Do Trauma Patients with a Glasgow Coma Scale Score of 3 and Bilateral Fixed and Dilated Pupils Have Any Chance of Survival?

Tien, Homer; Cunha, Josue R F; Wu, Sergio N; Chughtai, Talat; Tremblay, Lorraine N.; Brenneman, Fred; Rizoli, Sandro

doi:10.1097/01.ta.0000197177.13379.f4

Cited by 98 publications

(71 citation statements)

References 27 publications

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“…8 Tien et al reported an overall mortality rate of 76.8% in 173 patients with GCS score of 3; the mortality was 100% in patients with fixed, dilated pupils and 42% in patients with reactive pupils. 50 Other studies in adults show relatively consistent factors that correlate with survival and, conversely, death. Factors that are associated with poor survival include hypoxia, extremes of age, hypotension, hypercarbia, hyperglycemia, mechanism of injury, and hypothermia.…”

Section: Discussionmentioning

confidence: 99%

“…This is consistent with other published studies. 8,26,50 In patients with an absent pupil- lary response, the next most correlative predictive variable in our study was the presence of hypothermia. Note that we did not therapeutically induce hypothermia in any patient.…”

Section: Predictive Variables For Clinical Outcomementioning

confidence: 95%

“…Patients presenting with low postresuscitation GCS scores have extremely high morbidity and mortality rates. 14,18,29,50 Predictive variables for survival…”

Section: Discussionmentioning

confidence: 99%

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Analysis of long-term (median 10.5 years) outcomes in children presenting with traumatic brain injury and an initial Glasgow Coma Scale score of 3 or 4

Fulkerson

White

Rees

et al. 2015

PED

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OBJECT Patients with traumatic brain injury (TBI) with low presenting Glasgow Coma Scale (GCS) scores have very high morbidity and mortality rates. Neurosurgeons may be faced with difficult decisions in managing the most severely injured (GCS scores of 3 or 4) patients. The situation may be considered hopeless, with little chance of a functional recovery. Long-term data are limited regarding the clinical outcome of children with severe head injury. The authors evaluate predictor variables and the clinical outcomes at discharge, 1 year, and long term (median 10.5 years) in a cohort of children with TBI presenting with postresuscitation GCS scores of 3 and 4. METHODS A review of a prospectively collected trauma database was performed. Patients treated at Riley Hospital for Children (Indianapolis, Indiana) from 1988 to 2004 were reviewed. All children with initial GCS (modified for pediatric patients) scores of 3 or 4 were identified. Patients with a GCS score of 3 were compared with those with a GCS score of 4. The outcomes of all patients at the time of death or discharge and at 1-year and long-term follow-up were measured with a modified Glasgow Outcome Scale (GOS) that included a “normal” outcome. Long-term outcomes were evaluated by contacting surviving patients. Statistical "classification trees" were formed for survival and outcome, based on predictor variables. RESULTS Sixty-seven patients with a GCS score of 3 or 4 were identified in a database of 1636 patients (4.1%). Three of the presenting factors differed between the GCS 3 patients (n = 44) and the GCS 4 patients (n = 23): presence of hypoxia, single seizure, and open basilar cisterns on CT scan. The clinical outcomes were statistically similar between the 2 groups. In total, 48 (71.6%) of 67 patients died, remained vegetative, or were severely disabled by 1 year. Eight patients (11.9%) were normal at 1 year. Ten of the 22 patients with long-term follow-up were either normal or had a GOS score of 5. Multiple clinical, historical, and radiological factors were analyzed for correlation with survival and clinical outcome. Classification trees were formed to stratify predictive factors. The pupillary response was the factor most predictive of both survival and outcome. Other factors that either positively or negatively correlated with survival included hypothermia, mechanism of injury (abuse), hypotension, major concurrent symptoms, and midline shift on CT scan. Other factors that either positively or negatively predicted long-term outcome included hypothermia, mechanism of injury, and the assessment of the fontanelle. CONCLUSIONS In this cohort of 67 TBI patients with a presenting GCS score of 3 or 4, 56.6% died within 1 year. However, approximately 15% of patients had a good outcome at 10 or more years. Factors that correlated with survival and outcome included the pupillary response, hypothermia, and mechanism. The authors discuss factors that may help surgeons make critical decisions regarding their most serious pediatric trauma patients.

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Section: Discussionmentioning

confidence: 99%

Section: Predictive Variables For Clinical Outcomementioning

confidence: 95%

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Analysis of long-term (median 10.5 years) outcomes in children presenting with traumatic brain injury and an initial Glasgow Coma Scale score of 3 or 4

Fulkerson

White

Rees

et al. 2015

PED

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“…In comparison, 42.0% of the patients with reactive pupils died. 26 Whether the death of patients in the intensive care unit with severe TBI significantly contributes to shorter LOS and lower hospital treatment cost should be elucidated with future study.…”

Section: Discussionmentioning

confidence: 99%

Trends and outcome predictors after traumatic brain injury surgery: a nationwide population-based study in Taiwan

Shi¹,

Hwang

Lee³

et al. 2014

JNS

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Object.The authors sought to analyze trends in hospital resource utilization and mortality rates in a population of patients who had received traumatic brain injury (TBI) surgery.Methods. This nationwide population-based cohort study retrospectively analyzed 18,286 patients who had received surgical treatment for TBI between 1998 and 2010. The multiple linear regression model and Cox proportional hazards model were used for multivariate assessment of outcome predictors.Results. The prevalence rate of surgical treatment for patients with TBI gradually but significantly (p < 0.001) increased by 47.6% from 5.0 per 100,000 persons in 1998 to 7.4 per 100,000 persons in 2010. Age, sex, DeyoCharlson comorbidity index score, hospital volume, and surgeon volume were significantly associated with TBI surgery outcomes (p < 0.05). Over the 12-year period analyzed, the estimated mean hospital treatment cost increased 19.06%, whereas the in-hospital mortality rate decreased 10.9%. The estimated mean time of overall survival after TBI surgery (± SD) was 83.0 ± 4.2 months, and the overall in-hospital and 1-, 3-, and 5-year survival rates were 74.5%, 67.3%, 61.1%, and 57.8%, respectively.Conclusions. These data reveal an increased prevalence of TBI, especially in older patients, and an increased hospital treatment cost but a decreased in-hospital mortality rate. Health care providers and patients should recognize that attributes of the patient and of the hospital may affect hospital resource utilization and the mortality rate. These results are relevant not only to other countries with similar population sizes but also to countries with larger populations. (http://thejns.org/doi/abs/10.3171/2014.8.JNS131526) KeY worDS • traumatic brain injury • trends • predictors • hospital resource utilization • mortality rateAbbreviations used in this paper: BNHI = Bureau of National Health Insurance; DCCI = Deyo-Charlson comorbidity index; ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; IQR = interquartile range; LOS = length of stay; TBI = traumatic brain injury.* Drs. K. T. Lee and Lin contributed equally to this study.

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“…The authors concluded that patients with a GCS of 3 as well as fixed and dilated pupils have no reasonable chance of recovery. Similarly, in a retrospective study of Tien et al, [32] they found that patients with an initial GCS of 3 and bilateral fixed and dilated pupils had a 100% in-hospital mortality rate. Despite the hopeless results of these reports, Chamoun et al [33] presented a survival rate of 21.3% and a good outcome rate of 1.5% in this patient group in a recent study.…”

Section: Gcs Score Icp and Cpp Changes And Prognosismentioning

confidence: 99%

Effects of decompressive surgery in patients with severe traumatic brain injury and bilateral non-reactive dilated pupils

Göksu

Uçar²,

Akyuz³

et al. 2012

Ulus Travma Acil Cerrahi Derg

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AMAÇAğır travmatik beyin yaralanmalı (ATBY) ve bilateral reaktif olmayan pupil dilatasyonu (BRPD) olup, dekompresif cerrahi (DC) uygulanmış hastalarda Glasgow koma skalası (GKS), kafa içi basınç (KİB), serebral perfüzyon basın-cı (SPP) değişiklikleri ve uzun dönem klinik sonuçları değerlendirildi. GEREÇ VE YÖNTEMÇalışma gurubu, bölümümüzde ATBY nedeniyle DC uygulanan 147 hasta içerisinden BRPD'li 28 hastayı (11 kadın, 17 erkek) içerdi. BULGULAROrtalama GKS skoru, başvuruda 4,96±1,20, ameliyat ön-cesi dönemde 4 idi. Ölen hastalarda, DC sonrası ortalama KİB değerleri hayatta kalanlara göre anlamlı ölçüde yük-sekti (p<0,05). Ayrıca, DC sonrası KİB azalması, yaşayan hastalarda yine anlamlı olarak yüksekti (p<0,05). Tümden mortalite oranı %61,02 bulundu. Başvuruda ikinin üzeri GKS motor skoru anlamlı olarak düşük mortalite ile ilişki-li idi (p<0,05). Yaşayan 4 hasta taburcu sonrası birinci yıl-da (%14,28) işlevsel sonuç skoru (Glasgow sonuç skoru 4 ve 5) gösterdi. SONUÇATBY sonrası BRPD'li hastalarda sonuçlar her zaman ölümcül ya da olumsuz olmayabilir. Hızlı DC, özellikle başvuru GKS skoru 6, 7 olan hastalarda işlevsel sağkalım şansını artırabilir.Anahtar Sözcükler: Dekompresif cerrahi; travmatik beyin yaralanması; reaktif olmayan dilate pupil. BACKGROUNDWe investigated Glasgow Coma Scale (GCS) scores, intracranial pressure (ICP) and cerebral perfusion pressure (CPP) changes, and long-term clinical outcomes in patients with severe traumatic brain injury (STBI) associated with bilateral non-reactive dilated pupils (BNDP) who underwent decompressive surgery (DS). METHODSThe study group consisted of 28 patients (11 females, 17 males) with BNDP from among 147 patients who underwent DS due to STBI in our department. RESULTSThe mean GCS score was 4.96±1.20 at admission and 4 preoperatively. Mean ICP in non-surviving patients after DS was higher (p<0.05). ICP decrease after DS was also higher in surviving patients than in non-surviving patients (p<0.05). The overall mortality rate was 61.02%. A GCS motor score >2 at admission was associated with lower mortality (p<0.05). Four of the surviving patients (14.28%) had a functional outcome (Glasgow Outcome Score: 4 and 5) at one year after hospital discharge. CONCLUSIONOutcome in patients with BNDP after STBI may not always be fatal or poor. Rapid DS may increase the chance of functional survival, especially in patients with admission GCS score of 6 or 7.

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Do Trauma Patients with a Glasgow Coma Scale Score of 3 and Bilateral Fixed and Dilated Pupils Have Any Chance of Survival?

Cited by 98 publications

References 27 publications

Analysis of long-term (median 10.5 years) outcomes in children presenting with traumatic brain injury and an initial Glasgow Coma Scale score of 3 or 4

Analysis of long-term (median 10.5 years) outcomes in children presenting with traumatic brain injury and an initial Glasgow Coma Scale score of 3 or 4

Trends and outcome predictors after traumatic brain injury surgery: a nationwide population-based study in Taiwan

Effects of decompressive surgery in patients with severe traumatic brain injury and bilateral non-reactive dilated pupils

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