Inaccurate Early Assessment of Neurological Severity in Head Injury

Abstract

Intubation, which requires sedation and myorelaxants, may lead to inaccurate neurological evaluation of severely head-injured patients. Aims of this study were to describe the early clinical evolution of traumatic brain injured (TBI) patients admitted to intensive care unit (ICU), to identify cases of over-estimated neurological severity, and to quantify the risk factors for this over-estimation. A total of 753 TBI patients consecutively admitted to ICU of three academic neurosurgical hospitals (NSH) were assessed. Cases whose severity was potentially over-estimated were identified by four criteria and indicated as "mistakenly severe" (MS): (1) no surgical intracranial masses; (2) could not follow commands at neurological assessment; (3) were dismissed from the ICU in Յ3 days to a regular ward; and (4) had regained the ability to obey commands. A total of 675 patients were intubated and/or sedated-paralyzed at the post-stabilization evaluation. In all, 304 patients had surgically treated intracranial masses. Among the 449 non-surgical cases, 58 patients fulfilling the criteria for MS were identified. The main features distinguishing MS from truly severe cases were younger age, higher Glasgow Coma Scale (GCS) score at all time points, Marshall classification of Computerized Tomographic (CT) scan mostly Diffuse Injury I and II, fewer pupillary abnormalities, and a lower frequency of hypoxia, hypotension, and extra-cranial injuries. In a certain proportion of non-surgical TBI patients, mostly intubated and sedated, neurological examination is difficult and severity can be over-estimated. Risk factors for this inaccurate evaluation can be identified, and clinical decisions should be based on further examination.

Prognostic Value of The Glasgow Coma Scale And Pupil Reactivity in Traumatic Brain Injury Assessed Pre-Hospital And on Enrollment: An IMPACT Analysis

“…As a result, the ability to obtain an accurate assessment of the GCS is compromised (Stocchetti et al, 2004). In a recent survey of 17 major trauma centers in the United States, most centers evaluated the GCS within 1 h of admission, and neurosurgeons indicated that hypoxia and hypotension are stabilized before the scoring the initial GCS (Marion and Carlier, 1994).…”

Usefulness of the Abbreviated Injury Score and the Injury Severity Score in Comparison to the Glasgow Coma Scale in Predicting Outcome After Traumatic Brain Injury

“…1 The GCS has important limitations, particularly in patients who are intoxicated or who require pharmacologic sedation or paralysis. 2 Although GCS correlates with survival and functional outcome, the correlation is weak and inconsistent. [3][4][5][6] Since the 1980s, most patients with traumatic brain injury (TBI) are also evaluated with computerized tomography (CT) scans, and experienced clinicians use anatomic findings from CT scans in conjunction with GCS scores and other clinical information to assess injury severity and plan surgical or medical interventions.…”

Identification of clinical and radiological predictors of outcome in head trauma patients in the emergency department

“…In patients having SDH (25% of total), 40 patients (44.44%) had poor outcome. (19)(20)(21)(22)(23)(24) Moderate (11)(12)(13)(14)(15)(16)(17)(18) Severe ( In this study, the mean GCS score was 10.61 .110 patients had a GCS score 8 or less (31.42%). 80of those patients (72.72%) had GOS V score.…”

“…( Stocchetti N et al; The RTS correlates well with the probability of survival. It also used for assessing prognosis if the RTS on arrival is compared to the best RTS after resuscitation.…”