Deep coma does not always predict poor outcomes among patients with polytrauma.

PURPOSES: This study aimed to clarify the prognosis of polytrauma patients presenting to the emergency department (ED) with a Glasgow Coma Scale score (GCS) of 3. METHODS: A trauma registry system has been established at our institution since 2009. The current study reviewed patients in the registry who presented to the ED with a GCS of 3 from January 2011 to December 2015. Surviving and non-surviving patients were compared to identify the prognostic factors of patient survival. The study also aimed to determine the factors contributing to patients who survived with a GCS > 13 at discharge. RESULTS: During the study period, 145 patients were enrolled in the study, 119 of whom (82.1%) did not survive the traumatic insult. Of the 26 survivors, 13 (9.0%) had a GCS of 14 or 15 at discharge. The multiple logistic regression revealed that a lack of bilateral dilated and fixed pupils (BFDP) (OR 5.967, 95% CI 1.780-19.997, p = 0.004) and a GCS > 3 after resuscitation (OR 6.875, 95% CI 2.135-22.138, p = 0.001) were independent prognostic factors of survival. Based on the multiple logistic regression, an age under 40 years (OR 16.405, 95% CI 1.520-177.066, p = 0.021) and a GCS > 3 after resuscitation (OR 12.100, 95% CI 1.058-138.352, p = 0.045) were independent prognostic factors of a GCS > 13 at discharge. CONCLUSION: Aggressive resuscitation still provided benefit to polytrauma patients presenting with a GCS of 3, especially those with a rapid response to the resuscitation. Young patients with a deep coma on arrival had a higher probability of functional recovery after resuscitation in the ED.

Feasibility of instrumental swallowing assessments in patients with prolonged disordered consciousness while undergoing inpatient rehabilitation.

OBJECTIVE: To evaluate the feasibility, safety, and potential benefit of instrumental swallowing assessments for patients with prolonged disordered consciousness participating in rehabilitation. DESIGN: Case-control, retrospective. PARTICIPANTS: Thirty-five participants divided into 2 cohorts according to cognitive level at the time of baseline instrumental swallowing assessment. Group 1 (n = 17) participants were at Rancho Los Amigo (RLA) level II/III or RLA level III, while Group 2 (n = 18) participants were rated better than RLA level III. RESULTS: Aspiration and laryngeal penetration rates for both groups were similar (aspiration rate Group 1 = 41%, Group 2 = 39%; laryngeal penetration rate Group 1 = 59%, Group 2 = 61%). Overall, 76% (13/17) of Group 1 and 72% (13/18) of Group 2 were able to receive some type of oral feedings following baseline video fluoroscopic swallow study (VFSS) or endoscopic exam of the swallow (FEES). CONCLUSION: The majority of participants who underwent an instrumental swallowing examination while still functioning at RLA level II/III or RLA level III were able to return to some form of oral feedings immediately following their baseline examination. Swallowing as a treatment modality can be considered a part of the overall plan to facilitate neurobehavioral recovery for patients with prolonged disordered consciousness participating in rehabilitation.

Analysis of intracranial pressure changes during early versus late percutaneous tracheostomy in a neuro-intensive care unit.

BACKGROUND: We aimed to investigate intracranial pressure (ICP) changes during early versus late bedside percutaneous tracheostomy (PT) in a neuro-intensive care unit (NICU). METHODS: This study included 30 patients admitted to our NICU for head trauma, subarachnoid haemorrhage, intracerebral haematoma or brain tumour with a Glasgow Coma Score (GCS) less than 8. These patients also underwent ICP monitoring. Bedside PT was performed either early (within 7 days of ventilation) or late (after 7 days of ventilation) via the Griggs system. In all patients; ICP, systemic blood pressure, heart rate, oxygen saturation (Sat O(2)) and arterial blood gases were recorded 5 min before the procedure, during skin incision, during tracheal cannulation, as well as 5 min and 10 min after the procedure. FINDINGS: Thirty patients, 18 male and 12 female, with various intracranial pathologies between ages 18 and 78 (mean 38.7 +/- 20) were identified. The admission GCS ranged between 4 and 11 (median 7). Physiological variables did not differ significantly between the two groups. In the early group, ICP values measured 5 min before the procedure, during skin incision, during tracheal cannulation, as well as 5 min and 10 min after the procedure were 15.1 +/- 5.2, 22 +/- 10.1, 28.4 +/- 13.7, 17.3 +/- 7.1, 13.8 +/- 5.0 mmHg, respectively. In the late group, these values were 14.2 +/- 4.5, 17.2 +/- 5.5, 21.5 +/- 8.0, 15.1 +/- 5.3 and 12.4 +/- 4.1 mmHg. There was no significant difference between the early or late groups in terms of ICP increases during these predetermined 5 time points. CONCLUSIONS: In patients with decreased intracranial compliance, a relatively minimally invasive procedure such as PT may lead to significant increases in ICP. The timing of PT does not seem to influence ICP, mortality, pneumonia or early complications. During the PT procedure, ICP should be closely monitored and preventive strategies should be instituted in an attempt to prevent secondary insult to an already severely injured brain.