Optimum Baseline Clinical Severity Scale Cut Points for Prognosticating Intracerebral Hemorrhage: INTERACT Studies.

BACKGROUND: The optimal cut point of baseline National Institutes of Health Stroke Scale (NIHSS) and Glasgow Coma Scale scores for prognosticating acute intracerebral hemorrhage (ICH) is unknown. METHODS: Secondary analyses of participant data are from the INTERACT (Intensive Blood Pressure Reduction in Acute Intracerebral Hemorrhage Trials) 1 and 2 studies. Receiver operating characteristic analyses were used to compare the predictive performance of baseline NIHSS and Glasgow Coma Scale scores, ICH score, and max-ICH score. Optimal cut points for predicting 90-day clinical outcomes (death or major disability [defined as modified Rankin Scale scores 3-6], major disability [defined as modified Rankin Scale scores 3-5], and death alone) were determined using the Youden index. Logistic regression models were adjusted for age, sex, hematoma volume, and other known risk factors for poor prognosis. We validated our findings in the INTERACT1 database. RESULTS: There were 2829 INTERACT2 patients (age, 63.5±12.9 years; male, 62.9%; ICH volume, 10.96 [5.77-19.49] mL) included in the main analyses. The baseline NIHSS score (area under the curve, 0.796) had better prognostic utility for predicting death or major disability than the Glasgow Coma Scale score (area under the curve, 0.650) and ICH score (area under the curve, 0.674) and was comparable to max-ICH score (area under the curve, 0.789). Similar findings were observed when assessing the outcome of major disability. A cut point of 10 on baseline NIHSS optimally (sensitivity, 77.5%; specificity, 69.2%) predicted death or major disability (adjusted odds ratio, 4.50 [95% CI, 3.60-5.63]). The baseline NIHSS cut points that optimally predicted major disability and death alone were 10 and 12, respectively. The predictive effect of NIHSS≥10 for poor functional outcomes was consistent in all subgroups including age and baseline hematoma volume. Results were consistent when analyzed in the independent INTERACT1 validation database. CONCLUSIONS: In patients with mild-to-moderate ICH, a baseline NIHSS score of ≥10 was optimal for predicting poor outcomes at 90 days. Prediction based on baseline NIHSS is better than baseline Glasgow Coma Scale score. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifiers: NCT00226096 and NCT00716079.

Association between sub-phenotypes identified using latent class analysis and neurological outcomes in patients with out-of-hospital cardiac arrest in Japan.

BACKGROUND: In patients who experience out-of-hospital cardiac arrest (OHCA), it is important to assess the association of sub-phenotypes identified by latent class analysis (LCA) using pre-hospital prognostic factors and factors measurable immediately after hospital arrival with neurological outcomes at 30 days, which would aid in making treatment decisions. METHODS: This study retrospectively analyzed data obtained from the Japanese OHCA registry between June 2014 and December 2019. The registry included a complete set of data on adult patients with OHCA, which was used in the LCA. The association between the sub-phenotypes and 30-day survival with favorable neurological outcomes was investigated. Furthermore, adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were estimated by multivariate logistic regression analysis using in-hospital data as covariates. RESULTS: A total of, 22,261 adult patients who experienced OHCA were classified into three sub-phenotypes. The factor with the highest discriminative power upon patient's arrival was Glasgow Coma Scale followed by partial pressure of oxygen. Thirty-day survival with favorable neurological outcome as the primary outcome was evident in 66.0% participants in Group 1, 5.2% in Group 2, and 0.5% in Group 3. The 30-day survival rates were 80.6%, 11.8%, and 1.3% in groups 1, 2, and 3, respectively. Logistic regression analysis revealed that the ORs (95% CI) for 30-day survival with favorable neurological outcomes were 137.1 (99.4-192.2) for Group 1 and 4.59 (3.46-6.23) for Group 2 in comparison to Group 3. For 30-day survival, the ORs (95%CI) were 161.7 (124.2-212.1) for Group 1 and 5.78 (4.78-7.04) for Group 2, compared to Group 3. CONCLUSIONS: This study identified three sub-phenotypes based on the prognostic factors available immediately after hospital arrival that could predict neurological outcomes and be useful in determining the treatment strategy of patients experiencing OHCA upon their arrival at the hospital.

Effects of hyperbaric oxygen combined cabin ventilator on critically ill patients with liberation difficulty after tracheostomy.

BACKGROUND: Critically ill patients undergoing liberation often encounter various physiological and clinical complexities and challenges. However, whether the combination of hyperbaric oxygen and in-cabin ventilator therapy could offer a comprehensive approach that may simultaneously address respiratory and potentially improve outcomes in this challenging patient population remain unclear. METHODS: This retrospective study involved 148 patients experiencing difficulty in liberation after tracheotomy. Inclusion criteria comprised ongoing mechanical ventilation need, lung inflammation on computed tomography (CT) scans, and Glasgow Coma Scale (GCS) scores of ≤ 9. Exclusion criteria excluded patients with active bleeding, untreated pneumothorax, cerebrospinal fluid leakage, and a heart rate below 50 beats per minute. Following exclusions, 111 cases were treated with hyperbaric oxygen combined cabin ventilator, of which 72 cases were successfully liberated (SL group) and 28 cases (NSL group) were not successfully liberated. The hyperbaric oxygen chamber group received pressurization to 0.20 MPa (2.0 ATA) for 20 min, followed by 60 min of ventilator oxygen inhalation. Successful liberation was determined by a strict process, including subjective and objective criteria, with a prolonged spontaneous breathing trial. GCS assessments were conducted to evaluate consciousness levels, with scores categorized as normal, mildly impaired, moderately impaired, or severely impaired. RESULTS: Patients who underwent treatment exhibited improved GCS, blood gas indicators, and cardiac function indexes. The improvement of GCS, partial pressure of oxygen (PaO2), oxygen saturation of blood (SaO2), oxygenation index (OI) in the SL group was significantly higher than that of the NSL group. However, there was no significant difference in the improvement of left ventricular ejection fraction (LVEF), left ventricular end-systolic volume (LVESV), left ventricular end-diastolic volume (LVEDV), and stroke volume (SV) between the SL group and the NSL group after treatment. CONCLUSIONS: Hyperbaric oxygen combined with in-cabin ventilator therapy effectively enhances respiratory function, cardiopulmonary function, and various indicators of critically ill patients with liberation difficulty after tracheostomy.

Outcomes and Practices of Endotracheal Intubation Using the Glasgow Coma Scale in Acute Non-Traumatic Poisoning: A Systematic Review and Meta-Analysis of Proportions.

BACKGROUND: Acute poisoning often results in decreased consciousness, necessitating airway assessment and management. Existing literature in the trauma setting suggests the importance of airway protection in unconscious patients to prevent complications, including aspiration. Practices for endotracheal intubation in non-traumatic acute poisoning are poorly described and variable, particularly regarding the use of a Glasgow Coma Scale (GCS) ≤ 8 threshold for intubation. METHODS: A systematic review and meta-analysis of proportions was conducted to evaluate intubation rates and outcomes in patients presenting for acute non-traumatic poisoning. Studies were excluded if the primary indication for intubation was not airway protection. We analyzed rates of intubation, mortality, and aspiration by subgrouping patients into GCS ≤ 8, GCS 9-15, or mixed GCS. Common and random-effects analysis were used, supplemented by subgroup analyses. RESULTS: 39 studies were included in the analysis, involving 15,959 patients. Random-effects pooled intubation rates varied significantly across GCS categories: GCS ≤ 8 (30.0%, I2 = 92%, p < 0.01), GCS 9-15 (1.0%, I2 = 0%, p = 0.91), and mixed GCS (11.0%, I2 = 94%, p < 0.01), p-value <0.01 for subgroup difference. Aspiration rates also varied: GCS ≤ 8 (19.0%, I2 = 84%, p < 0.01), GCS 9-15 (4.0%, I2 = 78%, p < 0.01), and mixed group (5.0%, I2 = 72%, p < 0.01), p-value <0.01 for subgroup difference. Mortality rates remained low across all groups: GCS ≤ 8 (1.0%, I2 = 0%, p = 0.62), GCS 9-15 (1.0%, I2 = 0%, p = 0.99), and mixed group (2.0%, I2 = 68%, p < 0.01). CONCLUSION: The conventional "less than 8, intubate" approach may not be directly applicable to acute poisoning patients due to heterogeneity in patient presentation, intubation practices, and low mortality. Therefore, a nuanced approach is warranted to optimize airway management strategies tailored to individual patient needs.

The Glasgow Coma Scale: 50-year anniversary.

In 1974, Sir Graham Teasdale and Bryan Jennett wrote the "Assessment of coma and impaired consciousness, A practical scale," which has become one of the most influential papers in the history of traumatic brain injury, with more than 10,000 citations as of January 2024. Today, it is one of the most widely used tools in emergency departments, providing a reliable general overview of the patient's consciousness status.

Circulating soluble CD163 is associated with reduced Glasgow Coma Scale Score and 1-year all-cause mortality in traumatized patients.

Soluble CD163 (sCD163) is a biomarker of macrophage activation, not previously investigated in the circulation of traumatized patients. A biobank of 398 adult trauma patients was analyzed. Patients with an Injury Severity Score (ISS) >8 served as trauma patients (n = 195) and those with ISS ≤8 as trauma controls (n = 203). Serum samples obtained upon admission, 15h and 72h after were analyzed for sCD163 using an in-house ELISA. Multiple linear regression was used to analyze the association between admission levels of sCD163 with, 1: overall trauma severity (ISS), and 2: severity of injury to specified organs using Abbreviated Injury Score (AIS) and Glasgow Coma Scale (GCS). The association between the peak level of sCD163 with 1-year all-cause mortality was analyzed by logistic regression analysis. Median admission levels of sCD163 were higher in trauma patients than trauma controls [2.32 (IQR 1.73 to 2.86) vs. 1.92 (IQR 1.41 to 2.51) mg/L, p < 0.01]. Worsening GCS score was associated with a 10.3% (95% CI: 17.0 to 3.1, p < 0.01) increase in sCD163. Increasing Head-AIS score was associated with a 5.1% (95% CI: -0.5 to 11.0, p = 0.07) increase in sCD163. The remaining AIS scores and ISS were not consistently associated with sCD163 admission levels. Each mg/L increase in sCD163 peak level had an odds ratio 1.34 (95%CI: 0.98 to 1.83), p = 0.06) after adjustment for age, sex, and GCS. Circulating sCD163 is increased in traumatized patients and associated with worsening GCS. Our findings suggest an association between circulating sCD163 levels with 1-year all-cause mortality.

Validation of motor component of Glasgow coma scale in lieu of total Glasgow coma scale as a pediatric trauma field triage tool.

INTRODUCTION: Prehospital trauma triage and disability assessment of pediatric patients can be challenging on the field, especially in the pre-verbal age group. It would be useful if the same triage tool and criteria can be used for both adults and children to risk-stratify the need of higher acuity of trauma care. STUDY OBJECTIVE: We aimed to investigate if using only the motor component of Glasgow Coma Scale (mGCS), as a quick field trauma triage tool, was non-inferior to total GCS (tGCS), and if mGCS <6 was non-inferior to tGCS <14, in predicting the need for intensive care or mortality in the pediatric population. METHODS: We performed a retrospective review of patients <18-years-old, who presented to our emergency department (ED) with moderate (Injury Severity Score (ISS) 9-15) to severe (ISS > 15) traumatic injuries from January 2012 to December 2021. Using ED triage data, mortality and the need for intensive care unit (ICU) admission were used as surrogate outcomes to investigate if mGCS <6 was non-inferior to tGCS <14, and the area-under-the-receiver-operating-characteristic curve (AUROC) was used as a measure of comparability. RESULTS: Among 582 included for analysis, the median age was 7-years-old (2-12), and most were male (63.4%). 22.4% patients demised or required ICU care. mGCS <6 had an AUROC of 0.75 (95% CI 0.70 to 0.79), which was non-inferior to tGCS <14; AUROC 0.76, (95% CI 0.72 to 0.81), for identifying children requiring ICU management or demised. The results shown here were based on the AUROCs that were used to evaluate the discriminatory ability of tGCS <14 and mGCS <6 in prediction of mortality and the need for ICU care. CONCLUSION: Our study showed that mGCS was significantly associated with tGCS, and was non- inferior to the latter as a triage tool in pediatric trauma. It validated the use of mGCS <6 in lieu of tGCS <14 in the pre-hospital field triage of pediatric patients, in identification of children at risk of death or requiring ICU care. Larger prospective, observational studies using on-scene data would be required for more robust validation and determine optimal cut-offs.

Efficacy of 10%,25% and 50% dextrose in the treatment of hypoglycemia in the emergency department - A randomized controlled study.

INTRODUCTION: Documented symptomatic hypoglycemia is defined as "event during which typical symptoms of hypoglycemia are accompanied by measured blood glucose of ≤70 mg/dL. Most of the studies and recommendations for the unconscious hypoglycemic adult advocate the use of 25 g of glucose as 50 mL of 50% dextrose solution intravenous or 1 mg of intramuscular glucagon. OBJECTIVE: To compare the efficacy and safety of 5 g boluses of 10%, 25% and 50% dextrose in the treatment of hypoglycemic patients presenting to our emergency department. METHODS: This was a randomized controlled single blinded study. Hypoglycemic patients in altered mental status were randomized into three treatment arms to be administered 10%, 25% or 50% dextrose. 5 g aliquots of intravenous 10%,25% or 50% dextrose were administered over 1 min. Time taken to achieve a Glasgow Coma Scale (GCS) of 15 and median total doses (g) were the primary outcomes. RESULTS: Data of 204 patients were analysed in the study. There was no difference in the median time to achieve a GCS of 15 in all three treatment arms (6 min). Total median dose administered in the 10% and 25% groups was lower than 50% (10 g vs 15 g). Proportion of patients who received the maximum dose of 25 g was higher in the 50% group as compared to 10% and 25% groups (12%, 3%, 4%). CONCLUSION: There was no difference in 10% dextrose and 25% dextrose as compared to 50% dextrose in achieving the baseline mental status (or GCS 15) in the treatment of hypoglycemia in the ED.

Mapping Glasgow Coma scale to AVPU scores among adults in the prehospital setting.

OBJECTIVE: To develop a translation between the Glasgow Come Scale and the Alert-Verbal-Pain-Unresponsive (AVPU) scale among adults with out-of-hospital emergencies. METHODS: We performed a retrospective analysis of adults (≥18 years) from the 2022 National Emergency Medical Services (EMS) Information System with a ground scene encounter with a concurrently documented GCS and AVPU assessment. Using a training partition of 2.5 million encounters, we performed a grid search to identify all combinations of mutually exclusive cutpoints which divided the GCS into four segments. We identified the combination with the highest Kappa statistic and reported metrics of performance in this sample in the test partition. RESULTS: We identified 16,321,299 encounters with a concurrent AVPU and GCS. Using the AVPU scale, 93.3 % were classified as Alert; 2.9 % as Verbal; 1.5 % as Pain; and 2.3 % as Unresponsive. Using a grid-based search, optimal cutpoints were identified when using a GCS of 14-15 for Alert, 10-13 for Verbal, 7-9 for Pain, and 3-6 for Unresponsive. Cohen's Kappa was 0.63 in the test partition, indicating substantial agreement. Intraclass F1 score varied across different alertness levels and were 0.97 for "Alert", 0.43 for "Verbal", 0.49 for "Pain", and 0.83 for "Unresponsive". Findings were similar in analyses performed by age group and by the presence or absence of trauma. CONCLUSION: We report an optimal crosswalk between the AVPU and GCS scales. Performance in the Verbal and Pain categories was lower than the Alert and Unresponsive categories. These findings may facilitate clinician handovers between EMS and non-EMS clinicians.

Intoxication and Glasgow coma scale scores in patients with head trauma.

INTRODUCTION: The Glasgow Coma Scale (GCS) is an assessment tool commonly used by emergency department (ED) clinicians to objectively describe level of consciousness, especially in trauma patients. This study aims to assess the effect of drug and alcohol intoxication on GCS scores in cases of traumatic head injury. METHODS: In this retrospective chart review study, data were extracted from The Pennsylvania Trauma Systems Foundation Data Base Collection System. Eligible subjects included trauma patients aged 18 years and older, with head trauma, who presented between January 2019 and August 2023. Subjects were matched to controls who did not test positive for drugs or alcohol, matched by Injury Severity Score (ISS) category. RESULTS: Among 1088 subjects, the mean age was 63 (95% CI 62-64). The mean Injury Severity Score was 21 (95% CI 21-22). The median GCS among all subjects was 14 (IQR 6-15). Cases with alcohol or drug use were matched to controls without alcohol or drug use, and were matched by categories of Injury Severity Score. Cases with alcohol or drug use had lower GCS (median 13; IQR 3-15), compared to cases without alcohol or drug use (median 15; IQR 13-15) (p < 0.0001, Wilcoxon Rank Sum Test). CONCLUSIONS: Among patients with head trauma, intoxicated patients had statistically significant lower GCS scores as compared to matched patients with similar Injury Severity Scores.

Seizures, focal neurological signs, and pneumococcal aetiology associate with impaired consciousness in childhood bacterial meningitis.

AIM: A low Glasgow Coma Scale Score (GCS) on admission is a known predictor of poor outcome from childhood bacterial meningitis. In turn, the factors associated with the admission GCS are less known. Our aim was to identify them, both for clinical alerts of reserved prognosis and to find potential targets for intervention. METHODS: This study is a secondary analysis of data collected prospectively in Angola and in Latin America between 1996 and 2007. Children with bacterial meningitis were examined on hospital admission and their GCS was assessed using the age-adjusted scale. Associations between on-admission GCS and host clinical factors were examined. RESULTS: A total of 1376 patients with confirmed bacterial meningitis were included in the analysis (609 from Latin America and 767 from Angola). The median GCS was 13 for all patients (12 in Angola and 13 in Latin America). In the multivariate analysis, in the areas combined, seizures, focal neurological signs, and pneumococcal aetiology associated with GCS <13, as did treatment delay in Latin America. CONCLUSION: Besides pneumococcal aetiology, we identified characteristics, easily registrable on admission, which are associated with a low GCS in childhood bacterial meningitis. Of these, expanding pneumococcal vaccinations and treatment delays could be modified.

Performance of the neutrophil-lymphocyte ratio as a predictor of severity and mortality in children and adolescents with traumatic brain injury.

PURPOSE: An inflammatory cascade associated with the systemic neutrophil response can be triggered after traumatic brain injury (TBI), causing neuronal dysfunction, which is considered to be related to the prognosis of the victims. The scope of this research is to identify the performance of the neutrophil-lymphocyte ratio (NLR) as a predictor of prognosis considering TBI severity and death as outcomes in a group of pediatric patients. METHODS: We retrospectively evaluated NLR through a consecutive review of the medical records (cross-sectional study) of children and adolescents aged < 17 years victims of TBI. To determine the highest NLR value identified as a predictor, different cutoff points were tested for each outcome. The cutoff points were defined based on the area under curve (AUC) of the receiver operating characteristic (ROC). RESULTS: Among the 82 children with TBI included in the sample, the performance of AUC-ROC was 0.72 when evaluating NLR as a predictor of TBI severity, with NLR cutoff point of 3, and 0.76 when considering mortality as the outcome, with an increase in the cutoff point to 11. CONCLUSION: NLR can be considered a biomarker of brain injury in children and adolescent victims of TBI. Patients with NLR ≥ 3 had a fivefold higher probability of severe TBI and patients with NLR ≥ 11 experienced a ninefold higher risk of death.

"Biomarkers in severe traumatic brain injury: enhancing prognostic accuracy and therapeutic strategies".

This study examines the emerging role of biomarkers in the prognosis and management of severe traumatic brain injury (sTBI). Key findings highlight the significance of serum RIP-3, STC1, Nrf2, and cerebrospinal fluid galectin-3 and cytokines in predicting disease severity, mortality, and functional outcomes in sTBI patients. Elevated levels of RIP-3 and STC1 were linked to poor prognosis and increased mortality, with RIP-3 associated with necroptosis and inflammation, and STC1 with neuroprotective properties. Nrf2 was found to correlate with oxidative stress and adverse outcomes, while elevated CSF galectin-3 and IL-6 indicated neuroinflammation and neurodegeneration. These biomarkers show promise not only as prognostic tools but also as potential therapeutic targets. The study suggests further validation through multicenter research to enhance clinical applications and improve treatment strategies for sTBI.

The GCS-Pupils (GCS-P) score to assess outcomes after traumatic brain injury: a retrospective study.

INTRODUCTION: The Glasgow Coma Scale (GCS) and pupil response to light are commonly used to assess brain injury severity and predict outcomes. The aim of this study was to investigate whether the GCS combined with pupil response (GCS-P), compared to the GCS alone, could be a better predictor of hospital mortality for patients with traumatic brain injury (TBI). METHODS: A retrospective cohort study was undertaken at an adult level one trauma centre including patients with isolated TBI of Abbreviated Injury Scale above three. The GCS and pupil response were combined to an arithmetic score (GCS score (range 3-15) minus the number of nonreacting pupils (0, 1, or 2)), or by treating each factor as separate categorical variables. The association of in-hospital mortality with GCS-P as a categorical variable was evaluated using Nagelkerke's R2 and compared using areas under the receiver operating characteristic (AUROC) curve. RESULTS: There were 392 patients included over the study period of 1 July 2014 and 30 September 2017, with an overall mortality rate of 15.2%. Mortality was highest at GCS-P of 1 (79%), with lowest mortality at a GCS-P 15 (1.6%). Nagelkerke's R2 was 0.427 for GCS alone and 0.486 for GCS-P. The AUROC for GCS-P to predict mortality was 0.87 (95%CI: 0.82-0.72), higher than for GCS alone (0.85; 95%CI: 0.80-0.90; p < .001). DISCUSSION: GCS-P provided a better predictor of mortality compared to the GCS. As both the GCS and pupillary response are routinely recorded on all patients, combination of these pieces of information into a single score can further simplify assessment of patients with TBI, with some improvement in performance.

Cutoff of the reverse shock index multiplied by the Glasgow coma scale for predicting in-hospital mortality in adult patients with trauma: a retrospective cohort study.

BACKGROUND: Early identification of patients at risk of potential death and timely transfer to appropriate healthcare facilities are critical for reducing the number of preventable trauma deaths. This study aimed to establish a cutoff value to predict in-hospital mortality using the reverse shock index multiplied by the Glasgow Coma Scale (rSIG). METHODS: This multicenter retrospective cohort study used data from 23 emergency departments in South Korea between January 2011 and December 2020. The outcome variable was the in-hospital mortality. The relationship between rSIG and in-hospital mortality was plotted using the shape-restricted regression spline method. To set a cutoff for rSIG, we found the point on the curve where mortality started to increase and the point where the slope of the mortality curve changed the most. We also calculated the cutoff value for rSIG using Youden's index. RESULTS: A total of 318,506 adult patients with trauma were included. The shape-restricted regression spline curve showed that in-hospital mortality began to increase when the rSIG value was less than 18.86, and the slope of the graph increased the most at 12.57. The cutoff of 16.5, calculated using Youden's index, was closest to the target under-triage and over-triage rates, as suggested by the American College of Surgeons, when applied to patients with an rSIG of 20 or less. In addition, in patients with traumatic brain injury, when the rSIG value was over 25, in-hospital mortality tended to increase as the rSIG value increased. CONCLUSIONS: We propose an rSIG cutoff value of 16.5 as a predictor of in-hospital mortality in adult patients with trauma. However, in patients with traumatic brain injury, a high rSIG is also associated with in-hospital mortality. Appropriate cutoffs should be established for this group in the future.

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

BACKGROUND: The reverse shock index (rSI) combined with the Simplified Motor Score (sMS), that is, the rSI-sMS, is a novel and efficient prehospital triage scoring system for patients with COVID-19. In this study, we evaluated the predictive accuracy of the rSI-sMS for general ward and intensive care unit (ICU) admission among patients with COVID-19 and compared it with that of other measures, including the shock index (SI), modified SI (mSI), rSI combined with the Glasgow Coma Scale (rSI-GCS), and rSI combined with the GCS motor subscale (rSI-GCSM). METHODS: All patients who visited the emergency department of Taipei Tzu Chi Hospital between January 2021 and June 2022 were included in this retrospective cohort. A diagnosis of COVID-19 was confirmed through a SARS-CoV-2 reverse-transcription polymerase chain reaction test or SARS-CoV-2 rapid test with oropharyngeal or nasopharyngeal swabs and was double confirmed by checking International Classification of Diseases, Tenth Revision, Clinical Modification codes in electronic medical records. In-hospital mortality was regarded as the primary outcome, and sepsis, general ward or ICU admission, endotracheal intubation, and total hospital length of stay (LOS) were regarded as secondary outcomes. Multivariate logistic regression was used to determine the relationship between the scoring systems and the three major outcomes of patients with COVID-19, including. The discriminant ability of the predictive scoring systems was investigated using the area under the receiver operating characteristic curve, and the most favorable cutoff value of the rSI-sMS for each major outcome was determined using Youden's index. RESULTS: After 74,183 patients younger than 20 years (n = 11,572) and without COVID-19 (n = 62,611) were excluded, 9,282 patients with COVID-19 (median age: 45 years, interquartile range: 33-60 years, 46.1% men) were identified as eligible for inclusion in the study. The rate of in-hospital mortality was determined to be 0.75%. The rSI-sMS scores were significantly lower in the patient groups with sepsis, hyperlactatemia, admission to a general ward, admission to the ICU, total length of stay ≥ 14 days, and mortality. Compared with the SI, mSI, and rSI-GCSM, the rSI-sMS exhibited a significantly higher accuracy for predicting general ward admission, ICU admission, and mortality but a similar accuracy to that of the rSI-GCS. The optimal cutoff values of the rSI-sMS for predicting general ward admission, ICU admission, and mortality were calculated to be 3.17, 3.45, and 3.15, respectively, with a predictive accuracy of 86.83%, 81.94%%, and 90.96%, respectively. CONCLUSIONS: Compared with the SI, mSI, and rSI-GCSM, the rSI-sMS has a higher predictive accuracy for general ward admission, ICU admission, and mortality among patients with COVID-19.

Inconsistency in the Application of Glasgow Coma Scale in Pediatric Patients.

OBJECTIVE: The Glasgow Coma Scale (GCS) is widely used to objectively describe the extent of patients' impaired consciousness. However, there are known variations in scoring GCS both in adults and children which may impact patient management. The aim of this audit was to assess the application of GCS by medical and nursing staff in pediatric medical patients. SUBJECT AND METHODS: An online questionnaire was distributed amongst doctors and nurses working in the Department of Child and Adolescent Health at Mater Dei Hospital in Malta. The participants assigned GCS for 8 case scenarios involving children of different ages with varying levels of consciousness. Results were analyzed by calculating percentage agreement and by Cronbach's alpha. RESULTS: Sixty-six participants were studied, with a response rate of 52%. Performance was poor overall, with Cronbach alpha 0.53. Correlation was better at the upper and lower ends of the scale and the worst performance was for verbal response. Only respondents with 5-10 years of experience achieved acceptable consistency in the application of the GCS (Cronbach alpha 0.78). CONCLUSION: There is considerable variation in application of GCS in pediatric patients, highlighting the need for education and training to improve consistency for this commonly used neurological assessment tool.

Inter-rater reliability in the assessment of consciousness in patients receiving palliative care in intensive care: A prospective cross sectional observational study.

BACKGROUND: The Glasgow Coma Scale (GCS) is one of the methods that has validity for evaluating the consciousness levels of patients in the literature and is accepted by health authorities. AIM: The purpose of this study was to evaluate the inter-rater reliability of GCS in intensive care patients receiving palliative care. STUDY DESIGN: A prospective cross sectional observational study. The study was conducted in a general intensive care unit with 20 beds with patients receiving palliative care. In the unit, 18 nurses worked in two shifts, day and night. Each patient's primary palliative care nurse and two additional researchers were given one minute to independently record the patient's GCS total and subscale scores. All observations were completed within 5 min as there could be significant changes in the patient's GCS score during observations. RESULTS: A total of 258 assessments were completed. For the GCS total scoring, a moderate agreement was found between palliative care nurses and the first researcher-observer (49.0%) and also between palliative care nurses and the second researcher-observer (47.7%). In addition, there was a substantial agreement between the first and second researchers (78.9%) and also between all observers (61.5%) (all p = .001). CONCLUSIONS: Although there was a near-perfect agreement between the two researcher-observers, we found only moderate agreement among all observers (palliative care nurses and two researcher-observers) in the evaluation of GCS total and subscale scores. RELEVANCE TO CLINICAL PRACTICE: We found that lack of knowledge and training on the standardized use of GCS is still a problem for palliative and intensive care units. Because of the diversity of patients requiring GCS assessment in palliative care units, refresher training programs and hands-on workshops on consciousness assessment should be organized regularly for more experienced nurses.

Comparison of Glasgow Coma Scale and Full Outline of UnResponsiveness score to assess the level of consciousness in patients admitted to intensive care units and emergency departments: A quantitative systematic review.

OBJECTIVES: We aimed to investigate the reliability and validity of the Glasgow Coma Scale (GCS) and the Full Outline of UnResponsiveness (FOUR) score used by nurses and physicians to assess the level of consciousness in patients admitted to intensive care units (ICUs) and emergency departments (EDs). REVIEW METHOD USED: This systematic review was guided by the Cochrane Handbook for Systematic Reviews of Interventions and followed the reporting standards of the Preferred Reporting Items for Systematic Review and Meta-Analysis Statement. DATA SOURCES: A systematic search was conducted using the following databases: CINAHL, MEDLINE, and EMBASE. REVIEW METHODS: All authors performed the study selection process, data collection, and assessment of quality. The following psychometric properties were addressed: inter-rater reliability, internal consistency, and construct validity. RESULTS: Six articles were included. The GCS and the FOUR scores demonstrated excellent reliability and very strong validity when used by nurses and physicians to assess the level of consciousness in patients admitted to the ICU and ED. The FOUR score demonstrated slightly higher overall reliability and validity than the GCS. CONCLUSION: This systematic review indicates that the FOUR score is especially suitable for assessing the level of consciousness in patients admitted to the ICU and ED. The FOUR score demonstrated higher reliability and validity than the GCS, making it a promising alternative assessment scale, despite the GCS's longstanding use in clinical practice.

Unveiling the Complexity of Traumatic Brain Injury: Insights from Clinical Scoring Systems.

Krishnakumar M. Unveiling the Complexity of Traumatic Brain Injury: Insights from Clinical Scoring Systems. Indian J Crit Care Med 2024;28(3):193-195.