Relationship between tracheal intubation and the drugs used by patients with drug overdose due to self-harm

Background Tracheal intubation may be performed in patients with drug overdose due to self-harm; however, the details of the causative drug are unknown. The purpose of this study was to clarify the relationship between drugs or its blood levels of patients with drug overdose and the need for tracheal intubation based on the actual measurement results. Methods From October 2018 to March 2020, 132 patients with drug overdose due to self-harm who were transported to the emergency department (ED) were studied. Patient drugs were measured using gas chromatography–mass spectrometry (GC-MS) and were analyzed on the basis of the GC/MS Forensic Toxicological Database. Logistic analysis was performed by combining patient information and GC-MS information. Results The Glasgow Coma Scale (GCS) and Japan Coma Scale (JCS) efficiently predicted tracheal intubation in patients with drug overdose during transport triage; GCS (cut-off value: 12, area under the curve (AUC): 0.81, 95% confidence interval (CI): 0.71–0.88, sensitivity: 0.85, specificity: 0.71, P < 0.05) and JCS (cut-off value: 3, AUC: 0.74, 95% CI: 0.60–0.84, sensitivity: 0.60, specificity: 0.84, P < 0.05). The drugs detected in all patients with drug overdose in order were benzodiazepine receptor agonists (BZs; 43.9%), anticonvulsants (38.6%), antipsychotics (25.0%), and antidepressants (9.8%). In univariate logistic analysis, antipsychotics (odds ratio (OR) 2.46, 95% CI 1.19–5.20, P < 0.05), anticonvulsants (OR 2.71, 95% CI 1.26–5.98, P < 0.05), and anticonvulsants above alert blood levels (OR 27.8, 95% CI 2.92–264.1, P < 0.05) were significantly associated with tracheal intubation in patients with drug overdose, but not BZs and antidepressants. Also, in multivariate logistic analysis, antipsychotics (OR 2.27, 95% CI 1.07–4.83, P < 0.05), anticonvulsants (OR 2.50, 95% CI 1.14–5.64, P < 0.05) and in multivariate logistic analysis of blood levels, anticonvulsants above the alert blood levels (OR 24.9, 95% CI 2.56–241.6, P < 0.05) were significantly associated with tracheal intubation in patients with drug overdose respectively. Conclusions Logistic analysis revealed that the use of anticonvulsants and antipsychotics were significantly associated with an increased OR in the tracheal intubation of patients with drug overdose due to self-harm.

Effects of Not Intubating Non-Trauma Patients With Low Glasgow Coma Scale Scores: a Retrospective Study

Background: Endotracheal intubation (EI) is a critical life-saving procedure commonly performed on emergency department (ED) patients who present with altered mental status (AMS). Aims: We aimed to investigate the safety of observing, without EI, patients who present to the ED with decreased levels of consciousness (LOC). Methods: We reviewed the data of all adult ED patients with a Glasgow Coma Scale (GCS) score ≤ 8, during the period between 2012 and 2018, in an academic tertiary care centre. Trauma patients were excluded. The patients were divided into two groups for comparison: those who were intubated and those who were not. Data on mortality, morbidity, and baseline clinical characteristics were collected and analysed. Results: After screening 6334 electronic medical records of patients presenting to the ED with decreased LOC, only 257 patients met the inclusion criteria. 173 (67.3%) patients were intubated, while 84 (32.7%) were not. Among the intubated patients, 165 (95.4%) were intubated early (within two hours of presentation). Mortality, morbidity and length of stay for the intubated group were higher, although the baseline clinical characteristics were the same. Conclusion: It might be safe to observe non-trauma emergency patients with a GCS score ≤ 8 without intubation. However, such decision should be taken carefully, as delayed intubation can be associated with higher mortality and morbidity

Acute Neurologic Dysfunction in Critically Ill Children: The PODIUM Consensus Conference

CONTEXT Acute neurologic dysfunction is common in critically ill children and contributes to outcomes and end of life decision-making. OBJECTIVE To develop consensus criteria for neurologic dysfunction in critically ill children by evaluating the evidence supporting such criteria and their association with outcomes. DATA SOURCES Electronic searches of PubMed and Embase were conducted from January 1992 to January 2020, by using a combination of medical subject heading terms and text words to define concepts of neurologic dysfunction, pediatric critical illness, and outcomes of interest. STUDY SELECTION Studies were included if the researchers evaluated critically ill children with neurologic injury, evaluated the performance characteristics of assessment and scoring tools to screen for neurologic dysfunction, and assessed outcomes related to mortality, functional status, organ-specific outcomes, or other patient-centered outcomes. Studies with an adult population or premature infants (≤36 weeks' gestational age), animal studies, reviews or commentaries, case series with sample size ≤10, and studies not published in English with an inability to determine eligibility criteria were excluded. DATA EXTRACTION Data were abstracted from each study meeting inclusion criteria into a standard data extraction form by task force members. DATA SYNTHESIS The systematic review supported the following criteria for neurologic dysfunction as any 1 of the following: (1) Glasgow Coma Scale score ≤8; (2) Glasgow Coma Scale motor score ≤4; (3) Cornell Assessment of Pediatric Delirium score ≥9; or (4) electroencephalography revealing attenuation, suppression, or electrographic seizures. CONCLUSIONS We present consensus criteria for neurologic dysfunction in critically ill children.

Lower GCS is Related to Poor Outcome among Acute Stroke Patients with COVID-19 in A Tertiary Referral Hospital in Indonesia

BACKGROUND: The Coronavirus disease 2019 (COVID-19) pandemic has forced the health workforce to take mitigative measures such as physical distancing, screening, personal protective equipment donning, and confinement on patient care. We aimed to study the outcome of acute stroke patients with suspected, probable, or confirmed COVID-19 in a tertiary referral hospital in Indonesia during the first year of COVID-19 pandemic.METHODS: This was a retrospective study examining all medical records of adult patients suffering from acute stroke with suspected or confirmed COVID-19 who were admitted to R.D. Kandou Hospital, Manado, Indonesia, between March 2020 to March 2021. Clinical and laboratory parameters were compared between subjects with poor and good outcomes based on Glasgow Outcome Scale (GOS), divided into poor outcome (GOS 1-3) and good outcome (GOS 4-5).RESULTS: Fourty-six eligible subjects were enrolled in the study. Based on the GOS, 36 subjects (78.3%) were admitted to the hospital with poor prognosis. On admission, the median Glasgow Coma Scale (GCS) was 11, breathlessness was found in 54.3% of subjects, fever was found in only 15 subjects (32.6%), and the lowest oxygen saturation on admission 95%. We found that GCS significantly related to outcome after controlled for other factors using the logistic regression method (p=0.03; 95% CI=1.08-4.78).CONCLUSION: Lower GCS can be used to predict poor outcome in acute stroke patients with COVID-19.KEYWORDS: COVID-19, acute stroke, Glasgow Coma Scale, outcome, Indonesia

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.

A Child Presenting with a Glasgow Coma Scale Score of 13: Mild or Moderate Traumatic Brain Injury? A Narrative Review

Objective The objective of this article was to compare children with traumatic brain injury (TBI) and Glasgow Coma Scale score (GCS) 13 with children presenting with GCS 14 and 15 and GCS 9 to 12. Data Source We searched PubMed for clinical studies of children of 0 to 18 years of age with mild TBI (mTBI) and moderate TBI, published in English language in the period of 2000 to 2020. Study Selection We selected studies sub-classifying children with GCS 13 in comparison with GCS 14 and 15 and 9 to 12. We excluded reviews, meta-analyses, non-U.S./European population studies, studies of abusive head trauma, and severe TBI. Data Synthesis Most children (>85%) with an mTBI present at the emergency department with an initial GCS 15. A minority of only 5% present with GCS 13, 40% of which sustain a high-energy trauma. Compared with GCS 15, they present with a longer duration of unconsciousness and of post-traumatic amnesia. More often head computerized tomography scans show abnormalities (in 9–16%), leading to neurosurgical intervention in 3 to 8%. Also, higher rates of severe extracranial injury are reported. Admission is indicated in more than 90%, with a median length of hospitalization of more than 4 days and 28% requiring intensive care unit level care. These data are more consistent with children with GCS 9 to 12. In children with GCS 15, all these numbers are much lower. Conclusion We advocate classifying children with GCS 13 as moderate TBI and treat them accordingly.

Development and Implementation of an e-Learning Program on Glasgow Coma Scale

Background With the advancement in technology, e-learning is an attractive platform to facilitate online continuing medical education. The aim of the study was to develop a web-based nursing education program on the Glasgow coma scale (GCS) and to assess the effectiveness of this module in improving the knowledge of nurses. Methods A one-group pretest posttest study was conducted among nurses working in a tertiary care hospital in New Delhi, India, from November 2015 till July 2016. Before administering the GCS module, an online questionnaire was used to assess the baseline knowledge. After the completion of the module, a posttest questionnaire was administered and assessed. Results A total of 3500 users completed the e-learning GCS module. The mean pretest score was 4.2 ±2.1, and the mean posttest score was 7.3 ± 2.5. The mean difference in the score was statistically highly significant (p < 0.05). Conclusion The e-learning module is an effective means of providing continuing online education to the nurses, so that they can update their knowledge.

Difference and efficacy of simplified motor scale compared to Glasgow coma scale

There have been many limitations reported with using the Glasgow coma scale (GCS), including complexity, and being difficult to apply among aphasic, intubated, and pediatric patients. Accordingly, many researchers exerted serious efforts to enhance and modify the scale to make it more applicable and easy to interpret in these settings. The simplified motor score (SMS) was reported in the literature in 2012 for the assessment of patients with coma in different traumatic and non-traumatic settings. In the present study, we have discussed the findings of previous studies in the literature that compared the efficacy between the SMS and GCS in the assessment of patients with traumatic brain injuries within the emergency department and out-patient settings. Our results indicate the efficacy of the SMS is similar to that of the GCS score in predicting the different outcomes, including functional performance, need to perform tracheal intubation and hospital admission. Nevertheless, evidence regarding the prediction of mortality seems to be inconsistent across the different investigations. However, the differences between the two scores is not remarkable among these studies, indicating that the SMS is an efficacious tool in this regard within an acceptable test performance results. Furthermore, the SMS score can be easily applied within these without performing complex approaches, which makes it more advantageous than the GCS. However, this evidence is based on a limited number of investigations, and more studies are required.

Relation of Volume of Hemorrhage With Mortality Within First 48 Hours in Hemorrhagic Stroke

Background: Hemorrhagic stroke accounts for 10-15% of all strokes with higher mortality rates than cerebral infarction. Intracerebral hemorrhage has a reported 30-day mortality of 44% to 51%, with almost half of the death occurs within the first 48 hours. Advanced age, low level of consciousness, large volume of hemorrhage has been linked with poor outcome. Objectives: To predict early outcome of hemorrhagic stroke patient in relation with age, Glasgow Coma Scale, volume of hemorrhage and ventricular extension. Materials and Methods: Hospital based prospective study carried out in hundred hemorrhagic stroke patients. The formula of ABC/2 was used to calculate hemorrhage volume in bedside by using CT scan. Results: 1st month mortality rates of hemorrhagic stroke was 44% with 45.45% of patients died within the first 48 hours of onset. Mean age of patients of hemorrhagic stroke was 61.2 ± 13.88 years. Mortality rate of intracerebral hemorrhage after age of 60 was 51.06% in 1st month. Volume of intracerebral hemorrhage was the strongest predictor of both 48 hours and 30 days mortality. Using three categories of intracerebral hemorrhage (X for < 30 ml, Y for 30 - 50 ml and Z for > 50 ml group) calculated by ABC/2 formula showed 100% mortality rate in Z group, 50% in Y group and only 12% mortality rate in X group in 1st month. Among all death, 61.5% of Z group 25% of Y group and 16.67% of patients of X group died within 48 hours. Two categories of Glasgow Coma Scale (≤ 8 and ≥ 9) were used and shown death rates 80.77% in GCS ≤ 8 and 4.55% in GCS ≥ 9 in 1st month. Conclusion: Volume of intracerebral hemorrhage in combination with advanced age, initial Glasgow Coma Scale is a powerful and easy to use in both 48 hours and 1st month mortality in patients with spontaneous intracerebral hemorrhage. KYAMC Journal. 2021;12(3): 127-132