Clinical Monitoring Scales in Acute Brain Injury: Assessment of Coma, Pain, Agitation, and Delirium

Neurocritical Care

Volumn 21, Issue 2, 2014, Pages 27-37

  Riker, Richard ^a   Fugate, Jennifer ^c   Le Roux, Peter ^d   Menon, David K ^e   Vespa, Paul ^f   Citerio, Giuseppe ^g   Bader, Mary Kay ^h   Brophy, Gretchen M ⁱ   Diringer, Michael N ^j   Stocchetti, Nino ^k   Videtta, Walter ^l   Armonda, Rocco ^m   Badjatia, Neeraj ⁿ   Boesel, Julian ^o   Chesnut, Randal ^p   Chou, Sherry ^q   Claassen, Jan ^r   Czosnyka, Marek ^e   De Georgia, Michael ^s   Figaji, Anthony ^t   Helbok, Raimund ^u   Horowitz, David ^v   Hutchinson, Peter ^e   Kumar, Monisha ^w   McNett, Molly ^x   Miller, Chad ^y   Naidech, Andrew ^z   Oddo, Mauro ^aa   Olson, DaiWai ^ab   O’Phelan, Kristine ^ac   Provencio, Javier ^ad   Puppo, Corina ^ae   Robertson, Claudia ^af   Schmidt, J Michael ^r   Taccone, Fabio ^ag   more..

^a MAINE MEDICAL CENTER   (United States)

^b TUFTS UNIVERSITY SCHOOL OF MEDICINE   (United States)

^c MAYO CLINIC   (United States)

^d LANKENAU INSTITUTE FOR MEDICAL RESEARCH   (United States)

^e UNIVERSITY OF CAMBRIDGE   (United Kingdom)

^f UNIVERSITY OF CALIFORNIA   (United States)

^g SAN GERARDO HOSPITAL   (Italy)

^h Neuro Critical Care CNS Mission Hospital   (United States)

ⁱ VIRGINIA COMMONWEALTH UNIVERSITY   (United States)

^j WASHINGTON UNIVERSITY SCHOOL OF MEDICINE   (United States)

^k UNIVERSITY OF MILAN   (Italy)

^l HOSPITAL NACIONAL PROFESOR ALEJANDRO POSADAS   (Argentina)

^m GEORGETOWN UNIVERSITY HOSPITAL   (United States)

ⁿ UNIVERSITY OF MARYLAND MEDICAL CENTER   (United States)

^o UNIVERSITY HOSPITAL HEIDELBERG   (Germany)

^p UNIVERSITY OF WASHINGTON   (United States)

^q MASSACHUSETTS GENERAL HOSPITAL   (United States)

^r Columbia University College of Physicians & Surgeons ^*  (United States)

^s UNIVERSITY HOSPITALS OF CLEVELAND   (United States)

^t UNIVERSITY OF CAPE TOWN   (South Africa)

^u INNSBRUCK MEDICAL UNIVERSITY   (Austria)

^v UNIVERSITY OF PENNSYLVANIA   (United States)

^w UNIVERSITY OF PENNSYLVANIA   (United States)

^x The MetroHealth System   (United States)

^y OHIO STATE UNIVERSITY   (United States)

^z NORTHWESTERN UNIVERSITY   (United States)

^aa LAUSANNE UNIVERSITY HOSPITAL   (Switzerland)

^ab UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL CENTER   (United States)

^ac UNIVERSITY OF MIAMI MILLER SCHOOL OF MEDICINE   (United States)

^ad CLEVELAND CLINIC LERNER COLLEGE OF MEDICINE   (United States)

^ae UNIVERSIDAD DE LA REPÚBLICA   (Uruguay)

^af BAYLOR COLLEGE OF MEDICINE   (United States)

^ag ERASME HOSPITAL   (Belgium)

more..

Author keywords

Coma; Delirium; Neurologic examination; Pain; Scale; Sedation

Indexed keywords

ANALGESIC AGENT; CHOLINERGIC RECEPTOR BLOCKING AGENT; NEUROMUSCULAR BLOCKING AGENT; SEDATIVE AGENT;

AGITATION; AREA UNDER THE CURVE; ARTICLE; BEHAVIORAL PAIN SCALE; BRAIN INJURY; COMA; CONFUSION ASSESSMENT METHOD; CONSCIOUSNESS; CRITICAL CARE PAIN OBSERVATION TOOL; DELIRIUM; DIAGNOSTIC ACCURACY; DIAGNOSTIC TEST ACCURACY STUDY; FULL OUTLINE OF UNRESPONSIVENESS SCORE; GLASGOW COMA SCALE; HUMAN; INTENSIVE CARE DELIRIUM SCREENING CHECKLIST; NEUROLOGIC EXAMINATION; NOCICEPTION COMA SCALE; NUMERIC RATING SCALE; PAIN; PAIN ASSESSMENT; PREDICTIVE VALUE; PRIORITY JOURNAL; PUPIL; RATING SCALE; RECEIVER OPERATING CHARACTERISTIC; RICHMOND AGITATION SEDATION SCALE; SCORING SYSTEM; SEDATION AGITATION SCALE; SENSITIVITY AND SPECIFICITY; SYSTEMATIC REVIEW; TRAUMATIC BRAIN INJURY; BRAIN INJURIES; INJURY SCALE; INTENSIVE CARE; PSYCHOLOGY; PSYCHOMOTOR AGITATION; REPRODUCIBILITY;

BRAIN INJURIES; COMA; DELIRIUM; HUMANS; INTENSIVE CARE; NEUROLOGIC EXAMINATION; PAIN; PSYCHOMOTOR AGITATION; REPRODUCIBILITY OF RESULTS; TRAUMA SEVERITY INDICES;

EID: 84924985379     PISSN: 15416933     EISSN: 15560961     Source Type: Journal    
DOI: 10.1007/s12028-014-0025-5     Document Type: Article

References (65)

1. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974;13:81–4.
2. Juarez VJ, Lyons M. Interrater reliability of the Glasgow Coma Scale. J Neurosci Nurs. 1995;27:283–6.
3. Heron R, Davie A, Gillies R, Courtney M. Interrater reliability of the Glasgow Coma Scale scoring among nurses in sub-specialities of critical care. Aust Crit Care. 2001;14:100–5.
4. Menegazzi JJ, Davis EA, Sucov AN, Paris PM. Reliability of the Glasgow Coma Scale when used by emergency physicians and paramedics. J Trauma. 1993;34:46–8.
5. Rowley G, Fielding K. Reliability and accuracy of the Glasgow Coma Scale with experienced and inexperienced users. Lancet. 1991;337:535–8.
6. Gill M, Windemuth R, Steele R, Green SM. A comparison of the Glasgow Coma Scale score to simplified alternative scores for the prediction of traumatic brain injury outcomes. Ann Emerg Med. 2005;45:37–42.
7. Chamoun RB, Robertson CS, Gopinath SP. Outcome in patients with blunt head trauma and a Glasgow Coma Scale score of 3 at presentation. J Neurosurg. 2009;111:683–7.
8. Demetriades D, Kuncir E, Velmahos GC, Rhee P, Alo K, Chan LS. Outcome and prognostic factors in head injuries with an admission Glasgow Coma Scale score of 3. Arch Surg. 2004;10:1066–8.
9. Tien HC, Cunha JR, Wu SN, et al. Do trauma patients with a Glasgow Coma Scale score of 3 and bilateral fixed and dilated pupils have any chance of survival? J Trauma. 2006;60:274–8.
10. Tsau JW, Hemphill JC, Johnston SC, Smith WS, Bonovich DC. Initial Glasgow Coma Scale score predicts outcome following thrombolysis for posterior circulation stroke. Arch Neurol. 2005;62:1126–9.
11. Schwarz S, Egelhof T, Schwab S, Hacke W. Basilar artery embolism. Clinical syndrome and neuroradiologic patterns in patients without permanent occlusion of the basilar artery. Neurology. 1997;49:1346–52.
12. Chandra RV, Law CP, Yan B, Dowling RJ, Mitchell PJ. Glasgow coma scale does not predict outcome post-intra-arterial treatment for basilar artery thrombosis. AJNR Am J Neuroradiol. 2011;32:576–80.
13. Schefold JC, Storm C, Kruger A, Ploner CJ, Hasper D. The Glasgow Coma Score is a predictor of good outcome in cardiac arrest patients treated with therapeutic hypothermia. Resuscitation. 2009;80:658–61.
14. Starmark JE, Holmgren E, Stalhammar D. Current reporting of responsiveness in acute cerebral disorders. A survey of the neurosurgical literature. J Neurosurg. 1998;69:692–8.
15. Rutledge R, Lentz CW, Fakhry S, Hunt J. Appropriate use of the Glasgow Coma Scale in intubated patients: a linear regression prediction of the Glasgow verbal score from the Glasgow eye and motor scores. J Trauma. 1996;41:514–22.
16. Meredith W, Rutledge R, Fakhry SM, Emery S, Kromhout-Schiro S. The conundrum of the Glasgow Coma Scale in intubated patients: a linear regression prediction of the Glasgow verbal score from the Glasgow eye and motor scores. J Trauma. 1998;44:839–44.
17. Buechler CM, Blostein PA, Koestner A, Hurt K, Schaars M, McKernan J. Variation among trauma centers’ calculation of Glasgow Coma Scale score: results of a national survey. J Trauma. 1998;45:429–32.
18. Balestreri M, Czosynka M, Chatfield DA, et al. Predictive value of Glasgow Coma Scale after brain trauma: change in trend over the past ten years. J Neurol Neurosurg Psychiatry. 2004;75:161–2.
19. Wijdicks EF, Bamlet WR, Maramattom BV, Manno EM, McClelland RL. Validation of a new coma scale: the FOUR score. Ann Neurol. 2005;58:585–93.
20. Iver VN, Mandrekar JN, Danielson RD, Zubkov AY, Elmer JL, Wijdicks EF. Validity of the FOUR score coma scale in the medical intensive care unit. Mayo Clin Proc. 2009;84:694–701.
21. Stead LG, Wijdicks EF, Bhagra A, et al. Validation of a new coma scale, the FOUR score, in the emergency department. Neurocrit Care. 2009;10:50–4.
22. Wolf CA, Wijdicks EF, Bamlet WR, McClelland RL. Further validation of the FOUR score coma scale by intensive care nurses. Mayo Clin Proc. 2007;82:435–8.
23. Fischer M, Ruegg S, Czaplinski A, et al. Inter-rater reliability of the full outline of unresponsiveness score and the Glasgow Coma Scale in critically ill patients: a prospective observational study. Crit Care. 2010;14:R64.
24. Kramer AA, Wijdicks EF, Snavely VL, et al. A multicenter prospective study of interobserver agreement using the full outline of unresponsiveness score coma scale in the intensive care unit. Crit Care Med. 2012;40:2671–6.
25. Wijdicks EF, Rabinstein AA, Bamlet WR, Mandrekar JN. FOUR score and Glasgow Coma Scale in predicting outcome of comatose patients: a pooled analysis. Neurology. 2011;77:84–5.
26. Fugate JE, Rabinstein AA, Claassen DO, White RD, Wijdicks EF. The FOUR score predicts outcome in patients after cardiac arrest. Neurocrit Care. 2010;13:205–10.
27. Akavipat P, Sookplung P, Kaewsingha P, Maunsaivat P. Prediction of discharge outcome with the full outline of unresponsiveness (FOUR) score in neurosurgical patients. Acta Med Okayama. 2011;65:205–10.
28. Sadaka F, Patel D, Lakshmanan R. The FOUR score predicts outcome in patients after traumatic brain injury. Neurocrit Care. 2012;16:95–101.
29. Ropper AH, Cole D, Louis DN. Clinicopathologic correlation in a case of pupillary dilation from cerebral hemorrhage. Arch Neurol. 1991;48:1166–9.
30. Marmarou A, Lu J, Butcher I, et al. Prognostic value of the Glasgow Coma Scale and pupil reactivity in traumatic brain injury assessed pre-hospital and on enrollment: an IMPACT analysis. J Neurotrauma. 2007;24:270–80.
31. Hoffmann M, Lefering R, Rueger JM, et al. Pupil evaluation in addition to Glasgow Coma Scale components in prediction of traumatic brain injury and mortality. Br J Surg. 2012;99(Suppl 1):122–30.
32. Uzan M, Yentur E, Hanci M, et al. Is it possible to recover from uncal herniation? Analysis of 71 head injured cases. J Neurosurg Sci. 1998;42:89–94.
33. Smrcka M, Maca K, Juran V, et al. Cerebral perfusion pressure and SPECT in patients after craniocerebral injury with transtentorial herniation. Acta Neurochir Suppl. 2002;81:73–5.
34. Du R, Meeker M, Bacchetti P, Larson MD, Holland MC, Manley GT. Evaluation of the portable infrared pupillometer. Neurosurgery. 2005;57:198–203.
35. Hults KN, Knowlton SL, Oliver JW, Wolfson T, Gamst A. A study of pupillary assessment in outpatient neurosurgical clinics. J Neurosci Nurs. 2006;38:447–52.
36. Meeker M, Du R, Bacchetti P, et al. Pupil examination: validity and clinical utility of an automated pupillometer. J Neurosci Nurs. 2005;37:34–40.
37. Larson MD, Muhiudeen I. Pupillometric analysis of the ‘absent light reflex’. Arch Neurol. 1995;52:369–72.
38. Taylor WR, Chen JW, Meltzer H, et al. Quantitative pupillometry, a new technology: normative data and preliminary observations in patients with acute head injury. Technical note. J Neurosurg. 2003;98:205–13.
39. Manley GT, Larson MD. Infared pupillometry during uncal herniation. J Neurosurg Anesthesiol. 2002;14:223–8.
40. Chen JW, Gombart ZJ, Rogers S, Gardiner SK, Cecil S, Bullock RM. Pupillary reactivity as an early indicator of increased intracranial pressure: the introduction of the Neurological Pupil index. Surg Neurol Int. 2011;2:82.
41. Gelinas C, Klein K, Naidech AM, Skrobik Y. Pain, sedation, and delirium management in the neurocritically ill: lessons learned from recent research. Semin Respir Crit Care Med. 2013;34:236–43.
42. Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41:263–306.
43. Payen JF, Bru O, Bosson JL, et al. Assessing pain in critically ill sedated patients by using a behavioral pain scale. Crit Care Med. 2001;29:2258–63.
44. Gelinas C, Fillion L, Puntillo KA, Viens C, Fortier M. Validation of the critical-care pain observation tool in adult patients. Am J Crit Care. 2006;15:420–7.
45. Gottschalk A, Yaster M. The perioperative management of pain from intracranial surgery. Neurocrit Care. 2009;10:387–402.
46. Laureys S, Faymonville ME, Peigneux P, et al. Cortical processing of noxious somatosensory stimuli in the persistent vegetative state. Neuroimage. 2002;17:732–41.
47. Schnakers C, Chatelle C, Demertzi A, Majerus S, Laureys S. What about pain in disorders of consciousness? AAPS. 2012;14:437–44.
48. Yu A, Teitelbaum J, Scott J, et al. Evaluating pain, sedation, and delirium in the neurologically critically ill-feasibility and reliability of standardized tools: a multi-institutional study. Crit Care Med. 2013;41:2002–7.
49. Schnakers C, Chatelle C, Vanhaudenhuyse A, et al. The Nociception Coma Scale: a new tool to assess nociception in disorders of consciousness. Pain. 2010;148:215–9.
50. Chatelle C, Majerus S, Whyte J, Laureys S, Schnakers C. A sensitive scale to assess nociceptive pain in patients with disorders of consciousness. J Neurol Neurosurg Psychiatry. 2012;83:1233–7.
51. Seder DB, Riker RR, Jagoda A, Smith WS, Weingart SD. Emergency neurological life support: airway, ventilation, and sedation. Neurocrit Care. 2012;17(Suppl 1):S4–20.
52. Robinson BR, Berube M, Barr J, Riker R, Gélinas C. Psychometric analysis of subjective sedation scales in critically ill adults. Crit Care Med. 2013;41(9 Suppl 1):S16–29.
53. Deogaonkar A, Gupta R, DeGeorgia M, et al. Bispectral Index monitoring correlates with sedation scales in brain-injured patients. Crit Care Med. 2004;32:2403–6.
54. Olson DM, Thoyre SM, Peterson ED, Graffagnino C. A randomized evaluation of bispectral index-augmented sedation assessment in neurological patients. Neurocrit Care. 2009;11:20–7.
55. Augustes R, Ho KM. Meta-analysis of randomized controlled trials on daily sedation interruption for critically ill adult patients. Anaesth Intensive Care. 2011;39:401–9.
56. Mehta S, Burry L, Cook D, et al. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: a randomized controlled trial. JAMA. 2012;308:1985–92.
57. Skoglund K, Enblad P, Marklund N. Effects of the neurological wake-up test on intracranial pressure and cerebral perfusion pressure in brain-injured patients. Neurocrit Care. 2009;11:135–42.
58. Helbok R, Kurtz P, Schmidt MJ, et al. Effects of the neurological wake-up test on clinical examination, intracranial pressure, brain metabolism and brain tissue oxygenation in severely brain-injured patients. Crit Care. 2012;16:R226.
59. Mitasova A, Kostalova M, Bednarik J, et al. Poststroke delirium incidence and outcomes: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med. 2012;40:484–90.
60. Naidech AM, Beaumont JL, Rosenberg NF, et al. Intracerebral hemorrhage and delirium symptoms. Length of stay, function, and quality of life in a 114-patient cohort. Am J Respir Crit Care Med. 2013;188:1331–7.
61. Frontera JA. Delirium and sedation in the ICU. Neurocrit Care. 2011;14:463–74.
62. Ouimet S, Riker R, Bergeron N, Cossette M, Kavanagh B, Skrobik Y. Subsyndromal delirium in the ICU: evidence for a disease spectrum. Intensive Care Med. 2007;33:1007–13.
63. Haenggi M, Blum S, Brechbuehl R, Brunello A, Jakob SM, Takala J. Effect of sedation level on the prevalence of delirium when assessed with CAM-ICU and ICDSC. Intensive Care Med. 2013;39:2171–9.
64. Patel SB, Poston JT, Pohlman A, Hall JB, Kress JP. Rapidly reversible, sedation-related delirium versus persistent delirium in the ICU. Am J Respir Crit Care Med. 2014;189:658–65.
65. Kress JP, Pohlman AS, O’Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000;342:1471–7.