Variation among trauma centers' calculation of Glasgow Coma Scale score: results of a national survey.

BACKGROUND: Glasgow Coma Scale (GCS) scoring is enigmatic in intubated patients. To determine if there is consensus among Level I trauma centers, a national telephone survey was conducted. METHODS: Trauma registrars at state-verified or American College of Surgeons-verified Level I trauma centers were questioned about GCS scoring, recording, and reporting in patients who are intubated or intubated and pharmacologically paralyzed. RESULTS: Seventy-three centers were contacted. Seventy-one use initial GCS scores for registry recording. Intubated patients are given 1 point for verbal component plus eye and motor scores at 26% of centers and a total GCS score of 3 at 23%; GCS score is estimated with "T" given for verbal component at 16%, scored as unknown at 10%, always scored as 15 at 10%, and the method of scoring is unknown at 15%. Pharmacologically paralyzed intubated patients are given a total GCS score of 3 at 34%, GCS score is estimated with "T" given for verbal component at 18%, patients are given 1 point for verbal component plus eye and motor scores at 12%, scored as unknown at 11%, always scored as 15 at 8%, and the method of scoring is unknown at 16%. CONCLUSION: Wide variation in GCS scoring among Level I trauma centers was identified. Because GCS scores are used in treatment algorithms, trauma scoring, and outcome prediction (Trauma and Injury Severity Score), uniform scoring is essential and should be pursued. Use of state and national databases and outcome research may be adversely affected by the lack of consistent GCS scoring.

Cognitive screening in mild traumatic brain injuries: analysis of the neurobehavioral cognitive status examination when utilized during initial trauma hospitalization.

Cognitive screening following mild traumatic brain injury (MTBI) remains variable with method of diagnosis, indications for testing, and utilization of results differing between institutions. The Neurobehavioral Cognitive Status Examination (NCSE) was originally developed for use in organic brain dysfunction and central nervous system (CNS) lesions. When attention is given to both the objective cognitive area scores and the "process features" component of the exam, it is an effective tool for identifying cognitive deficits associated with MTBI. One hundred seven MTBI patients underwent cognitive screening in the acute care setting. Memory was the function most frequently affected in patients with positive cognitive screens. Several of the NCSE deficits also correlated significantly with each other but not with memory. Age, length of stay, injury severity score (ISS), and cranial computed tomography scan were not associated with cognitive screen results. An admission Glasgow Coma Scale (GCS) of 13 or 14 was significantly associated with a positive cognitive screen, but a GCS of 15 did not predict a negative cognitive screen. All patients with MTBI require cognitive screening to identify deficits, ensure patient and family education, and when necessary facilitate treatment.

Failure of methylprednisolone to improve the outcome of spinal cord injuries.

The infusion of methylprednisolone (MP) within 8 hours of injury for spinal cord injuries (SCI) has been advocated to improve the motor function of patients after this catastrophic injury. However, clinical improvement in the outcome of SCI has not been consistently identified, despite the use of MP. We reviewed the outcome of SCI patients with MP to those without MP (No-MP) at two Level I Trauma Centers from 1989-1992. Acute SCI patients were identified from the trauma registries with trauma demographics and hospital data obtained from registry and medical records. Rehabilitation data for Functional Independence Measure (FIM) was obtained from the rehabilitation institute database. Primary outcome parameters were mortality, and for survivors, patient mobility (6 point scale) and FIM scores. There were 145 acute SCI patients: 80 treated with MP and 65 with No-MP. FIM data was available on 45 MP and 25 No-MP patients. There was no difference in the admission trauma score, ICU length of stay (LOS), or hospital LOS between the two groups. The MP patients were significantly younger (30 years vs 38 years, P = < 0.05) and had lower ISS scores (24 vs 31, P = < 0.05). There was no statistically significant difference in mortality (MP, 3.8% vs No-MP, 10.7%) between the two groups. Although admission mobility was not statistically different (MP, 5.99 vs No-MP, 5.90), there was a significantly poorer discharge mobility in the MP group when compared to the No-MP group (MP, 5.16 vs No-MP, 4.67, P = < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Assuring trauma system quality by outcomes reporting in two voluntary regional trauma networks.

1. Providing optimal trauma care for large populations requires the collaboration and cooperation of hospitals providing all levels of care. 2. Those who are seriously injured or who have complex injuries requiring special resources are to be referred in a timely fashion to a trauma center capable of providing optimal care. 3. In two regional trauma networks, 24% of injured patients were referred to a trauma center for definitive care. Overall survival was excellent.

Cognitive screening in mild brain injury.

A study of patients with mild traumatic brain injuries was performed to determine if cognitive screening in the acute care setting can identify patients who will have cognitive dysfunction following discharge to home. While still hospitalized, 166 patients were assessed with a cognitive screening tool. After discharge, telephone follow-up contacts were made by a nurse to assess for subjective reports of cognitive difficulties. A subsample (N = 39) received additional comprehensive cognitive evaluation after discharge. Statistically significant results were noted between cognitive screen and cognitive evaluation results (chi-square = 24.28, p < .0000) and between cognitive screen results and follow-up findings (chi-square = 6.7, p = .0350). Study results support the use of cognitive screening in the acute care setting to identify patients with mild traumatic brain injury who are likely to experience residual cognitive deficits after discharge so appropriate intervention may be planned.

Functional outcome of pediatric trauma patients identified as 'non-salvageable survivors'.

A retrospective study of 305 pediatric trauma patients seen over 17 months was undertaken to evaluate the functional outcome of patients categorized as "non-salvageable survivors" (NSS). Functional outcome was determined by Denver Developmental Screen Tests (DDST) for children less than 5 years of age and Rappaport Severity Rating Scale (RDRS) for those 5 years old and older. Each patient was assigned Abbreviated Injury Scores (AIS). Injury Severity Score (ISS), Glasgow Coma Scale (GCS), and Trauma Score (TS). The total number of patients classified as severe was 65 (21%), and 13 were classified as non-salvageable, with seven non-salvageable survivors and six non-preventable deaths. Our study suggests that current trauma scoring systems tend to overestimate the non-salvageable population. Those identified as non-salvageable and who survived have a high probability of meaningful functional recovery. Current trauma scoring systems are in need of revision to better identify non-salvageable survivors and those children who will not make a meaningful neurologic recovery.