Initial Glasgow Coma Score Research Articles

Extensive Burns in an Elderly Man Found in a Brush Fire

This past spring, a flight team was activated by a rural advanced life support ground service for a scene call approximately 30 minutes from their base for an 80-year-old man found lying in the middle of a brush fire. The ground paramedics did not know how the patient came to this position. During the initial call to the flight service, ground emergency medical services (EMS) reported that the patient had 100% burns that varied in severity from superficial to full thickness. The intercept was requested for emergent transport to a burn center, analgesia, and advanced airway management. On arrival, the flight crew saw that a bag valve mask was being used to ventilate the patient. EMS had placed the patient on a spine board for extrication from the scene. His initial Glasgow Coma Score was noted to be 6 (E1, V1, M4). The flight team noted that the patient occasionally moved his upper extremities and his head. Immediately, there was concern for a compromised airway in the setting, with soot and edema noted in the nares and oropharynx. The ground EMS crew was able to ventilate the patient with difficulty. However, given the severity of the burns and noted trismus, an oral airway could not be placed. Stridor was noted, with obvious swelling of the neck.

Pre-hospital intubation by anaesthesiologists in patients with severe trauma: an audit of a Norwegian helicopter emergency medical service

BackgroundAnaesthesiologists are airway management experts, which is one of the reasons why they serve as pre-hospital emergency physicians in many countries. However, limited data are available on the actual quality and safety of anaesthesiologist-managed pre-hospital endotracheal intubation (ETI). To explore whether the general indications for ETI are followed and what complications are recorded, we analysed the use of pre-hospital ETI in severely traumatised patients treated by anaesthesiologists in a Norwegian helicopter emergency medical service (HEMS).MethodsA retrospective audit of prospectively registered data concerning patients with trauma as the primary diagnosis and a National Committee on Aeronautics score of 4 - 7 during the period of 1994-2005 from a mixed rural/urban Norwegian HEMS was performed.ResultsAmong the 1255 cases identified, 238 successful pre-hospital ETIs out of 240 attempts were recorded (99.2% success rate). Furthermore, we identified 47 patients for whom ETI was performed immediately upon arrival to the emergency department (ED). This group represented 16% of all intubated patients. Of the ETIs performed in the ED, 43 patients had an initial Glasgow Coma Score (GCS) < 9. Compared to patients who underwent ETI in the ED, patients who underwent pre-hospital ETI had significantly lower median GCS (3 (3-6) vs. 6 (4-8)), lower revised trauma scores (RTS) (3.8 (1.8-5.9) vs. 5.0 (4.1-6.0)), longer mean scene times (23 ± 13 vs. 11 ± 11 min) and longer mean transport times (22 ± 16 vs. 13 ± 14 min). The audit also revealed that very few airway management complications had been recorded.ConclusionsWe found a very high success rate of pre-hospital ETI and few recorded complications in the studied anaesthesiologist-manned HEMS. However, a substantial number of trauma patients were intubated first on arrival in the ED. This delay may represent a quality problem. Therefore, we believe that more studies are needed to clarify the reasons for and possible clinical consequences of the delayed ETIs.

Ventilator-associated pneumonia in pediatric trauma patients

Ventilator-associated pneumonia (VAP) is a significant cause of secondary morbidity and mortality in adult trauma patients. No study has characterized VAP in pediatric trauma patients. We determined the rates of and potential risk factors for VAP in pediatric trauma patients. A countywide trauma registry identified all pediatric trauma patients with potential VAP treated at a Regional Trauma Center. After a structured chart review, descriptive statistics were used to characterize the population. One hundred fifty-eight trauma patients younger than 16 years requiring intubation and mechanical ventilation were identified in 3388 pediatric trauma admissions from the period 1995-2006. Drownings and poisonings were excluded. The registry identified 14 potential VAPs, of which, on detailed review, 7 were true cases. The VAP rate for pediatric trauma patients was 0.2% overall or 4.4% of those mechanically ventilated. In addition, ventilator days were available in the registry from 2003 forward and the rate in ventilator days was found to be 13.83/1000. Although higher than the overall pediatric intensive care unit VAP rate (5.93/1000 ventilator days), the pediatric trauma VAP rate was substantially lower than the VAP rate in adult trauma patients (58.25/1000 ventilator days). On chart review, six of the seven patients were male and older than 10 years (mean age, 11.9 years). All seven patients with VAP were blunt trauma victims with head injury (mean initial Glasgow Coma Score, 5.6) with Injury Severity Scores over 25 (mean, 32.1). Pulmonary contusion was present in four of the seven. Although the in-hospital mortality rate of ventilated pediatric trauma patients was 17.1%, there was no mortality in those with VAP. The rate of VAP in pediatric trauma patients is substantially lower than in similar adults. Age older than 10 years, blunt trauma, head injury, and Injury Severity Score >25 may be risk factors. VAP is not associated with increased mortality in pediatric trauma patients.

Outcome after severe head injury: focal surgical lesions do not imply a better Glasgow Outcome Score than diffuse injuries at 3 months

BackgroundHistorically neurosurgeons have accepted head injured patients only in the presence of a mass lesion requiring surgical decompression. Underpinning this is an assumption that these patients have a better outcome than patients without a surgical lesion. This has meant that many patients without a surgical lesion have been managed locally in the referring hospital. However, there is now evidence that treatment of all head injured patients in a specialist centre leads to improved outcomes. Therefore, we have asked the question: does the presence of a surgical lesion imply better outcome from severe head injury?ResultsWe prospectively recorded the Glasgow Outcome score (GOS), at 3 months, of all the severely head injured patients treated at our institution over a two and a half year period. Of 116 patients admitted with an initial Glasgow Coma Score (GCS) of 8 or less, 58 had surgical lesions and 58 non-surgical head injuries. The two groups were well matched for presenting GCS and age. Overall our favourable outcome rate (GOS 4 and 5) at 3-months for the patients with a surgical lesion and for the non-surgical group were 47.3% and 46.6% respectively, with no significant difference between the two (P = 0.54).ConclusionThe assumption in the past has always been that patients presenting in coma from traumatic diffuse brain injury will do worse than those that have a mass lesion amenable to surgical decompression. Our series would suggest that this is not the case and all severely head injured patients should expect similar outcome when cared for in a neuroscience centre.

The Changing Face of Trauma: New Orleans before and after Hurricane Katrina

Charity Hospital (CH) was devastated by Hurricane Katrina and remains closed. Design and staffing of a new, temporary dedicated trauma hospital relied on data from prior experience at CH, updated census information, and a changed trauma demographic. The study objective was to analyze the new trauma program and evaluate changes in demographics, injury patterns, and outcomes between pre- (PK) and post-Katrina (POK) trauma populations. A retrospective review of trauma patients' demographics, anatomical variables, and physiological variables 6 months PK and POK was performed under an approved Institutional Review Board protocol. Trauma activation triage criteria between study periods were also analyzed. Continuous data comparisons between the two time periods were made with Student's t test. Dichotomous data were analyzed using chi2 test. The demographic of trauma patients is different in the POK interval, reflecting changes in the New Orleans population. Modification of triage criteria by the exclusion of mechanism as an activation criterion resulted in an increase of patients with higher acuity and Injury Severity Score, lower initial Glasgow Coma Score, and a higher proportion of penetrating mechanism. Outcome measures reflect longer length of stay (4.4 vs. 6.8 days, P < 0.0001) without a significant difference in mortality (6.0 vs 7.5, P = 0.227). Hospital data demonstrates that the POK trauma system was stressed by the increased acuity, penetrating injury, and number of procedures per patient (1.7 vs. 3.4). Resources should be directed toward patients requiring multidisciplinary care by increasing intensive care unit beds and operating room capacity. Future resource planning in the recovery phases of large-scale natural disasters should take into account these observations.

Prophylactic Antiepileptic Drug Use is Associated with Poor Outcome Following ICH

Intracerebral hemorrhage (ICH) is associated with a risk of early seizure and guidelines recommend consideration of prophylactic antiepileptic drugs (AEDs) for some patients, although the utility is uncertain. We analyzed data from the placebo arm of the Cerebral Hemorrhage and NXY-059 Trial (CHANT), an international multicenter randomized trial of a potential neuroprotectant that enrolled patients within 6 h of the onset of acute ICH. Logistic regression analyses were performed to determine whether early AED use was associated with poor outcome at day 90, defined as a modified Rankin Scale of 5 or 6 (severely disabled or dead). Excluding patients who were previously on AEDs, the primary analysis included 295 patients. The median ICH volume at admission was 14.9 (interquartile range, IQR 7.9-32.7) ml and the mean was 23.3 (+/-SD 22.8) ml. Seizures occurred in 5 patients (1.7%) after enrollment and 82 patients (28%) had a poor outcome at day 90. AEDs were initiated on 23 patients (8%) without documented seizure during the first 10 days of the trial. In logistic regression, initiation of AEDs was robustly associated with poor outcome (OR 6.8; 95% CI: 2.2-21.2, P = 0.001) after adjustment for other known predictors of outcome after ICH (age, initial hematoma volume, presence of intraventricular blood, initial Glasgow coma score, and prior warfarin use). In this clinical trial cohort, seizures were rare after the first few hours following ICH. In addition, prophylactic AED use was associated with poor outcome independent of other established predictors. Given the potential for residual confounding in this cohort, a randomized trial needs to be performed.

Outcome of the Severe Acute Subdural Hematoma

Objective: Acute subdural hematoma (ASDH) is one of the worst post-traumatic mass lesions. Early aggressive management may reduce the mortality rate, while it may cause unbearable sequelae or disabilities. Traditionally a surgical decision is made by the surgeon on the critical victim without delay. However, it is necessary to inform the relatives or family not only the possibility of survival, but also the quality of life after surgery, especially for the comatose victims with ASDHs. We investigate the outcome of the comatose (Glascow coma scale 3-8) patients with ASDH. Methods: From January 2005 to December 2006, we managed 141 patients with ASDH. In 52 patients, their initial Glasgow coma score (GCS) was 38. We examined the age, initial GCS, size and reflex of pupils, method of treatment, and the outcome at discharge. We also investigated the amount the hematoma, degree of midline shift, and status of the basal cisterns in computed tomographic scans. Statistical significance was tested using the chi-square test. It was considered significant, when p<0.05. Results: The overall outcome was poor; death in 29, vegetative in 12, severe disability in 10, and moderate disability in 1. There was no good recovery, at all. The outcome was dependent on the initial GCS and pupil. The outcome was independent on the age, amount of the hematoma, degree of midline shift, and method of treatment. However, the age was the only significant factor in deciding not to operate. Conclusion: In severe head injuries, even though we could save the life, the quality of life is too poor to bother not only the victims, but also their family and society. In this situation, it is never sufficient to explain that an immediate surgery is the only way to save the life. We should provide the information on the outcome of the severe head injuries after surgery. (J Kor Neurotraumatol Soc 2009;5:1-4)

Outcome of acute traumatic extradural hematoma.

To assess the surgical outcome of acute extradural hematoma in terms of neurological recovery and survival. Case series. Postgraduate Medical Institute, Neurosurgery Unit, Hayatabad Medical Complex, Peshawar, from January to October 2006. All patients admitted and operated for acute traumatic extradural hematoma during the study period were included. Demographic data, history, mode of trauma, examination findings, investigations and outcome were recorded. Glasgow coma scale was used for initial assessment and Glasgow outcome scale was applied to assess outcome in terms of neurological recovery in all patients. The follow-up period was 3 months. A total of 30 patients were operated during the period of 10 months including 22 males and 8 females. Patients were in the age range of 20-30 years comprised 30% of all. Most common causes were road traffic accident (50%), fall from height (33%) and assault (17%). Patients were divided according to the initial Glasgow Coma Score (GCS) after resuscitation. The GCS was 3-8 in 6 patients, 9-12 in 7 patients, 13-15 in 17 patients. Twenty-four patients had good outcome, one patient had moderate disability in the form of left sided weakness, one patient remained in vegetative state, while 3 (10%) patients died. Chi-square test was significant for good outcome in patients with GCS 13-15 (p=0.01) and for death in patients with GCS 3-8 (p=0.01). Extradural hematoma in head injuries affected young males more commonly. The outcome was better when the initial GCS was in the higher range.

VERBAL MEMORY DEFICIT FOLLOWING TRAUMATIC BRAIN INJURY: ASSESSMENT USING ADVANCED MRI METHODS

Traumatic axonal injury resulting in disruption of functional networks in the brain is thought to be a major contributor to cognitive dysfunction in survivors of traumatic brain injury (TBI).1 However, the true significance of this disruption is not known as current clinical imaging modalities do not directly assess axonal injury or functional network connectivity. Modern MRI techniques such as resting-state fMRI correlation analysis may overcome this limitation.2,3 A 21-year-old right-handed woman presented to the outpatient TBI clinic because she was “having trouble in school and remembering things.” At 15, she was a passenger in a head-on motor vehicle collision. She had a severe TBI, clavicle fracture, and pulmonary contusions. Her initial Glasgow Coma Score was 4 (range: 3, deeply comatose, to 15, normal). Her initial head CT revealed a large left subdural hematoma with 1 cm left-to-right shift, bifrontal hemorrhagic contusions, subarachnoid hemorrhage, intraventricular hemorrhage, and punctate hemorrhages in the subcortical white matter, pons, and splenium of the corpus callosum. A left craniotomy was performed and the subdural hematoma was evacuated. She made a progressive neurologic recovery over 2 months. At discharge she was able to speak complete sentences and had no cranial nerve, motor, or sensory deficits. However, she has experienced persistent difficulties with memory and concentration affecting school performance and everyday life. Neuropsychological testing at age 21 revealed a moderately severe verbal memory deficit for auditory information but otherwise generally …

Predictors of Mortality in Trauma Patients With Intracranial Hemorrhage on Preinjury Aspirin or Clopidogrel

The mortality risk in elderly patients who sustained head trauma resulting in intracranial hemorrhage (ICH) while taking the antiplatelet agents aspirin (ASA) or clopidogrel or both (Plavix) was evaluated. A retrospective review identified trauma patients, age 50 or greater, who had computed tomography (CT) evidence of ICH and were taking ASA, clopidogrel, or a combination of both. Patient demographics, type of medication, mechanism of injury, Glasgow Coma Score (GCS), grading of head CT scans, and outcomes were characterized. One hundred nine patients including 61 men and 48 women were identified; the mean age was 77 years +/- 10 years. Injury was due to level fall (73), fall from height (21), motor vehicle crash (11), and other (4). Twenty (18%) patients died; age, gender, type of medication, and mechanism of injury were not predictive of death. The initial GCS for survivors was 14.2 +/- 1.9 versus 11.3 +/- 4.9 for nonsurvivors (p < 0.007). Deaths based on initial CT grade were: grade 1, 5 of 70; grade 2, 4 of 17; grade 3, 5 of 10; grade 4, 6 of 12 (p = 0.002). Follow-up CT scans were performed in 81 patients who were not taken to surgery and had grade 1 or 2 hemorrhage initially. Of 4 patients with hemorrhage progression, there was 1 death (25%) versus 6 deaths in 77 patients without progression (8%; p = 0.70). There is high mortality rate associated with ASA or clopidogrel or both in elderly patients who have head trauma resulting in ICH. The presenting GCS and initial grade of CT scan are most predictive of death. Progression of hemorrhage after admission is unusual. The risk of brain injury, particularly from falls, should be explained to elderly patients taking these medications.

The Impact of Premorbid Conditions on Temporal Pattern and Location of Adult Blunt Trauma Hospital Deaths

This study was designed to show the importance of age, presence of premorbid conditions, and the type of injury on time and location of adult inhospital trauma mortality. All acute blunt trauma deaths at a Level I urban trauma center between April 1, 1993 and March 31, 2003 were individually reviewed to collect data on the following variables: age, gender, presence and number of premorbid conditions, mechanisms of trauma, location of death, acute transfer from another hospital, delay to death, initial Glasgow Coma Score (GCS), Abbreviated Injury Score (AIS), Injury Severity Score (ISS), and revised trauma score (RTS). Bivariate analysis using simple logistic regression was used to show the association between each variable and delay to death. Variables significantly associated with death underwent multivariate analysis to yield adjusted odds ratios (aORs) with 95% confidence interval (CI). During the study period there were 463 blunt trauma deaths (6.8%). Their mean age was 67.5 years, mean ISS was 22.6, mean GCS was 11.0, and 55.3% were male. Most deaths occurred in either the intensive care unit (45.8%) or the ward (46.4%); there were few deaths in the emergency department (6.8%) or the operating room (0.4%). The following were significant bivariate predictors for death: presence of premorbid conditions, number of premorbid conditions, age >60, pulmonary diseases, cardiac diseases, diabetes mellitus, neurologic diseases, GCS, AIS > or =4, and ISS. Multivariate analysis demonstrated the following significant findings: patients with severe thoracic injuries were significantly more likely to die in the first 6 hours (aOR = 1.37; CI = 1.12-1.68; p = 0.002); and patients with severe head injuries were more likely to die after 48 hours (aOR = 1.275; CI = 1.158-1.405; p = 0.0001). Older patients and those with neurologic diseases were more likely to die later and in a hospital ward (aOR = 2.18; CI = 1.25-3.81; p = 0.006). Men and women differed as to age, ISS, mechanism of injury, and type of injury, but not as to delay to death. Age, body area injured, and presence and type of premorbid conditions are significant predictors of location of and delay to death after blunt trauma. We think that incorporating information on premorbid conditions is essential for mortality analysis in an aging population.

Clinical Examination and its Reliability in Identifying Cervical Spine Fractures

The Eastern Association for the Surgery of Trauma (EAST) guidelines recommend that cervical spine (c-spine) radiographic evaluation is unnecessary in the awake, alert blunt trauma patient who is not intoxicated, has no distracting injuries, and demonstrates no tenderness over the c-spine or neurologic deficits. The purpose of this study was to compare the reliability of the clinical examination (CE) with that of computed tomography in identifying the presence of c-spine fractures. We prospectively evaluated 534 blunt trauma patients between February 2004 and January 2005. Positive CE was defined as complaints of neck pain, external trauma of the c-spine or neurologic deficit, tenderness or abnormalities to palpation over the cervical spine. Computed tomography was used to define the accuracy of CE. There were 52 patients with, and 482 patients without, c-spine fractures. Forty of the 52 patients with fractures were accurately identified by CE for a sensitivity of 76.9% and a negative predictive value (NPV) of 95.7%. In the group with an initial Glasgow Coma Score of 15, 16 of 24 patients with fractures were accurately identified for a sensitivity of 66.7% and an NPV of 96.5%. In the subset of patients who by EAST guidelines would not require any radiographic evaluation, there were 17 fractures and 10 were accurately identified by clinical examination. The sensitivity in this group was 58.8% with an NPV of 96.4%. Four of the seven missed injuries required intervention. This trial suggests that with a normal Glasgow Coma Score, CE cannot be relied upon to rule out c-spine fracture. CE is unreliable to diagnose or exclude a cervical spine fracture.

Intracranial stab wound: a case report

Intracranial stab wounds are relatively uncommon, as the adult skull usually provides an effective barrier to penetration. We present an interesting case of a penetrating intracranial stab wound with several important teaching points. A 44-year-old man presented to the emergency department with a 1.2-cm stab wound to the left temporal area. His initial Glasgow Coma Score was 14/15. Computerized tomography of his brain revealed a left temporal lobe haemorrhage and contusion. Magnetic resonance images of his brain revealed a linear haematoma extending from his left temporal lobe into the left middle cerebellar peduncle, consistent with a penetrating injury. He was managed conservatively with intravenous antibiotics and made an excellent recovery. Three weeks after injury, he had mild residual problems with recall and attention. Several leaning points exist in this case. Firstly, as stab wounds to the brain frequently present as apparently innocuous facial or scalp lacerations, a high index of suspicion is needed to prevent these injuries presenting with serious late infective complications. Secondly, reports of similar cases in the literature suggest that stab wounds to the temporal region are associated with a high morbidity and mortality. This case demonstrates that a patient with an injury such as this can occasionally make a good functional recovery. Finally, this case highlights the advantage of magnetic resonance imaging over computerized tomography in patients with these injuries once it has been established that there is no residual intracranial metal fragment prior to magnetic resonance imaging. In this case, the entire wound tract was only evident on magnetic resonance imaging and not on the initial computerized tomography scans.

Clinical outcome of severe head injury in different protocol-driven therapies

In the past 5 years cerebral perfusion pressure (CPP) management has become mainstream in the treatment of severe head injuries. The American Association of Neurological Surgeons guidelines (2000) suggest that CPP should be maintained at least 70 mmHg; however, there is still debate about optimal CPP level. The purpose of this study is to evaluate the effectiveness of three widely used therapies: intracranial pressure (ICP)-targeted therapy, CPP-targeted therapy with CPP > 70 mmHg, and modified CPP-targeted therapy with CPP > 60 mmHg. The clinical procedures, complications, and patient outcomes are compared. Data including patient age, sex, initial Glasgow Coma Score (GCS), ICP, CPP, fluid status, amount of mannitol and vasopressor used, daily intake and output, complications, and clinical results were collected from 213 patients with severe head injuries over a 12-year period. Patients were categorized into three groups (ICP, CPP, modified CPP [mCPP]) according to treatment protocol used. Retrospective data collection was by chart review. The mortality rate was 28.6%, 14.3%, and 13.5% in groups ICP, CPP, and mCPP, respectively. Highest intake/output ratio, amount of vasopressor used, and pulmonary complication rates were seen in group CPP patients. Group mCPP patients showed the best clinical outcome and lowest complication rate. Though CPP-targeted therapy is the most recommended therapeutic protocol, our data showed that the outcome is as good in the mCPP-targeted group with CPP > 60 mmHg as in the CPP-targeted group, but complications are fewer in the mCPP group.

Recent Neuroimaging Techniques in Mild Traumatic Brain Injury

Recent Neuroimaging Techniques in Mild Traumatic Brain Injury

Computed Tomography-Estimated Specific Gravity of Noncontused Brain Areas as a Marker of Severity in Human Traumatic Brain Injury

In this study, we assessed the relationship between brain estimated specific gravity (eSG) and clinical symptoms, therapeutic intensity level, and outcome in human traumatic brain injury (TBI). Brain weight, volume, and eSG of the noncontused hemispheric areas were measured from computed tomography (CT) DICOM images on the initial (5 +/- 6 h) CT of 120 patients with severe TBI. Control values were obtained from 40 healthy patients. The eSG of the noncontused hemispheric areas was significantly higher in TBI patients than in controls. eSG was higher in patients having a Marshall CT classification of 3 or 4 or a low initial Glasgow coma score. Two groups were defined according to the eSG of the noncontused hemispheric areas: less than (n = 83, 69%) or more than (n = 37, 31%) the threshold of normality (defined as 1.96 sd above normal = 1.0355 g/mL). The occurrence of mydriasis, use of osmotherapy at the scene of the accident, and therapeutic intensity level were higher in the increased eSG group. The outcome at intensive care unit discharge was worse in patients with an increased eSG although the difference was no longer significant at 1 yr. eSG determination by CT analysis might be relevant in the early management of TBI.

Neurologic prognosis and withdrawal of life support after resuscitation from cardiac arrest

To study the impact of neurologic prognostication on the decision to withdraw life-sustaining therapies (LST) in comatose patients resuscitated after cardiac arrest. The authors prospectively studied a consecutive series of post-resuscitation comatose patients referred for neurologic prognostication at a single center for 4 years. For most patients, neurologic prognostication was not sought due to early death or rapid return to consciousness. Prognostication was based on Glasgow Coma Score (GCS) and Brainstem Reflex Score (BRS), with EEG and cortical evoked potentials (CEP), which were graded as benign, uncertain, and malignant. The outcomes were as follows: survivors (Group S), brain or cardiac death (Group D), and death from withdrawal of life sustaining therapy (Group W). In Group W, the time interval to withdrawal of LST was analyzed by EEG and CEP grades. Of 58 patients studied, 10 were in Group S, 8 in Group D, and 40 in Group W. Initial median GCS and BRS was similar for all groups with significant improvement noted in Group S, but not in Group D or Group W. In Group W, CEP grade correlated with the median duration of continued therapy before a decision to withdraw LST: 7 days for benign CEP, 2 days for uncertain CEP, and 1 day for malignant CEP, p = 0.0004. In patients with poor neurologic recovery early after resuscitation from cardiac arrest, physicians appear to use the cortical evoked potential grade to estimate prognosis. Cortical evoked potential grade correlated with the waiting time until life sustaining therapies were withdrawn after no improvement in neurologic examination was seen.

Exertional Heat Stroke during a Cool Weather Marathon

A well-trained male runner in his late 30s collapsed 10 m before the finish line, nearly completing the 42.1-km marathon course in 3 h, 15 min. He was responsive to pain, agitated, diaphoretic, and unable to walk. The race start temperature was 6 degrees C (43 degrees F) with relative humidity of 99% and the 3-h temperature was 9.5 degrees C (49 degrees F) with a 62% relative humidity. Approximately 27 min after his collapse, his rectal temperature in the emergency department was 40.7 degrees C (105.3 degrees F), and his failing respiratory status required intubation. His initial Glasgow coma score was 6-7 of 15. His renal output was minimal until he was cooled and given a large fluid flush. His initial echocardiogram showed a "stunned" myocardium with an ejection fraction of 35%. He had a viral syndrome the week prior to the race and was paced by a "fresh" runner the last 16 km of the race. He left the hospital in 5 d and has now returned to running without problems, although several months passed before he felt well while exercising. Exertional heat stroke can occur in cool conditions, and rectal temperature should be checked in all collapsed runners who do not progress with rapid recovery of vital signs and cognitive function. Runners should be instructed not to compete when ill and should not use nonparticipant pacers during the runs.

Advanced Age and Preinjury Warfarin Anticoagulation Increase the Risk of Mortality After Head Trauma

A large population of patients on oral anticoagulants is exposed to the risk of traumatic brain injury (TBI). Effects of age and anticoagulation on TBI outcomes need to be assessed separately. Retrospective analysis of consecutive series of TBI patients (age 18 years and older) in a suburban teaching hospital. A total of 1,493 adult blunt head trauma patients between January 2001 and May 2005 were analyzed. Of these, 159 patients were warfarin-anticoagulated at the time of trauma. The mortality in anticoagulated patients was statistically significantly higher than in the control group (38/159, 23.9% vs. 66/1,334, 4.9%; p < 0.001; odds ratio 6.0). Mortality of patients over 70 years of age was significantly higher than in the younger population (p < 0.001). Both mortality and the occurrence of intracranial hemorrhage (ICH) after head trauma were significantly increased with higher INR (Cochran's linear trend p < 0.001), especially with INR over 4.0 (mortality 50%, risk of ICH 75%). Preinjury warfarin anticoagulation and age were found to be predictive of survival in a binary logistic regression model (92.5% correct prediction, p = 0.027). Addition of Injury Severity Score and initial Glasgow Coma Score to this model only modestly improved its predictive performance (95.4% correct prediction, p < 0.001). Both age and warfarin anticoagulation are independent predictors of mortality after blunt TBI. Warfarin anticoagulation carries a six-fold increase in TBI mortality. Age over 70 years and excessive anticoagulation are associated with higher mortality, as well.

Hematoma growth is a determinant of mortality and poor outcome after intracerebral hemorrhage

Although volume of intracerebral hemorrhage (ICH) is a predictor of mortality, it is unknown whether subsequent hematoma growth further increases the risk of death or poor functional outcome. To determine if hematoma growth independently predicts poor outcome, the authors performed an individual meta-analysis of patients with spontaneous ICH who had CT within 3 hours of onset and 24-hour follow-up. Placebo patients were pooled from three trials investigating dosing, safety, and efficacy of rFVIIa (n = 115), and 103 patients from the Cincinnati study (total 218). Other baseline factors included age, gender, blood glucose, blood pressure, Glasgow Coma Score (GCS), intraventricular hemorrhage (IVH), and location. Overall, 72.9% of patients exhibited some degree of hematoma growth. Percentage hematoma growth (hazard ratio [HR] 1.05 per 10% increase [95% CI: 1.03, 1.08; p < 0.0001]), initial ICH volume (HR 1.01 per mL [95% CI: 1.00, 1.02; p = 0.003]), GCS (HR 0.88 [95% CI: 0.81, 0.96; p = 0.003]), and IVH (HR 2.23 [95% CI: 1.25, 3.98; p = 0.007]) were all associated with increased mortality. Percentage growth (cumulative OR 0.84 [95% CI: 0.75, 0.92; p < 0.0001]), initial ICH volume (cumulative OR 0.94 [95% CI: 0.91, 0.97; p < 0.0001]), GCS (cumulative OR 1.46 [95% CI: 1.21, 1.82; p < 0.0001]), and age (cumulative OR 0.95 [95% CI: 0.92, 0.98; p = 0.0009]) predicted outcome modified Rankin Scale. Gender, location, blood glucose, and blood pressure did not predict outcomes. Hematoma growth is an independent determinant of both mortality and functional outcome after intracerebral hemorrhage. Attenuation of growth is an important therapeutic strategy.