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.

Failed rapid sequence intubation in trauma patients: esophageal tracheal combitube is a useful adjunct.

OBJECTIVE: To characterize the use of the esophageal tracheal combitube (ETC) in trauma patients who fail orotracheal rapid sequence intubation (RSI). DESIGN: Prospective protocol design and retrospective chart review. MATERIALS AND METHODS: Flight nurses were trained in the use of the ETC by mannequin simulation, videotape review, and didactic sessions. ETC insertion was attempted after failure of two or more attempts at orotracheal RSI. Over a 12-month period, 12 patients had ETC insertion, and 10 cases qualified for review. Injuries, number of failed orotracheal RSI attempts, definitive airway, initial arterial blood gas results, and outcome were recorded. RESULTS: ETC insertion was successful in all 10 patients in whom it was attempted. Definitive airway control was achieved by conversion to orotracheal intubation in seven patients, emergency department cricothyroidotomy in one patient, and operative room tracheostomy in two patients. No patient died because of failure to control the airway. Seven patients requiring ETC had mandible fractures. CONCLUSION: ETC insertion is an effective method of airway control in trauma patients who fail orotracheal RSI. It may be particularly useful in the patient with maxillofacial trauma and offers a practical alternative to surgical cricothyroidotomy in difficult airway situations.

Computed tomography of the chest in blunt thoracic trauma: results of a prospective study.

BACKGROUND: Computed tomography of the chest (CTC) is more sensitive than conventional roentgenography at detecting blunt thoracic injuries. Its effect on subsequent therapy remains incompletely characterized. METHODS: Nine criteria believed to represent the presence of, or the potential for, significant thoracic injuries were defined, and patients were followed prospectively. Forty consecutive patients had CTC after initial evaluation. Physiologic and anatomic findings were compared, and the effect of CTC on therapy was analyzed. RESULTS: CTC detected 76 injuries not found on plain roentgenograms, and plain roentgenograms detected 25 injuries not visible on CTC scans. Six patients had therapy changes based on CTC findings, five of which involved chest tube modification. The percentage of pulmonary contusion did not predict the need for mechanical ventilation but did correlate with physiologic contusion. CONCLUSIONS: Blunt thoracic injuries detected by CTC infrequently require immediate therapy. If immediate therapy is needed, findings will be visible on plain roentgenograms or on clinical exam. Routine CTC in blunt trauma is not recommended but may be helpful in selected cases.

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.

Trauma patient outcomes: six-month follow-up.

One hundred forty-six trauma patients discharged from an acute care setting to home were followed during a 6-month period after discharge to determine functional problems they experienced and the time required to return to normal activity levels. At 1 week, 58% were unable to drive a care, 59% experienced difficulty with lifting, and 76% were unable to return to work. At 1 month, 27% continued to have trouble driving, 32% had trouble lifting, and 37% had not returned to work yet. Head injury patients and those with orthopedic injuries of the extremities or pelvis experienced problems returning to work. The head injury group also experienced vocational problems. By 6 months, 89% of the patients reported a return to normal activities. Findings suggest that a return to normal functioning level is a long-term process, and that certain injury types are at high risk for experiencing specific identifiable problems.

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.