ABSTRACT
Objetivo. Comparar los pacientes traumáticos con una puntuación de 3 en la escala de coma de Glasgow (Glasgow Coma Scale, GCS) en función de la reactividad pupilar e investigar los factores asociados a la mortalidad hospitalaria en los pacientes con GCS 3 y midriasis bilateral arreactiva.Método. Estudio observacional, prospectivo y multicéntrico. Se incluyeron todos los pacientes traumáticos recogidos con GCS 3 ingresados en las unidades de cuidados intensivos (UCI) participantes desde marzo 2015 hasta diciembre 2019. Se realizó un análisis de regresión logística para el estudio de los factores asociados a la mortalidad hospitalaria en pacientes con GCS 3 puntos y midriasis bilateral arreactiva.Resultados. De los 933 pacientes con GCS 3 puntos, 454 (48,7%) presentaron pupilas simétricas y reactivas, 201 (21,5%) anisocoria arreactiva y 278 (29,8%) midriasis bilateral arreactiva. La mortalidad hospitalaria fue elevada en los 3 grupos: 32,5% con pupilas normales, 54,6% con anisocoria arreactiva y 91,0% con midriasis bilateral arreactiva. La edad, la puntación de 3 o más en el Abbreviated Injury Scale (cabeza) y el shock o shock refractario se aso-ciaron de forma significativa con la mortalidad hospitalaria, siendo la lesión difusa tipo I y II y la lesión masa evacuada factores protectores en los pacientes con 3 puntos en la GCS y midriasis bilateral arreactiva. De los 26 pacientes que sobrevivieron con GCS 3 y midriasis bilateral arreactiva, 12 (46,1%) tuvieron un GCS de 14-15 al alta hospitalaria.Conclusiones. La mortalidad hospitalaria de los pacientes traumáticos con 3 puntos en la GCS y midriasis bilateral arreactiva fue del 91%. La edad, la puntación de 3 o más en el Abbreviated Injury Scale (cabeza) y el shock o shock refractario se asociaron de forma significativa con la mortalidad hospitalaria, siendo la lesión difusa tipo I y II, y la lesión masa evacuada factores protectores en este grupo de pacientes. (AU)
Objectives. To compare patients with a Glasgow Coma Scale (GCS) score of 3 stratified according to pupillary reaction and to explore factors associated with in-hospital death in those with bilateral fixed dilated pupils.Methods. Prospective, observational, multicenter study. We included all patients with trauma and GCS scores of 3 admitted to the intensive care unit from March 2015 to December 2019. Factors associated with in-hospital mortality in the patients with bilateral dilated pupils were explored using multiple regression analysis.Results. Of the 933 patients included, 454 (48.7%) had responsive pupils, 201 (21.5%) had a single fixed dilated pupil, and 278 (29.8%) had bilateral dilation. Hospital mortality was high in all 3 groups: 32.5% in those with normal responsive pupils, 54.6% in those with a single unreactive pupil, and 91.0% in those with bilateral dilation. Factors significantly associated with in-hospital death were age, a score of 3 or more on the Abbreviated Injury Scale for the head, and shock or refractory shock. Types I or II diffuse lesions and evacuated mass lesions were protective in patients with GCS scores of 3 and bilateral dilated pupils. Twelve of the 26 patients (46.1%) with bilateral dilated pupils and GCS scores of 3 had GCS scores of 14 or 15 on discharge from the hospital.Conclusions. The in-hospital mortality was 91% in this study of trauma patients with GCS scores of 3 and bilateral dilated pupils. Factors significantly associated with in-hospital death were age, a score of 3 or more on the Abbreviated Injury Scale for the head, and shock or refractory shock. Types I or II diffuse lesions and evacuated mass lesions were protective in patients with GCS scores of 3 and bilateral dilated pupils. (AU)
Subject(s)
Humans , Male , Female , Adult , Middle Aged , Aged , Glasgow Coma Scale , Mydriasis/mortality , Prospective Studies , Brain Injuries, Traumatic , Hospital Mortality , SpainABSTRACT
BACKGROUND: Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. Many prognostic models predicting mortality in patients with TBI were developed, which also include patients with mild or moderate TBI and patients who suffered major extracranial injuries. METHODS: From a prospective database, we conducted a retrospective medical chart review covering the period between January 2000 and December 2012 of patients with isolated severe TBI (Abbreviated Injury Score for head, AISH ≥ 3) without extracranial injuries, who were intubated in the field using the rapid sequence intubation method and were of age 16 or more. Prehospital vital signs, Injury Severity Score (ISS) and laboratory tests were compared in two study groups: survivors (n = 25) and non-survivors (n = 27). Selected variables identified during univariate analysis (p < 0.1) were then subjected to multivariate analysis logistic regression model. RESULTS: Univariate analysis showed that in-hospital mortality was statistically significantly associated with male sex (p = 0.040), ISS (p = 0.005) and mydriasis (p = 0.012). For predicting mortality, area under the curve (AUC) was calculated: for ISS 0.76 (95 % confidence interval, CI; 0.63-0.90; p < 0.001) and for initial Glasgow Coma Scale (GCS) 0.64 (95 % CI, 0.49-0.80, p = 0.079). In the multivariate analysis, ISS (odds ratio, OR; 1.19, 95 % CI, 1.06-1.35; p = 0.004) and mydriasis (OR, 5.73; 95 % CI, 1.06-30.88; p = 0.042) were identified as independent risk factors for in-hospital mortality. The AUC for the regression model was 0.83 (95 % CI, 0.71-0.94; p < 0.001). CONCLUSIONS: In prehospital intubated patients with isolated severe TBI only ISS and mydriasis were found to be independent predictors of in-hospital mortality.
