Validation of the Simplified Motor Score in the Out-of-Hospital Setting for the Prediction of Outcomes After Traumatic Brain Injury

Comparison of on-scene Glasgow Coma Scale with GCS-motor for prediction of 30-day mortality and functional outcomes of patients with trauma in Asia

BACKGROUND AND IMPORTANCE

This study compared the on-scene Glasgow Coma Scale (GCS) and the GCS-motor (GCS-M) for predictive accuracy of mortality and severe disability using a large, multicenter population of trauma patients in Asian countries.

OBJECTIVE

To compare the ability of the prehospital GCS and GCS-M to predict 30-day mortality and severe disability in trauma patients.

DESIGN

We used the Pan-Asia Trauma Outcomes Study registry to enroll all trauma patients >18 years of age who presented to hospitals via emergency medical services from 1 January 2016 to November 30, 2018.

SETTINGS AND PARTICIPANTS

A total of 16,218 patients were included in the analysis of 30-day mortality and 11 653 patients in the analysis of functional outcomes.

OUTCOME MEASURES AND ANALYSIS

The primary outcome was 30-day mortality after injury, and the secondary outcome was severe disability at discharge defined as a Modified Rankin Scale (MRS) score ≥4. Areas under the receiver operating characteristic curve (AUROCs) were compared between GCS and GCS-M for these outcomes. Patients with and without traumatic brain injury (TBI) were analyzed separately. The predictive discrimination ability of logistic regression models for outcomes (30-day mortality and MRS) between GCS and GCS-M is illustrated using AUROCs.

MAIN RESULTS

The primary outcome for 30-day mortality was 1.04% and the AUROCs and 95% confidence intervals for prediction were GCS: 0.917 (0.887-0.946) vs. GCS-M:0.907 (0.875-0.938), P  = 0.155. The secondary outcome for poor functional outcome (MRS ≥ 4) was 12.4% and the AUROCs and 95% confidence intervals for prediction were GCS: 0.617 (0.597-0.637) vs. GCS-M: 0.613 (0.593-0.633), P  = 0.616. The subgroup analyses of patients with and without TBI demonstrated consistent discrimination ability between the GCS and GCS-M. The AUROC values of the GCS vs. GCS-M models for 30-day mortality and poor functional outcome were 0.92 (0.821-1.0) vs. 0.92 (0.824-1.0) ( P  = 0.64) and 0.75 (0.72-0.78) vs. 0.74 (0.717-0.758) ( P  = 0.21), respectively.

CONCLUSION

In the prehospital setting, on-scene GCS-M was comparable to GCS in predicting 30-day mortality and poor functional outcomes among patients with trauma, whether or not there was a TBI.

Reverse shock index multiplied by simplified motor score as a predictor of clinical outcomes for patients with COVID-19

BACKGROUND

The reverse shock index (rSI) combined with the Simplified Motor Score (sMS), that is, the rSI-sMS, is a novel and efficient prehospital triage scoring system for patients with COVID-19. In this study, we evaluated the predictive accuracy of the rSI-sMS for general ward and intensive care unit (ICU) admission among patients with COVID-19 and compared it with that of other measures, including the shock index (SI), modified SI (mSI), rSI combined with the Glasgow Coma Scale (rSI-GCS), and rSI combined with the GCS motor subscale (rSI-GCSM).

METHODS

All patients who visited the emergency department of Taipei Tzu Chi Hospital between January 2021 and June 2022 were included in this retrospective cohort. A diagnosis of COVID-19 was confirmed through a SARS-CoV-2 reverse-transcription polymerase chain reaction test or SARS-CoV-2 rapid test with oropharyngeal or nasopharyngeal swabs and was double confirmed by checking International Classification of Diseases, Tenth Revision, Clinical Modification codes in electronic medical records. In-hospital mortality was regarded as the primary outcome, and sepsis, general ward or ICU admission, endotracheal intubation, and total hospital length of stay (LOS) were regarded as secondary outcomes. Multivariate logistic regression was used to determine the relationship between the scoring systems and the three major outcomes of patients with COVID-19, including. The discriminant ability of the predictive scoring systems was investigated using the area under the receiver operating characteristic curve, and the most favorable cutoff value of the rSI-sMS for each major outcome was determined using Youden's index.

RESULTS

After 74,183 patients younger than 20 years (n = 11,572) and without COVID-19 (n = 62,611) were excluded, 9,282 patients with COVID-19 (median age: 45 years, interquartile range: 33-60 years, 46.1% men) were identified as eligible for inclusion in the study. The rate of in-hospital mortality was determined to be 0.75%. The rSI-sMS scores were significantly lower in the patient groups with sepsis, hyperlactatemia, admission to a general ward, admission to the ICU, total length of stay ≥ 14 days, and mortality. Compared with the SI, mSI, and rSI-GCSM, the rSI-sMS exhibited a significantly higher accuracy for predicting general ward admission, ICU admission, and mortality but a similar accuracy to that of the rSI-GCS. The optimal cutoff values of the rSI-sMS for predicting general ward admission, ICU admission, and mortality were calculated to be 3.17, 3.45, and 3.15, respectively, with a predictive accuracy of 86.83%, 81.94%%, and 90.96%, respectively.

CONCLUSIONS

Compared with the SI, mSI, and rSI-GCSM, the rSI-sMS has a higher predictive accuracy for general ward admission, ICU admission, and mortality among patients with COVID-19.

PREHOSPITAL SHOCK INDEX MULTIPLIED BY AVPU SCALE AS A PREDICTOR OF CLINICAL OUTCOMES IN TRAUMATIC INJURY

ABSTRACT

Objectives: Many prehospital trauma triage scores have been proposed, but none has emerged as a criterion standard. Therefore, a rapid and accurate tool is necessary for field triage. The shock index (SI) multiplied by the AVPU (Alert, responds to Voice, responds to Pain, Unresponsive) score (SIAVPU) reflected the hemodynamic and neurological conditions through a combination of the SI and AVPU. This study aimed to investigate the prediction performance of SI multiplied by the AVPU and to compare the prediction performance of other prehospital trauma triage scores in a population with traumatic injury. Patients and Methods: This study included 6,156 patients with trauma injury from the Taipei Tzu Chi trauma database. We investigated the accuracy of four scoring systems in predicting mortality, intensive care unit (ICU) admission, and prolonged hospital stay (defined as a duration of hospitalization >14 days). In the subgroup analysis, we also analyzed the effects of age, injury mechanism and severity, underlying diseases, and traumatic brain injury. Results: The predictive accuracy of SIAVPU for mortality, ICU admission, and prolonged hospital stay was significantly higher than that of SI, modified SI, and SI multiplied by age in the traumatic injury population, with an area under the receiver operating characteristic curve of 0.738 for mortality, 0.641 for ICU admission, and 0.606 for prolonged hospital stay. In the subgroup analysis, the prediction accuracy of mortality, ICU admission, and prolonged hospital stay of SIAVPU was also better in patients with younger age, older age, major trauma (Injury Severity Score ≥16), motor vehicle collisions, fall injury, healthy, cardiovascular disease, mixed traumatic brain injury, and isolated traumatic brain injury. The best cutoff levels of SIAVPU score to predict mortality, ICU admission, and total length of stay ≥14 days in trauma injury patients were 0.90, 0.82, and 0.80, with accuracies of 88.56%, 79.84%, and 78.62%, respectively. Conclusions: In conclusion, SIAVPU is a rapid and accurate field triage score with better prediction accuracy for mortality, ICU admission, and prolonged hospital stay than SI, modified SI, and SI multiplied by age in patients with trauma. Patients with SIAVPU ≥0.9 should be considered for the highest-level trauma center available within the geographic constraints of regional trauma systems.

Validation of the Japan Coma Scale for the prediction of mortality in children: analysis of a nationwide trauma database

Objective

The Japan Coma Scale (JCS) is widely used in clinical practice to evaluate levels of consciousness in Japan. There have been several studies on the usefulness of JCS in adults. However, its usefulness in evaluating children has not been reported. Therefore, this study aimed to assess the usefulness of the JCS for the prediction of mortality in children.

Methods

This is a multicenter cohort study which used data from a national trauma registry (Japan Trauma Data Bank). This study included patients under 16 years of age who were treated between 2004 and 2015.

The primary outcome measure was in-hospital mortality. Two models were used to examine each item of the Glasgow Coma Scale (GCS) and the JCS. Model A included the discrete levels of each index. In model B, data regarding age, sex, vital signs on arrival to hospital, the Injury Severity Score, and blunt trauma were added to each index. The effectivity of the JCS score was then evaluated using the area under the curve (AUC) for discrimination, a calibration plot, and the Hosmer-Lemeshow test for calibration.

Results

A total of 9045 patients were identified. The AUCs of the GCS and JCS were 0.929 (95% confidence interval (CI) 0.904 to 0.954) and 0.930 (95% CI 0.906 to 0.954) in model A and 0.975 (95% CI 0.963 to 0.987) and 0.974 (95% CI 0.963 to 0.985) in model B, respectively. The results of the Hosmer-Lemeshow test were 0.00 (p=1.00) and 0.00 (p=1.00) in model A and 4.14 (p=0.84) and 8.55 (p=0.38) in model B for the GCS and JCS, respectively.

Conclusions

We demonstrated that the JCS is as valid as the GCS for predicting mortality. The findings of this study indicate that the JCS is a useful and relevant tool for pediatric trauma care and future research.

Parenteral nutrition prolongs hospital stay in children with nonoperative blunt pancreatic injury: A propensity score weighted analysis

BACKGROUND

Blunt pancreatic injury is frequently managed nonoperatively in children. Nutritional support practices - either enteral or parenteral - are heterogeneous and lack evidence-based guidelines. We hypothesized that use of parenteral nutrition (PN) in children with nonoperatively managed blunt pancreatic injury would 1) be associated with longer hospital stay and more frequent complications, and 2) differ in frequency by trauma center type.

METHODS

We conducted a retrospective cohort study using the National Trauma Data Bank (2007-2016). Children (≤18 years) with blunt pancreatic injury were included. Patients were excluded for duodenal injury, mortality <4 days from admission, or laparotomy. We compared children that received versus those that did not receive PN. Logistic regression was used to model patient characteristics, injury severity, and trauma center type as predictors for propensity to receive PN. Treatment groups were balanced using the inverse probability of treatment weights. Outcomes included hospital length of stay, intensive care unit days, incidence of complications and mortality.

RESULTS

554 children with blunt pancreatic injury were analyzed. PN use declined in adult centers from 2012 to 2016, but remained relatively stable in pediatric centers. Propensity-weighted analysis demonstrated longer median length of stay in patients receiving PN (14 versus 4 days, rate ratio 2.19 [95% CI: 1.97, 2.43]). Children receiving PN also had longer ICU stay (rate ratio 1.73 [95% CI: 1.30, 2.30]). There was no significant difference in incidence of complications or mortality.

CONCLUSIONS

Use of PN in children with blunt pancreatic injury that are managed nonoperatively differs between adult and pediatric trauma centers, and is associated with longer hospital stay. Early enteral feeding should be attempted first, with PN reserved for children with prolonged intolerance to enteral feeds.

LEVEL OF EVIDENCE

III, Retrospective cohort.

Association between the Japan Coma Scale scores at the scene of injury and in-hospital outcomes in trauma patients: an analysis from the nationwide trauma database in Japan

OBJECTIVE

Japan Coma Scale (JCS) is a grading system used to evaluate disturbed consciousness in prehospital care settings. We aimed to identify the association between the JCS levels at the scene with in-hospital mortality, as well as the discrimination ability for the outcomes.

DESIGN

A retrospective cohort study based on the nationwide trauma database in Japan.

SETTING

Multicentre cohort study using data from the Japan Trauma Data Bank, which is a nationwide, prospective, observational trauma registry derived from 235 hospitals.

PARTICIPANTS

Adult trauma victims transferred directly from the scene of injury to the hospital from January 2004 to December 2017 were eligible for inclusion.

PRIMARY AND SECONDARY OUTCOMES

Primary outcome was the association between the JCS levels at the scene with in-hospital mortality. We conducted a multivariate logistic regression analysis to calculate the adjusted ORs of JCS levels with 95% CIs for in-hospital mortality. We also calculated the c-statistics for in-hospital mortality.

RESULTS

164 723 patients were included in the analysis. In a multivariate logistic regression analysis, the corresponding adjusted ORs of JCS levels 2 and 3 referred to level 1 for in-hospital mortality were 4.1 (95% CI 3.8 to 4.4) and 26.0 (95% CI 24.8 to 27.2). The c-statistics of the JCS level for in-hospital mortality was 0.845 (95% CI 0.842 to 0.849).

CONCLUSIONS

Data from large multicentre prospective registry revealed strong associations of the JCS level at the scene of injury with in-hospital mortality as well as the good discriminatory performance for this outcome.

Management of severe traumatic brain injury (first 24hours)

The latest French Guidelines for the management in the first 24hours of patients with severe traumatic brain injury (TBI) were published in 1998. Due to recent changes (intracerebral monitoring, cerebral perfusion pressure management, treatment of raised intracranial pressure), an update was required. Our objective has been to specify the significant developments since 1998. These guidelines were conducted by a group of experts for the French Society of Anesthesia and Intensive Care Medicine (Société francaise d'anesthésie et de réanimation [SFAR]) in partnership with the Association de neuro-anesthésie-réanimation de langue française (ANARLF), The French Society of Emergency Medicine (Société française de médecine d'urgence (SFMU), the Société française de neurochirurgie (SFN), the Groupe francophone de réanimation et d'urgences pédiatriques (GFRUP) and the Association des anesthésistes-réanimateurs pédiatriques d'expression française (ADARPEF). The method used to elaborate these guidelines was the Grade^® method. After two Delphi rounds, 32 recommendations were formally developed by the experts focusing on the evaluation the initial severity of traumatic brain injury, the modalities of prehospital management, imaging strategies, indications for neurosurgical interventions, sedation and analgesia, indications and modalities of cerebral monitoring, medical management of raised intracranial pressure, management of multiple trauma with severe traumatic brain injury, detection and prevention of post-traumatic epilepsia, biological homeostasis (osmolarity, glycaemia, adrenal axis) and paediatric specificities.

Clinical diagnosis versus autopsy diagnosis in head trauma

The correct and complete diagnosis is essential for the adequate care and the favourable clinical evolution of the patients with head trauma. Purpose: To identify the error rate in the clinical diagnosis of head injuries as shown in comparison with the autopsy diagnosis and to identify the most common sources of error. Material and method: We performed a retrospective study based on data from the medical files and the autopsy reports of patients with head trauma who died in the hospital and underwent forensic autopsy. We collected: demographic data, clinical and laboratory data and autopsy findings. To quantify the concordance rate between the clinical diagnosis of death and the autopsy diagnosis we used a 4 classes classification, which ranged from 100% concordance (C1) to total discordance (C4) and two classes of partial discordance: C2 (partial discordance in favour of the clinical diagnosis- missing injuries in the autopsy reports) and C3 (partial discordance in favor of the necroptic diagnosis- missing injuries in the medical files). Data were analyzed with SPSS version 20.0. Results: We analyzed 194 cases of death due to head injuries. We found a total concordance between the clinical death diagnosis and autopsy diagnosis in 30.4% of cases and at least one discrepancy in 69.6% of cases. Increasing the duration of hospitalization directly correlates with the amount of the imaging investigations and these in turn correlates with an increased rate of diagnosis concordance. Among the patients with stage 3 coma who associated a spinal cord injury, we found a partial diagnosis discordance in 50% of cases and a total discordance in 50% of cases, possibly due to the need for conducting emergency imaging investigation and the need for surgical treatment. In cases with partial and total discordant diagnosis, at least one lesion was omitted in 45.1% of the cases. The most commonly omitted injuries in C2 cases were subdural hematoma, intracerebral hematoma and ventricular hemorrhage (21.6%). In C3 cases the most frequently omitted injuries were subarachnoidian hemorrhage and skull base fractures (17.9%). Conclusions: The clinical cause of death is not always concordant with the autopsy diagnosis. Autopsy may identify the inconsistencies in diagnosis, the injuries frequently skipped and the factors favoring the discordance rate between the clinical death diagnosis and the autopsy diagnosis, making it a valuable tool for improving the clinical care of the patients with head trauma.

The Glasgow Coma Scale and evidence-informed practice: a critical review of where we are and where we need to be

AIMS AND OBJECTIVES

This paper aims to critically consider the evidence since the Glasgow Coma Scale was first launched, reflecting on how that evidence has shaped practice. It illustrates the lack of clarity and consensus about the use of the tool in practice and draws upon existing evidence to determine the route to clarity for an evidence-informed approach to practice.

BACKGROUND

The Glasgow Coma Scale has permeated and influenced practice for over 40 years, being well-established worldwide as the key tool for assessing level of consciousness. During this time, the tool has been scrutinised, evaluated, challenged and re-launched in a plethora of publications. This has led to an insight into the challenges, and to some extent the opportunities, in using the Glasgow Coma Scale in practice but has also resulted in a lack of clarity.

DESIGN

This is a discursive paper that invites readers to explore and arrive at a more comprehensive understanding of the Glasgow Coma Scale in practice and is based on searches of Scopus, Web of Knowledge, PubMed, Science Direct and CINAHL databases.

RESULTS

While the Glasgow Coma Scale has been rivalled by other tools in an attempt to improve upon it, a shift in practice to those tools has not occurred. The tool has withstood the test of time in this respect, indicating the need for further research into its use and a clear education strategy to standardise implementation in practice.

CONCLUSION

Further exploration is needed into the application of painful stimuli in using the Glasgow Coma Scale to assess level of consciousness. In addition, a robust educational strategy is necessary to maximise consistency in its use in practice.

RELEVANCE TO CLINICAL PRACTICE

The evidence illustrates inconsistency and confusion in the use of the Glasgow Coma Scale in practice; this has the potential to compromise care and clarity around the issues is therefore necessary.

Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD): explanation and elaboration

The TRIPOD (Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis) Statement includes a 22-item checklist, which aims to improve the reporting of studies developing, validating, or updating a prediction model, whether for diagnostic or prognostic purposes. The TRIPOD Statement aims to improve the transparency of the reporting of a prediction model study regardless of the study methods used. This explanation and elaboration document describes the rationale; clarifies the meaning of each item; and discusses why transparent reporting is important, with a view to assessing risk of bias and clinical usefulness of the prediction model. Each checklist item of the TRIPOD Statement is explained in detail and accompanied by published examples of good reporting. The document also provides a valuable reference of issues to consider when designing, conducting, and analyzing prediction model studies. To aid the editorial process and help peer reviewers and, ultimately, readers and systematic reviewers of prediction model studies, it is recommended that authors include a completed checklist in their submission. The TRIPOD checklist can also be downloaded from www.tripod-statement.org.

The prehospital management of traumatic brain injury

Traumatic brain injury (TBI) is an important cause of death and disability, particularly in younger populations. The prehospital evaluation and management of TBI is a vital link between insult and definitive care and can have dramatic implications for subsequent morbidity. Following a TBI the brain is at high risk for further ischemic injury, with prehospital interventions targeted at reducing this secondary injury while optimizing cerebral physiology. In the following chapter we discuss the prehospital assessment and management of the brain-injured patient. The initial evaluation and physical examination are discussed with a focus on interpretation of specific physical examination findings and interpretation of vital signs. We evaluate patient management strategies including indications for advanced airway management, oxygenation, ventilation, and fluid resuscitation, as well as prehospital strategies for the management of suspected or impending cerebral herniation including hyperventilation and brain-directed hyperosmolar therapy. Transport decisions including the role of triage models and trauma centers are discussed. Finally, future directions in the prehospital management of traumatic brain injury are explored.

Evaluation and treatment of trauma related collapse in athletes

Although blunt traumatic injuries are common in athletes, life-threatening trauma is fortunately rare. Most current literature has focused on nontraumatic causes of athlete death though traumatic injuries may be more common. Although prevention of these injuries may be more difficult than nontraumatic causes, prompt recognition and treatment is paramount. Common traumatic causes of collapse athlete generally involve the head, neck, and trunk and are more frequent in collision sports. Other higher risk sports include track and field, cheerleading, snow sports, and those involving motorized vehicles. Health care providers who participate in sports coverage should be aware of the potential for these injuries as emergency treatment is required to maximize outcomes. Emergency action plans allow providers to expediently activate emergency management services while providing treatment and stabilization.

Identification of a neurologic scale that optimizes EMS detection of older adult traumatic brain injury patients who require transport to a trauma center

OBJECTIVE

We sought to identify a scale or components of a scale that optimize detection of older adult traumatic brain injury (TBI) patients who require transport to a trauma center, regardless of mechanism.

METHODS

We assembled a consensus panel consisting of nine experts in geriatric emergency medicine, prehospital medicine, trauma surgery, geriatric medicine, and TBI, as well as prehospital providers, to evaluate the existing scales used to identify TBI. We reviewed the relevant literature and solicited group feedback to create a list of candidate scales and criteria for evaluation. Using the nominal group technique, scales were evaluated by the expert panel through an iterative process until consensus was achieved.

RESULTS

We identified 15 scales for evaluation. The panel's criteria for rating the scales included ease of administration, prehospital familiarity with scale components, feasibility of use with older adults, time to administer, and strength of evidence for their performance in the prehospital setting. After review and discussion of aggregated ratings, the panel identified the Simplified Motor Scale, GCS-Motor Component, and AVPU (alert, voice, pain, unresponsive) as the strongest scales, but determined that none meet all EMS provider and patient needs due to poor usability and lack of supportive evidence. The panel proposed that a dichotomized decision scheme that includes domains of the top-rated scales -level of alertness (alert vs. not alert) and motor function (obeys commands vs. does not obey) -may be more effective in identifying older adult TBI patients who require transport to a trauma center in the prehospital setting.

CONCLUSIONS

Existing scales to identify TBI are inadequate to detect older adult TBI patients who require transport to a trauma center. A new algorithm, derived from elements of previously established scales, has the potential to guide prehospital providers in improving the triage of older adult TBI patients, but needs further evaluation prior to use.

Randomized controlled trial of a scoring aid to improve Glasgow Coma Scale scoring by emergency medical services providers

STUDY OBJECTIVE

Emergency medical services (EMS) personnel frequently use the Glasgow Coma Scale (GCS) to assess injured and critically ill patients. This study assesses the accuracy of EMS providers' GCS scoring, as well as the improvement in GCS score assessment with the use of a scoring aid.

METHODS

This randomized, controlled study was conducted in the emergency department (ED) of an urban academic trauma center. Emergency medical technicians or paramedics who transported a patient to the ED were randomly assigned one of 9 written scenarios, either with or without a GCS scoring aid. Scenarios were created by consensus of expert attending emergency medicine, EMS, and neurocritical care physicians, with universal consensus agreement on GCS scores. χ(2) And Student's t tests were used to compare groups.

RESULTS

Of 180 participants, 178 completed the study. Overall, 73 of 178 participants (41%) gave a GCS score that matched the expert consensus score. GCS score was correct in 22 of 88 (25%) cases without the scoring aid. GCS was correct in 51 of 90 (57%) cases with the scoring aid. Most (69%) of the total GCS scores fell within 1 point of the expert consensus GCS score. Differences in accuracy were most pronounced in scenarios with a correct GCS score of 12 or below. Subcomponent accuracy was eye 62%, verbal 70%, and motor 51%.

CONCLUSION

In this study, 60% of EMS participants provided inaccurate GCS score estimates. Use of a GCS scoring aid improved accuracy of EMS GCS score assessments.

Patients with severe traumatic brain injury transferred to a Level I or II trauma center: United States, 2007 to 2009

BACKGROUND

Patients with severe traumatic brain injury (TBI), head Abbreviated Injury Scale (AIS) score of 3 or greater, who are indirectly transported from the scene of injury to a nontrauma center can experience delays to definitive neurosurgical management. Transport to a hospital with appropriate initial emergency department treatment and rapid admission has been shown to reduce mortality in a state's trauma system. This study was conducted to see if the same finding holds with a nationally representative sample of patients with severe TBI seen at Level I and II trauma centers.

METHODS

This study is based on adult (≥18 years), severe TBI patients treated in a nationally representative sample of Level I and II trauma centers, submitting data to the National Trauma Databank National Sample Program from 2007 to 2009. We analyzed independent variables including age, sex, primary payer, race, ethnicity, mode of transport, injury type (blunt vs. penetrating), mechanism of injury, trauma center level, head AIS, initial Glasgow Coma Scale (GCS), Injury Severity Score (ISS), and systolic blood pressure by transfer status. The primary outcome variable was inpatient death, with discharge disposition, neurosurgical procedures, and mean hospital, intensive care unit, and ventilator days serving as secondary outcomes.

RESULTS

After exclusion criteria were applied (ISS < 16; age < 18 years; GCS motor score = 6; non-head AIS score ≥ 3; head AIS < 3; patients with missing transfer status, and death on arrival), a weighted sample of 51,300 (16%) patients was eligible for analysis. In bivariate analyses, transferred patients were older (≥60 years), white, insured, less severely injured (head AIS score ≤ 4, ISS ≤ 25), and less likely to have sustained penetrating trauma (p < 0.001). After controlling for all variables, direct transport, 1 or more comorbidities, advanced age, head AIS score, intracranial hemorrhage, and firearm injury remained significant predictors of death. Being transferred (adjusted odds ratio, 0.79; 95% confidence interval, 0.64-0.96) lowered the risk of death.

CONCLUSION

Patients with severe TBI who were transferred to a Level I or II trauma center had lower injury severity, including less penetrating trauma, and, as a result, were less likely to die compared with patients who were directly admitted to a Level I or II trauma center. The results may demonstrate adherence with the current Guidelines for Prehospital Management of Traumatic Brain Injury and Guidelines for Field Triage of Injured Patients, which recommend the direct transport of patients with severe TBI to the highest level trauma center. Patients with severe TBI who cannot be taken to a trauma center should be stabilized at a nontrauma center and then transferred to a Level I or II trauma center. Regional and national trauma databases should consider collecting information on patient outcomes at referral facilities and total transport time after injury, to better address the outcomes of patient triage decisions.

LEVEL OF EVIDENCE

Prognostic study, level III; therapeutic study, level IV.

Predictive value of initial Glasgow coma scale score in pediatric trauma patients

OBJECTIVE

The objective of this study was to determine the predictive value of the Glasgow coma scale (GCS) and the Glasgow motor component (GMC) for overall mortality, death on arrival, and major injury and the relationship between GCS and length of stay (LOS) in the emergency department (ED) and hospital.

METHODS

Records from the American College of Surgeons National Trauma Data Base from 2007 to 2009 were extracted. Patients 0 to 18 years old transported from a trauma scene with complete initial scene data were included. Statistical analysis, including construction of receiver-operator curves, determined the correlation between GCS, GMC, and the clinical outcomes of interest.

RESULTS

There were 104,035 records with complete data for analysis, including 3946 deaths. Mean patient age was 12.6 (SD, 5.5) years. Glasgow coma scale was predictive of overall mortality, with area under the receiver-operator curve (AUC) of 0.946 (95% confidence interval [CI], 0.941-0.951); death on arrival, with AUC of 0.958 (95% CI, 0.953-0.963); and risk of major injury, with AUC of 0.720 (0.715-0.724). Lower GCS scores were associated with shorter ED LOS and longer hospital stays (P <0.001, analysis of variance) except GCS 3, associated with shorter hospitalizations. For predicting overall mortality, the AUC for GMC was 0.940 (95% CI, 0.935-0.945), and for predicting major injury, the AUC was 0.681 (95% CI, 0.677-0.686).

CONCLUSIONS

For pediatric trauma victims, the GCS is predictive of mortality and injury outcomes, as well as both ED and hospital LOS, and has excellent prognostic accuracy. The GMC has predictive value for injury and mortality that is nearly equivalent to the full GCS.

Global emergency medicine: a review of the literature from 2011

OBJECTIVES

The Global Emergency Medicine Literature Review (GEMLR) conducts an annual search of published and unpublished articles relevant to global emergency medicine (EM) to identify, review, and disseminate the most important research in this field to a wide audience of academics and practitioners.

METHODS

This year, 7,924 articles written in seven languages were identified by our search. These articles were divided up among 20 reviewers for initial screening based on their relevance to the field of global EM. An additional two reviewers searched the grey literature. A total of 206 articles were deemed appropriate by at least one reviewer and approved by their editor for formal scoring of their overall quality and importance.

RESULTS

Of the 206 articles that met our predetermined inclusion criteria, 24 articles received scores of 17 or higher and were selected for formal summary and critique. Interrater reliability for our scoring system was good with an interclass correlation coefficient of 0.628 (95% confidence interval = 0.51 to 0.72).

CONCLUSIONS

Compared to previous reviews, there was a significant increase in the number of articles that were devoted to emergency care in resource-limited settings, with fewer articles related to disaster and humanitarian response. The majority of articles that met our selection criteria were reviews that examined the efficacy of particular treatment regimens for diseases that are primarily seen in low- and middle-income countries.