Predictors of In-Hospital Mortality in Stroke Patients

Background: In-hospital mortality is a good indicator to assess the efficacy of stroke care. Identifying the predictors of in-hospital mortality is important to advance the stroke outcome and plan the future strategies of stroke management. Methods: This was a prospective observational study conducted at a tertiary referral center in Sri Lanka to identify the possible predictors of in-hospital mortality. The study included 246 confirmed stroke patients. The diagnosis of stroke was established on the clinical history, examination and neuroimaging. The differentiation of stroke in to haemorrhagic type and ischaemic type was based on the results of computed tomography. In all patients, demographic data, comorbidities, clinical signs (pulse rate, respiratory rate, systolic blood pressure, diastolic blood pressure, on admission Glasgow Coma Scale (GCS) score) and imaging findings were recorded. Serum electrolyte test was performed in all stroke patients and hyponatremia was defined as serum Na+ less than 131mmol/l. All patients were followed up throughout their hospital course and the in-hospital mortality was recorded. In hospital mortality was defined as the deaths which occurred due to stroke after 24 hours of hospital admission. Results: The incidence of in-hospital mortality was 11.7% (95% confidence interval 8-16.4). The mean day of in-hospital deaths to occur was 5.9 days (SD±3.8 Min 2 Max 20). According to multivariate logistic regression analysis on admission GCS score (Odds Ratio (OR)-0.71) and haemorrhagic stroke type (OR-5.12) predict the in-hospital mortality. The area under the curve of receiver operating curve drawn for the on admission GCS score was 0.78 with a sensitivity of 96.31% and specificity of 41.38% for a patient presented with the GCS score of <10. Conclusion: On admission GCS and haemorrhagic stroke are independent predictors of in-hospital mortality. Patients with on admission GCS <10 have a moderate predictive ability in predicting the in-hospital mortality. Thus, a special attention should be given to the patients with low GCS score and haemorrhagic strokes for reducing rates of in-hospital mortality.

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

Penetrating Brain Trauma due to Air Gun Shot – a Case Report

Cases of severe injuries caused by air guns are really uncommon, but they can lead to a fatal outcome. Usually, these injuries occur in children due to their not fully developed skull bones or in adults through less resistant and thin regions of the cranium. Most of them are accidental events, followed by low percentage of suicidal attempts. In this paper, we present the case of a 68-year-old man suffering from severe depression, with self-inflicted air gun injury to the head. The patient was admitted to the hospital in a coma with a Glasgow Coma Scale (GCS) score of 8, with severe penetrating head injury manifested with brain contusion and intraventricular bleeding seen at the CT examination. Metal particles from the projectile were seen inside the brain. The entry wound had inverted margins, abraded collar and skin defect. The additional neurological examination of the patient showed symptoms of increased intracranial pressure. The treatment started with the air gun wound care. Craniotomy surgery was also done and bone fragments around the entry wound were successfully extracted with subsequent debridement and duraplasty. The patient was treated with new-generation combined antibiotics for preventing inflammatory complications. On the nineteenth day, the patient was discharged with mild hemiparesis on the left side and with GCS score of 15. Air-gun traumatic cases with head injury or with injury to other parts of the body are often mistaken for firearm accidents, because air guns are seriously underestimated devices. Nevertheless, they could lead to severe health consequences and severe disability. This case highlights the necessity of strict monitoring of air guns by the responsible government institutions which should apply the same regulations in controlling these weapons as they implement in controlling the firearm guns. Presence of severe depression, mental illnesses, and neoplasms are risk factors for committing suicide with this type of weapons and the control over the air weapons in this group of people should be stricter.

Factors Associated with the Development of Coagulopathy after Open Traumatic Brain Injury

Background: The incidence of coagulopathy after open traumatic brain injury (TBI) is high. Coagulopathy can aggravate intracranial hemorrhage and further increase morbidity and mortality. The purpose of this study was to determine the clinical characteristics of coagulopathy after open TBI and its relationship with the prognosis. Methods: This study retrospectively evaluated patients with isolated open TBI from December 2018 to December 2020. Coagulopathy was defined as international normalized ratio (INR) > 1.2, activated thromboplastin time (APTT) > 35 s, or platelet count <100,000/μL. We compared the relationship between the clinical, radiological, and laboratory parameters of patients with and without coagulopathy, and the outcome at discharge. Logistic regression analysis was used to evaluate the risk factors associated with coagulopathy. We then compared the effects of treatment with and without TXA in open TBI patients with coagulopathy. Results: A total of 132 patients were included in the study; 46 patients developed coagulopathy. Patients with coagulopathy had significantly lower platelet levels (170.5 × 109/L vs. 216.5 × 109/L, p < 0.001), and significantly higher INR (1.14 vs. 1.02, p < 0.001) and APTT (30.5 s vs. 24.5 s, p < 0.001) compared to those with no coagulopathy. A Low Glasgow Coma Scale (GCS) score, high neutrophil/lymphocyte ratio (NLR), low platelet/lymphocyte ratio (PLR), and hyperglycemia at admission were significantly associated with the occurrence of coagulopathy. Conclusions: Coagulopathy often occurs after open TBI. Patients with a low GCS score, high NLR, low PLR, and hyperglycemia at admission are at greater risk of coagulopathy, and therefore of poor prognosis. The efficacy of TXA in open TBI patients with coagulopathy is unclear. In addition, these findings demonstrate that PLR may be a novel indicator for predicting coagulopathy.

Chronic subdural hematoma pressure measurement and its correlation with clinical characteristics and postoperative neurological outcome

Background: The pressure of the chronic SDH (subdural haemotoma), the age of the patient, preoperative GCS score and midline shift were considered prognostic dependent factors. The study aimed at the significance of the pressure of chronic SDH in the outcome of patients.Methods: A correlation between subdural hematoma pressure and preoperative and postoperative clinical variables such as hematoma volume, midline shift, age, GCS score and postoperative modified ranking scale score as well as complications were assessed and analyzed.Results: According to the pressure of chronic SDH, 56 patients were grouped into 4 groups. In the pressure group <15 cm/h20 group the mean age was 85 and postoperative ranking score was 3 and the recurrence was 21 % while in high pressure group (>25 cm/h20) the mortality was 14% and no recurrence.Conclusions: The pressure of the chronic SDH has significant prognostic value in chronic SDH surgeries.

Alcohol is not associated with increased mortality in adolescent traumatic brain injury patients

Purpose Compared to adults, there is a paucity of data regarding the association of a positive alcohol screen (PAS) and outcomes in adolescent patients with traumatic brain injury (TBI). We hypothesize adolescent TBI patients with a PAS on admission to have increased mortality compared to patients with a negative alcohol screen. Methods The 2017 Trauma Quality Improvement Program database was queried for patients aged 13–17 years presenting with a TBI and serum alcohol screen. Patients with missing information regarding midline shift on imaging and Glasgow Coma Scale (GCS) score were excluded. A multivariable logistic regression analysis for mortality was performed. Results From 2553 adolescent TBI patients with an alcohol screen, 220 (8.6%) had a PAS. Median injury severity scores and rates of penetrating trauma (all p > 0.05) were similar between alcohol positive and negative patients. Patients with a PAS had a similar mortality rate (13.2% vs. 12.1%, p = 0.64) compared to patients with a negative screen. Multivariate logistic regression controlling for risk factors associated with mortality revealed a PAS to confer a similar risk of mortality compared to alcohol negative patients (p = 0.40). Conclusion Adolescent TBI patients with a PAS had similar associated risk of mortality compared to patients with a negative alcohol screen.

Clinical consequences of Hypotension in patient with organophosphate poisoning

Objective: Aim of study is to describe the clinical consequences of hypotension in patient with organophosphate poisoning. Method: In the retrospective cohort study, we analyzed data of 66 patients with organophosphate poisoning who were treated at Bir Hospital, Nams Kathmandu. Data from those with hypotension and normal blood pressure were compared to identify significant clinical consequences. Results: All together 66 patients were enrolled in this study out of which 44(66.7%) were female and 22(33.3%) were male. After analyzing data, we found 18.2% of case with severe poisoning (ACHE < 700 U/L). Among all, 41(62%) were found to have normal blood pressure and 25(37.9%) were found to have low blood pressure. Among those with hypotension, around 56% were found to have prolonged QTc interval, p < 0.003 and there was statistically significant association between QTc prolongation and vasopressor requirement, X2(1) = 22.98, P < 0.001. Patients requiring higher dose to reach atropinization had statistically significant hypotension, P < 0.001. Those with low blood pressure were found to require more days of hospital admission, P < 0.001. Patients with hypotension were found to have severe poisoning both on the basis of POP Score severity grading, 16(64%) P <0.002 and ACHE Severity scale, 7(28%) P < 0.05. In comparison with normal blood pressure group, low blood pressure group had significantly more chance of developing complications like septic shock (2), aspiration pneumonia (5), ARDS (1) and bed sore, P = 0.002. Vasopressor requirement was significantly more among those with low blood pressure, P < 0.001. Most of hypotensive patients were needing ICU care, found to have higher WBC count P = 0.002 and lower GCS Score at admission P < 0.001. There was positive correlation between hypotension and POP Score at admission P < 0.001. Conclusion: Hypotension is a common complication in patient with organophosphate poisoning and is associated with higher POP Score, lower ACHE level, lower GCS Score, increased vasopressor requirement, more hospital stays, increasing ICU admission, more chance of developing septic shock and aspiration pneumonia.

Effect of early tranexamic acid treatment on fatigue in patients with mild traumatic brain injury: data from the CRASH-3 clinical trial

Background: Each year world-wide about 65 million people sustain a mild traumatic brain injury (mTBI). Fatigue is a common and distressing symptom after mTBI. We examine the effect of tranexamic acid (TXA) on fatigue in patients with mTBI using data from the CRASH-3 trial. Methods: The CRASH-3 trial randomised 9,202 patients with traumatic brain injury and no significant extracranial bleeding to receive TXA or placebo within 3 hours of injury. The primary outcome was death from head injury within 28 days of injury. The methods and results are presented elsewhere. Fatigue was recorded as “None”, “Moderate” or “Extreme.” This study examines the effect of TXA on extreme fatigue in the 2,632 patients with mTBI (Glasgow Coma Scale [GCS] score≥13). Our analyses were not prespecified. Results: Our study primary outcome, extreme fatigue, was reported for 10 (0.8%) of 1,328 patients receiving TXA and 19 (1.5%) of 1,288 patients receiving placebo (risk ratio [RR]=0.51, 95% confidence interval [CI] 0.24-1.09). Death within 28 days of injury was reported for 34 (2.6%) of 1,328 patients receiving TXA versus 47 (3.6%) of 1,288 patients receiving placebo (RR=0.70, 95% CI 0.45-1.08). Among patients allocated to TXA, 44 (3.3%) patients either died or reported extreme fatigue versus 66 (5.1%) patients among those allocated to placebo (RR=0.65, 95% CI 0.44-0.94). Conclusions: Early tranexamic acid treatment may reduce fatigue in mTBI patients, but these results need to be confirmed in a larger trial. Registration: ISRCTN (ISRCTN15088122, 19/07/2011), ClinicalTrials.gov (NCT01402882, 26/07/2011), EudraCT (2011-003669-14, 25/07/2011), Pan African Clinical Trial Registry (PACTR20121000441277, 30/10/2012).

A Rare Cause of Septic Shock Secondary to Trauma: Morel Lavallée Lesion - Case Report

Introduction Morel Lavallée lesion is a hemolymphatic collection in between muscular fascia that can be caused by the separation of soft tissue and muscular fascia in degloving fashion. Morel Lavallée lesion is an infrequent lesion but should be known for medico-legal reports Morel Lavallée is a rare presentation that can cause life-threatening septic and hemorrhagic shock. Case PresentationIn this case report we are going present Morel Lavallée lesion which can present with septic shock and bleeding and can be mortal. Our patient, fourty seven years old male, arrived at the emergency department with an ambulance 1 hour after an extravehicular traffic accident. Apart from a right hemopneumothorax with multiple rib fractures, grade 2 laceration in spleen and bilateral kidneys, zone 2 fracture of sacrum, computer tomography (CT) revealed a closed, degloving injury of the pelvis , also known as a Morel-Lavallée lesion. On CT, Morel Lavallée lesion appear as well-defined, encapsulated fluid collections that occasionally show fluid fluid levels .. Heavy fluid collection was detected in control CT which was actually a collection infected hematoma in the operative setting. Patient was diagnosed in the first 12 hours and necrotic tissues were debrided. Patient was considered deceased after 15 days without any improvement in his GCS score.ConclusionsThere is one report that describe mortality after Morel Lavallée lesion in the autopsy setting. Early diagnosis and treatment are essential to decrease severity of necrosis and sepsis though our patient has deceased due to complications of sepsis

Multimodal Monitoring in Large Hemispheric Infarction: Quantitative Electroencephalography Combined With Transcranial Doppler for Prognosis Prediction

Background: We aimed to explore whether transcranial Doppler (TCD) combined with quantitative electroencephalography (QEEG) can improve prognosis evaluation in patients with a large hemispheric infarction (LHI) and to establish an accurate prognosis prediction model.Methods: We prospectively assessed 90-day mortality in patients with LHI. Brain function was monitored using TCD-QEEG at the bedside of the patient.Results: Of the 59 (55.3 ± 10.6 years; 17 men) enrolled patients, 37 (67.3%) patients died within 90 days. The Cox regression analyses revealed that the Glasgow Coma Scale (GCS) score ≤ 8 [hazard ratio (HR), 3.228; 95% CI, 1.335–7.801; p = 0.009], TCD-terminal internal carotid artery as the offending vessel (HR, 3.830; 95% CI, 1.301–11.271; p = 0.015), and QEEG-a (delta + theta)/(alpha + beta) ratio ≥ 3 (HR, 3.647; 95% CI, 1.170–11.373; p = 0.026) independently predicted survival duration. Combining these three factors yielded an area under the receiver operating characteristic curve of 0.905 and had better predictive accuracy than those of individual variables (p &lt; 0.05).Conclusion: TCD and QEEG complement the GCS score to create a reliable multimodal method for monitoring prognosis in patients with LHI.