Cerebrospinal fluid biomarkers versus glasgow coma scale and glasgow outcome scale in pediatric traumatic brain injury: the role of young age and inflicted injury

The Glasgow Coma Scale (GCS) and Glasgow Outcome Scale (GOS) are widely used clinical scoring systems to measure the severity of neurologic injury after traumatic brain injury (TBI), but have recognized limitations in infants and small children. Cerebrospinal fluid (CSF) concentrations of neuron-specific enolase (NSE) and S100B show promise as markers of brain injury. We hypothesized that the initial GCS and 6-month GOS scores would be inversely associated with CSF NSE and/or S100B concentrations after severe pediatric TBI. Using banked CSF obtained during ongoing studies of pediatric TBI, NSE and S100B were determined in CSF collected within 24 h of trauma from 88 infants and children with severe TBI (GCS < or = 8) versus 20 non-injured controls. Victims of inflicted (iTBI) and non-inflicted TBI (nTBI) showed similar (>10-fold) increases in both NSE and S100B versus control. Both markers showed overall significant, inverse correlation with GCS and GOS scores. In subgroup analysis, both markers correlated significantly with GCS and GOS scores only in older (>4 years) victims of nTBI; no correlation was found for patients < or =4 years old or victims of iTBI. While confirming the overall correlations between GCS/GOS score and CSF NSE and S100B seen in prior studies, we conclude that these clinical and CSF biomarkers of brain injury do not correlate in children < or =4 years of age and/or victims of iTBI. Although further, prospective study is warranted, these findings suggest important limitations in our current ability to assess injury severity in this important population.     

A prehospital glasgow coma scale score < or = 14 accurately predicts the need for full trauma team activation and patient hospitalization after motor vehicle collisions

BACKGROUND: Trauma team activation protocols should ideally minimize the undertriage of seriously injured patients and eliminate unnecessary activations for those patients that do not require hospitalization. This study examined which physiologic parameter(s) most reliably predicted the need for hospitalization after motor vehicle collisions (MVCs). METHODS: A prehospital triage tool using standard physiologic parameters was developed and prospectively analyzed for reliability in predicting subsequent patient admission at a Level II trauma center after MVCs. Data were collected on 4,014 consecutive patients, 2,880 (72%) of whom had all of the physiologic parameters reported and recorded. Patients who arrived in extremis, who were dead on arrival, or who died shortly after arrival despite appropriate trauma team activation were ineligible for the study. Multivariate stepwise logistic regression analysis was used to determine which parameters were associated with hospital admission. RESULTS: The Glasgow Coma Scale (GCS) score was the only prehospital physiologic parameter providing a clinically identifiable difference between those patients admitted (13 +/- 4) and those discharged to home (15 +/- 0.5) (mean + SD) (relative risk for hospitalization, 2.24; 95% confidence interval, 1.86-2.70 for GCS score < 14). CONCLUSION: The prehospital GCS score is a reliable physiologic parameter for predicting hospital admission after MVC. When obvious indicators (hypoxemia, multiple long bone fractures, focal neurologic deficits) for trauma team activation are lacking, the prehospital GCS score may be used to reduce overtriage and undertriage rates.     

Effect of alcohol intoxication on the diagnosis and apparent severity of brain injury

Because alcohol intoxication is common among brain-injured patients, we performed this study to determine the extent to which alcohol alters the initial assessment of brain injury severity in these patients by depressing the level of consciousness. The Glasgow coma scale was used to measure the level of consciousness of 257 brain-injured adults admitted to the University of Virginia Hospital, both on arrival in the emergency room and 6 to 10 hours later. Improvement in the level of consciousness between the first and second measurements was significantly related to the blood alcohol concentration on admission. Patients with the highest blood alcohol concentrations showed the greatest improvement. Most of this effect occurred in patients with a blood alcohol concentration of 0.20% or higher. Alcohol intoxication is a potential source of bias in the clinical classification of brain injuries according to severity.     

Waiting for hip revision surgery: the impact on patient disability

Objective

Increased wait times for total joint arthroplasty (TJA) are a concern nationally and provincially. Additionally, the number of patients requiring revision of their initial TJA is increasing. The purpose of this study was to evaluate the wait times and impact of waiting for revision TJA.

Methods

We followed 127 revision hip arthroplasty patients (mean age 68 y) prospectively while they waited for surgery. We collected Western Ontario and McMaster Universities Osteoarthritis Index (pain, stiffness and physical function) data at the decision for surgery and at 6-month intervals until surgery.

Results

The mean wait time for surgery was 123.8 days (mean wait times for individual surgeons ranged from 7 to 213 d). Of the patients, 106 waited < 6 months, 12 waited 6–12 months and 9 waited > 12 months. Wait times evaluated up to 6 months, 6–12 months or > 12 months demonstrated significant increases in pain (F = 7.12, p = 0.01), with a mean change of 2.6 points when patients waited > 6 months. Physical disability increased (F = 4.61, p = 0.01), with a mean change of 5.1 points when the wait time was 6–12 months and 8.8 points when the wait time was > 12 months.

Conclusion

Waiting > 6 months for revision hip arthroplasty resulted in significant increases in pain and physical disability.     

The prognostic reliability of the Glasgow coma score in traumatic brain injuries: evaluation of MRI data

Purpose

To clarify the predictive power of the Glasgow coma score (GCS) after traumatic brain injury (TBI) and in the context of brain stem lesions.

Methods

In 143 patients who had suffered severe TBI, the GCS was correlated to brain damage as visualized by cranial magnetic resonance imaging (MRI). This technique evaluates the damage to the brain stem in particular. The Brussels coma score (BCS) was also used.

Results

The GCS was not significantly correlated to brain stem lesions when it was only scored at the time of admission. When MRI was not used later on, the GCS showed a poor ability to predict the outcome. After 24 h, and on the day of MRI screening, the GCS was significantly correlated with two parameters: outcome (the higher the GCS, the better the outcome) and the frequency of patients without injuries to the brainstem in MRI (the higher the GCS, the higher this frequency). These correlations were much more evident when the BCS was used. The prognostic power of the GCS was found to vary over time; for example: a GCS of 3 at admission was associated with a favorable prognosis; a GCS of 4 signified a poor prognosis, irrespective of the time point at which the GCS was scored; and the prognostic power of a GCS of 5 deteriorated from the day of the MRI onwards, whereas the prognostic power of a GCS of 6 or 7 varied little over time.

Conclusions

We only recommend the use of the GCS for prognostic evaluation in a multidimensional model. Study protocols should contain additional brain stem function parameters (BCS, pupil condition, MRI).     

The effects of alcohol intoxication on the initial treatment and hospital course of patients with acute brain injury.

The effect of alcohol intoxication at the time of injury on hospital outcome was evaluated in 520 adult patients diagnosed with brain injury who were admitted to the emergency department of Harborview Medical Center. Data were collected for each subject's status from field intervention through hospitalization. Serum alcohol levels were measured from blood drawn in the emergency room, and the subjects were stratified into two groups: intoxicated (> or = 100 mg/dL, n = 191) and nonintoxicated (< 100 mg/dL, n = 329). Compared with subjects who were not intoxicated, intoxicated patients were more likely to be intubated in the field or emergency department (relative risk [RR] = 1.3, 95% confidence interval [CI] = 1.1-1.5), require placement of an intracranial pressure bolt (RR = 1.4, 95% CI = 1.1-1.8), develop respiratory distress requiring ventilatory assistance during hospitalization (RR = 1.8, 95% CI = 1.0-3.3), or develop pneumonia (RR = 1.4, 95% CI = 0.9-2.2). The similarities in the clinical presentation of patients with acute brain injury and those who are intoxicated appear to influence prehospital care and also suggest that a more objective assessment of cerebral injury than provided by clinical diagnostic measures alone is required, thus accounting for the elevated likelihood of intracranial pressure monitoring in intoxicated trauma patients.     

Effect of alcohol intoxication on hemodynamic physiology and outcome in patients with traumatic cardiac tamponade.

BACKGROUND: Alcohol intoxication has a detrimental effect on hypovolemic shock. Our aim, was to study its effects on "pure" cardiac tamponade (i.e., without hypovolemia) in patients with penetrating chest injuries. METHODS: Thirty-five intoxicated and 15 nonintoxicated patients (blood alcohol > and < 17 mmol/L) were studied. Initial vital signs (trauma scores), special investigations (hematologic profiles, blood gases, glucose, lactate, and catecholamines), clinical progress (24- and 72-hour acute physiology and chronic health evaluation II scores) and outcome were compared. RESULTS: Intoxicated patients were older (p = 0.02) and more tachypneic on admission (p = 0.006), but no other differences were noted. Mortality was proportional to the degree of shock and was greater in patients who had "front-room" thoracotomies (p < 0.001). Despite the higher percentage of intoxicated patients who were "lifeless" or "in extremis" on admission, they fared no worse than nonintoxicated patients. CONCLUSION: Alcohol intoxication does not have an adverse affect on traumatic cardiac tamponade.     

Prediction of mortality in pediatric trauma patients: new injury severity score outperforms injury severity score in the severely injured

BACKGROUND: The Injury Severity Score (ISS) is a widely accepted method of measuring severity of traumatic injury. A modification has been proposed--the New Injury Severity Score (NISS). This has been shown to predict mortality better in adult trauma patients, but it had no predictive benefit in pediatric patients. The aim of this study was to determine whether the NISS outperforms the ISS in a large pediatric trauma population. METHODS: Admissions in the National Pediatric Trauma Registry between April 1996 and September 1999 were included. The ISS and NISS were calculated for each patient. The study endpoints were mortality at hospital discharge, functional outcome in three domains (expression, locomotion, and feeding), and discharge disposition for the survivors. Predictive ability of each score was assessed by area under the receiver operating characteristic curve. RESULTS: The NISS and ISS performed equally well at predicting mortality in patients with lower injury severity (ISS < 25), but the NISS was significantly better at predicting mortality in the more severely injured patients. Both scores performed equally well at predicting expression and feeding ability. The NISS was superior to the ISS in predicting locomotion ability at discharge. Thirty-seven percent of patients had an NISS that was higher than their ISS. These patients had a significantly higher mortality and suffered worse functional outcomes. CONCLUSION: The NISS performs as well as the ISS in pediatric patients with lower injury severity and outperforms the ISS in those with higher injury severity.     

Effect of patient age on use of the knee joint score

AIM OF THE STUDY: Clinical studies are done with the help of scores though different factors of influence lower comparability. The underlying study examines the influence of patient age as this always presents a certain span. METHOD: 96 degree I damaged knee joints were examined by 3 examiners using the Larson-, Lysholm-, Marshall-, HSS- and OAK-score. Furthermore ratings by a VAS and the Tegner activity score were done. With the Friedman test, the rank correlation coefficient by Spearman and the contingency chart by Bowker it was tested if the examiners and the scores rate equally. To find out the influence of the age three age groups were made up. RESULTS: The examiners judged significantly different excluding the Marshall and the OAK scores. In between two examiners no significant difference could be found between the young and the middle-aged patient group. Between two other examiners no significant difference was found only for the Lysholm and the HSS score in the young group and only for the Lysholm score in the middle-aged group. In the group of the senior patients no significant difference for the scores by Lysholm, Marshall and OAK were found. In the comparison of the second examiner pair no significant differences could be proven by the scores by Larson, the OAK and the HSS. All other comparisons were significantly different. In the comparison of all five scores significant differences were seen between the Larson score and the HSS and the Lysholm and the HSS. The Lysholm score proved to be the strictest, the HSS to be the leanest. CONCLUSION: Especially for the senior patients in dependency of the examiner and the chosen score significant differences were found concluding that the relevance of results lessens for future times as the score results drop with patient age anyway. The age span in one study should have a maximum of 10-20 years to reduce the influence of age on the final result.     

A clinical approach to coma: neurological assessment of the comatose patient

Coma is a state marked by the absence of arousal (wakefulness, vigilance) and awareness of one's self and environment. Patients in coma do not respond to internal or external stimuli and cannot be roused. Coma results from diffuse dysfunction of neuronal systems that govern awareness and arousal, and is a neurological emergency. The three main mechanisms of coma are structural brain lesions, diffuse neuronal dysfunction, and rarely psychiatric causes. Firstly, the patient should be stabilized by treating life-threatening conditions. Diagnostic and therapeutic steps should occur simultaneously. The history, physical examination and investigation results should be used to identify structural causes and diagnose treatable conditions. In many instances, the diagnosis is clear. Adoption of a systematic approach, based on the underlying principles of coma pathophysiology, combined with knowledge of the reversible causes increases the probability of establishing an early diagnosis. Patients not undergoing brain imaging should be regularly re-assessed. If CT imaging is unrevealing, then consideration should be given to advanced imaging and looking for evidence of treatable infection or poisoning, seizures including non-convulsive status epilepticus, endocrine disorders or thiamine deficiency.     

Clinical experience of the management for the most severely head—injured patients with GCS score of 3

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Glasgow coma scale compared to other trauma scores in discriminating in-hospital mortality of traumatic brain injury patients admitted to urban Indian hospitals: A multicentre prospective cohort study

BackgroundGlasgow Coma Scale (GCS) is one of the most commonly used trauma scores and is a good predictor of outcome in traumatic brain injury (TBI) patients. There are other more complex scores with additional physiological parameters. Whether they discriminate better than GCS in predicting mortality in TBI patients is debatable. The aim of this study was to compare the discrimination of GCS with that of MGAP, GAP, RTS and KTS for 24-hour and 30-day in-hospital mortality in adult TBI patients, in a resource limited LMIC setting.MethodWe analysed data from the multicentre, observational trauma cohort Towards Improved Trauma Care Outcome (TITCO) in India. We included all patients 18 years or older, admitted from the emergency department with TBI. The Area Under the Receiver Operating Characteristic (AUROC) curve was used to quantify and compare the discrimination of all scores: GCS; Revised Trauma Score (RTS); mechanism, GCS, age, systolic blood pressure (MGAP); GCS, age, systolic blood pressure (GAP) and Kampala Trauma Score (KTS) in the prediction of 24-hour and 30-day in-hospital mortality.ResultsA total of 3306 TBI patients were included in this study. The majority were within the GCS range 3-8. The commonest mechanism of injury was road traffic injuries [1907(58.0%)]. In-hospital mortality was 27.2% (899). There was no significant difference in discrimination in 24-hour in-hospital mortality when comparing GCS with MGAP and GAP. While GCS performed better than KTS, RTS performed better than GCS. For 30-day in-hospital mortality, GCS discriminated significantly better compared with KTS, but there was no significant difference when compared to MGAP and RTS. GAP discriminated significantly better when compared with GCS.ConclusionThis study shows that the discrimination of GCS is comparable to that of more complex trauma scores in predicting 24-hour and 30-day in-hospital mortality in adult TBI patients in a resource limited LMIC setting.     

Ankle fracture follow up using the Chertsey Outcome score for Trauma. Floor and ceiling effect of the scale

BackgroundPatient reported outcome measures (PROMs) are increasingly used by orthopaedic surgeons in order to measure their results. The Chertsey Outcome Score for Trauma (COST) is a recently validated PROM, which treats trauma as pathology, is not site or pathology specific. It measures the rehabilitation of the patients after an injury, using the pre-injury status as the default state of the patients. The aim of the present study was to focus on a narrow group of patients with similar ankle fracture injuries, investigate if there is any floor or ceiling effect of the scale and examine its use during the ankle fracture at the immediate post-injury rehabilitation period.Materials and methodsAll patients who had isolated ankle fractures treated either operatively or conservatively between March 2018 and December 2019, were included in the study. A COST and a FADI questionnaire was completed prior to their follow-up at 2, 6 and 12 weeks post injury/operation. Demographic data were also collected.ResultsA total of 527 COST questionnaires from 314 different patients (aged 51.4 ± 18.4 years) were included in the study. The average COST score was 40.28 ± 18 and the average FADI score was 60.1 ± 21.8. The VAS score reached 3.57 ± 2.2. There was no significant floor and ceiling effect for the COST score. The COST score had good correlation with the FADI score (Spearman’s Rho=0.69) and good internal consistency (Cronbach’s Alpha=0.85).ConclusionNo significant floor or ceiling effect was identified for the COST score, during the short and medium term follow up period following an ankle fracture, treated with either conservative or operative management. The scale was found to be valid and with good internal consistency.