Glasgow coma scale and its components on admission: are they valuable prognostic tools in acute mixed drug poisoning?

The Predictive Value of the Verbal Glasgow Coma Scale in Traumatic Brain Injury: A Systematic Review

BACKGROUND

Traumatic brain injury (TBI) is a major global health concern, imposing significant burdens on individuals and healthcare systems. The Glasgow Coma Scale (GCS), a widely utilized instrument for evaluating neurological status, includes 3 variables: motor, verbal, and eye opening. The GCS plays a crucial role in TBI severity stratification. While extensive research has explored the predictive capabilities of the overall GCS score and its motor component, the Verbal Glasgow Coma Scale (V-GCS) has garnered less attention.

OBJECTIVE

To examine the predictive accuracy of the V-GCS in assessing outcomes in patients with TBI, with a particular focus on functional outcome and mortality. In addition, we intend to compare its predictive performance with other components of the GCS.

METHODS

A systematic review, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, was conducted utilizing the PubMed, Scopus, and Web of Science databases. Inclusion criteria encompassed 10 clinical studies involving patients with TBI, wherein the level of consciousness was assessed using the verbal GCS score. Predominant statistical measures employed were odds ratios (ORs) and area under the curve (AUC).

RESULTS

Recorded findings consistently underscore that lower V-GCS scores are associated with adverse functional outcomes and mortality in patients with TBI. Despite the predictive accuracy of the V-GCS, the Motor Glasgow Coma Scale (M-GCS) emerges as a superior predictor.

CONCLUSION

In the context of TBI outcome prediction, the V-GCS demonstrates its efficacy as a prognostic tool. However, the M-GCS exhibits superior performance compared with the V-GCS. These insights underscore the multifaceted nature of TBI assessment and emphasize the necessity of considering distinct components of the Glasgow Coma Scale for comprehensive evaluation. Further research is warranted to refine and improve the application of these predictive measures in clinical practice.

Adverse outcomes of GHB use: Analysis of ambulance attendances in metropolitan and regional Victoria

BACKGROUND

Gamma-hydroxybutyrate (GHB) use and attributable harms have been increasing in Australia, however changes over time, including the impact of COVID-19 lockdowns and restrictions on harms requiring an ambulance attendance, are unknown. This study utilised a novel population-based surveillance system to identify the types of GHB-related harms between January 2018 and 31 December 2021 in Victoria, Australia.

METHODS

A cross-sectional, retrospective analysis of all GHB-related ambulance attendances between January 2018 and 31 December 2021 in Victoria, Australia was undertaken. Paramedic clinical notes and Glasgow Coma Scale scores were used to assess conscious state. Event codes were classified using dispatch information available in the database. Crude rates (per 100,000 population) and descriptive analyses were calculated for metropolitan and regional settings. Adjusted Odds ratios (aOR) with 95% confidence intervals [95% CI] were used to assess the relationship between GCS severity and polysubstance combinations with GHB.

RESULTS

There were 6,836 ambulance attendances for GHB recorded during the study period. A statistically significant increase in GHB-related attendance numbers was observed State-wide in 2019 (n = 1,402, p<0.001) and 2020 (n = 2,622, p<0.001), when comparing year on year attendances. While both numbers and rates (per 100,000 population) of GHB-related attendances were significantly lower in regional areas, significant increases were evident in both metropolitan and regional areas in 2019 and 2020 (both p<0.001). Attendances involving GHB and alcohol had higher odds of a severe GCS score (aOR:1.25; 95%: 1.04-1.49; p<0.019). A high proportion of GHB-attendances involved harms of significant concern including: overdose (56%) and a loss of, or altered state of consciousness (45%).

CONCLUSIONS

We observed increases in GHB-related ambulance attendances over time in both metropolitan and regional areas, placing a significant burden on ambulance services. Our study demonstrates the value of using ambulance surveillance to obtain representative data on acute GHB-related harms.

Prognostic factors in acute poisoning with central nervous system xenobiotics: development of a nomogram predicting risk of intensive care unit admission

Background

Acute intoxication with central nervous system (CNS) xenobiotics is an increasing global problem. Predicting the prognosis of acute toxic exposure among patients can significantly alter the morbidity and mortality. The present study outlined the early risk predictors among patients diagnosed with acute exposure to CNS xenobiotics and endorsed bedside nomograms for identifying patients requiring intensive care unit (ICU) admission and those at risk of poor prognosis or death.

Methods

This study is a 6-year retrospective cohort study conducted among patients presented with acute exposure to CNS xenobiotics.

Results

A total of 143 patients' records were included, where (36.4%) were admitted to the ICU, and a significant proportion of which was due to exposure to alcohols, sedative hypnotics, psychotropic, and antidepressants (P = 0.021). ICU admission was associated with significantly lower blood pressure, pH, and HCO₃ levels and higher random blood glucose (RBG), serum urea, and creatinine levels (P < 0.05). The study findings indicate that the decision of ICU admission could be determined using a nomogram combining the initial HCO₃ level, blood pH, modified PSS, and GCS. HCO₃ level < 17.1 mEq/L, pH < 7.2, moderate-to-severe PSS, and GCS < 11 significantly predicted ICU admission. Moreover, high PSS and low HCO₃ levels significantly predicted poor prognosis and mortality. Hyperglycemia was another significant predictor of mortality. Combining initial GCS, RBG level, and HCO₃ is substantially helpful in predicting the need for ICU admission in acute alcohol intoxication.

Conclusion

The proposed nomograms yielded significant straightforward and reliable prognostic outcomes predictors in acute exposure to CNS xenobiotics.

The Glasgow Coma Scale: a tool to decide the need for tracheal intubation in acutely intoxicated patients?

The Glasgow Coma Scale aids decision making with regards to advanced airway management of acutely intoxicated patients. There is some evidence for lower levels of gastric aspiration when using a Glasgow Coma Scale score of eight or less to decide upon tracheal intubation, but this is not substantiated in the literature.

Epidemiological Characteristics of Sedative-Hypnotics and Opioid Painkillers at High-Frequency Exposure

Drug poisoning has a high incidence and serious consequences in medical institutions; its epidemiological characteristics also directly affect the changes in national laws and policies and the implementation of local management policies. Chinese statistics on drug-related abnormal death cases generally come from judicial appraisal centers and medical units. However, due to differences in work content and professional restrictions, there are differences in information management forms, which makes it difficult for appraisers to conduct a professional and systematic analysis of drug-related cases. This article focuses on the analysis of epidemiological characteristics of sedative-hypnotics and opioid painkillers and their exposure patterns in cases of poisoning death by analyzing the annual report of the American Association of Poison Control Center, combined with the characteristics of drug exposure in China.

Outcomes following Naloxone Administration by Bystanders and First Responders

Background: Naloxone is widely available to bystanders and first responders to treat patients with suspected opioid overdose. In these patients, the prognostic factors and potential benefits associated with additional naloxone administered by emergency medical services (EMS) are uncertain. Objectives: We sought to identify prognostic factors for admission to the hospital following prehospital administration of naloxone for suspected opioid overdose by bystanders and first responders. We secondarily examined whether administration of additional naloxone by paramedics after initial treatment by non-EMS personnel was associated with improvement in level of consciousness prior to hospital arrival. Methods: This is a retrospective cross-sectional study of patients treated within a single urban EMS system from 2013 to 2016. Inclusion criteria were administration of naloxone by bystanders or first responders and transport to one of three academic medical centers. For the secondary analysis, only patients with a Glasgow Coma Scale (GCS) score ≤12 on paramedic arrival were included. We performed univariate and multivariable analyses examining a primary outcome of hospital admission and secondary outcome of improvement in consciousness as defined by GCS >12 in patients with initial GCS ≤12. Results: Of 359 patients identified for the primary analysis, 60 were admitted to the hospital. Factors associated with increased rate of admission included higher total naloxone dosage (OR 1.36, 95% CI 1.09-1.70) and presence of alternate/additional non-opioid central nervous system (CNS) depressants (OR 2.51, 95% CI 1.13-5.56). Among 178 patients who had poor neurologic status (GCS ≤12) on paramedic arrival following naloxone administered by bystander or first responder, administration of additional naloxone was not associated with a better rate of neurologic improvement prior to hospital arrival (77% improved with additional naloxone, 81% improved without additional naloxone; OR 0.82, 95% CI 0.39-1.76). Conclusions: Among patients with suspected opioid overdose treated with naloxone by bystanders and first responders, a higher total dose of naloxone and polysubstance intoxication with additional CNS depressants were predictors of admission. Administration of additional naloxone by paramedics was not associated with a higher rate of neurologic improvement prior to hospital arrival, suggesting a ceiling effect on naloxone efficacy in opioid overdose.

A quarter of admitted poisoned patients have a mild poisoning and require no treatment: An observational study

BACKGROUND

Poisoned patients are frequently admitted following Emergency Department (ED) presentation, while the necessity of such admissions is hardly investigated. We determined the proportion and characteristics of poisoned patients who were admitted, but in retrospect had an uneventful admission.

METHODS

For this observational cohort study, all patients presented to the ED of a Dutch University Hospital with various poisonings during a 1.5-year period (January 2015-July 2016) were included. The uneventfulness of admissions, defined as patients with a low Poisoning Severity Score (PSS) who received no treatment, was determined in retrospect.

RESULTS

We included 417 patients who visited the ED for poisoning. 247 Patients were admitted: 30% to a general ward, 58% to a MCU, and 12% to the ICU. The poisoning severity scores of the admitted patients were none to mild in 38%, moderate to severe in 59%, and fatal in 2%. Upon admission, 60% of the patients received treatment. In retrospect, 77% of the admitted patients had a moderate, severe or fatal poisoning and/or required treatment. However, 23% of the admitted patients had a mild poisoning and required no treatment. This group involved younger patients (median age of 23 versus 42 years) and a higher proportion of patients reporting exposure to only one substance (65% versus 51%).

CONCLUSIONS

The majority of poisoned patients presented to the ED was admitted, while in retrospect, a quarter of these admissions were uneventful. Predictive parameters should be sought to identify patients who can be sent home safely.

Bispectral Index in Poisoning Cases with Multi-drug Ingestion: A Predictable Role for Early Endotracheal Intubation

Objective:

Bispectral index (BIS) is one of the several methods used to monitor the depth of anesthesia. Poisoning with ingestion of different drugs is one of the most common poisonings that have different clinical signs from drowsiness to coma. This study was performed to compare the BIS index number in poisoned patients with multi drugs ingestion with or without the need for endotracheal intubation.

Methods:

This cross-sectional study was performed on poisoned patients with ingestion of different drugs referring to Clinical Toxicology Department of Noor University Hospital, Isfahan, Iran. The clinical signs and symptoms and the vital signs at the admission time were measured, and the required therapies were given. The endotracheal intubation was done for patients who had the indication of intubation. BIS was monitored and compared for all patients with or without a need for intubation on the admission time and time of endotracheal intubation. Obtained data were analyzed by SPSS software.

Findings:

At the admission time, the mean (standard error [SE]) BIS index value for poisoned patients who needed endotracheal intubation was 66.47 ± 2.57 in comparison with 85.21 ± 1.47 for patients who did not need intubation (P < 0.001). The results of receiver operating characteristic curve (mean ± SE) showed the discrimination was excellent for BIS (0.899 ± 0.04; 95% confidence interval: 0.81–0.98) (P < 0.0001). BIS <79.5 had the sensitivity 88% and specificity 87% for endotracheal intubation.

Conclusion:

BIS is an appropriate index for prediction of the need to intubation in poisoned patients with ingestion of different drugs.

Biomarkers, lactate, and clinical scores as outcome predictors in systemic poisons exposures

Acute exposure to systemic poisons represents an important challenge in clinical toxicology. We aimed to analyze the potential role of cardiac biomarkers, routine laboratory tests, and clinical scores as morbidity and in-hospital mortality predictors in patients intoxicated with various systemic poisons. We conducted a prospective study on adults acutely exposed to systemic poisons. We determined the PSS, Glasgow Coma Scale (GCS), and we performed electrocardiogram, laboratory tests, lactate and cardiac biomarkers (which were reassessed 4 h, respectively 6 h later). Of 120 patients included, 45% developed complications, 19.2% had a poor outcome, and 5% died. Multivariate logistic regression sustained lactate (odds ratio (OR) 1.58; confidence interval (CI) 95%: 0.97-2.59; p 0.066), MB isoenzyme of creatine kinase (6h-CKMB; OR 1.08; CI 95%: 1.02-1.16; p 0.018) as predictors for a poor outcome. A GCS < 10 (OR 0.113; CI 95%: 0.019-0.658; p 0.015) and 4h-lactate (OR 4.87; CI 95%: 0.79-29.82; p 0.087) predicted mortality after systemic poisons exposure. Receiver operating characteristic analysis showed that brain natriuretic peptide (area under the curve (AUC), 0.96; CI 95%: 0.92-0.99; p < 0.001), lactate (AUC, 0.91; CI 95%: 0.85-0.97; p < 0.001), and 6h-CKMB have good discriminatory capacity for predicting a poor outcome. In conclusion, these biomarkers, lactate, and GCS can be used to predict morbidity and mortality after systemic poisons exposure.

Alcohol-induced impairment in adolescents admitted to inpatient treatment after heavy episodic drinking: effects of age and gender

OBJECTIVE

In Germany and many other countries, the number of adolescent heavy episodic drinking-induced hospital admissions (HEDHA) in pediatric units markedly increased during the past decade. A low level of response to alcohol in young adults is associated with high risk for later development of alcohol use disorders (AUDs).

METHOD

We performed a retrospective chart review of all 1,123 HEDHA cases in adolescents aged 11-17 years who were admitted to one of the pediatric inpatient units covering the cities of Dresden, Pirna, and Rostock, Germany, between 2000 and 2008. Blood alcohol concentration (BAC) and Glasgow Coma Scale (GCS) measures on admission were documented in 846 cases.

RESULTS

The mean (SD) BAC was 155 (50) mg/100 ml full blood, and M (SD) GCS was 12.21 (3.02). These parameters were negatively correlated with each other (r = -.256, p < .001), indicating more impairment at higher BACs. To describe a numerical estimate of how severely a subject was compromised relative to his BAC, the GCS scores were inverted (making high scores indicate severe impairment) and divided by BAC. The resulting alcohol-induced impairment index (AIII) was significantly influenced by an interaction between age and gender, decreasing with age in boys but increasing in girls.

CONCLUSIONS

During adolescence, alcohol-induced impairment develops differently in boys and girls, which may be because of the girls' developmental edge. The high variability of observed AIII might help to predict the risk for later AUDs in the emergency department, simply by measuring BAC and GCS.

Scores and scales used in emergency medicine. Practicability in toxicology

Medical scores, criteria and classification systems support clinical decision-making and management. They enable the clinician to predict the outcome, stratify risk, assess conditions and diagnose diseases accurately. In the emergency medicine, it is very important to ascertain safety criteria to discharge patients, time to remain in the E.R., and also ascertain the time intervals for discharge/admission. The use of the scores in the emergency medicine, toxicology and other areas of intensive medicine have become increasingly efficient. Creating a prognostic score for the acute intoxications to be used by the personnel from the Emergency Departments may have positive effects in the management of the poisoned patients (e.g. the admission in a certain treatment space: cases expected to have a trend towards worsening will be directed to the resuscitation space and after a short period of time admitted in the appropriate facility; this way, the bed occupancy time in the Emergency Department will be shortened).

Applicability of different scoring systems in outcome prediction of patients with mixed drug poisoning-induced coma

Background:

Mixed drugs poisoning (MDP) is common in the emergency departments. Because of the limited number of intensive care unit beds, recognition of risk factors to divide the patients into different survival groups is necessary. Poisoning due to ingestion of different medications may have additive or antagonistic effects on different parameters included in the scoring systems; therefore, the aim of the study was to compare applicability of the different scoring systems in outcomes prediction of patients admitted with MDP-induced coma.

Methods:

This prospective, observational study included 93 patients with MDP-induced coma. Clinical and laboratory data conforming to the Acute Physiology and Chronic Health Evaluation (APACHE II), Modified APACHE II Score (MAS), Mainz Emergency Evaluation Scores (MEES) and Glasgow Coma Scale (GCS) were recorded for all patients on admission (time₀) and 24 h later (time₂₄). The outcome was recorded in two categories: Survived with or without complication and non-survived. Discrimination was evaluated using receiver operating characteristic (ROC) curves and area under the ROC curve (AUC).

Results:

The mortality rate was 9.7%. Mean of each scoring system was statistically significant between time₀ and time₂₄ in the survivors. However, it was not significant in non-survivors. Discrimination was excellent for GCS₂₄ (0.90±0.05), APACHE II₂₄ (0.89±0.01), MAS₂₄ (0.86±0.10), and APACHE II₀ (0.83±0.11) AUC.

Conclusion:

The GCS₂₄, APACHE II₂₄, MAS₂₄, and APACHE II₀ scoring systems seem to predict the outcome in comatose patients due to MDP more accurately. GCS and MAS may have superiority over the others in being easy to perform and not requiring laboratory data.