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Podell JE, Morris NA. Traumatic Brain Injury and Traumatic Spinal Cord Injury. Continuum (Minneap Minn) 2024; 30:721-756. [PMID: 38830069 DOI: 10.1212/con.0000000000001423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE This article reviews the mechanisms of primary traumatic injury to the brain and spinal cord, with an emphasis on grading severity, identifying surgical indications, anticipating complications, and managing secondary injury. LATEST DEVELOPMENTS Serum biomarkers have emerged for clinical decision making and prognosis after traumatic injury. Cortical spreading depolarization has been identified as a potentially modifiable mechanism of secondary injury after traumatic brain injury. Innovative methods to detect covert consciousness may inform prognosis and enrich future studies of coma recovery. The time-sensitive nature of spinal decompression is being elucidated. ESSENTIAL POINTS Proven management strategies for patients with severe neurotrauma in the intensive care unit include surgical decompression when appropriate, the optimization of perfusion, and the anticipation and treatment of complications. Despite validated models, predicting outcomes after traumatic brain injury remains challenging, requiring prognostic humility and a model of shared decision making with surrogate decision makers to establish care goals. Penetrating injuries, especially gunshot wounds, are often devastating and require public health and policy approaches that target prevention.
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de Souza JC, Letson HL, Gibbs CR, Dobson GP. The burden of head trauma in rural and remote North Queensland, Australia. Injury 2024; 55:111181. [PMID: 37951809 DOI: 10.1016/j.injury.2023.111181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/29/2023] [Accepted: 10/31/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Head trauma is a leading cause of death and disability worldwide. Young males, Indigenous people, and rural/remote residents have been identified as high-risk populations for head trauma, however, Australian research is limited. Our aim was to define and describe the incidence, demographics, causes, prehospital interventions, and outcomes of head trauma patients transported by aeromedical services within North Queensland, Australia. We hypothesized that young, Indigenous males living remotely would be disproportionately affected by head trauma. METHODS We conducted a retrospective study of all head trauma patients transferred by air to or between Townsville, Cairns, Mount Isa and Mackay Hospitals between January 1, 2016 and December 31, 2018. Patients were identified from the Trauma Care in the Tropics data registry and followed for a median 30-months post-injury. Primary endpoints were patient and injury characteristics. Secondary outcome measures were hospital stay and mortality. RESULTS A total of 981 patients were included and 31.1 % were Indigenous. Sixty-seven percent of injuries occurred remotely and the median time from injury to hospital was 5.8-hours (range 67-3780 min). Eighty percent of severe head injuries occurred in males (p = 0.007). Indigenous and remote patients were more likely to sustain mild injuries. The most common mechanism of injury overall was vehicle accident (37.5 %), compared to assault in the Indigenous subgroup (46.6 %, p<0.001). The overall mortality rate was 4.9 %, with older age and lower initial Glasgow Coma Score significant predictors of in-hospital mortality. Prehospital intubation was associated with a 7-fold increased risk of mortality (p = 0.056), while patients that received tranexamic acid (TXA) were almost 5-times more likely to die. CONCLUSIONS In North Queensland, young Indigenous males are at highest risk of traumatic head injuries. Vehicle accidents are an important preventable cause of head injury in the region. TXA administration is an important consideration for remote head trauma retrievals, in which time to emergency care is prolonged. Appropriate treatment and risk stratification strategies considering time to definitive care, severity of injury, and other prehospital patient factors require further investigation.
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Affiliation(s)
- Julia Chequer de Souza
- College of Medicine & Dentistry, James Cook University, 1 James Cook Drive, Townsville, Queensland 4811, Australia
| | - Hayley L Letson
- College of Medicine & Dentistry, James Cook University, 1 James Cook Drive, Townsville, Queensland 4811, Australia.
| | - Clinton R Gibbs
- Retrieval Services Queensland, 100 Angus Smith Drive, Douglas, Queensland 4814, Australia; Emergency Department, Townsville University Hospital, Townsville Hospital and Health Service, 100 Angus Smith Drive, Douglas, Queensland 4814, Australia; College of Public Health, Medical and Veterinary Sciences, James Cook University, 1 James Cook Drive, Townsville, Queensland 4811, Australia
| | - Geoffrey P Dobson
- College of Medicine & Dentistry, James Cook University, 1 James Cook Drive, Townsville, Queensland 4811, Australia
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Thomas MB, Urban S, Carmichael H, Banker J, Shah A, Schaid T, Wright A, Velopulos CG, Cripps M. Tick-tock: Prehospital intubation is associated with longer field time without any survival benefit. Surgery 2023; 174:1034-1040. [PMID: 37500409 DOI: 10.1016/j.surg.2023.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/16/2023] [Accepted: 06/18/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Prehospital endotracheal intubation is a debated topic, and few studies have found it beneficial after trauma. A growing body of evidence suggests that prehospital endotracheal intubation is associated with increased morbidity and mortality. Our study was designed to compare patients with attempted prehospital endotracheal intubation to those intubated promptly upon emergency department arrival. METHODS A retrospective review of a single-center trauma research data repository was utilized. Inclusion criteria included age ≥15 years, transport from the scene by ground ambulance, and undergoing prehospital endotracheal intubation attempts or intubation within 10 minutes of emergency department arrival without prior prehospital endotracheal intubation attempt. Propensity score matching was used to minimize differences in baseline characteristics between groups. Standard mean differences are also presented for pre- and post-matching datasets to evaluate for covariate balance. RESULTS In total, 208 patients met the inclusion criteria. Of these, 95 patients (46%) underwent prehospital endotracheal intubation, which was successful in 47% of cases. A control group of 113 patients (54%) were intubated within 10 minutes of emergency department arrival. We performed propensity score matching between cohorts based on observed differences after univariate analysis and used standard mean differences to estimate covariate balance. After propensity score matching, patients who underwent prehospital endotracheal intubation experienced a longer time on scene as compared with those intubated in the emergency department (9 minutes [interquartile range 6-12] vs 6 minutes [interquartile range 5-9], P < .01) without difference in overall mortality (67% vs 65%, P = 1.00). Rapid sequence intubation was not used in the field; however, it was used for 58% of patients intubated within 10 minutes of emergency department arrival. After matched analysis, patients with a failed prehospital intubation attempt were equally likely to receive rapid sequence intubation during re-intubation in the emergency department as compared with those undergoing a first attempt (n = 13/28, 46% vs n = 28/63, 44%, P = 1.00, standard mean differences 0.04). Among patients with prehospital arrest (n = 98), prehospital endotracheal intubation was associated with shorter time to death (8 minutes [interquartile range 3-17] vs 14 minutes [interquartile range 8-45], P = .008) and longer total transport time (23 minutes [interquartile range 19-31] vs 19 minutes [interquartile range 16-24], P = .006), but there was no difference in observed mortality (n = 29/31, 94% vs n = 30/31, 97%, P = 1.00, standard mean differences = 0.15) after propensity score matching. CONCLUSION Prehospital providers should prioritize expeditious transport over attempting prehospital endotracheal intubation, as prehospital endotracheal intubation is inconsistently successful, may delay definitive care, and appears to have no survival benefit.
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Affiliation(s)
- Madeline B Thomas
- Department of Surgery, University of Colorado, School of Medicine, Anschutz Medical Campus, Aurora, CO.
| | - Shane Urban
- Department of Surgery, University of Colorado, School of Medicine, Anschutz Medical Campus, Aurora, CO
| | - Heather Carmichael
- Department of Surgery, University of Colorado, School of Medicine, Anschutz Medical Campus, Aurora, CO. https://twitter.com/hcarmichaelmd
| | - Jordan Banker
- Department of Surgery, University of Colorado, School of Medicine, Anschutz Medical Campus, Aurora, CO
| | - Ananya Shah
- Department of Surgery, University of Colorado, School of Medicine, Anschutz Medical Campus, Aurora, CO
| | - Terry Schaid
- Department of Surgery, University of Colorado, School of Medicine, Anschutz Medical Campus, Aurora, CO
| | - Angela Wright
- Department of Emergency Medicine, University of Colorado, School of Medicine, Anschutz Medical Campus, Aurora, CO
| | - Catherine G Velopulos
- Department of Surgery, University of Colorado, School of Medicine, Anschutz Medical Campus, Aurora, CO. https://twitter.com/CVelopulos
| | - Michael Cripps
- Department of Surgery, University of Colorado, School of Medicine, Anschutz Medical Campus, Aurora, CO. https://twitter.com/MichaelCrippsMD
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Lin CC, Chen HY, Tseng CY, Yang CC. Effect of Acupuncture on Recovery of Consciousness in Patients with Acute Traumatic Brain Injury: A Multi-Institutional Cohort Study. Healthcare (Basel) 2023; 11:2267. [PMID: 37628465 PMCID: PMC10454345 DOI: 10.3390/healthcare11162267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/03/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023] Open
Abstract
Traumatic brain injury (TBI) causes cognitive dysfunction and long-term impairments. This study aims to examine the effectiveness of acupuncture on the recovery of consciousness in TBI patients. This is a retrospective, multi-institutional cohort study. We enrolled patients with newly diagnosed TBI from 1 January 2007 to 3 August 2021, aged 20 years and older, from the Chang Gung Research Database (CGRD). The outcome was defined based on the difference between the first and last Glasgow Coma Scale (GCS). A total of 2163 TBI patients were analyzed, and 237 (11%) received acupuncture in the treatment period. Generally, the initial GCS was lower in the acupuncture users (11 vs. 14). For the results of our study, a higher proportion of acupuncture patients achieved significant improvement (GCS differences ≥ 3) compared to non-acupuncture users (46.0% vs. 22.4%, p-value < 0.001). The acupuncture users had a 2.11 times higher chance of achieving a significant improvement when considering all assessable covariates (adjusted odds ratio (aOR) 2, 11, 95% confidence interval [CI]: 1.31-3.40; p-value = 0.002). Using 1:1 propensity score matching (PSM), the acupuncture users still had better outcomes than the non-acupuncture users (45.3% vs. 32.9%, p-value = 0.020). In conclusion, this study suggests that acupuncture treatment may be beneficial for TBI patients.
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Affiliation(s)
- Chun-Chieh Lin
- Division of Acupuncture and Traumatology, Center for Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taoyuan 33378, Taiwan; (C.-C.L.); (C.-Y.T.)
| | - Hsing-Yu Chen
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 330036, Taiwan;
- Division of Chinese Internal Medicine, Center for Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taoyuan 33378, Taiwan
- School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Chu-Yao Tseng
- Division of Acupuncture and Traumatology, Center for Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taoyuan 33378, Taiwan; (C.-C.L.); (C.-Y.T.)
| | - Chien-Chung Yang
- Division of Acupuncture and Traumatology, Center for Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taoyuan 33378, Taiwan; (C.-C.L.); (C.-Y.T.)
- School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
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Patient Outcomes Based on the 2011 CDC Guidelines for Field Triage of Injured Patients. J Trauma Nurs 2023; 30:5-13. [PMID: 36633338 DOI: 10.1097/jtn.0000000000000691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND The Centers for Disease Control and Prevention Guidelines for Field Triage of Injured Patients drive the destination decision for millions of emergency medical services (EMS)-transported trauma patients annually, yet limited information exists regarding performance and relationship with patient outcomes as a whole. OBJECTIVE To evaluate the association of positive findings on Centers for Disease Control and Prevention Guidelines for Field Triage of Injured Patients with hospitalization and mortality. METHODS This retrospective study included all 911 responses from the 2019 ESO Data Collaborative research dataset with complete Centers for Disease Control and Prevention Guidelines for Field Triage of Injured Patients and linked emergency department dispositions, excluding children and cardiac arrests prior to EMS arrival. Patients were categorized by Centers for Disease Control and Prevention Guidelines for Field Triage of Injured Patients step(s) met. Outcomes were hospitalization and emergency department or inhospital mortality. RESULTS There were 86,462 records included: n = 65,967 (76.3%) met no criteria, n = 16,443 (19.0%) met one step (n = 1,571 [9.6%] vitals, n = 1,030 [6.3%] anatomy of injury, n = 993 [6.0%] mechanism of injury, and n = 12,849 [78.1%] special considerations), and n = 4,052 (4.7%) met multiple. Compared with meeting no criteria, hospitalization odds increased threefold for vitals (odds ratio [OR]: 3.07, 95% confidence interval [CI]: 2.77-3.40), fourfold for anatomy of injury (OR: 3.94, 95% CI: 3.48-4.46), twofold for mechanism of injury (OR: 2.00, 95% CI: 1.74-2.29), or special considerations (OR: 2.46, 95% CI: 2.36-2.56). Hospitalization odds increased ninefold when positive in multiple steps (OR: 8.97, 95% CI: 8.37-9.62). Overall, n = 84,473 (97.7%) had mortality data available, and n = 886 (1.0%) died. When compared with meeting no criteria, mortality odds increased 10-fold when positive in vitals (OR: 9.58, 95% CI: 7.30-12.56), twofold for anatomy of injury (OR: 2.34, 95% CI: 1.28-4.29), or special considerations (OR: 2.10, 95% CI: 1.71-2.60). There was no difference when only positive for mechanism of injury (OR: 0.22, 95% CI: 0.03-1.54). Mortality odds increased 23-fold when positive in multiple steps (OR: 22.7, 95% CI: 19.7-26.8). CONCLUSIONS Patients meeting multiple Centers for Disease Control and Prevention Guidelines for Field Triage of Injured Patients steps were at greater risk of hospitalization and death. When meeting only one step, anatomy of injury was associated with greater risk of hospitalization; vital sign criteria were associated with greater risk of mortality.
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Cevik AA, Alao DO, Alyafei E, Abu-Zidan F. Those who speak survive: the value of the verbal component of GCS in trauma. Eur J Trauma Emerg Surg 2022; 49:837-842. [PMID: 36335514 PMCID: PMC10175383 DOI: 10.1007/s00068-022-02153-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 10/21/2022] [Indexed: 11/08/2022]
Abstract
Abstract
Aim
To evaluate the value of the individual components of GCS in predicting the survival of trauma patients in the Emergency Department.
Methods
Trauma patients who were admitted for more than 24 h or died after arrival at Al-Ain Hospital from January 2014 to December 2017 were studied. Children < 16 years, elderly > 80 years, patients with facial injuries, those intubated in the ER, and those with missing primary outcomes were excluded. Demography, vital signs, Glasgow Coma Scale (GCS), GCS components, Injury Severity Score (ISS), head AIS, and death were compared between those who died and those who survived. Factors with a p value of < 0.1 were entered into a backward likelihood logistic regression model to define factors that predict death.
Results
A total of 2548 patients were studied, out of whom 11 (0.4%) died. The verbal component of GCS (p < 0.001) and the ISS (p = 0.047) were the only significant predictors for death in the logistic regression model. The AUC (95% CI) of the GCS-VR was 0.763 (0.58–0.95), p = 0.003. The best point of GCS-VR that predicted survival was 5, having a sensitivity of 97%, a specificity of 54.5%, positive predictive value of 99. 8%, negative predictive value of 7.3%, and likelihood ratio of 2.13.
Conclusion
In general trauma patients, acute trauma care professionals can use GCS-VR to predict survival when clinical condition permits instead of the total GCS score or ISS.
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Csók I, Grauvogel J, Scheiwe C, Bardutzky J, Wehrum T, Beck J, Reinacher PC, Roelz R. Basic Surveillance Parameters Improve the Prediction of Delayed Cerebral Infarction After Aneurysmal Subarachnoid Hemorrhage. Front Neurol 2022; 13:774720. [PMID: 35309593 PMCID: PMC8926032 DOI: 10.3389/fneur.2022.774720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 01/19/2022] [Indexed: 11/13/2022] Open
Abstract
Background To establish a practical risk chart for prediction of delayed cerebral infarction (DCI) after aneurysmal subarachnoid hemorrhage (aSAH) by using information that is available until day 5 after ictus. Methods We assessed all consecutive patients with aSAH admitted to our service between September 2008 and September 2015 (n = 417). The data set was randomly split into thirds. Two-thirds were used for model development and one-third was used for validation. Characteristics that were present between the bleeding event and day 5 (i.e., prior to >95% of DCI diagnoses) were assessed to predict DCI by using logistic regression models. A simple risk chart was established and validated. Results The amount of cisternal and ventricular blood on admission CT (Hijdra sum score), early sonographic vasospasm (i.e., mean flow velocity of either intracranial artery >160 cm/s until day 5), and a simplified binary level of consciousness score until day 5 were the strongest predictors of DCI. A model combining these predictors delivered a high predictive accuracy [the area under the receiver operating characteristic (AUC) curve of 0.82, Nagelkerke's R2 0.34 in the development cohort]. Validation of the model demonstrated a high discriminative capacity with the AUC of 0.82, Nagelkerke's R2 0.30 in the validation cohort. Conclusion Adding level of consciousness and sonographic vasospasm between admission and postbleed day 5 to the initial blood amount allows for simple and precise prediction of DCI. The suggested risk chart may prove useful for selection of appropriate candidates for interventions to prevent DCI.
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Affiliation(s)
- István Csók
- Department of Neurosurgery, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jürgen Grauvogel
- Department of Neurosurgery, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christian Scheiwe
- Department of Neurosurgery, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jürgen Bardutzky
- Department of Neurology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Thomas Wehrum
- Department of Neurology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peter C. Reinacher
- Department of Stereotactic and Functional Neurosurgery, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Fraunhofer Institute for Laser Technology, Aachen, Germany
| | - Roland Roelz
- Department of Neurosurgery, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- *Correspondence: Roland Roelz
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Capuano B, Cone DC. An Analysis of the Distribution of Glasgow Coma Scale Scores across Pan-Asian Trauma Outcomes Study (PATOS) Regions. Prehosp Disaster Med 2022; 37:1-7. [PMID: 35156605 DOI: 10.1017/s1049023x2200019x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The Glasgow Coma Scale (GCS) was devised in 1974 as a way of tracking the progress of neurosurgical coma patients. It is comprised of three components: eye movement, response to verbal commands, and motor function. Since then, it has become the primary tool in Emergency Medical Services (EMS) and emergency departments for assessing cognitive function and triaging patients in the setting of acute trauma. However, the GCS was never intended to be used in such a way. It has been demonstrated that there is a high degree of inter-rater variability when assigning GCS scores for trauma patients. Potential differences in GCS score assignments between different countries were examined. It was hypothesized there would be differences in mean total and component scores. METHODS Using de-identified data from the Pan-Asian Trauma Outcomes Study (PATOS), the distributions of GCS scores from six countries were assessed: Japan, Korea, Malaysia, Taiwan, Thailand, and Vietnam. Using SPSS data analysis, a one-way ANOVA and Bonferroni post-hoc tests were performed to compare the means of the three GCS components and the total GCS scores reported by EMS personnel caring for trauma patients. RESULTS Data from 15,173 cases showed significant differences in mean total GCS score between countries (P <.001) as well as in mean component GCS scores (P <.001 for each of eye, verbal, and motor). Post-hoc tests showed that EMS personnel in Korea assigned significantly lower scores compared to all other countries in both component and total GCS scores. Field personnel in Japan, Malaysia, and Vietnam assigned the highest scores and significantly differed from the other three countries on component and total scores; Thailand and Taiwan had similar scores but significantly differed from the other four countries on component and total scores. Visual inspection of mean component and total GCS score histograms revealed differences in score assignment patterns among countries. CONCLUSIONS There are a number of significant differences in the mean total and component GCS scores assigned by EMS personnel in the six Asian countries studied. More investigation is necessary to determine if there is clinical significance to these differences in GCS score assignments, as well as the reasons for the differences.
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Affiliation(s)
- Benjamin Capuano
- Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, Connecticut, USA
| | - David C Cone
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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Enomoto Y, Tsutsumi Y, Tsuchiya A, Kido T, Ishigami K, Togo M, Yasuda S, Inoue Y. Validation of the Japan Coma Scale for the prediction of mortality in children: analysis of a nationwide trauma database. WORLD JOURNAL OF PEDIATRIC SURGERY 2022; 5:e000350. [DOI: 10.1136/wjps-2021-000350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 12/10/2021] [Indexed: 11/04/2022] Open
Abstract
ObjectiveThe 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.MethodsThis 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.ResultsA 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.ConclusionsWe 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.
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Li Y, Wang L, Liu Y, Zhao Y, Fan Y, Yang M, Yuan R, Zhou F, Zhang Z, Kang H. Development and Validation of a Simplified Prehospital Triage Model Using Neural Network to Predict Mortality in Trauma Patients: The Ability to Follow Commands, Age, Pulse Rate, Systolic Blood Pressure and Peripheral Oxygen Saturation (CAPSO) Model. Front Med (Lausanne) 2021; 8:810195. [PMID: 34957169 PMCID: PMC8709125 DOI: 10.3389/fmed.2021.810195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 11/19/2021] [Indexed: 11/16/2022] Open
Abstract
Objective: Most trauma scoring systems with high accuracy are difficult to use quickly in field triage, especially in the case of mass casualty events. We aimed to develop a machine learning model for trauma mortality prediction using variables easy to obtain in the prehospital setting. Methods: This was a retrospective prognostic study using the National Trauma Data Bank (NTDB). Data from 2013 to 2016 were used for model training and internal testing, and data from 2017 were used for validation. A neural network model (NN-CAPSO) was developed using the ability to follow commands (whether GCS-motor was <6), age, pulse rate, systolic blood pressure (SBP) and peripheral oxygen saturation, and a new score (the CAPSO score) was developed based on logistic regression. To achieve further simplification, a neural network model with the SBP variable removed (NN-CAPO) was also developed. The discrimination ability of different models and scores was compared based on the area under the receiver operating characteristic curve (AUROC). Furthermore, a reclassification table with three defined risk groups was used to compare NN-CAPSO and other models or scores. Results: The NN-CAPSO had an AUROC of 0.911(95% confidence interval 0.909 to 0.913) in the validation set, which was higher than the other trauma scores available for prehospital settings (all p < 0.001). The NN-CAPO and CAPSO score both reached the AUROC of 0.904 (95% confidence interval 0.902 to 0.906), and were no worse than other prehospital trauma scores. Compared with the NN-CAPO, CAPSO score, and the other trauma scores in reclassification tables, NN-CAPSO was found to more accurately classify patients to the right risk groups. Conclusions: The newly developed CAPSO system simplifies the method of consciousness assessment and has the potential to accurately predict trauma patient mortality in the prehospital setting.
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Affiliation(s)
- Yun Li
- Medical School of Chinese PLA, Beijing, China.,Department of Critical Care Medicine, The First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Lu Wang
- Medical School of Chinese PLA, Beijing, China.,Department of Critical Care Medicine, The First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Yuyan Liu
- Medical School of Chinese PLA, Beijing, China.,Department of Critical Care Medicine, The First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Yan Zhao
- Department of Critical Care Medicine, The First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Yong Fan
- Center for Artificial Intelligence in Medicine, Chinese PLA General Hospital, Beijing, China
| | - Mengmeng Yang
- Department of Critical Care Medicine, The First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Rui Yuan
- Department of Critical Care Medicine, The First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Feihu Zhou
- Department of Critical Care Medicine, The First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Zhengbo Zhang
- Center for Artificial Intelligence in Medicine, Chinese PLA General Hospital, Beijing, China
| | - Hongjun Kang
- Department of Critical Care Medicine, The First Medical Centre, Chinese PLA General Hospital, Beijing, China
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Bodien Y, Barra A, Temkin N, Barber J, Foreman B, Vassar M, Robertson CS, Taylor SR, Markowitz AJ, Manley GT, Giacino J, Edlow BL. Diagnosing Level of Consciousness: The Limits of the Glasgow Coma Scale Total Score. J Neurotrauma 2021; 38:3295-3305. [PMID: 34605668 DOI: 10.1089/neu.2021.0199] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
In nearly all clinical and research contexts, the initial severity of a traumatic brain injury (TBI) is measured using the Glasgow Coma Scale (GCS) total score. However, the GCS total score may not accurately reflect level of consciousness, a critical indicator of injury severity. We investigated the relationship between GCS total scores and level of consciousness in a consecutive sample of 2,455 adult subjects assessed with the GCS 69,487 times as part of the multi-center Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study. We assigned each GCS subscale score combination a level of consciousness rating based upon published criteria for the following disorders of consciousness (DoC) diagnoses: coma, vegetative state/unresponsive wakefulness syndrome, minimally conscious state, and post-traumatic confusional state, and present our findings using summary statistics and four illustrative cases. Participants had the following characteristics: mean (standard deviation) age 41.9 (17.6) years, 69% male, initial GCS 3-8=13%; 9-12=5%; 13-15=82%. All GCS total scores between 4-14 were associated with more than one DoC diagnosis; the greatest variability was observed for scores of 7-11. Furthermore, a wide range of total scores were associated with identical DoC diagnoses. Importantly, a diagnosis of coma was only possible with GCS total scores of 3-6. The GCS total score does not accurately reflect level of consciousness based on published DoC diagnostic criteria. To improve the classification of patients with TBI and to inform the design of future clinical trials, clinicians and investigators should consider individual subscale behaviors and more comprehensive assessments when evaluating TBI severity.
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Affiliation(s)
- Yelena Bodien
- Massachusetts General Hospital, 2348, Neurology, Boston, Massachusetts, United States.,Spaulding Rehabilitation Hospital, 24498, Physical Medicine and Rehabilitation, Charlestown, Massachusetts, United States;
| | | | - Nancy Temkin
- University of Washington, 7284, Departments of Neurological Surgery and Biostatistics, Seattle, Washington, United States;
| | - Jason Barber
- University of Washington, 7284, Seattle, Washington, United States;
| | - Brandon Foreman
- University of Cincinnati, Neurology, Cincinnati, Ohio, United States;
| | - Mary Vassar
- University of California San Francisco, 8785, San Francisco, California, United States;
| | - Claudia S Robertson
- Baylor College of Medicine, Neurosurgery, One Baylor Plaza, Houston, Texas, United States, 77030;
| | - Sabrina R Taylor
- University of California San Francisco Department of Neurological Surgery, 189227, San Francisco, California, United States;
| | - Amy J Markowitz
- University of California, San Francisco, Brain and Spinal Injury Center (BASIC), 1001 Potrero Ave, Bldg 1 Rm 101, San Francisco, California, United States, 94110;
| | - Geoffrey T Manley
- University of California San Francisco, Neurosurgery, San Francisco, California, United States.,UCSF Weill Institute for Neurosciences, San Francisco, California, United States;
| | - Joseph Giacino
- Spaulding Rehabilitation Hospital, 24498, PM&R, 300 1st Ave, Charlestown, Massachusetts, United States, 02129-3109;
| | - Brian L Edlow
- Harvard Medical School, 1811, 175 Cambridge Street - Suite 300, Boston, Massachusetts, United States, 02115.,Massachusetts General Hospital, 2348, Athinoula A. Martinos Center for Biomedical Imaging, Boston, Massachusetts, United States;
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12
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Urban S, Carmichael H, Moe M, Kramer A, Al-Azzawi O, Dumond R, Wright A, McIntyre R, Velopulos C. The Critical Intervention Screen: A Novel Tool to Determine the use of Lights and Sirens During the Transport of Trauma Patients. PREHOSP EMERG CARE 2021; 26:566-572. [PMID: 34313543 DOI: 10.1080/10903127.2021.1961040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Objective: EMS use of lights and sirens has long been employed in EMS systems, despite an increased risk of motor vehicle collisions associated with their use. The specific aims of this study were to assess the current use of lights and sirens during the transport of trauma patients in a busy metropolitan area and to subsequently develop a novel tool, the Critical Intervention Screen, to aid EMS professionals tasked with making transport decisions in the presence of acute injury.Methods: This single-center, retrospective study included all patients transported to an academic Level One trauma center by ground ambulance from the scene of presumed or known injury. A subset of patients was identified as being most likely to benefit from shorter transport times if they received one of the following critical interventions within 20 minutes of emergency department arrival: intubation, thoracotomy, chest tube, blood products, central line, arterial line, REBOA, disposition to an operating room, or death. Stepwise logistic regression was employed for the development of the Critical Intervention Screen, with a subset of data retained for internal validation.Results: 1296 patients were available for analysis. Overall, 217 patients (16.7%) received a critical intervention, and 112 patients (8.6%) of those patients received a critical intervention within 20 minutes of emergency department arrival. At baseline, EMS use of lights and sirens was 91.1% sensitive and 80.3% specific for receiving a critical intervention. Stepwise logistic regression demonstrated that the need for assisted ventilation, GCS Motor <6, and penetrating trauma to the trunk were the most predictive prehospital data for receiving at least one critical intervention. The Critical Intervention Screen, defined as having at least one of these risk factors in the prehospital setting, modestly increased sensitivity and specificity (96.4% and 87.9%, respectively) predicting the need for a critical intervention.Conclusion: These findings indicate that EMS are able to correctly identify high-acuity trauma patients, but at times employ L&S during the transport of patients with a low likelihood of receiving a time-sensitive intervention upon emergency department arrival. Therefore, the Critical Intervention Screen has the potential to reduce the use of lights and sirens and improve EMS safety.
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Affiliation(s)
- Shane Urban
- Department of Trauma Services, UCHealth University of Colorado Hospital, Aurora, USA
| | - Heather Carmichael
- Department of Trauma and Acute Care Surgery, University of Colorado, Aurora, USA
| | - Martin Moe
- Department of Trauma Services, UCHealth University of Colorado Hospital, Aurora, USA
| | - Andrea Kramer
- Department of Trauma Services, UCHealth University of Colorado Hospital, Aurora, USA
| | - Omar Al-Azzawi
- Department of Trauma Services, UCHealth University of Colorado Hospital, Aurora, USA
| | - Robbie Dumond
- Department of Trauma Services, UCHealth University of Colorado Hospital, Aurora, USA
| | - Angela Wright
- Department of Trauma and Acute Care Surgery, University of Colorado, Aurora, USA
| | - Robert McIntyre
- Department of Trauma and Acute Care Surgery, University of Colorado, Aurora, USA
| | - Catherine Velopulos
- Department of Trauma and Acute Care Surgery, University of Colorado, Aurora, USA
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Surge Capacity Crisis and Mitigation Plan in Trauma Setting Based on Real-Time National Trauma Registry Data. Disaster Med Public Health Prep 2021; 16:689-697. [PMID: 33729119 DOI: 10.1017/dmp.2020.462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The objective of this study was to assess the current breaking point of crisis surge capacity of trauma services in Qatar and to develop a mitigation plan. METHODS The study utilized real-time data from the National Trauma Registry. Data was explored cumulatively by weeks, months and a year's interval and all trauma admissions within this time frame were considered as 1 'Disaster Incident.' RESULTS A total of 2479 trauma patients were included in the study over 1 year. The mean age of patients was 31.5 ± 15.9 and 84% were males. The number of patients who sustained severe trauma which necessitated Level 1 activation was 16%. The emergency medical services (EMS) surge attained crisis of operational capacity at 5 months of disaster incident for priority 1 cases. Bed capacity at the floor was the first to reach operational crisis followed by the ICU and operating room. The gap in the surge for surgical interventions was specific to the specialty and surgery type which reached operational crisis at 3 months. CONCLUSION The study highlights the surge capacity and capability of the healthcare system at a Level 1 trauma center. The identified gaps in surge capacity require several key components of healthcare resources to be addressed across the continuum of care.
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Lin Y, Zhang S, Zhang W, Wang X, Huang L, Luo H. The prediction value of Glasgow coma scale-pupils score in neurocritical patients: a retrospective study. Brain Inj 2021; 35:547-553. [PMID: 33645359 DOI: 10.1080/02699052.2021.1890821] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND External validation is necessary before its clinical recommendation in new setting. The aim is to externally validate Glasgow Coma Scale-pupils score (GCS-P) in neurocritical patients and to compare its performances with Glasgow Coma Scale (GCS) and its derivatives. METHODS GCS-P at admission was calculated for individual based on the model developed by Brennan et al. Area under the receiver operating characteristic curves (AUCs), Nagelkerke's R2 and Brier scores were used to assess external validity of GCS-P to predict mortality in neurocritical patients and to compare predictive performance with GCS and its derivatives. SUBJECTS 4372 neurocritical patients from intensive care units of Beth Israel Deaconess Medical Center, United States between 2001 and 2012. RESULTS GCS-P showed good discrimination (AUC 0.847 for in-hospital mortality and 0.774 for ninety-day mortality), modest calibration (Nagelkerke's R2 33.1% for in-hospital mortality and 23.3% for ninety-day mortality). Predictive performances of GCS and its derivatives was inferior to GCS-P. CONCLUSIONS GCP-P discriminated well in between death in neurocritical patients. GCP-P improved predictive performance for short-term mortality over GCS and its derivatives in neurocritical patients. It would be a simple, early and reasonable daily routine option for prognosis assessment in neurocritical setting.
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Affiliation(s)
- Yingxin Lin
- Department of Intensive Care, Peking University Shenzhen Hospital, Shenzhen, China
| | - Sheng Zhang
- Department of Intensive Care, Peking University Shenzhen Hospital, Shenzhen, China
| | - Weixing Zhang
- Department of Intensive Care, Peking University Shenzhen Hospital, Shenzhen, China
| | - Xinxin Wang
- Department of Intensive Care, Peking University Shenzhen Hospital, Shenzhen, China
| | - Lei Huang
- Department of Intensive Care, Peking University Shenzhen Hospital, Shenzhen, China
| | - Hua Luo
- Department of Intensive Care, Peking University Shenzhen Hospital, Shenzhen, China
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15
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Deeb AP, Phelos HM, Peitzman AB, Billiar TR, Sperry JL, Brown JB. The Whole is Greater Than the Sum of its Parts: GCS Versus GCS-Motor for Triage in Geriatric Trauma. J Surg Res 2021; 261:385-393. [PMID: 33493891 DOI: 10.1016/j.jss.2020.12.051] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/29/2020] [Accepted: 12/08/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Trauma field triage matches injured patients to the appropriate level of care. Prior work suggests the Glasgow Coma Scale motor (GCSm) is as accurate as the total GCS (GCSt) and easier to use. However, older patients present with higher GCS for a given injury, and as such, it is unclear if this substitution is advisable. Our objective was to compare the GCS deficit patterns between geriatric and adult patients presenting with severe traumatic brain injury (TBI), as well as the diagnostic performance of the GCSm versus GCSt within the field triage criteria in these populations. MATERIALS AND METHODS We conducted a retrospective, observational cohort study of patients ≥16 y in the National Trauma Data Bank 2007-2015. GCS deficit patterns were compared between adults (16-65) and geriatric patients (>65). Measures of diagnostic performance of GCSt≤13 versus GCSm≤5 criteria to predict trauma center need (TCN) were compared. RESULTS In total, 4,480,185 patients were analyzed (28% geriatric). Geriatric patients more frequently presented with non-motor-only deficits than adults (16.4% versus 12.4%, P < 0.001), and these patients demonstrated higher severe TBI (40.3% versus 36.7%, P < 0.001) and craniotomy (5.8% versus 5.1%, P < 0.001) rates. GCSt was more sensitive and accurate in predicting TCN for geriatric patients and had lower rates of undertriage as compared to GCSm. CONCLUSIONS Geriatric patients more frequently present with non-motor-only deficits after injury, and this is associated with severe head injury. Substitution of GCSm for GCSt would exacerbate undertriage in geriatric patients and, thus, the total GCS should be maintained for field triage in geriatric patients.
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Affiliation(s)
- Andrew-Paul Deeb
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| | - Heather M Phelos
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Andrew B Peitzman
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Timothy R Billiar
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jason L Sperry
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Joshua B Brown
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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16
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Early cognitive impairment is common after intracranial hemorrhage with mild traumatic brain injury. J Trauma Acute Care Surg 2020; 89:215-221. [PMID: 32102043 DOI: 10.1097/ta.0000000000002641] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKDROP The incidence of early cognitive impairment (ECI) after traumatic brain injury (TBI) is unknown. We hypothesized ECI is common and can be predicted based on Glasgow Coma Scale (GCS) and Brain Injury Guideline (BIG) category. METHODS A single-center, retrospective review of adult trauma patients (2014-2016) with intracranial hemorrhage (ICH) and mild TBI (GCS score, 13-15) was performed. The primary outcome was ECI, defined as a Rancho Los Amigos score less than 8. Routine cognitive evaluation is performed on all ICH patients at our institution. Comparisons between ECI and no-ECI groups regarding demographic, cognitive, and clinical outcomes were evaluated using bivariate statistics. The odds of ECI were evaluated using a multivariable logistic regression. RESULTS There were 465 patients with mild TBI, 70.3% were male, and the average age was 53 ± 23 years. The most common mechanism of injury was fall (41.1%) followed by motor vehicle collision (15.9%). The incidence of ECI was 51.4% (n = 239). The incidence in patients with a GCS score of 15 was 42.9%, and BIG 1 category was 42.7%. There were no differences in demographics (age, sex, comorbidities), mechanism of injury, or imaging when comparing ECI patients with no-ECI patients. The GCS score was lower in the ECI group (14.4 vs. 14.7, p < 0.001). Patients with ECI were also less likely to be discharged home (58.2% vs. 78.3%, p < 0.001). Lower GCS-verbal, BIG category 3, and presence of pelvic/extremity fractures were strong risk factors for ECI in a logistic regression model adjusted for age, loss of consciousness, anticoagulants, narcotic administration, and Rotterdam score. CONCLUSION Half of all patients with ICH and mild TBI had ECI. Both lower initial GCS score and BIG category 3 were associated with increased likelihood of ECI. Therefore, we recommend all patients with ICH and mild TBI undergo cognitive evaluation. LEVEL OF EVIDENCE Prognostic Study, Level III.
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Dunn MS, Beck B, Simpson PM, Cameron PA, Kennedy M, Maiden M, Judson R, Gabbe BJ. Comparing the outcomes of isolated, serious traumatic brain injury in older adults managed at major trauma centres and neurosurgical services: A registry-based cohort study. Injury 2019; 50:1534-1539. [PMID: 31204027 DOI: 10.1016/j.injury.2019.06.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 06/03/2019] [Accepted: 06/08/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND The incidence of older adult traumatic brain injury (TBI) is increasing in both high and middle to low-income countries. It is unknown whether older adults with isolated, serious TBI can be safely managed outside of major trauma centres. This registry based cohort study aimed to compare mortality and functional outcomes of older adults with isolated, serious TBI who were managed at specialised Major Trauma Services (MTS) and Metropolitan Neurosurgical Services (MNS). METHOD Older adults (65 years and over) who sustained an isolated, serious TBI following a low fall (from standing or ≤ 1 m) were extracted from the Victorian State Trauma Registry from 2007 to 2016. Multivariable models were fitted to assess the association between hospital designation (MTS vs. MNS) and the two outcomes of interest: in-hospital mortality and functional outcome, adjusting for potential confounders. Functional outcomes were measured using the Glasgow Outcome Scale Extended at six months post-injury. RESULTS From 2007-2016, there were 1904 older adults who sustained an isolated, serious TBI from a low fall who received definitive care at an MTS (n = 1124) or an MNS (n = 780). After adjusting for confounders, there was no mortality benefit for patients managed at an MTS over an MNS (OR = 0.84; 95% CI: 0.65, 1.08; P = 0.17) or improvement in functional outcome six months post-injury (OR = 1.13; 95% CI: 0.94, 1.36; P = 0.21). CONCLUSION For older adults with isolated, serious TBI following a low fall, there was no difference in mortality or functional outcome based on definitive management at an MTS or an MNS. This confirms that MNS without the added designation of a major trauma centre are a suitable destination for the management of isolated, serious TBI in older adults.
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Affiliation(s)
- Matthew S Dunn
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
| | - Ben Beck
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Pam M Simpson
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Peter A Cameron
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Marcus Kennedy
- Adult Retrieval Victoria, Ambulance Victoria, Melbourne, Victoria, Australia
| | - Matthew Maiden
- Department of Intensive Care, Geelong University Hospital, Geelong, Australia; Department of Intensive Care, Royal Adelaide Hospital, Adelaide, Australia
| | - Rodney Judson
- Department of General Surgery, The Royal Melbourne Hospital, Melbourne, Victoria, Australia; Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - Belinda J Gabbe
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Health Data Research UK, Swansea University Medical School, Swansea University, Swansea, United Kingdom
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Pek JH, Ong YKG, Quek ECS, Feng XYJ, Allen JC, Chong SL. Evaluation of the criteria for trauma activation in the paediatric emergency department. Emerg Med J 2019; 36:529-534. [PMID: 31326954 DOI: 10.1136/emermed-2018-207857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 06/26/2019] [Accepted: 07/03/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND Trauma team activation criteria have a variable performance in the paediatric population. We aimed to identify predictors for high-level resource utilisation during trauma resuscitation in the ED. METHODS A retrospective study was conducted in the ED of a tertiary paediatric hospital. Patient data were collected from trauma surveillance registry and analysis was performed to identify significant predictors. We then assessed the sensitivity and specificity of proposed models with respect to observed patient outcomes. RESULTS Among 11 282 cases, the mean age was 6.1±4.9 (SD) years old. Fall was the most common mechanism of injury in 7364 (65.3%) patients. Eighty-eight (0.8%) patients required at least one high-level resource. Significant predictors for high-resource utilisation were overall GCS of <14 (relative risk (RR) 38.841, 95% CI 21.328 to 70.739, p<0.001), high-risk mechanisms of fall from height and motor vehicle collision (RR 7.863, 95% CI 4.687 to 13.192, p<0.001), as well as age-specific tachycardia (RR 1.796, 95% CI 1.145 to 2.817, p=0.0108). A model consisting of GCS and high-risk mechanism would under-triage 21 (0.2%) patients and over-triage 681 (6.0%) patients. When age-specific tachycardia was added, 8 (0.1%) less patients would be under-triaged but an additional 3251 (28.9%) patients would be over-triaged. CONCLUSION As utilisation of high-level resources in paediatric trauma was rare, it was difficult to find an appropriate balance between under-triage and over-triage. Between the two, minimising the proportion of under-triage is more important as patient safety is paramount in paediatric trauma care.
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Affiliation(s)
- Jen Heng Pek
- Department of Emergency Medicine, Sengkang General Hospital, Singapore, Singapore
| | - Yong-Kwang Gene Ong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| | - En Ci Samuel Quek
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| | | | - John Carson Allen
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore, Singapore
| | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore
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Gang MC, Hong KJ, Shin SD, Song KJ, Ro YS, Kim TH, Park JH, Jeong J. New prehospital scoring system for traumatic brain injury to predict mortality and severe disability using motor Glasgow Coma Scale, hypotension, and hypoxia: a nationwide observational study. Clin Exp Emerg Med 2019; 6:152-159. [PMID: 31261485 PMCID: PMC6614045 DOI: 10.15441/ceem.18.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 08/03/2018] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Assessing the severity of injury and predicting outcomes are essential in traumatic brain injury (TBI). However, the respiratory rate and Glasgow Coma Scale (GCS) of the Revised Trauma Score (RTS) are difficult to use in the prehospital setting. This investigation aimed to develop a new prehospital trauma score for TBI (NTS-TBI) to predict mortality and disability. METHODS We used a nationwide trauma database on severe trauma cases transported by fire departments across Korea in 2013 and 2015. NTS-TBI model 1 used systolic blood pressure <90 mmHg, peripheral capillary oxygen saturation <90% measured via pulse oximeter, and motor component of GCS. Model 2 comprised variables of model 1 and age >65 years. We assessed discriminative power via area under the curve (AUC) value for in-hospital mortality and disability defined according to the Glasgow Outcome Scale with scores of 2 or 3. We then compared AUC values of NTS-TBI with those of RTS. RESULTS In total, 3,642 patients were enrolled. AUC values of NTS-TBI models 1 and 2 for mortality were 0.833 (95% confidence interval [CI], 0.815 to 0.852) and 0.852 (95% CI, 0.835 to 0.869), respectively, while AUC values for disability were 0.772 (95% CI, 0.749 to 0.796) and 0.784 (95% CI, 0.761 to 0.807), respectively. AUC values of NTS-TBI model 2 for mortality and disability were higher than those of RTS (0.819 and 0.761, respectively) (P<0.01). CONCLUSION Our NTS-TBI model using systolic blood pressure, motor component of GCS, oxygen saturation, and age was feasible for prehospital care and showed outstanding discriminative power for mortality.
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Affiliation(s)
- Min Chul Gang
- Department of Emergency Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Ki Jeong Hong
- Department of Emergency Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Do Shin
- Department of Emergency Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Kyoung Jun Song
- Department of Emergency Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Young Sun Ro
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - Tae Han Kim
- Department of Emergency Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Jeong Ho Park
- Department of Emergency Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Joo Jeong
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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Does an assessment aid improve Glasgow Coma Scale scoring by helicopter rescuers in Hong Kong: A randomised controlled trial. Australas Emerg Care 2019; 21:105-110. [PMID: 30998881 DOI: 10.1016/j.auec.2018.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 05/15/2018] [Accepted: 06/01/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Glasgow Coma Scale (GCS) is one of the most commonly used patient assessment tools. This study aimed to determine whether an assessment aid can improve the GCS scoring accuracy by helicopter rescuers in Hong Kong. METHODS In this randomised controlled trial, Air Crewman Officers (ACMOs) of Government Flying Service in Hong Kong were randomised into two groups, with and without assessment aid. The group with the assessment aid was provided a printed copy of the GCS scoring table while watching the patient simulated videos. Ten videos with GCS scores ranging from 3 to 15 were used to test the performance of total GCS (tGCS) and motor component of GCS (mGCS) scoring. RESULTS 78% (n=25/32) of ACMOs participated in the study. By comparing the groups with and without an assessment aid, there was no significant difference in the accuracy of tGCS score (60% versus 60%; p=0.85) or mGCS score (80% versus 80%; p=0.75). Overall, mGCS has a higher accuracy than tGCS (p<0.001). The accuracy of mGCS was better than tGCS in mild and moderate brain injury scenarios. CONCLUSION The use of an assessment aid did not improve GCS scoring by helicopter rescuers. The assessing of mGCS was more accurate than tGCS, further supporting the use of mGCS for prehospital conscious level assessment.
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van Rein EAJ, Jochems D, Lokerman RD, van der Sluijs R, Houwert RM, Lichtveld RA, van Es MA, Leenen LPH, van Heijl M. Diagnostic value of emergency medical services provider judgement in the identification of head injuries among trauma patients. Eur J Neurol 2018; 26:274-280. [DOI: 10.1111/ene.13804] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 08/28/2018] [Indexed: 11/29/2022]
Affiliation(s)
- E. A. J. van Rein
- Department of Traumatology; University Medical Centre Utrecht; Utrecht
| | - D. Jochems
- Department of Traumatology; University Medical Centre Utrecht; Utrecht
| | - R. D. Lokerman
- Department of Traumatology; University Medical Centre Utrecht; Utrecht
| | - R. van der Sluijs
- Department of Traumatology; University Medical Centre Utrecht; Utrecht
| | - R. M. Houwert
- Department of Traumatology; University Medical Centre Utrecht; Utrecht
- Trauma Centre Utrecht; Utrecht
| | | | - M. A. van Es
- Department of Neurology; University Medical Centre Utrecht; Utrecht
| | - L. P. H. Leenen
- Department of Traumatology; University Medical Centre Utrecht; Utrecht
| | - M. van Heijl
- Department of Traumatology; University Medical Centre Utrecht; Utrecht
- Department of Surgery; Diakonessenhuis Utrecht/Zeist/Doorn; Utrecht The Netherlands
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A Two-Center Validation of “Patient Does Not Follow Commands” and Three Other Simplified Measures to Replace the Glasgow Coma Scale for Field Trauma Triage. Ann Emerg Med 2018; 72:259-269. [DOI: 10.1016/j.annemergmed.2018.03.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 03/21/2018] [Accepted: 03/26/2018] [Indexed: 11/22/2022]
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23
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Algorithmus für das initiale klinische Management bei einem Massenanfall von Verletzten. Notf Rett Med 2018. [DOI: 10.1007/s10049-017-0373-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Glasgow Coma Scale Score in Trauma Triage: A Measurement Without Meaning. Ann Emerg Med 2018; 72:270-271. [PMID: 30144864 DOI: 10.1016/j.annemergmed.2018.06.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Indexed: 01/10/2023]
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Beck B, Gantner D, Cameron PA, Braaf S, Saxena M, Cooper DJ, Gabbe BJ. Temporal Trends in Functional Outcomes after Severe Traumatic Brain Injury: 2006-2015. J Neurotrauma 2018; 35:1021-1029. [PMID: 29256832 DOI: 10.1089/neu.2017.5287] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Severe traumatic brain injury (TBI) is associated with poor outcomes; however, little is known about whether these outcomes are improving over time. This study examined temporal trends in functional outcomes of severe TBI at six months post-injury. We conducted a retrospective cohort study (January 1, 2006 to December 31, 2015) of hospitalized adult (≥16 years) patients with severe TBI using data from the population-based Victorian State Trauma Registry. The primary outcome was the Glasgow Outcome Scale-Extended (GOS-E) at six months post-injury, dichotomized as upper severe disability or worse (GOS-E ≤4, termed "unfavorable outcome") and lower moderate disability or better (GOS-E ≥5; termed "favorable outcome"). Multivariable logistic regression was used to investigate temporal trends in functional outcomes at six months post-injury. Of the 1966 patients with severe TBI who were followed up at six months post-injury (median age, 42 years (interquartile range [IQR]: 25-68); male, 73%), a majority of patients had an unfavorable outcome (GOS-E ≤4; n = 1372, 70%). After adjusting for confounders, there was no change in functional outcomes over time (adjusted odds ratio [AOR] = 1.02, 95% confidence interval [CI]: 0.98,1.06; p = 0.35). Similarly, there was no change in the adjusted odds of death (GOS-E = 1) at six months post-injury (AOR = 1.04, 95% CI: 1.00,1.08; p = 0.08). Using a population-wide, high quality, comprehensive registry, we demonstrated no change in death or functional outcomes after severe TBI between 2006 and 2015 in a mature trauma system. There is a clear need to identify targeted improvements in the treatment of these patients with the aim of reducing in-hospital death and improving long-term outcomes.
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Affiliation(s)
- Ben Beck
- 1 Department of Epidemiology and Preventive Medicine, Monash University , Melbourne, Victoria, Australia
| | - Dashiell Gantner
- 2 Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University , Melbourne, Victoria, Australia .,3 Department of Intensive Care and Hyperbaric Medicine, The Alfred , Melbourne, Victoria, Australia
| | - Peter A Cameron
- 1 Department of Epidemiology and Preventive Medicine, Monash University , Melbourne, Victoria, Australia .,4 Emergency and Trauma Centre, The Alfred Hospital , Melbourne, Victoria, Australia
| | - Sandra Braaf
- 1 Department of Epidemiology and Preventive Medicine, Monash University , Melbourne, Victoria, Australia
| | - Manoj Saxena
- 5 Intensive Care Unit, St George Hospital , Sydney, New South Wales, Australia .,6 Critical Care & Trauma Division, The George Institute for Global Health , University of New South Wales, Sydney, New South Wales, Australia
| | - D James Cooper
- 2 Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University , Melbourne, Victoria, Australia .,3 Department of Intensive Care and Hyperbaric Medicine, The Alfred , Melbourne, Victoria, Australia
| | - Belinda J Gabbe
- 1 Department of Epidemiology and Preventive Medicine, Monash University , Melbourne, Victoria, Australia .,7 Farr Institute, Swansea University Medical School, Swansea University , Swansea, United Kingdom
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Kong VY, Odendaal J, Sartorius B, Clarke DL, Bruce JL, Laing GL, Esterhuizen T. Developing a simplified clinical prediction score for mortality in patients with cerebral gunshot wounds: The Maritzburg Score. Ann R Coll Surg Engl 2018; 100:97-100. [PMID: 29022788 PMCID: PMC5838685 DOI: 10.1308/rcsann.2017.0141] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2017] [Indexed: 11/22/2022] Open
Abstract
Introduction Cerebral gunshot wounds are highly lethal and literature on the clinical scores for mortality prediction is limited. Materials and methods A retrospective study was undertaken over a 5-year period at the Pietermaritzburg Metropolitan Trauma Service in South Africa. A simplified clinical prediction score was developed based on clinical and/or physiological variables readily available in the resuscitation room. Results A total of 102 patients were included; 92% (94/102) were male and the mean age was 29 years; 22% (22/102) died during the admission. The presence of visible brain matter (odds ratio 12.4, P = 0.003) and motor score less than 5 (odds ratio 89.6, P < 0.001) allows the prediction success of 92% (sensitivity 73% and specificity 98%). The area under the receiver operating characteristic curve was 94% (95% confidence interval 88-100%, P < 0.001). Conclusions The presence of visible brain matter, together with a motor score of less than 5, allows accurate identification of non-survivors of cerebral gunshot wounds. Further study is required to validate this score.
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Affiliation(s)
- V Y Kong
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal , Durban , South Africa
| | - J Odendaal
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal , Durban , South Africa
| | - B Sartorius
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal , Durban , South Africa
| | - D L Clarke
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal , Durban , South Africa
- Department of Surgery, University of the Witwatersrand , Johannesburg , South Africa
| | - J L Bruce
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal , Durban , South Africa
| | - G L Laing
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal , Durban , South Africa
| | - T Esterhuizen
- Centre for Evidence Based Health Care, Department of Global Health, University of Stellenbosch , Stellenbosch , South Africa
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Chou R, Totten AM, Carney N, Dandy S, Fu R, Grusing S, Pappas M, Wasson N, Newgard CD. Predictive Utility of the Total Glasgow Coma Scale Versus the Motor Component of the Glasgow Coma Scale for Identification of Patients With Serious Traumatic Injuries. Ann Emerg Med 2017; 70:143-157.e6. [DOI: 10.1016/j.annemergmed.2016.11.032] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 11/09/2016] [Accepted: 11/18/2016] [Indexed: 10/20/2022]
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Green SM, Haukoos JS, Schriger DL. How to Measure the Glasgow Coma Scale. Ann Emerg Med 2017; 70:158-160. [PMID: 28169051 DOI: 10.1016/j.annemergmed.2016.12.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Steven M Green
- Loma Linda University Medical Center and Loma Linda University Children's Hospital, Loma Linda, CA.
| | - Jason S Haukoos
- University of Colorado School of Medicine and the Department of Epidemiology, Colorado School of Public Health, Aurora, CO, and the Denver Health Medical Center, Denver, CO
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Hu Y, Cao J, Hou X, Liu G. MIS Score: Prediction Model for Minimally Invasive Surgery. World Neurosurg 2017; 99:624-629. [PMID: 28049035 DOI: 10.1016/j.wneu.2016.12.102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 12/21/2016] [Accepted: 12/23/2016] [Indexed: 01/04/2023]
Abstract
BACKGROUND Reports suggest that patients with spontaneous intracerebral hemorrhage (ICH) can benefit from minimally invasive surgery, but the inclusion criterion for operation is controversial. This article analyzes factors affecting the 30-day prognoses of patients who have received minimally invasive surgery and proposes a simple grading scale that represents clinical operation effectiveness. METHODS The records of 101 patients with spontaneous ICH presenting to Qianfoshan Hospital were reviewed. Factors affecting their 30-day prognosis were identified by logistic regression. A clinical grading scale, the MIS score, was developed by weighting the independent predictors based on these factors. RESULTS Univariate analysis revealed that the factors that affect 30-day prognosis include Glasgow coma scale score (P < 0.01), age ≥80 years (P < 0.05), blood glucose (P < 0.01), ICH volume (P < 0.01), operation time (P < 0.05), and presence of intraventricular hemorrhage (P < 0.001). Logistic regression revealed that the factors that affect 30-day prognosis include Glasgow coma scale score (P < 0.05), age (P < 0.05), ICH volume (P < 0.01), and presence of intraventricular hemorrhage (P < 0.05). The MIS score was developed accordingly; 39 patients with 0-1 MIS scores had favorable prognoses, whereas only 9 patients with 2-5 MIS scores had poor prognoses. CONCLUSIONS The MIS score is a simple grading scale that can be used to select patients who are suited for minimal invasive drainage surgery. When MIS score is 0-1, minimal invasive surgery is strongly recommended for patients with spontaneous cerebral hemorrhage. The scale merits further prospective studies to fully determine its efficacy.
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Affiliation(s)
- Yuanyuan Hu
- Department of Neurosurgery, Qianfoshan Hospital affiliated to Shandong University, Jinan, Shandong, People's Republic of China
| | - Jingwei Cao
- Department of Neurosurgery, Qilu Hospital of Shandong University, Brain Science Research Institute, Shandong University, Jinan, Shandong, People's Republic of China
| | - Xianzeng Hou
- Department of Neurosurgery, Qianfoshan Hospital affiliated to Shandong University, Jinan, Shandong, People's Republic of China
| | - Guangcun Liu
- Department of Neurosurgery, Qianfoshan Hospital affiliated to Shandong University, Jinan, Shandong, People's Republic of China.
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