Initial Glasgow Coma Score Research Articles

Readmission and mortality during the first year after an acute stroke: A prospective cohort study from Cameroon.

Hospital readmission after discharge for stroke is associated with high morbidity and mortality. There is a paucity of data on the burden of stroke readmission in most sub-Saharan African countries. We aimed to determine the rate, reasons and predictors of hospital readmission and the mortality rate within 12 months of discharge among stroke survivors in Cameroon. This prospective cohort included patients who survived hospitalization for an acute stroke and who were discharged from two referral hospitals in the capital city of Cameroon between January 2013 and December 2013.We performed logistic regression analysis to identify demographic and clinical factors associated with readmission within 1 year of discharge and causes of readmission. Of the 254 consecutive patients admitted for acute stroke, 198 were discharged alive. There were 107 (54%) males, and their mean age (SD) was 61.7 (13.9) years (range: 10 to 95 years). A total of 30 (15.2%) patients were readmitted following discharge from the index admission over a mean follow-up time of 286.9 (127.6) days. Of these, 14 (46.7%) were discharged and 16 (53.3%) died after readmission. Thirty percent (30%) of readmissions occurred within the first month. The most frequent causes of readmissions were infections (30%) and recurrent stroke (26.7%). Factors associated with readmission in bivariate analysis were initial admission temperature > 37.5°C (risk ratio [RR]: 1.3, p = 0.021) and initial admission Glasgow Coma Score < 14 (RR: p = 1.23, p = 0.019). After stratified adjustment for age and sex, temperature > 37.5°C (adjusted RR: 1.3, 95% CI: 1-1.7, p = 0.036) and GCS <14 (adjusted RR: 1.23, 95% CI: 1-1.6, p = 0.041) were associated with readmission. Readmission after discharge for stroke was common with nearly one third occurring within the first month and more than half dying following readmission. The most common causes of readmission were infections and recurrent stroke.

Need for Blood Transfusion Volume Is Associated With Increased Mortality in Severe Traumatic Brain Injury

IntroductionMany patients suffering from isolated severe traumatic brain injury (sTBI) receive blood transfusion on hospital arrival due to hypotension. We hypothesized that increasing blood transfusions in isolated sTBI patients would be associated with an increase in mortality. MethodsWe performed a trauma quality improvement program (TQIP) (2017-2019) and single-center (2013-2021) database review filtering for patients with isolated sTBI (Abbreviated Injury Scale head ≥3 and all other areas ≤2). Age, initial Glasgow Coma Score (GCS), Injury Severity Score (ISS), initial systolic blood pressure (SBP), mechanism (blunt/penetrating), packed red blood cells (pRBCs) and fresh frozen plasma (FFP) transfusion volume (units) within the first 4 h, FFP/pRBC ratio (4h), and in-hospital mortality were obtained from the TQIP Public User Files. ResultsIn the TQIP database, 9257 patients had isolated sTBI and received pRBC transfusion within the first 4 h. The mortality rate within this group was 47.3%. The increase in mortality associated with the first unit of pRBCs was 20%, then increasing approximately 4% per unit transfused to a maximum mortality of 74% for 11 or more units. When adjusted for age, initial GCS, ISS, initial SBP, and mechanism, pRBC volume (1.09 [1.08-1.10], FFP volume (1.08 [1.07-1.09]), and FFP/pRBC ratio (1.18 [1.08-1.28]) were associated with in-hospital mortality. Our single-center study yielded 138 patients with isolated sTBI who received pRBC transfusion. These patients experienced a 60.1% in-hospital mortality rate. Logistic regression corrected for age, initial GCS, ISS, initial SBP, and mechanism demonstrated no significant association between pRBC transfusion volume (1.14 [0.81-1.61]), FFP transfusion volume (1.29 [0.91-1.82]), or FFP/pRBC ratio (6.42 [0.25-164.89]) and in-hospital mortality. ConclusionsPatients suffering from isolated sTBI have a higher rate of mortality with increasing amount of pRBC or FFP transfusion within the first 4 h of arrival.

The Brain Injury Guidelines (BIG) and emergency department observation and admission rates: A retrospective cohort study

BackgroundEmergency Department (ED) Observation Units (OU) can provide safe, effective care for low risk patients with intracranial hemorrhages. We compared current ED OU use for patients with subdural hematomas (SDH) to the validated Brain Injury Guidelines (BIG) to evaluate the potential impact of implementing this risk stratification tool. MethodsRetrospective cohort of patients ≥18 years old with SDH of any cause from 2014 to 2020 to evaluate for potential missed OU cases. Missed OU cases were defined as patients with an initial Glasgow Coma Score (GCS) of 15 with hospital length of stays (LOS) <2 days, who did not meet the composite outcome and were not cared for in the OU or discharged from the ED. Composite outcome included in-hospital death or transition to hospice care, neurosurgical intervention, GCS decline, and worsening SDH size. Secondary outcomes were whether application of BIG would increase ED OU use or reduce CT use. Results264 patients met inclusion criteria over 5.3 year study timeframe. Mean age was 61 years (range 19–93) and 61.4% were male. SDH were traumatic in 76.9% and 60.2% of the cohort had additional injuries. The admission rate was 81.4% (n = 215). Fourteen (6.5%) missed OU cases were identified (2.6/year). Retrospective application of BIG resulted in 82.6% (n = 217) at BIG 3, 10.2% (n = 27) at BIG 2 and 7.6% (n = 20) at BIG 1. Application of BIG would not have decreased admission rates (82.6% BIG 3) and BIG 1 and 2 admissions were often for medical co-morbidities. The composite outcome was met in 50% of BIG 3, 22% of BIG 2, and no BIG 1 patients. ConclusionIn a level 1 trauma center with an established observation unit, current clinical care processes missed very few patients who could be discharged or placed in ED OU for SDH. Hospital admissions in BIG 1/2 were driven by co-morbidities and/or injuries, limiting applicability of BIG to this population.

240 Impact of a Large Geographical Area on Outcomes in Acute Traumatic Intracranial Extra-axial Haemorrhage Requiring Urgent Surgical Evacuatio

INTRODUCTION: The Princess Alexandra Hospital (PAH) Department of Neurosurgery services a population of 1.85 million people over a 420,000 km2 area in Queensland, Australia. Increased distance from a neurosurgical centre has previously been correlated with poorer outcomes in traumatic brain injury. METHODS: This single-centre retrospective study identified patients aged 16-85 who underwent evacuation of an acute traumatic subdural (ASDH) or extradural haemorrhage (EDH) between 2016 and 2022. Initial Glasgow Coma Score (GCS), pupillary abnormalities, time to intervention, distance from PAH and the Extended Glasgow Outcome Scale (GOS-E) at 6 months were recorded. RESULTS: 106 and 50 patients underwent evacuation of ASDH and EDH respectively. In the ASDH group, age was inversely correlated (p = 0.03, r2 = 0.04) and the motor component of the initial GCS was directly correlated (p = 0.002, r2 = 0.09) with GOS-E at 6 months. Distance from PAH directly correlated with an increased time to intervention (p&lt;0.0001, r2 = 0.23) but did not correlate with GOS-E at 6 months (p = 0.09). There was no difference between survivors and non-survivors regarding distance from PAH (43.43 ± 75.05 km vs. 25.56 ± 41.32 km, p = 0.15) or time to operation (276.14 ± 192.77 mins vs. 217.40 ± 147.27 mins, p = 0.08). This was also found for survivors with poor (GOS-E &lt;6) and fair (GOS-E = 6) recovery at 6 months. In the EDH group there was no correlation between distance, time to operative intervention, age or initial motor score with outcomes at 6 months. CONCLUSIONS: Whilst increased distance from treatment centre correlated with increased time to surgical intervention for ASDH, it did not impact on survival or functional outcomes at 6 months. For ASDH requiring urgent evacuation, increasing age and severity of primary brain injury are predictors of poorer long-term outcomes.

Critical ICP thresholds in relation to outcome: Is 22 mmHg really the answer?

PurposeIntensive care for patients with traumatic brain injury (TBI) aims, among other tasks, at avoiding high intracranial pressure (ICP), which is perceived to worsen motor and cognitive deficits and increase mortality. International recommendations for threshold values for ICP were increased from 20 to 22 mmHg in 2016 following the findings in a study by Sorrentino et al., which were based on an observational study of patients with TBI of averaged ICP values. We aimed to reproduce their approach and validate the findings in a separate cohort.MethodsThree hundred thirty-one patients with TBI were included and categorised according to survival/death and favourable/unfavourable outcome at 6 months (based on Glasgow Outcome Score—Extended of 6–8 and 1—5, respectively). Repeated chi-square tests of survival and death (or favourable and unfavourable outcome) vs. high and low ICP were conducted with discrimination between high and low ICP sets at increasing values (integers) between 10 and 35 mmHg, using the average ICP for the entire monitoring period. The ICP limit returning the highest chi-square score was assumed to be the threshold with best discriminative ability. This approach was repeated after stratification by sex, age, and initial Glasgow Coma Score (GCS).ResultsAn ICP limit of 18 mmHg was found for both mortality and unfavourable outcome for the entire cohort. The female and the low GCS subgroups both had threshold values of 18 mmHg; for all other subgroups, the threshold varied between 16 and 30 mmHg. According to a multiple logistic regression analysis, age, initial GCS, and average ICP are independently associated with mortality and outcome.ConclusionsUsing identical methods and closely comparable cohorts, the critical thresholds for ICP found in the study by Sorrentino et al. could not be reproduced.

Impact of Prehospital Exsanguinating Airway-Breathing-Circulation Resuscitation Sequence on Patients with Severe Hemorrhage.

At the 2023 ATLS symposium, the priority of circulation was emphasized through the "x-airway-breathing-circulation (ABC)" sequence, where "x" stands for exsanguinating hemorrhage control. With growing evidence from military and civilian studies supporting an x-ABC approach to trauma care, a prehospital advanced resuscitative care (ARC) bundle emphasizing early transfusion was developed in our emergency medical services (EMS) system. We hypothesized that prioritization of prehospital x-ABC through ARC would reduce in-hospital mortality. This was a single-year prospective analysis of patients with severe hemorrhage. These patients were combined with our institution's historic controls before prehospital blood implementation. Included were patients with systolic blood pressure (SBP) less than 90 mmHg. Excluded were patients with penetrating head trauma or prehospital cardiac arrest. Two-to-one propensity matching for x-ABC to ABC groups was conducted, and the primary outcome, in-hospital mortality, was compared between groups. A total of 93 patients (x-ABC = 62, ABC = 31) met the inclusion criteria. There was no difference in patient age, sex, initial SBP, initial Glasgow Coma Score, and initial shock index between groups. When compared with the ABC group, x-ABC patients had significant improvement in vitals at emergency department admission. Overall mortality was lower in the x-ABC group (13% vs 47%, p < 0.001). Multivariable regression revealed that prehospital circulation-first prioritization was independently associated with decreased in-hospital mortality (odds ratio 0.15, 95% CI 0.04 to 0.54, p = 0.004). This is the first analysis to demonstrate a prehospital survival benefit of x-ABC in this subset of patient with severe injury and hemorrhagic shock. Standardization of prehospital x-ABC management in this patient population warrants special consideration.

The burden of head trauma in rural and remote North Queensland, Australia

BackgroundHead trauma is a leading cause of death and disability worldwide. Young males, Indigenous people, and rural/remote residents have been identified as high-risk populations for head trauma, however, Australian research is limited. Our aim was to define and describe the incidence, demographics, causes, prehospital interventions, and outcomes of head trauma patients transported by aeromedical services within North Queensland, Australia. We hypothesized that young, Indigenous males living remotely would be disproportionately affected by head trauma. MethodsWe conducted a retrospective study of all head trauma patients transferred by air to or between Townsville, Cairns, Mount Isa and Mackay Hospitals between January 1, 2016 and December 31, 2018. Patients were identified from the Trauma Care in the Tropics data registry and followed for a median 30-months post-injury. Primary endpoints were patient and injury characteristics. Secondary outcome measures were hospital stay and mortality. ResultsA total of 981 patients were included and 31.1 % were Indigenous. Sixty-seven percent of injuries occurred remotely and the median time from injury to hospital was 5.8-hours (range 67–3780 min). Eighty percent of severe head injuries occurred in males (p = 0.007). Indigenous and remote patients were more likely to sustain mild injuries. The most common mechanism of injury overall was vehicle accident (37.5 %), compared to assault in the Indigenous subgroup (46.6 %, p<0.001). The overall mortality rate was 4.9 %, with older age and lower initial Glasgow Coma Score significant predictors of in-hospital mortality. Prehospital intubation was associated with a 7-fold increased risk of mortality (p = 0.056), while patients that received tranexamic acid (TXA) were almost 5-times more likely to die. ConclusionsIn North Queensland, young Indigenous males are at highest risk of traumatic head injuries. Vehicle accidents are an important preventable cause of head injury in the region. TXA administration is an important consideration for remote head trauma retrievals, in which time to emergency care is prolonged. Appropriate treatment and risk stratification strategies considering time to definitive care, severity of injury, and other prehospital patient factors require further investigation.

785: EVALUATION OF SUGAMMADEX DOSING FOR DEEP NEUROMUSCULAR BLOCKADE REVERSAL IN THE EMERGENCY DEPARTMENT

Introduction: Neuromuscular blocking agents (NMBAs) are often administered to facilitate rapid sequence intubation (RSI). The effects of neuromuscular blockade may be prolonged in the setting of organ dysfunction or need for rapid attainment of a neurological examination may be necessary. The primary objective of this study is to evaluate low (2 mg/kg) versus standard dose (4 mg/kg) sugammadex for reversal of deep neuromuscular blockade in the emergency department (ED) to facilitate neurological examination. Methods: A single-center, retrospective cohort study was performed and approved by the local Institutional Review Board. Patients were identified using sugammadex charge codes between 01/01/2017 - 07/15/2022. Adult patients were included if they received sugammadex in the ED to facilitate neurological examination, were given rocuronium or vecuronium for RSI, and had a documented train-of-four (TOF) before and after sugammadex administration. Patients were excluded if records were incomplete, initial sugammadex dose other than 2 mg/kg or 4 mg/kg was used and if initial TOF was 1 – 4. The primary outcome of this study was successful deep neuromuscular blockade reversal defined by achieving a post-treatment TOF of 4. Results: Of 36 sugammadex doses administered in the ED, 26 patients were included in the final analysis, with 10 in the low-dose group and 16 patients in the standard-dose group. The median dose was 2.28 mg/kg and 4.09 mg/kg for low- and standard-dose, respectively. The overall cohort was predominantly male (65.4%) with a median age of 68.4 years (49.7-76.9). Most patients presented for intraparenchymal hemorrhage (53.8%), with 57.7% of bleeds being traumatic in origin. Median initial Glasgow Coma Score was 3, and all initial TOF were zero. Paralytics were administered in the pre-hospital setting in 85% of patients, with rocuronium use predominating (92.3%). No significant difference in success rate of NMBA reversal was found between low-dose versus standard-dose sugammadex (100.0% vs. 93.8%, P = 1.000). Conclusions: Low-dose sugammadex did not result in a significantly different success rate of NMBA reversal when compared to standard-dose. Low-dose sugammadex may be a viable option for deep NMBA reversal in the ED to facilitate neurological examinations.

Factors Affecting Peripheral Intravenous Catheter Placement During Pediatric Trauma Resuscitation

IntroductionIntravenous access is required for resuscitation of injured patients but may be delayed in children because of challenges associated with peripheral intravenous (PIV) catheter placement. Early identification of factors predisposing patients to difficult PIV placement can assist in deciding strategies for timely intravenous access. MethodsWe conducted a retrospective, video-based review of injured children and adolescents treated between April 2018 and May 2019. Patient demographic, physiological, injury, and resuscitation characteristics were obtained from the patient record, including age, race, weight, injury type, Injury Severity Score, initial systolic blood pressure, initial Glasgow Coma Score, intubation status, activation level, and presence of prearrival notification. Video review was used to determine the time to PIV placement, the number of attempts required, the purpose for additional access, and the reason for abandonment of PIV placement. Multivariable regressions were used to determine factors associated with successful placement. ResultsDuring the study period, 154 consented patients underwent attempts at PIV placement in the trauma bay. Placement was successful in 139 (90.3%) patients. Older patients (OR [odds ratio]: 0.9, 95% confidence interval [CI]: 0.9, 0.9) and patients who required the highest level activation response (OR: 0.0, 95% CI: 0.0, 0.3) were less likely to have an attempt at PIV placement abandoned. Children with nonblunt injuries (OR: 11.6, 95% CI: 1.3, 119.2) and pre-existing access (OR: 39.6, 95% CI: 7.0, 350.6) were more likely to have an attempt at PIV placement abandoned. Among patients with successful PIV placement, the time required for establishing PIV access was faster as age increased (−0.5 s, 95% CI: −1.1, −0.0). ConclusionsYounger age was associated with abandonment of PIV attempts and, when successful, increased time to placement. Strategies to improve successful PIV placement and alternate routes of access should be considered early to prevent treatment delays in younger children.

Abstract 146: Risk Factors For Early Mortality After Fall From Height In An Urban Area

Introduction: Death after falls from height are relatively common in urban areas. However, risk factors for early mortality are not clearly established, even fall height is still debated. The aim of this study was to identify risk factors for death on scene, after fall from a height, in patients aged 16 and over. Method: An Emergency Medical Service’s (EMS) database was used, it included all Advanced Life Support interventions. This EMS was located in an urban area with 300,000 inhabitants. All patients aged 16 and over, who fell from a height over 6.6 feet, between 2003 and 2018, were included. Age, gender, cause of fall (suicide or accidental), height of fall, landing surface (hard or soft), how the body hit the ground (headfirst landing or other), Index Severity Score (ISS) and initial Glasgow Coma Score (GCS) were collected. A backward stepwise logistic regression was used with occurrence of death on site as main outcome. Results: Six hundred and eighteen patients were included. The average age was 43.5 years (min 16-max 102) and sex ratio 2. Forty-eight percent were suicides. The average fall height was 36 feet (SD ± 35). The landing surface was hard in 51% of cases and landing was on head in 6%. The average ISS was 32 (SD ± 29.5) and mean GCS was 10 (SD ± 5.6). One hundred and ninety two (31%) patients died on scene. Results of the final logistic regression model are in table 1. Conclusion: In this study, age over 60, head first landing, suicide attempt, height of fall over 33 feet and hard landing surface, were significantly associated with on scene mortality after fall from height. Suicide prevention is one obvious way to reduce mortality from falls from heights.

Machine learning-based prediction of emergency neurosurgery within 24 h after moderate to severe traumatic brain injury

BackgroundRapid referral of traumatic brain injury (TBI) patients requiring emergency neurosurgery to a specialized trauma center can significantly reduce morbidity and mortality. Currently, no model has been reported to predict the need for acute neurosurgery in severe to moderate TBI patients. This study aims to evaluate the performance of Machine Learning-based models to establish to predict the need for neurosurgery procedure within 24 h after moderate to severe TBI.MethodsRetrospective multicenter cohort study using data from a national trauma registry (Traumabase®) from November 2011 to December 2020. Inclusion criteria correspond to patients over 18 years old with moderate or severe TBI (Glasgow coma score ≤ 12) during prehospital assessment. Patients who died within the first 24 h after hospital admission and secondary transfers were excluded. The population was divided into a train set (80% of patients) and a test set (20% of patients). Several approaches were used to define the best prognostic model (linear nearest neighbor or ensemble model). The Shapley Value was used to identify the most relevant pre-hospital variables for prediction.Results2159 patients were included in the study. 914 patients (42%) required neurosurgical intervention within 24 h. The population was predominantly male (77%), young (median age 35 years [IQR 24–52]) with severe head injury (median GCS 6 [3–9]). Based on the evaluation of the predictive model on the test set, the logistic regression model had an AUC of 0.76. The best predictive model was obtained with the CatBoost technique (AUC 0.81). According to the Shapley values method, the most predictive variables in the CatBoost were a low initial Glasgow coma score, the regression of pupillary abnormality after osmotherapy, a high blood pressure and a low heart rate.ConclusionMachine learning-based models could predict the need for emergency neurosurgery within 24 h after moderate and severe head injury. Potential clinical benefits of such models as a decision-making tool deserve further assessment. The performance in real-life setting and the impact on clinical decision-making of the model requires workflow integration and prospective assessment.

Accuracy of prehospital clinicians’ perceived prognostication of long-term survival in critically ill patients: a nationwide retrospective cohort study on helicopter emergency service patients

ObjectivesPrehospital critical care physicians regularly attend to patients with poor prognosis and may limit the advanced therapies. The aim of this study was to evaluate the accuracy of poor prognosis...

The Effect of Frailty versus Initial Glasgow Coma Score in Predicting Outcomes Following Chronic Subdural Hemorrhage: A Preliminary Analysis.

BackgroundInitial Glasgow Coma Score (iGCS) is a well-known predictor of adverse outcomes following chronic subdural hemorrhage (cSDH). Frailty, i.e. a reduced physiologic reserve, is associated with poorer outcomes across the surgical literature, however, there is no consensus on the best measure of frailty. To date, no study has compared frailty’s ability to predict cSDH outcomes versus iGCS. The goal of this study was to, therefore, examine the prognostic value of the 5- (mFI-5) and 11-factor (mFI-11) modified frailty index, and Charlson Comorbidity Index (CCI) versus iGCS following cSDH.MethodsBetween January, 2016 and June, 2018, patients who presented to the emergency department with cSDH were retrospectively identified using the International Classification of Diseases (ICD) codes. mFI-5, mFI-11, and CCI scores were calculated using patient baseline characteristics. Primary endpoints were death and discharge home and subgroup analyses were performed among operative cSDH. Univariate and multivariate logistic regressions were used to determine predictors of primary endpoints.ResultsOf the 109 patients identified, the average age was 72.6±1.6 years and the majority (69/109, 63.3%) were male. The average CCI, mFI-5, and mFI-11 were 4.5 ±0.2, 1.5 ±0.1, and 2.2 ±0.1, respectively. Fifty (45.9%) patients required surgical intervention, 11 (10.1%) died, and 48 (43.4%) were discharged home. In the overall cohort, while the only multivariate predictor of mortality was iGCS (OR=0.58; 95%CI:0.44-0.77; p=0.0001), the CCI (OR=0.73; 95%CI:0.58-0.92; p=0.0082) was a superior predictor of discharge home compared to iGCS (OR=1.46; 95%CI:1.13-1.90; p=0.0041). Conversely, among those who received an operative intervention, the CCI, but not iGCS, independently predicted both mortality (OR=4.24; 95%CI:1.01-17.86; p=0.0491) and discharge home (OR=0.55; 95%CI:0.33-0.90; p=0.0170). Neither mFI nor age predicted primary outcomes in multivariate analysis.ConclusionWhile frailty is associated with worse surgical outcomes, the clinical utility of the mFI-5, mFI-11, and CCI in cSDH is unclear. We show that the iGCS is an overall superior predictor of mortality following cSDH but is outperformed by the CCI after operative intervention. Similarly, the CCI is the superior predictor of discharge home in cSDH patients overall and following an operative intervention. These results indicate that while the iGCS best predicts mortality overall, the CCI may be considered when prognosticating post-operative course and hospital disposition.

Etiology and Determinants of In-Hospital Survival in Patients Resuscitated After Out-of-Hospital Cardiac Arrest in an Urban Medical Center

Out-of-hospital cardiac arrest (OHCA) is a leading cause of mortality globally. The goals of this study were to describe common causes of OHCA in an urban US medical center, identify predictive factors for survival, and to assess whether neurological status upon return of spontaneous circulation might be predictive of outcomes: 124 consecutive patients aged 18 years and older with OHCA admitted at Advocate Illinois Masonic Medical Center were studied. All patients resuscitated in the field with return of spontaneous circulation then transferred to the emergency department were included. The Glasgow Coma Score (GCS) was evaluated immediately on hospital arrival. In the total group, 34% (42 of 124) were discharged alive. In patients with coronary artery disease (CAD), 51% (20 of 39) were discharged alive versus 26% (22 of 85) of non-CAD patients (p <0.01). Initial GCS ≥ 9 was highly predictive of survival: 94% (34 of 36) of patients with GCS ≥ 9 survived versus 9% (8 of 88) with GCS ≤ 8 (p <0.0001). Defibrillation in the field was predictive of survival (chi-square = 7.81, p = 0.005). In the CAD group, all 16 patients with GCS ≥ 9 on presentation to the Emergency Department survived whereas all 13 with GCS ≤ 5 died (both p <0.0001). In the non-CAD group, 18 of 20 patients with GCS ≥ 9 survived, whereas only 2 of 52 with GCS ≤ 5 survived (both p <0.0001). Multivariate analysis by logistic regression showed that the strongest predictor of survival in the non-CAD subgroup was GCS (OR 0.27, CI 0.19 to 0.55, p <0.001). In conclusion, the etiology of the OHCA, immediate neurologic status, and defibrillation in the field (suggesting presenting arrhythmia) were predictive of survival. Immediate neurological recovery (GCS ≥ 9) regardless of etiology was a strong predictor of survival to discharge. Additional predictive factors depend on the etiology of the OHCA event. These data suggest that these straightforward factors can be helpful in predicting outcome in patients resuscitated after OHCA.

Outcomes of tranexamic acid administration in military trauma patients with intracranial hemorrhage: a cohort study

BackgroundTranexamic acid (TXA) may be a useful adjunct for military patients with severe traumatic brain injury (TBI). These patients are often treated in austere settings without immediate access to neurosurgical intervention. The purpose of this study was to evaluate any association between TXA use and progression of intracranial hemorrhage (ICH), neurologic outcomes, and venous thromboembolism (VTE) in TBI.MethodsThis was a retrospective cohort study of military casualties from October 2010 to December 2015 who were transferred to a military treatment facility (MTF) in the United States. Data collected included: demographics, types of injuries, initial and interval head computerized tomography (CT) scans, Glasgow Coma Scores (GCS), and six-month Glasgow Outcome Scores (GOS). Results were stratified based on TXA administration, progression of ICH, and VTE.ResultsOf the 687 active duty service members reviewed, 71 patients had ICH (10.3%). Most casualties were injured in a blast (80.3%), with 36 patients (50.7%) sustaining a penetrating TBI. Mean ISS was 28.2 ± 12.3. Nine patients (12.7%) received a massive transfusion within 24 h of injury, and TXA was administered to 14 (19.7%) casualties. Patients that received TXA had lower initial reported GCS (9.2 ± 4.4 vs. 12.5 ± 3.4, p = 0.003), similar discharge GCS (13.3 ± 4.0 vs. 13.8 ± 3.2, p = 0.58), and a larger improvement between initial and discharge GCS (3.7 ± 3.9 vs. 1.3 ± 3.1, p = 0.02). However, there was no difference in mortality (7.1% vs. 7.0%, p = 1.00), progression of ICH (45.5% vs. 14.7%, p = 0.09), frequency of cranial decompression (50.0% vs. 42.1%, p = 0.76), or mean GOS (3.5 ± 0.9 vs. 3.8 ± 1.0, p = 0.13). Patients administered TXA had a higher rate of VTE (35.7% vs. 7.0%, p = 0.01). On multivariate analysis, however, TXA was not independently associated with VTE.ConclusionsPatients that received TXA were associated with an improvement in GCS but not in progression of ICH or GOS. TXA was not independently associated with VTE, although this may be related to a paucity of patients receiving TXA. Decisions about TXA administration in military casualties with ICH should be considered in the context of the availability of neurosurgical intervention as well as severity of extracranial injuries and need for massive transfusion.

Extubation strategies in neuro-intensive care unit patients and associations with outcomes: the ENIO multicentre international observational study.

BackgroundProlonged invasive ventilation is common in patients with severe brain injury. Information on optimal management of extubation and on the use of tracheostomy in these patients is scarce. International guidelines regarding the ventilator liberation and tracheostomy are currently lacking.MethodsThe aim of ‘Extubation strategies in Neuro-Intensive care unit patients and associations with Outcomes’ (ENIO) study is to describe current management of weaning from invasive ventilation, focusing on decisions on timing of tracheal extubation and tracheostomy in intensive care unit (ICU) patients with brain injury. We conducted a prospective, international, multi-centre observational study enrolling patients with various types of brain injury, including trauma, stroke, and subarachnoid haemorrhage, with an initial Glasgow Coma Score equal or less than 12, and a duration of invasive ventilation longer than 24 hours from ICU admission. ENIO is expected to include at least 1,500 patients worldwide. The primary endpoint of the ENIO study is extubation success in the 48 hours following endotracheal tube removal. The primary objective is to validate a score predictive of extubation success. To accomplish this, the study population will be randomly divided to a development cohort (2/3 of the included patients) and a validation cohort (the remaining 1/3). Secondary objectives are: to determine the incidence of extubation success rate according to various time-frames (within 96 hours, >96 hours after extubation); to validate (existing) prediction scores for successful extubation according to various time-frames and definitions (i.e., tracheostomy as extubation failure); and to describe the current practices of extubation and tracheostomy, and their associations.DiscussionENIO will be the largest prospective observational study of ventilator liberation and tracheostomy practices in patients with severe brain injury undergoing invasive mechanical ventilation, providing a validated predictive score of successful extubation.Trial registrationThe ENIO study is registered in the Clinical Trials database: NCT 03400904.

Clinical role of low hemoglobin ratio in poor neurologic outcomes in infants with traumatic intracranial hemorrhage

Traumatic brain injury (TBI) is the leading cause of pediatric morbidity and mortality worldwide, and half of all fatalities occur in infants aged less than 1 year. We analyzed 129 infants diagnosed with TBI complicated with intracranial hemorrhage confirmed by brain computed tomography. We defined delta hemoglobin (ΔHB) as nadir HB - age specific mean HB, and the ratio of HB (%) as ΔHB/age specific mean HB x 100. Infants with poor neurologic outcomes had a lower admission HB and ΔHB (p < 0.05). The in-hospital mortality rate was 10.1% (13 infants), and the infants who died had a significantly lower ΔHB ratio compared to the survivors. The area under the receiving operating characteristic curve (AUC) of initial Glasgow Coma Score (GCS) in predicting neurologic outcomes was higher than that of ratio of ΔHB (0.881 v.s 0.859). In multivariate logistic regression analysis with the optimal cutoff ratio of ΔHB, it remained an independent predictor for in-hospital mortality and poor neurologic outcomes at discharge and at 6 months. AUC analysis for the ratio of ΔHB for poor neurologic outcomes in infants aged from 0–6 months was 0.85 and the optimal cutoff was −30.7% (sensitivity, 69%; specificity, 92%; positive likelihood ratio (LR+), 8.24; negative likelihood ratio (LR−), 0.34); the AUC was 0.88 in infants aged from 6–12 months and the optimal cutoff was −20.6% (sensitivity, 89%; specificity, 79%; LR+, 4.13; LR−, 0.15).

The Role of Desmopressin on Hematoma Expansion in Patients with Mild Traumatic Brain Injury Prescribed Pre-injury Antiplatelet Medications.

Desmopressin (DDAVP) has been suggested for antiplatelet medication reversal in patients with traumatic brain injury (TBI) but there are limited data describing its effect on clinical outcomes. The purpose of this study was to evaluate the effect of DDAVP on hematoma expansion and thrombosis in patients with TBI who were prescribed pre-injury antiplatelet medications. Consecutive adult patients who were admitted to our level I trauma center and prescribed pre-injury antiplatelet medications between July, 2012, and May, 2018, were retrospectively identified. Patients were excluded if their hospital length of stay was < 24h, if DDAVP was administered by any route other than intravenous, if they received a DDAVP dose < 0.3 mcg/kg or there was no evidence of brain hemorrhage on computed tomography (CT) scan. Patients were stratified based on the use of DDAVP, and the incidence of hematoma expansion was compared between groups. Thrombotic events were reviewed as a secondary outcome. Multivariate analysis was utilized to control for confounding variables. Of 202 patients included in analysis, 158 (78%) received DDAVP. The mean age was 76 ± 12years; the most common injury mechanism was falls (76%); 69% had acute subdural hematoma, and 49% had multi-compartmental hemorrhage. Initial Glasgow coma score was between 13 and 15 for 91% of patients. Aspirin was the most common antiplatelet regimen prescribed (N = 151, 75%), followed by dual antiplatelet regimens (N = 26, 13%) and adenosine diphosphate (ADP)-receptor inhibitors (N = 25, 12%). The incidence of hematoma expansion was 14% and 30% for patients who did and did not receive DDAVP, respectively (p = 0.015). After controlling for age, injury severity score, multi-compartmental hemorrhage, and receipt of pre-injury high-dose aspirin (> 81mg), ADP-receptor inhibitors, oral anticoagulants, prothrombin complex concentrates or platelets in a multivariate analysis, the association between DDAVP and hematoma expansion remained significant (adjusted OR 0.259 [95% CI 0.103-0.646], p = 0.004). Thrombotic events were similar between the two groups (DDAVP, 2.5%, no DDAVP, 4.5%; p = 0.613). DDAVP was associated with a lower incidence of hematoma expansion in patients with mild TBI who were prescribed pre-injury antiplatelet medications. These results justify a randomized controlled trial to further evaluate the role of DDAVP for this indication.

The Prognostic Significance of a Cast Fourth Ventricle in Ruptured Aneurysm Patients With Intraventricular Hemorrhage in the Barrow Ruptured Aneurysm Trial (BRAT).

Ruptured aneurysms causing intraventricular hemorrhage (IVH) are associated with high morbidity. The presence of blood that completely fills the fourth ventricle (cast fourth ventricle, CFV) is thought to be particularly ominous, but studies documenting the outcome of such cases are lacking. To investigate the outcomes of patients with aneurysmal subarachnoid hemorrhage (aSAH) and CFV. We reviewed 406 patients enrolled in the Barrow Ruptured Aneurysm Trial (BRAT, NCT01593267, clinicaltrials.gov); 238 patients with aSAH and IVH were identified, and imaging was reviewed for the presence of CFV. Outcome was evaluated at the 1-yr follow-up. A poor outcome was defined as modified Rankin Scale score>2. CFV was identified in 25 patients. Admission Glasgow Coma Score was lower in CFV patients, 7.8 versus 11.5 (P<.001). At discharge and the 1-yr follow-up, patients with CFV had a greater risk of a poor outcome (P<.001 and P=.002, respectively). In a subgroup analysis of 79 patients with IVH and initial Glasgow Coma Score≤8, almost 50% of the patients with IVH but without CFV had made a good recovery versus 7% of patients with CFV (odds ratio [OR] 15, P=.002). On multivariate analysis, CFV was a greater predictor of a poor prognosis at 1 yr post-aSAH than Hunt and Hess grade>3 (6.4 OR vs 2.9 OR [P<.001], respectively). The presence of CFV is a predictor of poor outcome in patients with aSAH. When compared to other patients with IVH and aSAH, CFV is a stronger predictor of a poor outcome than a poor Hunt and Hess Grade.

Hepatitis B vaccine and risk of acute myocardial infarction among patients with diabetes

The objective of our study was to incorporate stricter probable nonfatal opioid overdose case criteria, and advanced epidemiologic approaches to more reliably detect local clustering in nonfatal opioid overdose activity in EMS runs data.Data were obtained using emsCharts for our study area in southwestern Pennsylvania from 2007 to 2018. Cases were identified as emergency medical service (EMS) responses where naloxone was administered, and improvement was noted in patient records between initial and final Glasgow Coma Score. A subsample of all-cause EMS responses sites were used as controls and exact matched to cases on sex and 10-year-age category. Clustering was assessed using difference in Ripley's K function for cases and controls and Kulldorff scan statistics.Difference in K functions indicated no significant difference in probable nonfatal overdose EMS runs across the study area compared to all-cause EMS runs. However, scan statistics did identify significant local clustering of probable nonfatal overdose EMS runs (maximum likelihood = 16.40, P = 0.0003).Results highlight relevance of EMS data to detect community-level overdose activity and promote reliable use through stricter case definition criteria and advanced methodological approaches. Techniques examined have the potential to improve targeted delivery of neighborhood-level public health response activities using a near real-time data source.