GCS-Pupil Score Has a Stronger Association with Mortality and Poor Functional Outcome than GCS Alone in Pediatric Severe Traumatic Brain Injury

<b><i>Background:</i></b> The Glasgow Coma Scale (GCS), used to classify the severity of traumatic brain injury (TBI), is associated with mortality and functional outcomes. However, GCS can be affected by sedation and neuromuscular blockade. GCS-Pupil (GCS-P) score, calculated as GCS minus Pupil Reactivity Score (PRS), was shown to better predict outcomes in a retrospective cohort of adult TBI patients. We evaluated the applicability of GCS-P to a large retrospective pediatric severe TBI (sTBI) cohort. <b><i>Methods:</i></b> Admissions to pediatric intensive care units in the Virtual Pediatric Systems (VPS, LLC) database from 2010 to 2015 with sTBI were included. We collected GCS, PRS (number of nonreactive pupils), cardiac arrest, abusive head trauma status, illness severity scores, pediatric cerebral performance category (PCPC) score, and mortality. GCS-P was calculated as GCS minus PRS. χ² or Fisher’s exact test and Mann-Whitney U test compared categorical and continuous variables, respectively. Classification and regression tree analysis identified thresholds of GCS-P and GCS along with other independent factors which were further examined using multivariable regression analysis to identify factors independently associated with mortality and unfavorable PCPC at PICU discharge. <b><i>Results:</i></b> Among the 2,682 patients included in the study, mortality was 23%, increasing from 4.7% for PRS = 0 to 80% for PRS = 2. GCS-P identified more severely injured patients with GCS-P scores 1 and 2 who had worse outcomes. GCS-P ≤ 2 had higher odds for mortality, OR = 68.4 (95% CI = 50.6–92.4) and unfavorable PCPC, OR = 17.3 (8.1, 37.0) compared to GCS ≤ 5. GCS-P ≤ 2 also had higher specificity and positive predictive value for both mortality and unfavorable PCPC compared to GCS ≤ 5. <b><i>Conclusions:</i></b> GCS-P, by incorporating pupil reactivity to GCS scoring, is more strongly associated with mortality and poor functional outcome at PICU discharge in children with sTBI.

The Yield of Neuroimaging in Patients Presenting to the Emergency Department With Isolated Neuro-Ophthalmological Complaints

Background: Neuro-ophthalmological emergencies require prompt assessment and management to avoid vision or life-threatening sequelae. The decision to perform a neuroimaging procedure is currently based on the clinical judgement of the medical team, without defined indications. This study aims to identify presenting symptoms and physical exam findings associated with relative positive findings on neuroimaging studies,Methods: This study was conducted by reviewing the electronic medical records of patients presenting to the Emergency Department (ED) with isolated neuro-ophthalmologic complaints between January 1st, 2013 and September 30th 2019. We collected data on the clinical presentation, neuroimaging procedures and results, consults, and diagnoses.Results: We reviewed the charts of 211 patients of whom 50.7% were females and had a mean age of 41.2 ±21.4 years. Most presented with unilateral eye complaints (53.6%), and the most common symptoms were blurred vision (77.3%) and headaches (42.2%). A total of 126 imaging procedures were performed of which 74.6% were normal, while 25.4% showed relevant abnormal findings. Complaining of blurry vision (p=0.038) or visual field changes (p=0.014) at presentation were associated with having positive findings on imaging. Physical exam findings of a visual field defect (p=0.016), abnormal pupil reactivity (p=0.028), afferent pupillary defect (p=0.018), or abnormal optic disc exam (p=0.009) were also associated with positive findings on imaging.Conclusion: Neuroimaging is more likely to yield positive findings in patients presenting to the ED with blurred vision or changes in visual field and in those found to have visual field irregularities, afferent pupillary defects or abnormal optic discs on physical exam. These findings - when combined with the proper clinical setting - should lower the threshold to proceed with neuroimaging in the emergency department. Based on our results, larger-scale studies might lead to a well-structured algorithm to be followed by ED physicians in decision making.

Cardiac arrest after severe traumatic brain injury can be survivable with good outcomes

BackgroundResuscitation for traumatic cardiac arrest (TCA) in patients with severe traumatic brain injury (sTBI) has historically been considered futile. There is little information on the characteristics and outcomes of these patients to guide intervention and prognosis. The purpose of the current study is to report the clinical characteristics, survival, and long-term neurological outcomes in patients who experienced TCA after sTBI and analyze the factors contributing to survival.MethodsA retrospective review identified 42 patients with TCA from a total of 402 patients with sTBI (Glasgow Coma Scale (GCS) score ≤8) who were admitted to Stony Brook University Hospital, a level I trauma center, from January 2011 to December 2018. Patient demographics, clinical characteristics, survival, and neurological functioning during hospitalization and at follow-up visits were collected.ResultsOf the 42 patients, the average age was 45 years and 21.4% were female. Eight patients survived the injury (19.0%) to discharge and seven survived with good neurological function. Admission GCS score and bilateral pupil reactivity were found to be significant indicators of survival. The mean GCS score was 5.3 in survivors and 3.2 in non-survivors (p=0.020). Age, Injury Severity Score, or cardiac rhythm was not associated with survival. Frequent neuroimaging findings included subarachnoid hemorrhage, subdural hematoma, and diffuse axonal injury.DiscussionTCA after sTBI is survivable and seven out of eight patients in our study recovered with good neurological function. GCS score and pupil reactivity are the best indicators of survival. Our results suggest that due to the possibility of recovery, resuscitation and neurosurgical care should not be withheld from this patient population.Level of evidenceLevel IV, therapeutic/care management.

The Glasgow Coma Scale Pupils score: a nurse's perspective

The Glasgow Coma Scale Pupils (GCS–P) score is calibrated from 1 to 15 and is calculated by subtracting the patient's pupil reactivity score (PRS) from their Glasgow Coma Scale score. The additional clinical information gained from the patient's PRS (0–2) enables practitioners to access a more qualitative framework to facilitate discussion of predictive information with families regarding the patient's potential for recovery or good outcome following a severe brain injury.

The crude ostracism detection system: Pupils react to minimal cues of exclusion

When people are rejected by others, they typically feel an immediate sense of pain—referred to as social pain. Social pain is hypothesized to be the alarm response of a “quick and crude” ostracism detection system, a system that is highly sensitive to even minimal signs of exclusion. Physiological reactivity has been found to accompany this social pain, but it is unclear whether the physiological mechanism underlying the ostracism detection system is also “quick and crude.” To test whether physiological reactivity to exclusion is “quick and crude,” the present study investigated whether pupil dilation (an index of physiological reactivity) differs when detecting exclusion from human entities versus nonhuman entities and when experiencing versus witnessing exclusion using a Cyberball paradigm. Experiment 1 showed that pupil size decreased less when viewing players who were exclusive than those who were inclusive, regardless of whether the players were human (i.e., undergraduate students) or nonhuman (i.e., computerized) entities. The same pupil reactivity pattern was observed in Experiment 2 after participants watched interactions in which another person was included or excluded by human or nonhuman entities. In Experiment 3, participating in real-life interactions with human players did not cause pupil reactivity to be greater to human players compared to nonhuman players, but pupil size again decreased less when viewing exclusive players compared to inclusive players. Across all three experiments, pupil size decreased less when viewing players who were exclusive than inclusive regardless of the social identity of the players. These findings support the idea of a highly sensitive, “quick and crude” physiological mechanism that underlies the ostracism detection system.

The crude ostracism detection system: Pupils react to minimal cues of exclusion

When people are rejected by others, they typically feel an immediate sense of pain – referred to as social pain. Social pain is hypothesized to be the alarm response of a “quick and crude” ostracism detection system, a system that is highly sensitive to even minimal signs of exclusion. Physiological reactivity has been found to accompany this social pain, but it is unclear whether the physiological mechanism underlying the ostracism detection system is also “quick and crude.” To test whether physiological reactivity to exclusion is “quick and crude,” the present study investigated whether pupil dilation (an index of physiological reactivity) differs when detecting exclusion from human entities versus non-human entities and when experiencing versus witnessing exclusion using a Cyberball paradigm. Experiment 1 showed that pupil size decreased less when viewing players who were exclusive than those who were inclusive, regardless of whether the players were human (i.e., undergraduate students) or non-human (i.e., computerized) entities. The same pupil reactivity pattern was observed in Experiment 2 after participants watched interactions in which another person was included or excluded by human or non-human entities. In Experiment 3, participating in real life interactions with human players did not cause pupil reactivity to be greater to human players compared to non-human players, but pupil size again decreased less when viewing exclusive players compared to inclusive players. Across all three experiments, pupil size decreased less when viewing players who were exclusive than inclusive regardless of the social identity of the players. These findings support the idea of a highly sensitive, “quick and crude” physiological mechanism that underlies the ostracism detection system.