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Concept: Glasgow Coma Scale


Background Limited data are available to guide the choice of a target for the systolic blood-pressure level when treating acute hypertensive response in patients with intracerebral hemorrhage. Methods We randomly assigned eligible participants with intracerebral hemorrhage (volume, <60 cm(3)) and a Glasgow Coma Scale (GCS) score of 5 or more (on a scale from 3 to 15, with lower scores indicating worse condition) to a systolic blood-pressure target of 110 to 139 mm Hg (intensive treatment) or a target of 140 to 179 mm Hg (standard treatment) in order to test the superiority of intensive reduction of systolic blood pressure to standard reduction; intravenous nicardipine to lower blood pressure was administered within 4.5 hours after symptom onset. The primary outcome was death or disability (modified Rankin scale score of 4 to 6, on a scale ranging from 0 [no symptoms] to 6 [death]) at 3 months after randomization, as ascertained by an investigator who was unaware of the treatment assignments. Results Among 1000 participants with a mean (±SD) systolic blood pressure of 200.6±27.0 mm Hg at baseline, 500 were assigned to intensive treatment and 500 to standard treatment. The mean age of the patients was 61.9 years, and 56.2% were Asian. Enrollment was stopped because of futility after a prespecified interim analysis. The primary outcome of death or disability was observed in 38.7% of the participants (186 of 481) in the intensive-treatment group and in 37.7% (181 of 480) in the standard-treatment group (relative risk, 1.04; 95% confidence interval, 0.85 to 1.27; analysis was adjusted for age, initial GCS score, and presence or absence of intraventricular hemorrhage). Serious adverse events occurring within 72 hours after randomization that were considered by the site investigator to be related to treatment were reported in 1.6% of the patients in the intensive-treatment group and in 1.2% of those in the standard-treatment group. The rate of renal adverse events within 7 days after randomization was significantly higher in the intensive-treatment group than in the standard-treatment group (9.0% vs. 4.0%, P=0.002). Conclusions The treatment of participants with intracerebral hemorrhage to achieve a target systolic blood pressure of 110 to 139 mm Hg did not result in a lower rate of death or disability than standard reduction to a target of 140 to 179 mm Hg. (Funded by the National Institute of Neurological Disorders and Stroke and the National Cerebral and Cardiovascular Center; ATACH-2 number, NCT01176565 .).

Concepts: Blood, Hypertension, Stroke, Blood pressure, Cerebral hemorrhage, Disability, Orthostatic hypotension, Glasgow Coma Scale


BACKGROUND:Hospital mortality has decreased over time for critically ill patients with various forms of brain injury. We hypothesized that the proportion of patients who progress to neurologic death may have also decreased. METHODS:We performed a prospective cohort study involving consecutive adult patients with traumatic brain injury, subarachnoid hemorrhage, intracerebral hemorrhage or anoxic brain injury admitted to regional intensive care units in southern Alberta over a 10.5-year period. We used multivariable logistic regression to adjust for patient age and score on the Glasgow Coma Scale at admission, and to assess whether the proportion of patients who progress to neurologic death has changed over time. RESULTS:WeThe cohort consisted of 2788 patients. The proportion of patients who progressed to neurologic death was 8.1% at the start of the study period, and the adjusted odds of progressing to neurologic death decreased over the study period (odds ratio [OR] per yr 0.92, 95% confidence interval [CI] 0.87-0.98, p = 0.006). This change was most pronounced among patients with traumatic brain injury (OR per yr 0.87, 95% CI 0.78-0.96, p = 0.005); there was no change among patients with anoxic injury (OR per yr 0.96, 95% CI 0.85-1.09, p = 0.6). A review of the medical records suggests that missed cases of neurologic death were rare (≤ 0.5% of deaths). INTERPRETATION:The proportion of patients with brain injury who progress to neurologic death has decreased over time, especially among those with head trauma. This finding may reflect positive developments in the prevention and care of brain injury. However, organ donation after neurologic death represents the major source of organs for transplantation. Thus, these findings may help explain the relatively stagnant rates of deceased organ donation in some regions of Canada, which in turn has important implications for the care of patients with end-stage organ failure.

Concepts: Epidemiology, Death, Stroke, Traumatic brain injury, Intensive care medicine, Subarachnoid hemorrhage, Glasgow Coma Scale, Coma


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

Concepts: Hospital, Physician, Trauma center, Emergency medicine, Glasgow Coma Scale, Coma, Emergency department, Trauma team


BackgroundDecreased level of consciousness is a rare neurological manifestation of spontaneous intracranial hypotension (SIH), which typically presents with orthostatic headache. The optimal management of this uncommon presentation remains uncertain.MethodsWe analyzed the presentation, management and outcome of two patients in our institution and reviewed 22 patients reported in the literature with SIH and decreased level of consciousness, defined as any decrease in the patient’s Glasgow Coma Scale score.ResultsThere were 20 male and four female patients (M:F ratio of 5:1) with an average age of 52 years (range 37 to 68 years). There was a variable time interval of up to many months between the initial presentation of SIH and changes in the level of consciousness. An epidural autologous blood patch was eventually successful in 79% of the patients, although up to three trials were necessary in seven of these patients. Intrathecal saline infusion used as a temporizing measure resulted in excellent response within hours in five out of six patients who received this treatment. Drainage of the subdural collection either did not result in any sustained improvement or resulted in clinical deterioration in 12 out of 12 patients who received this treatment.ConclusionsIn the absence of a clinical trial because of the rarity of this entity, the treatment of SIH complicated by decreased level of consciousness remained controversial in the past. However, current collective experience supports early treatment of patients with SIH and decreased level of consciousness with one or more epidural blood patches. Fibrin glue and surgical duroplasty are the next steps in the management of patients in whom epidural blood patches fail. Drainage of the subdural collections may be detrimental.

Concepts: Patient, Neurology, Orthostatic hypotension, Glasgow Coma Scale, Coma, Result, Spontaneous cerebrospinal fluid leak, Orthostatic headache


To assess: (i) the clinical characteristics and injury descriptors of patients with severe traumatic brain injury in Northern Sweden admitted to the single Neurotrauma Center (NC) serving this region; (ii) the care pathway of patients from injury to 3 months after discharge from the NC; and (iii) the outcomes at 3 months post-injury. Population-based prospective 2-year cohort study. Patients age 17-65 years with acute severe traumatic brain injury, lowest non-sedated Glasgow Coma Scale (GCS) score of 3-8 within 24 h post-trauma. Patients were treated according to an intracranial pressure-oriented protocol based on the Lund concept at the NC. They were assessed at 3 weeks after injury with Rancho Los Amigos Cognitive Scale Revised (RLAS-R), Levels of Cognitive functioning, and at 3 months with RLAS-R and Glasgow Outcome Scale Extended (GOSE). A total of 37 patients were included. Hospital deaths within 3 months post-injury occurred in 5 patients. After 3 months the RLAS-R scores were significantly improved (< 0.001). Eight patients had both "superior cognitive functioning" on the RLAS-R and "favourable outcome" on the GOSE. Thirty-four patients (92%) were directly admitted to the NC. By contrast, after discharge patients were transferred back to one of several county hospitals or to one of several local hospitals, and some had multiple transfers between different hospitals and departments. Overall outcomes were surprisingly good in this group of severely injured patients. The routines for transferring patients with severe traumatic brain injury from a geographically large, sparsely populated region to a regional NC to receive well-monitored neurosurgical care seem to work very well. The post-acute clinical pathways are less clearly reflecting an optimized medical and rehabilitative strategy.

Concepts: Brain, Traumatic brain injury, Intracranial pressure, Cognition, Glasgow Coma Scale, Brain injury, Coma, Rancho Los Amigos Scale


There are no established biomarkers for mild traumatic brain injury (mTBI), in part because post-concussive symptoms (PCS) are subjective and conventional imaging is typically unremarkable. To test whether diffuse axonal abnormalities quantified with three-dimensional (3D) proton magnetic resonance spectroscopic imaging (1H-MRSI) correlated with patients' PCS, we retrospectively studied 26 mTBI patients (mean Glasgow Coma Scale score of 14.7), 18-56 years old, 3 - 55 days post injury and 13 controls. All were scanned at 3 Tesla with T1-and T2-weighted MRI and 3D 1H-MRSI (480 voxels over 360 cm3, ~30% of the brain). On scan day patients completed a symptom questionnaire and those indicating at least one of the most common acute/subacute mTBI symptoms (headache, dizziness, sleep disturbance, memory deficits, blurred vision) were grouped as PCS-positive. Global gray- and white matter (GM/WM) absolute concentrations of N-acetylaspartate (NAA), choline (Cho), creatine (Cr) and myo-inositol (mI) in the PCS-positive and PCS-negative patients were compared to age- and gender-matched controls using two-way analysis of variance. The results showed that the PCS-negative group (n=11) and controls (n=8) did not differ in any GM or WM metabolite level. The PCS-positive patients (n=15), however, had lower WM NAA than the controls (n=12): 7.0±0.6 mM (mean± standard deviation) versus 7.9±0.5mM (p=0.0007). Global WM NAA, therefore, showed sensitivity to the TBI sequelae associated with common PCS in individuals with mostly normal neuroimaging as well as GCS scores. This suggests a potential biomarker role in a patient population in which objective measures of injury and symptomatology are currently lacking.

Concepts: Brain, Traumatic brain injury, Nuclear magnetic resonance, Magnetic resonance imaging, Normal distribution, Standard deviation, Post-concussion syndrome, Glasgow Coma Scale


This study aimed to examine the correlation between the alterations in serum sex hormones testosterone (T) and estradiol (E2) in the early stages after craniocerebral and extracranial injuries, to assess the Injury Severity Score (ISS) and Glasgow Coma Scale (GCS) score in patients with multiple injuries, and to investigate the significance of the posttrauma changes in ISS and GCS as well as their ratio.

Concepts: Traumatic brain injury, Luteinizing hormone, Testosterone, Human sexuality, Physical trauma, Glasgow Coma Scale, Coma, Injury Severity Score


Background. Toxin-induced methemoglobinemia is seen in poisoning with oxidizing agents. We report the clinical features and outcome of patients admitted with severe methemoglobinemia due to intentional ingestion of toxicants. Methods. In this observational case series, patients admitted with toxin-induced methemoglobinemia between September 2011 and January 2014 were identified from the institutional poisoning database. Clinical profile and outcome of patients with methemoglobin concentration greater than or equal to 49% is reported. Results. Of the 824 patients admitted with poisoning, 5 patients with methemoglobin concentration greater than or equal to 49% were included. The implicated compounds were nitrobenzene, benzoylphenylurea, flubendamide and Rishab™. One patient refused to name the compound. All patients were managed in the intensive care unit. Altered sensorium [Glasgow coma scale (GCS) < 10] was common (80%); 2 patients presented with a GCS greater than 4. All patients manifested cyanosis, low oxygen saturation and chocolate-brown-colored blood despite supplemental oxygen therapy. The median methemoglobin concentration was 64.7% (range 49.8-91.6%); 2 patients had methemoglobin concentration greater than 70%. One patient needed inotropes. Four patients required mechanical ventilation for 4-14 days. All patients were treated with methylene blue; 4 received more than one dose. Three patients also received intravenous ascorbic acid 500 mg, once daily, for 3 days. Following treatment, there was evidence of haemolysis in all patients; 2 required blood transfusion. All patients survived. Conclusion. Patients with severe toxin-induced methemoglobinemia present with altered sensorium and cyanosis and may require ventilatory support and inotropes. Though methemoglobin concentrations greater than 70% are considered fatal, aggressive management with methylene blue and supportive therapy can lead to survival.

Concepts: Oxygen, Intensive care medicine, Chronic obstructive pulmonary disease, Methemoglobinemia, Methylene blue, Glasgow Coma Scale, Oxygen therapy, Equality


Hanging is known not only as a common method of suicide but also as a capital punishment method in some countries. Although several cases have been reported to survive after the attempted suicidal/accidental hanging, to the extent of our knowledge, no modern case of survival after judicial hanging exists. We reported a case of an individual who revived after modern judicial hanging despite being declared dead. The case was admitted with poor clinical presentations and the Glasgow Coma Scale of 6/15. The victim received all the standard supportive intensive care and gained complete clinical recovery.

Concepts: Scientific method, Death, Intensive care medicine, Capital punishment, Hanging, Glasgow Coma Scale, Coma, Plato


This study was designed to investigate the quality of data in the pre-hospital and emergency departments when using a wearable vital signs monitor and examine the efficacy of a combined model of standard vital signs and respective data quality indices (DQIs) for predicting the need for life-saving interventions (LSIs) in trauma patients. It was hypothesised that prediction of needs for LSIs in trauma patients is associated with data quality. Also, a model utilizing vital signs and DQIs to predict the needs for LSIs would be able to outperform models using vital signs alone. Data from 104 pre-hospital trauma patients transported by helicopter were analysed, including means and standard deviations of continuous vital signs, related DQIs and Glasgow coma scale (GCS) scores for LSI and non-LSI patient groups. DQIs involved percentages of valid measurements and mean deviation ratios. Various multivariate logistic regression models for predicting LSI needs were also obtained and compared through receiver-operating characteristic (ROC) curves. Demographics of patients were not statistically different between LSI and non-LSI patient groups. In addition, ROC curves demonstrated better prediction of LSI needs in patients using heart rate and DQIs (area under the curve [AUC] of 0.86) than using heart rate alone (AUC of 0.73). Likewise, ROC curves demonstrated better prediction using heart rate, total GCS score and DQIs (AUC of 0.99) than using heart rate and total GCS score (AUC of 0.92). AUCs were statistically different (p < 0.05). This study showed that data quality could be used in addition to continuous vital signs for predicting the need for LSIs in trauma patients. Importantly, trauma systems should incorporate processes to regulate data quality of physiologic data in the pre-hospital and emergency departments. By doing so, data quality could be improved and lead to better prediction of needs for LSIs in trauma patients.

Concepts: Regression analysis, Statistics, Hospital, Prediction, Mean, Standard deviation, Emergency medicine, Glasgow Coma Scale