Observer variability in assessing impaired consciousness and coma.

Teasdale, Graham M.; Knill‐Jones, R. P.; Sande, J. van der

doi:10.1136/jnnp.41.7.603

Cited by 269 publications

(88 citation statements)

References 12 publications

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“…In addition, it is plausible that many of the overdoses were mixed ingestions; therefore, it is difficult to determine the expected response to naloxone in mixed co-ingestions of different toxins. Finally, prehospital provider training for objective criteria such as respiratory rate and GCS is quite uniform and the inter-rater reliability is exceedingly high [21,22]. For these reasons, we believe the use of EAR in this study was appropriate.…”

Section: Discussionmentioning

confidence: 92%

“…Treatment response was known at the time of documentation and may have influenced what was recorded. There was no possibility of independent verification to the accuracy of objective measures like GCS scores; however, the inter-rater reliability for GCS has previously been shown to be exceedingly high [21,22]. Similarly, the accurate documentation of vital signs by EMS providers in this study may have been outweighed by the need for urgent administration of naloxone to patients with impending respiratory arrest; however, the training of paramedics is fairly uniform throughout the region and the clinical information sought did not require additional training to obtain reliably.…”

Section: Limitationsmentioning

confidence: 99%

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Validation of Criteria to Guide Prehospital Naloxone Administration for Drug-Related Altered Mental Status

Friedman

Manini

2016

J. Med. Toxicol.

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Introduction We aimed to validate previously derived clinical criteria to predict successful prehospital response to naloxone in patients with altered mental status treated by EMS. We hypothesized that prehospital naloxone criteria would have high sensitivity for effective antidote response, but would be underutilized, in patients with drug-related altered mental status (DRAMS). Methods This study was a secondary data analysis of a prospective cohort of acute DRAMS at an urban ED. Naloxone criteria (respiratory rate (RR) <12, miotic pupils, or drug paraphernalia) and mental status, graded by either AVPU (Alert, Verbal, Painful, Unresponsive) or Glasgow Coma Scales, were abstracted from prehospital care reports. Interventions were compared for effective antidote response (EAR), defined as immediate improvement in RR, AVPU, or GCS. Results EMS transported 249 DRAMS over 17 months (48 % males, mean age 41.5, ALS 33.7 %). Forty-three (17 %) patients met naloxone criteria, of whom 44.2 % received the antidote. Naloxone criteria significantly predicted EAR (OR 7.0, p < 0.05) with 83 % sensitivity (95 % CI, 55-95 %). Miotic pupils (OR 20.0, p < 0.01) outperformed RR (OR 2.3, p = NS) as the best single criterion with 91 % sensitivity (95 % CI, 62-98 %). Conclusions This study validates prehospital criteria to guide naloxone administration. In addition, prehospital naloxone was underutilized for DRAMS. Further studies should address potential barriers to prehospital naloxone administration.

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Section: Discussionmentioning

confidence: 92%

Section: Limitationsmentioning

confidence: 99%

Validation of Criteria to Guide Prehospital Naloxone Administration for Drug-Related Altered Mental Status

Friedman

Manini

2016

J. Med. Toxicol.

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“…20 The interobserver agreement in the use of the Glasgow Coma Scale has been proved good, as has the agreement between nurses and physicians. 22 It is sobering that in the subsequent 4 years the rational approach embodied by the WFNS scale has not perceptibly replaced the traditional scale.…”

Section: Discussionmentioning

confidence: 99%

Definition of initial grading, specific events, and overall outcome in patients with aneurysmal subarachnoid hemorrhage. A survey.

Gijn¹,

Bromberg²,

Lindsay³

et al. 1994

Stroke

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Scientific communication in medicine can be effective only if reports are based on unequivocal criteria for clinical conditions or specific diagnoses. We reviewed all articles about subarachnoid hemorrhage published in nine neurosurgical or neurological journals from 1985 through 1992 and assessed the presence and the precision of definitions used for reporting the initial grade, the specific complications of rebleeding, delayed cerebral ischemia, and hydrocephalus, and the overall outcome. We identified 184 articles reporting direct observations in at least 10 patients on one or more of these conditions. Of 161 articles reporting the initial condition, only 19% used an unequivocal grading system (World Federation of Neurological Surgeons Scale or Glasgow Coma Scale); this proportion did not increase after 1988, when the World Federation of Neurological Surgeons Scale was introduced. The specific outcome events of rebleeding, ischemia, and hydrocephalus (283 instances) were sufficiently defined in only 31% of instances, incompletely in 22%, and not at all in 47%. The proportions were similar when the results were analyzed according to the type of complication, the year of publication, or per study. The four exclusively neurosurgical journals featured suitable definitions for any of the three outcome events in 20% of 209 instances, whereas the five mainly neurological journals published fewer articles about subarachnoid hemorrhage (74 instances of outcome events) but more often with precise criteria (65%). Overall outcome was adequately reported in 63% of all articles, with an increase over the years (54% in 1985 through 1988, 71% in 1989 through 1992). Reports about subarachnoid hemorrhage require closer scrutiny before publication to ascertain whether the conclusions about specific outcome events are based on unequivocal criteria.

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“…We stratified randomization for country and total ICH score (0, 1, 2, Ͼ3) 23 at admission, which is based on location and size of the hematoma, involvement of ventricles, age, and the Glasgow Coma Scale. 24 The Glasgow Coma Scale is not validated for use specifically in stroke patients, but indicates the level of consciousness in brain injured patients. The study drug was prepared for infusion to a final concentration of 15 mg/mL in 0.9% saline, with NXY-059 and placebo (0.9% saline) in vials of identical appearance.…”

Section: Study Interventionmentioning

confidence: 99%

Safety and Tolerability of NXY-059 for Acute Intracerebral Hemorrhage

Lyden

Shuaib

Lees

et al. 2007

Stroke

165

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Background and Purpose-NXY-059 is a free radical-trapping neuroprotectant developed for use in acute ischemic stroke. To facilitate prompt administration of treatment, potentially before neuroimaging, we investigated the safety of NXY-059 in patients with intracerebral hemorrhage (ICH). Methods-We randomized 607 patients within 6 hours of acute ICH to receive 2270 mg intravenous NXY-059 over 1 hour and then up to 960 mg/h over 71 hours, or matching placebo, in addition to standard care. The primary outcome was safety: the mortality and the frequency of adverse events, and the change from baseline for a variety of serum, imaging, and electrophysiological measurements. We also studied the overall distribution of disability scores on the modified Rankin Scale (mRS) and the Barthel index. Results-We treated 300 patients with NXY-059 and 303 with placebo. Treatment groups were well matched for prognostic variables including Glasgow Coma Scale, risk factors, and age. The mean National Institute of Health Stroke Scale score on admission was 14 in both groups. The baseline hemorrhage volume was 22.4Ϯ20.1 mL in the NXY-059 group and 23.3Ϯ22.8 mL in the placebo group (meanϮSD). Most hemorrhages were related to hypertension or anticoagulant use. Mortality was similar in both groups: 20.3% for NXY-059 and 19.8% for placebo-treated patients. The proportion of patients who experienced an adverse event was the same for both groups, whereas for serious adverse events the proportion was slightly higher in the NXY-059 group. However, no pattern emerged to indicate a safety concern. Serum potassium fell transiently in both groups, lower in the NXY-059 group. There were no differences in 3-month function, disability, or neurological deficit scores. The odds ratio for an improved outcome in 3-month mRS scores in the NXY-059 group was 1.01 (95% CI 0.75, 1.35). Conclusions-NXY-059 given within 6 hours of acute ICH has a good safety and tolerability profile, with no adverse effect on important clinical outcomes.

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Observer variability in assessing impaired consciousness and coma.

Cited by 269 publications

References 12 publications

Validation of Criteria to Guide Prehospital Naloxone Administration for Drug-Related Altered Mental Status

Validation of Criteria to Guide Prehospital Naloxone Administration for Drug-Related Altered Mental Status

Definition of initial grading, specific events, and overall outcome in patients with aneurysmal subarachnoid hemorrhage. A survey.

Safety and Tolerability of NXY-059 for Acute Intracerebral Hemorrhage

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