at discharge (p＜0.01).ConclusionsDCI was the most common cause of ICU readmission in patients with aSAH. Readmission may indicate clinical deterioration, and patients who are at a high risk for DCI should be monitored to prevent readmission.

Early cognitive impairment is common in pediatric patients following mild traumatic brain injury.

The incidence and factors related to early cognitive impairment (ECI) after mild traumatic brain injury (mTBI) in pediatric trauma patients (PTPs) are unknown. Prior data in the adult population demonstrated an ECI incidence of 51% after mTBI and strong correlation with initial Glasgow Coma Scale (GCS) and Brain Injury Guidelines (BIG) category. Therefore, we hypothesized that ECI is common after mTBI in PTPs and associated with initial GCS and BIG category. A single-center, retrospective review of PTPs (age, 8-17 years) from 2015 to 2019 with intracranial hemorrhage and mTBI (GCS score, 13-15) was performed. Primary outcome was ECI, defined as Ranchos Los Amigos score less than 8. Comparisons between ECI and non-ECI groups regarding Injury Severity Score (ISS), demographics, and cognitive and clinical outcomes were evaluated using χ2 statistics and Wilcoxon rank sum tests. Odds of ECI were evaluated using multivariable logistic regression. From 47 PTPs with mTBI, 18 (38.3%) had ECI. Early cognitive impairment patients had a higher ISS than non-ECI patients (19.7 vs. 12.6, p = 0.003). Injuries involving motor vehicles were more often related to ECI than non-auto-involved mechanisms (55% vs. 15%, p = 0.005). Lower GCS score (odds ratio [OR], 6.60; 95% confidence interval [CI], 1.34-32.51, p = 0.02), higher ISS (OR, 1.12; 95% CI, 1.01-1.24; p = 0.030), and auto-involved injuries (OR, 6.06; 95% CI, 1.15-31.94; p = 0.030) were all associated with increased risk of ECI. There was no association between BIG category and risk of ECI (p > 0.05). Nearly 40% of PTPs with mTBI suffer from ECI. Lower initial GCS score, higher ISS, and autoinvolved mechanism of injury were associated with increased risk of ECI. Brain Injury Guidelines category was not associated with ECI in pediatric patients. Prognostic study, Level III.

Corticothalamic Connectivity in Aneurysmal Subarachnoid Hemorrhage: Relationship with Disordered Consciousness and Clinical Outcomes.

We present an exploratory analysis of the occurrence of early corticothalamic connectivity disruption after aneurysmal subarachnoid hemorrhage (SAH) and its correlation with clinical outcomes. We conducted a retrospective study of patients with acute SAH who underwent continuous electroencephalography (EEG) for impairment of consciousness. Only patients undergoing endovascular aneurysm treatment were included. Continuous EEG tracings were reviewed to obtain artifact-free segments. Power spectral analyses were performed, and segments were classified as A (only delta power), B (predominant delta and theta), C (predominant theta and beta), or D (predominant alpha and beta). Each incremental category from A to D implies greater preservation of corticothalamic connectivity. We dichotomized categories as AB for poor connectivity and CD for good connectivity. The modified Rankin Scale score at follow-up and in-hospital mortality were used as outcome measures. Sixty-nine patients were included, of whom 58 had good quality EEG segments for classification: 28 were AB and 30 were CD. Hunt and Hess and World Federation of Neurological Surgeons grades were higher and the initial Glasgow Coma Scale score was lower in the AB group compared with the CD group. AB classification was associated with an adjusted odds ratio of 5.71 (95% confidence interval 1.61-20.30; p < 0.01) for poor outcome (modified Rankin Scale score 4-6) at a median follow-up of 4months (interquartile range 2-6) and an odds ratio of 5.6 (95% confidence interval 0.98-31.95; p = 0.03) for in-hospital mortality, compared with CD. EEG spectral-power-based classification demonstrates early corticothalamic connectivity disruption following aneurysmal SAH and may be a mechanism involved in early brain injury. Furthermore, the extent of this disruption appears to be associated with functional outcome and in-hospital mortality in patients with aneurysmal SAH and appears to be a potentially useful predictive tool that must be validated prospectively.

All body region injuries are not equal: Differences in pediatric discharge functional status based on Abbreviated Injury Scale (AIS) body regions and severity scores

PurposeFunctional outcomes have been proposed for assessing quality of pediatric trauma care. Outcomes assessments often rely on Abbreviated Injury Scale (AIS) severity scores to adjust for injury characteristics, but the relationship between AIS severity and functional impairment is unknown. This study's primary aim was to quantify functional impairment associated with increasing AIS severity scores within body regions. The secondary aim was to assess differences in impairment between body regions based on AIS severity. MethodsChildren with serious (AIS≥ 3) isolated body region injuries enrolled in a multicenter prospective study were analyzed. The primary outcome was functional status at discharge measured using the Functional Status Scale (FSS). Discharge FSS was compared (1) within each body region across increasing AIS severity scores, and (2) between body regions for injuries with matching AIS scores. ResultsThe study included 266 children, with 16% having abnormal FSS at discharge. Worse FSS was associated with increasing AIS severity only for spine injuries. Abnormal FSS was observed in a greater proportion of head injury patients with a severely impaired initial Glasgow Coma Scale (GCS) (GCS< 9) compared to those with a higher GCS score (43% versus 9%; p < 0.01). Patients with AIS 3 extremity and severe head injuries had a higher proportion of abnormal FSS at discharge than AIS 3 abdomen or non-severe head injuries. ConclusionsAIS severity does not account for variability in discharge functional impairment within or between body regions. Benchmarking based on functional status assessment requires clinical factors in addition to AIS severity for appropriate risk adjustment. Level of evidence1 (Prognostic and Epidemiological).

Diagnosing Level of Consciousness: The Limits of the Glasgow Coma Scale Total Score.

In nearly all clinical and research contexts, the initial severity of a traumatic brain injury (TBI) is measured using the Glasgow Coma Scale (GCS) total score. The GCS total score however, may not accurately reflect level of consciousness, a critical indicator of injury severity. We investigated the relationship between GCS total scores and level of consciousness in a consecutive sample of 2455 adult subjects assessed with the GCS 69,487 times as part of the multi-center Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study. We assigned each GCS subscale score combination a level of consciousness rating based on published criteria for the following disorders of consciousness (DoC) diagnoses: coma, vegetative state/unresponsive wakefulness syndrome, minimally conscious state, and post-traumatic confusional state, and present our findings using summary statistics and four illustrative cases. Participants had the following characteristics: mean (standard deviation) age 41.9 (17.6) years, 69% male, initial GCS 3-8 = 13%; 9-12 = 5%; 13-15 = 82%. All GCS total scores between 4-14 were associated with more than one DoC diagnosis; the greatest variability was observed for scores of 7-11. Further, a wide range of total scores was associated with identical DoC diagnoses. Importantly, a diagnosis of coma was only possible with GCS total scores of 3-6. The GCS total score does not accurately reflect level of consciousness based on published DoC diagnostic criteria. To improve the classification of patients with TBI and to inform the design of future clinical trials, clinicians and investigators should consider individual subscale behaviors and more comprehensive assessments when evaluating TBI severity.

323 Risk Factors, Management Strategies, and Outcomes in Patients with Isolated Parafalcine or Tentorial Subdural Hematomas

Parafalcine and tentorial subdural hematomas (SDH) are infrequent but regularly occurring traumatic brain injuries (TBI). Appropriate management of patients with these injuries is unclear. The study objective is to derive and validate a clinical decision rule that identifies patients with parafalcine/tentorial SDHs that are at low risk for complications such that hospitalization may be avoided. This was a multicenter retrospective trauma registry and medical record review. Patients with parafalcine or tentorial SDHs had their data from the trauma registry collected and additional data was abstracted from the medical record using standard chart review methodology. The outcome considered was significant injury. This was defined as: any injury that underwent neurosurgery, death, or discharge to a rehabilitation/skilled nursing facility. The clinical decision rule was derived by identifying variables independently associated with the outcome of interest using multivariable logistic regression. The decision rule was then validated on a separate cohort of patients abstracted without knowledge of the decision rule. In the derivation sample, 136 patients with parafalcine/tentorial SDHs were identified. The mean age was 63 ± 19 years and 84 (62%) were male. Seventy-two (53%) had significant injuries. Variables independently associated with a significant injury included: age ≥ 60 years, adjusted odds ratio (aOR) = 3.71, (95% CI 1.37, 10.06), initial Glasgow Coma Scale score < 15, aOR = 8.30 (95% CI 3.14, 21.93) and additional TBIs on CT, aOR = 6.35 (95% CI 2.67, 15.13). In the derivation set, these three high risk variables had a sensitivity = 72/72 (100%, 95% CI 96, 100%) and specificity = 13/64 (20%, 95% CI 11, 32%). In the validation sample, the mean age was 62 ± 21 years and 48 (59%) were male. The three high risk variables had a sensitivity for significant injury of 26/26 (100%, 95% CI 89, 100%) and specificity = 7/55 (13%, 95% CI 5.3, 24%). All 35 patients who underwent neurosurgery had additional TBI findings on their cranial CT scan. Patients with parafalcine/tentorial SDHs who have initial GCS score < 15, are 60 years of age or older, and have other TBIs on their CT are at increased risk of complications and require hospitalization.

Aspiration risk in relation to Glasgow Coma Scale score and clinical parameters in patients with severe acute alcohol intoxication: a single-centre, retrospective study

ObjectivesIn alcohol intoxicated patients, the decision for or against airway protection can be challenging and is often based on the Glasgow Coma Scale (GCS). Primary aim of this study was...