Glasgow昏迷计分与智残评分在脑复苏监测中的联合应用

Ｇｌａｓｇｏｗ昏迷计分与智残评分在脑复苏监测中的联合应用蔡春１姜信平１李月彩１王家同２陈习进３Ｇｌａｓｇｏｗ昏迷计分（Ｇｌａｓｇｏｗｃｏｍａｓｃａｌｅ，ＧＣＳ）是目前危重症患者急性生理学及慢性健康状况评价Ⅰ、Ⅱ（ａｃｕｔｅｐｈｙｓｉｏｌｏｇｙａｎｄｃ...     

APACHE评分与GCS用于ICU严重脑外伤患者的比较

目的 :探讨急性生理学及慢性健康状况评分 (APACHE)系统用于严重脑外伤患者的可行性及临床使用的价值。方法 :以前瞻性随机方法对 95例严重脑外伤患者应用 APACHE 、APACHE 及格拉斯哥昏迷评分 (GCS)的结果进行比较研究。结果 :3种评分均与患者的病死率密切相关 ,且在存活与死亡患者之间存在显著性差异 (P<0 .0 1) ;APACHE 与 APACHE 优于 GCS,尤以 APACHE 为佳。结论 :APACHE评分不但可用于判定脑外伤患者的病情严重程度 ,并且可对其预后作出较准确的预测。     

脑外伤急性期血糖水平与格拉斯哥昏迷评分和预后的相关性研究

探讨脑外伤急性期（住院时）血糖水平与格拉斯哥昏迷评分（ＧＣＳ）和预后的相互关系。测定５３例脑外伤患者住院４８小时内的血糖水平，本组中２６例ＧＣＳ评分９～１５分（Ⅰ组），２７例ＧＣＳ评分≤８分（Ⅱ组）。研究结果表明：ＧＣＳ评分≤８分患者的血糖明显高于ＧＣＳ评分９～１５分者（平均血糖８．３４ｍｍｏｌ／Ｌ与５．００ｍｍｏｌ／Ｌ）；预后不良的患者其血糖水平明显高于预后良好者；Ⅱ组（ＧＣＳ评分≤８分，平均血糖８．３４ｍｍｏｌ／Ｌ）患者中死亡４例，植物生存２例，中度～重度致残５例，而Ⅰ组（ＧＣＳ评分９～１５分，平均血糖５．００ｍｍｏｌ／Ｌ）中仅１例伴有可逆性皮质盲。提示：高血糖可加重神经缺陷；测定血糖有助于评价颅脑外伤患者病情的严重程度和预后；此外，对这类患者补充低糖溶液可能有助于改善高血糖状态。     

脑外伤患者康复治疗的疗效观察

1资料与方法1.1一般资料选择2004年7月—2007年7月本院住院脑外伤患者45例,诊断符合1995年全国第四届脑血管病会议诊断标准[1],并经头颅CT或MRI证实。排除标准:有明显精神障碍和     

血浆和肽素水平与脑外伤患者病情严重程度相关性研究

目的 探讨血浆和肽素水平与脑外伤患者病情严重程度相关性及临床意义。方法 研究对象选取2010年4月～2014年10月收治脑外伤患者共81例,其中入院格拉斯哥昏迷评分(GCS)3～5分共27例,6～8分共29例,9～12分共25例,另选同期体检健康者30例,均行血浆和肽素水平检测; 分析血浆和肽素水平与脑外伤患者GCS评分、预后关系,采用ROC曲线评估血浆和肽素水平对临床预后预测价值。结果 健康组血浆和肽素水平(0.94±0.17 ng/ml)均显著低于其他组(3.80±0.62 ng/ml,6.37±1.18 ng/ml,14.44±2.87 ng/ml),差异有统计学显著性意义(t=6.24,5.10,3.81,P<0.05); 根据相关性分析显示,脑外伤患者血浆和肽素水平与入院GCS评分呈负相关(r=-0.82,P<0.05); 植物人或死亡组患者和肽素水平(18.75±2.66 ng/ml)均显著高于其他组(9.34±1.51 ng/ml,7.23±1.18 ng/ml),差异有统计学显著性意义(t=6.13,5.25,P<0.05); 植物人或死亡组患者入院GCS评分(5.37±1.08)均显著低于其他组(7.62±1.53,9.43±1.85),差异有统计学显著性意义(t=2.56,2.31,P<0.05); 以30天内死亡作为研究重点,血浆和肽素水平AUC值为0.815(95%CI为0.723～0.902); 分界值为8.3 ng/ml,预测敏感度为83.7%,预测特异度为67.2%。结论 血浆和肽素水平与脑外伤患者病情严重程度具有相关性,可用于临床预后检测。     

脑外伤患者希望水平及其家庭关怀度的关系研究

目的探讨脑外伤患者希望水平及与其家庭关怀度的关系。方法采用Herth希望量表和家庭关怀度指数问卷对212例脑外伤患者进行问卷调查,采用分层回归分析探讨脑外伤患者希望水平的影响因素。结果 1脑外伤患者的希望水平总分为(28.55±4.30)分,其中希望水平较低者占18.87%,希望水平中等者占60.38%,希望水平较高者占20.75%;2脑外伤患者家庭关怀度总分为(7.47±1.56)分;3住院时间、家庭收入、亲密度、情感度和适应度是脑外伤患者希望水平的影响因素。结论脑外伤患者希望水平处于中等水平,家庭关怀度为脑外伤患者希望水平的影响因素,提高家庭关怀度,有利于改善其希望水平。     

GCS与智残评分联合监测脑复苏

Glasgow昏迷计分对昏迷患者脑功能的监测有一定价值，但对于全脑/前脑缺血损伤患者智能监测不能量化。本文采用GCS与智残评分联合计分监测了40例昏迷患者，在一定程度上能反映脑复苏的变化趋势。根据监测结果，在药物治疗、休疗的基础上，配合智能训练，使病人智能在最大程度上得到早期治疗，收到了满意的效果。     

酒精中毒患者血液酒精浓度和尿酸水平的相关性研究

目的观察酒精中毒患者血液中酒精浓度和血清尿酸水平的动态变化与相关性。方法测定急、慢性酒精中毒患者各50例入院时血液酒精浓度和血清尿酸,正常人50例作为对照组。结果重度酒精中毒者血液酒精浓度(148±112mg/dl)、血清尿酸(568.45±46.35)μmol/L水平较正常人对照组明显升高(P均<0.05)。结论重度酒精中毒可引起体内尿酸(UA)水平升高,酒精与高尿酸血症对痛风病者极有可能带来致命性的危险。     

影响重型脑外伤患者康复效果的诸因素分析

目的：探讨影响康复因素的有关问题对重型脑外伤恢复期康复效果的影响。方法：85例重型脑外伤患治愈后随访半年，以神经功能缺损评估（GOS）为康复评判标准，设定相应分值，在年龄，Glasgow昏迷量表（GCS），脑疝，手术时间，气管切开5个方面进行组内比较。结果：44岁以下患康复效果明显优于60岁以上GCS＞6分效果优于＜6分，出现迥效果较差，脑疝前手术效果较好，气管切开效果好，结论年龄越轻，GCS评分在6－8分，无脑疝康复效果好。     

危重患者APACHE Ⅲ评分与血脂水平的关系

目的探讨危重病患者APACHEⅢ评分与血脂水平的关系.方法对综合ICU 282例危重患者入ICU后第一个24h内参数计算APACHEⅢ分值,以其分值将患者分为A组(≤60分)、B组(61～90分)、C组(91～120分)、D组(＞120分);同时抽取静脉血查血清甘油三酯(TG)、总胆固醇(TC)、高密度脂蛋白胆固醇(HDL-C)和低密度脂蛋白胆固醇(LDL-C),将APACHEⅢ分值与血脂值进行相关分析与线性回归,并对APACHEⅢ分值分组与血脂水平进行比较.结果①TG、TC、LDL-C水平与APACHEⅢ分值呈负相关(分别为TGrs=-0.121,P=0.047;TCrs=-0.160,P=0.008;LDL-Crs=-0.220,P=0.001).②TCA组与C、D组及B组与D组比较均有显著差异(P均＜0.05);HDL-CA组与B、D组,B组与A、C、D组,C组与B、D组及D组与A、B、C组比较均有显著差异(P＜0.05和＜0.01).③线性回归分析血脂各项对APACHEⅢ分值的影响从大到小依次为TC、HDL-C、TG、LDL-C;逐步回归分析显示只有TC对APACHEⅢ分值有显著性影响(P=0.009).结论随APACHEⅢ分值增高,TC、HDL-C、TG及LDL-C值下降,且TC、HDL-C下降幅度愈大,与疾病严重程度相关,综合ICU危重患者TC值结合APACHEⅢ评分可更为准确的预测其疾病的严重程度及预后.     

Glasgow Coma Scale: variation in mortality among permutations of specific total scores

Objective: The objective of this study was to determine whether different score permutations of the Glasgow Coma Scale (GCS) giving the same GCS total score were associated with significantly different mortality.¶Design: For each GCS total we compared the mortality associated with each of the different GCS permutations using a Fisher's exact test. The relationship between components of the GCS score and mortality was also examined using uni- and multivariate logistic regression.¶Setting: Data were collected from the intensive care unit at Wellington Hospital, a multidisciplinary, tertiary referral unit.¶Patients: We analysed the GCS and mortality data from all admissions over a 4 year period (January 1994–January 1998). Patients with GCS scores of 3 or 15 were excluded, since these two total scores do not have multiple permutations, leaving 1390 patients with GCS scores of 4–14 for analysis.¶Results: The incidence of mortality was significantly different for the different permutations for total GCS scores of 7, 9, 11 and 14.¶Conclusions. It is possible for patients to have the same total GCS score, but significantly different risks of mortality due to differences in the GCS profile making up that score. This suggests that GCS scores may be more useful reported in terms of profiles rather than totals. This could also have implications for the use of other scoring systems such as Acute Physiology and Chronic Health Evaluation and Simplified Acute Physiology Score.     

高压氧治疗对脑外伤患者血糖的影响

目的　探讨脑外伤后血糖改变与高压氧疗效之间的关系。方法　选取 70例脑外伤患者为研究对象 ,分为治疗组和对照组 ,以GCS评分判断疗效 ,并测定 2组患者治疗前、后的血糖浓度 ,进行比较判定。结果　治疗组治疗后GCS评分为 (11.9± 1.7)分 ,对照组评分为 (10 .7± 2 .0 )分 ,2组比较差异有非常显著性意义 (P <0 .0 1) ,治疗组疗效明显优于对照组。治疗前治疗组血糖为 (8.5 0± 4.5 5 )mmol/L ,对照组为 (8.76± 2 .78)mmol/L ,2组间差异无显著性意义 (P >0 .0 5 ) ;治疗后治疗组血糖为 (5 .46± 0 .84)mmol/L ,对照组为(6.0 4± 0 .86)mmol/L ,差异有非常显著性意义 (P <0 .0 1) ,治疗组血糖明显低于对照组。结论　脑外伤后血糖显著升高 ;高压氧能提高受损脑组织对葡萄糖的利用 ,使血糖下降 ;高压氧治疗是脑外伤的辅助治疗方法。     

The association between field Glasgow Coma Scale score and outcome in patients undergoing paramedic rapid sequence intubation

Early intubation is standard for treating severe traumatic brain injury (TBI). Aeromedical crews and select paramedic agencies use rapid sequence intubation (RSI) to facilitate intubation after TBI, with Glasgow Coma Scale (GCS) score commonly used as a screening tool. To explore the association between paramedic GCS and outcome in patients with TBI undergoing prehospital RSI, paramedics prospectively enrolled adult major trauma victims with GCS 3–8 and clinical suspicion for head trauma to undergo succinylcholine-assisted intubation as part of the San Diego Paramedic RSI Trial. The following data were abstracted from paramedic debriefing interviews and the county trauma registry: demographics, mechanism, vital signs including GCS score, clinical evidence of aspiration before RSI, arrival laboratory values, hospital course, and outcome. Paramedic GCS calculations were confirmed during debriefing interviews. Patients were stratified by GCS score, with chi-square and receiver-operator-curve (ROC) analysis used to explore the relationship between GCS and hypoxia, head injury severity, aspiration, intensive care unit (ICU) length of stay, and outcome. Cohort analysis was used to explore potential reasons for early extubation and discharge from the ICU in some patients. A total of 412 patients were included in this analysis. A total of 81 patients (20%) were extubated and discharged from the ICU in 48 h or less; these patients had higher pre-RSI oxygen saturation (SaO₂) values and higher arrival serum ethanol levels. Paramedic and physician GCS calculations had high agreement (kappa = 0.995). A statistically significant relationship was observed between GCS score and Head Abbreviated Injury Score (AIS), survival, and pre-RSI SaO₂ values. However, ROC analysis revealed a limited ability of GCS to predict the presence of severe TBI, injury severity, desaturation, aspiration, ICU length of stay, or ultimate survival. In conclusion, paramedics seem to accurately calculate GCS values before prehospital RSI. Although a relationship between paramedic GCS and outcome exists, the ability to predict the severity of injury, airway-related complications, ICU length of stay, and overall survival is limited using this single variable. Other factors should be considered to screen TBI patients for prehospital RSI.     

Prehospital use of the Glasgow Coma Scale in severe head injury

To determine the prognostic value of prehospital Glasgow Coma Scale (GCS) scores in severe blunt head injuries, the GCS at the scene of injury (INGCS) and the GCS in the emergency department (EDGCS) were compared with neurologic outcomes in 33 consecutive head-injured patients. Patients were categorized according to final outcome: Group I (n = 7) had no neurologic deficits, group II (n = 3) had only minor neurologic deficits, group III (n = 11) had major neurologic deficits, and group IV (n = 12) died. Mean INGCS was not significantly different for any of the four groups (range 4.14 to 4.67). However, mean EDGCS was significantly higher (P less than .05) for group I (9.43 +/- 4.08) than for group IV (5.17 +/- 3.13), and mean EDGCS for groups I and II (8.8 +/- 3.99) were significantly higher (P less than .05) than that of groups III and IV (5.7 +/- 2.88). The net change in GCS (EDGCS--INGCS) was significantly higher (P less than .05) for groups I and II (4.5 +/- 4.4) than for groups III and IV (1.3 +/- 2.91). We conclude that INGCS alone has no prognostic value, but that EDGCS and any prehospital change in GCS may have prognostic value for severely head-injured patients.     

The status of the Glasgow Coma Scale

The Glasgow Coma Scale (GCS) was first introduced in the 1970s to provide a simple and reliable method of recording and monitoring change in the level of consciousness of head injured patients. Since its introduction, the GCS has been widely utilized in the trauma community and its use expanded beyond the original intentions of the score. In the context of traumatic injury, this paper discusses the use of the GCS as a predictor of outcome, the limitations of the GCS, the reliability of the GCS and potential alternatives through a critical review of the literature. The relevance to Australian trauma populations is also addressed.     

Decreased Glasgow Coma Scale Score Does Not Mandate Endotracheal Intubation in the Emergency Department

Background: Decreased consciousness is a common reason for presentation to the emergency department (ED) and admission to acute hospital beds. In trauma, a Glasgow Coma Scale score (GCS) of 8 or less indicates a need for endotracheal intubation. Some advocate a similar approach for other causes of decreased consciousness, however, the loss of airway reflexes and risk of aspiration cannot be reliably predicted using the GCS alone. Study Objective: A survey of all poisoned patients with a decreased GCS who were admitted to an ED short-stay ward staffed by experienced emergency physicians, to establish the incidence of clinically significant aspiration or other morbidities and endotracheal intubation. Methods: A prospective, observational study was conducted of all patients admitted to the ED short-stay ward with a decreased level of consciousness (GCS < 15). Results: The study included 73 patients with decreased consciousness as a result of drug or alcohol intoxication. The GCS ranged from 3 to 14, and 12 patients had a GCS of 8 or less. No patient with a GCS of 8 or less aspirated or required intubation. There was one patient who required intubation; this patient had a GCS of 12 on admission to the ward. Conclusions: This study suggests that it can be safe to observe poisoned patients with decreased consciousness, even if they have a GCS of 8 or less, in the ED.     

A Comparison of Five Simplified Scales to the Out-of-hospital Glasgow Coma Scale for the Prediction of Traumatic Brain Injury Outcomes

Background: The 15-point Glasgow Coma Scale (GCS) frequently is used in the initial evaluation of traumatic brain injury (TBI) in out-of-hospital settings. We hypothesized that the GCS might be unnecessarily complex for out-of-hospital use.
Objectives: To assess whether a simpler scoring system might demonstrate similar accuracy in the prediction of TBI outcomes.
Methods: We performed a retrospective analysis of a trauma registry consisting of patients evaluated at our Level 1 trauma center from 1990 to 2002. The ability of out-of-hospital GCS scores to predict four clinically relevant TBI outcomes (emergency intubation, neurosurgical intervention, brain injury, and mortality) by using areas under receiver operating characteristic curves (AUROCs) was calculated. The same analyses for five simplified scales were performed, and compared with the predictive accuracies of the total GCS score.
Results: In this evaluation of 7,233 trauma patients over a 12-year period of time, the AUROCs for the total GCS score were 0.83 (95% confidence interval [CI] = 0.81 to 0.84) for emergency intubation, 0.86 (95% CI = 0.85 to 0.88) for neurosurgical intervention, 0.83 (95% CI = 0.82 to 0.84) for brain injury, and 0.89 (95% CI = 0.88 to 0.90) for mortality. The five simplified scales approached the performance of the total GCS score for all clinical outcomes.
Conclusions: In the evaluation of injured patients, five simplified neurological scales approached the performance of the total GCS score for the prediction of four clinically relevant TBI outcomes.     

对护士实施格拉斯哥昏迷评分的评价

目的 为了解护士对意识障碍病人格拉斯哥昏迷评分(Glasgow Coma Scale，GCS)掌握的情况。方法 护士在神经外科ICU对意识障碍病人进行200次Clasgow昏迷评分，并对结果进行分析，组织护士学习前后的评分结果进行对比。结果 组织护士学习前GCS评分的正确率为62％，学习后的正确率为96％。结论 通过不断地学习和实践，对护士评分的正确性有很大帮助。建议ICU护士应不断加强学习，以期得出正确的结论，为病人的护理提供准确的依据。     

Variability in agreement between physicians and nurses when measuring the Glasgow Coma Scale in the emergency department limits its clinical usefulness

Objective: To assess the interrater reliability of the Glasgow Coma Scale (GCS) between nurses and senior doctors in the ED. Methods: This was a prospective observational study with a convenience sample of patients aged 18 or above who presented with a decreased level of consciousness to a tertiary hospital ED. A senior ED doctor (emergency physicians and trainees) and registered nurse each independently scored the patient’s GCS in blinded fashion within 15 min of each other. The data were then analysed to determine interrater reliability using the weighted kappa statistic and the size and directions of differences between paired scores were examined. Results: A total of 108 eligible patients were enrolled, with GCS scores ranging from 3 to 14. Interrater agreement was excellent (weighted kappa > 0.75) for verbal scores and total GCS scores, and intermediate (weighted kappa 0.4–0.75) for motor and eye scores. Total GCS scores differed by more than two points in 10 of the 108 patients. Interrater agreement did not vary substantially across the range of actual numeric GCS scores. Conclusions: Although the level of agreement for GCS scores was generally high, a significant proportion of patients had GCS scores which differed by two or more points. This degree of disagreement indicates that clinical decisions should not be based solely on single GCS scores.     

Performance of the Pediatric Glasgow Coma Scale in Children with Blunt Head Trauma

Objectives: To compare the accuracy of a pediatric Glasgow Coma Scale (GCS) score in preverbal children with blunt head trauma with the standard GCS score in older children. Methods: The authors prospectively enrolled children younger than 18 years with blunt head trauma. Patients were divided into cohorts of those 2 years and younger and those older than 2 years. The authors assigned a pediatric GCS score to the younger cohort and the standard GCS score to the older cohort. Outcomes were 1) traumatic brain injury (TBI) on computed tomography (CT) scan or 2) TBI in need of acute intervention. The authors created and compared receiver operating characteristic (ROC) curves between the age cohorts for the association of GCS scores and TBI. Results: The authors enrolled 2,043 children, and 327 were 2 years and younger. Among these 327, 15 (7.7%; 95% confidence interval [CI] = 4.4% to 12.4%) of 194 who underwent imaging with CT had TBI visible and nine (2.8%; 95% CI = 1.3% to 5.2%) had TBI needing acute intervention. In children older than 2 years, 83 (7.7%; 95% CI = 6.2% to 9.5%) of the 1,077 who underwent imaging with CT had TBI visible and 96 (5.6%; 95% CI = 4.6% to 6.8%) had TBI needing acute intervention. For the pediatric GCS in children 2 years and younger, the area under the ROC curve was 0.72 (95% CI = 0.56 to 0.87) for TBI on CT scan and 0.97 (95% CI = 0.94 to 1.00) for TBI needing acute intervention. For the standard GCS in older children, the area under the ROC curve was 0.82 (95% CI = 0.76 to 0.87) for TBI on CT scan and 0.87 (95% CI = 0.83 to 0.92) for TBI needing acute intervention. Conclusions: This pediatric GCS for children 2 years and younger compares favorably with the standard GCS in the evaluation of children with blunt head trauma. The pediatric GCS is particularly accurate in evaluating preverbal children with blunt head trauma with regard to the need for acute intervention.