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Waiting for the Patient to 'Sober Up': Effect of Alcohol Intoxication on Glasgow ... presence of shock or hypothermia, concomitant use of other CNS depressants, and ... – PowerPoint PPT presentation

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Title: Waiting for the Patient to


1
Waiting for the Patient to Sober Up Effect of
Alcohol Intoxication on Glasgow Coma Scale Score
of Brain Injured Patients
  • Jason L. Sperry, MD, Larry M. Gentilello, MD,
    Joseph P. Minei, MD, Ramon R. Diaz-Arrastia, MD,
    PhD,
  • Randall S. Friese, MD, and Shahid Shafi, MD, MPH
  • J Trauma. 20066113051311.

2
Background
  • The Glasgow Coma Scale (GCS) is a physiologic
    measure of level of consciousness. It is commonly
    used to assess severity of traumatic brain injury
    (TBI).
  • 1315 (mild), 912 (moderate), 8 (severe)
  • widely used for clinical decision making
  • ATLS guideline GCS 8 endotracheal intubation
  • Brain Trauma Foundations (BTF) management
    guidelines GCS 8 and abnormal head CT scan
    intracranial pressure monitoring

3
  • TBI is the most important determinant of GCS
    score, but factors other than TBI may alter level
    of consciousness and GCS score.
  • Alcohol (CNS depressant) intoxication is reported
    to be present in 35 to 50 of TBI patients
  • 80 mg/dL minor motor impairments
  • 150 mg/dL gross motor impairment (balance and
    coordination)
  • 200 mg/dL amnesia or coma

4
  • The implications of whether alcohol confounds the
    GCS score of patients with brain injury are
    important.
  • If alcohol intoxication decreases the GCS score
    of TBI patients,
  • the effect of alcohol needs to be accounted for,
    so that unnecessary interventions are not
    performed.
  • if alcohol intoxication does not significantly
    decrease the GCS score of TBI patients,
  • a low GCS score should not be attributed to
    alcohol intoxication, and other causes should be
    aggressively sought so that a delay in needed
    interventions does not occur.

5
  • Published data on the effects of alcohol on GCS
    scores of TBI patients are conflicting.
  • The purpose of the current study was to determine
    whether alcohol intoxication alters GCS scores of
    patients with and without TBI.
  • Our specific hypothesis was that patients
    intoxicated with alcohol had a reduced GCS score
    compared with nonintoxicated patients with
    similar severity of brain injury.

6
Methods
  • A 10-year retrospective analysis of a large,
    urban Level I trauma center registry (19952004)
    was undertaken.
  • The study population consisted of blunt
    head-injured patients who were tested for BAC in
    the emergency department.
  • Patients with incomplete information on initial
    GCS score or final Abbreviated Injury Score (AIS)
    for head injuries, and those with fatal head
    injuries (AIS 6), were excluded.

7
Nonintoxicated (BAC0 mg/dL) n571
Intoxicated (legal limit for driving,
80mg/dL) n504
n1075
8
nonintoxicated patients sustaining more severe
head injuries
Nonintoxicated patients were more often injured
because of MVC whereas intoxicated patients were
more likely injured by assault.
9
  • Correlation between BAC level and GCS score
  • stratified by severity of head injury
  • The effects of systemic hypotension, airway
    control, and severity of injury on measurement of
    GCS score
  • Severely intoxicated patients (BAC gt250 mg/dL)
  • Specific GCS components (eye, verbal, and motor
    scores).
  • Patients without documented TBI (n 4,988)
  • Multivariate linear regression techniques were
    used to determine whether BAC was an independent
    predictors of GCS score.

10
  • For all statistical tests, a p value lt0.05 was
    considered significant.
  • Because a small change in mean GCS score may be
    statistically significant with this larger sample
    size, we defined a difference of at least one
    point in total GCS score as clinically
    significant.

11
Results
  • There was no linear relationship between blood
    alcohol concentration and GCS score.
  • (Spearman correlation coefficient 0.033, p
    0.275)
  • There was no difference in mean GCS score between
    the two groups.
  • (nonintoxicated 10.1 4.8, intoxicated 10.3
    4.7, p 0.500)

12
  • When stratified by severity of head injury,
    difference in mean GCS score between the two
    groups was less than a single point in all grades
    of TBI, except in those with head AIS 5, where
    the difference was 1.4 GCS points.

13
Hypotension (SBPlt90 mmHg)
Endotracheal intubation
Severe injury (ISSgt18)
Normotensive difference in mean GCS score was 1.5
Severely injured difference in mean GCS score was
1.4
14
  • Similarly, mean GCS score did not differ by more
    than 1 point in each TBI category in the severely
    intoxicated patients (BAC gt250 mg/dL).

15
  • We compared mean eye, verbal, and motor scores in
    nonintoxicated versus intoxicated patients for
    each TBI category and did not find any difference
    greater than 1 point.

16
  • Mean GCS score for patients without documented
    TBI (n4,988) also showed no difference greater
    than a single GCS point.
  • (nontoxicated 12.8 0.08 versus intoxicated 13.2
    0.06, p gt0.001)

17
  • Blood alcohol concentration was not an
    independent determinant of GCS score in a
    multivariate model.

18
Discussion
  • The primary finding of this study is that alcohol
    intoxication does not significantly alter the GCS
    score of trauma patients with TBI, except for
    patients with the most severe Injuries.
  • These results reject the study hypothesis (and
    conventional wisdom), and validate the value of
    the GCS as a measure of level of consciousness
    determined by severity of TBI, unaffected by
    alcohol intoxication.

19
Possible explanation of our findings
  • The effect of alcohol on an individual patients
    level of consciousness is highly variable,
    depending upon the frequency and rate of alcohol
    consumption, as well as the rate of its
    metabolism.
  • Hence, although an individual patients GCS score
    may be lowered by alcohol intoxication, it may
    not be true for the group as a whole.

20
Possible explanation of our findings
  • level of intoxication used in this study (mean
    and median BAC around 200 mg/dL) was not high
    enough to impair patients mental status.
  • Galbraith reported that a BACgt200 mg/dL was
    required to depress the level of consciousness.
  • Jagger found that alcohol significantly lowered
    GCS scores of TBI patients and the effect was
    most pronounced in those with a BACgt200. But,
    interestingly, even in this group, there was no
    effect of alcohol on GCS score of 70 of the
    patients.
  • In another study, Minion reported that 88 of
    patients with BAC in excess of 400 mg/dL were
    alert and oriented to time, place, and person.
  • It is also entirely possible that BAC has little
    meaning because of the individuals tolerance of
    alcohol.

21
Possible explanation of our findings
  • Finally, it is possible that the GCS score is not
    a sensitive measure of mental status in
    intoxicated patients with TBI.
  • Of course, the most logical explanation of our
    findings is that any decrease in the level of
    consciousness in trauma patients is a result of
    factors other than alcohol intoxication, most
    important of which is the severity of brain
    injury.

22
  • Other factors that may affect the level of
    consciousness include severity of other
    non-neurologic injuries, presence of shock or
    hypothermia, concomitant use of other CNS
    depressants, and hypoxia or hypercarbia.
  • Our findings underscore the fact that in patients
    with depressed GCS score, these factors should be
    aggressively sought and treated, without waiting
    for alcohol to wear off.

23
Limitations of this study
  • It is a single institution experience, and may
    only reflect local patient characteristics.
  • Retrospective reviews unmeasured or unknown
    confounding variables
  • Throughout the study period, BAC levels were
    drawn selectively, likely resulting in selection
    bias.

24
Conclusion
  • Alcohol intoxication does not reduce the GCS
    score more than one point for patients with TBI,
    except for patients with the most severe
    injuries.
  • Hence, diagnostic and therapeutic interventions
    indicated by patients GCS scores should be
    undertaken promptly, and not delayed waiting for
    patients to sober up.

25
Thanks for your attention!
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