Sathish Kumar, M (2022) Comparison of Glasgow Coma Scale and the Full Outline of Unresponsiveness Score in Predicting Mortality and Neurological Outcome in Patients with Altered Sensorium Admitted in a Medical Intensive Care Unit. Masters thesis, Madras Medical College, Chennai.
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Abstract
INTRODUCTION: The International Classification of Diseases -10 defined altered consciousness as “any level of arousal other than normal”. Altered sensorium and coma constitute one of the most important diagnostic challenges for any physician. The causes are varied and diverse. One can confidently claim that any busy hospital will always have atleast one patient with altered sensorium at any point of time in their emergency ward. The incidence of altered sensorium in India is said to be around 70 to 80/100,000 persons per year. The most important challenge for the physician in the emergency room confronting a patient with altered sensorium is to think and act “on their feet” with requirements of prioritising Airway, Breathing and Circulation for emergency care while simultaneously evaluating for the varied and diverse causes of coma. The most common cause of altered sensorium worldwide is surprisingly Metabolic Encephalopathy and not trauma! However, identification of the etiology cannot be made with the presenting complaints, adding to the challenge. The second most important challenge for the physician after early stabilisation is to prognosticate the patient and decide regarding need for specialist care. Upto the early 1970’s, there was no universal tool for this purpose which contributed to poor outcomes. The Glasgow Coma Scale (GCS) was invented in 1974 for this purpose and has since revolutionised patient care. However, the pitfalls of the Glasgow coma scale have been studied and documented over time – such as inability to assess intubated patients adequately, lack of incorporation of important neurological examination such as brainstem reflexes etc. Newer scales and scores were introduced to overcome these fallacies but they were too complex and did not gain popularity beyond the regional centres which invented them. It was at this juncture, the FOUR (Full Outline of Un Responsiveness) score was invented in 2005 to overcome the shortcomings of the Glasgow Coma Scale. The FOUR score is easy to perform, incorporates important diagnostic data and is as useful as GCS in triage centres. Studies conducted so far have acknowledged the advantages of the FOUR score while specifying the need for conducting multiple studies across different patient populations to prove its validity. The aim of this thesis is to compare the FOUR score with the Glasgow Coma Scale to predict mortality and neurological outcome in patients with altered sensorium. This will contribute to patient care in the form of better prognostication and better communication to the attenders of patients admitted with altered sensorium. AIM OF THE STUDY: To compare the Full Outline of Un Responsiveness score (FOUR) with the Glasgow Coma scale (GCS) in predicting mortality and neurological outcome in patients admitted with altered mental status in the Medical ICU. MATERIALS AND METHODS: STUDY DESIGN: Comparative diagnostic study. STUDY PLACE: Medical ICUs of Rajiv Gandhi Government General Hospital, Institute of Internal Medicine, Madras Medical College and COVID ICU, Rajiv Gandhi Government General Hospital, Chennai. STUDY PERIOD: May 2021 to October 2021. STUDY POPULATION: Patients admitted with altered mental status in the Medical ICUs and COVID ICU of Rajiv Gandhi Government General Hospital, Chennai. CASE DEFINITION: Patients admitted with altered sensorium (defined by International Classification of Diseases – ICD 10 as “any measure of arousal other than normal”) and patients/legal attenders consenting to the study. INCLUSION CRITERIA: 1. Patients above 18 years of age presenting with altered sensorium (defined by ICD 10 as “any measure of arousal other than normal”). 2. Patients/Legal representatives giving consent to the study. EXCLUSION CRITERIA: 1. Patients/Legal representatives not willing to participate in the study. 2. Patients less than 18 years of age. 3. Patients with Traumatic brain injury/ polytrauma. 4. Patients diagnosed as “brain dead” at the time of admission (determined by the American Academy of Neurology Criteria). SAMPLE SIZE: 250 patients (above 18 years of age admitted with altered sensorium, who met the eligibility criteria during the study period. CONCLUSION: The FOUR score is better than the GCS in predicting mortality, in view of its superior specificity, positive predictive value and negative predictive value compared to the GCS. The neurological outcome among the survivors was better predicted by the GCS than the FOUR score as lower scores on the GCS were associated with poor neurological outcome, while higher scores were associated with a better neurological outcome. LIMITATIONS OF THE STUDY: ● The study, even though done over a sample size of 250, is relatively smaller. More number of patients have to be recruited for better results. ● The patients included in the study included a disproportionate number of patients with Metabolic encephalopathy and Ischemic stroke, compared to other diagnoses; hence the results are also likely to be skewed in their favor. ● The outcome of the patient is not dependent upon Neurological status alone ; The presence of co morbidities, initiation of treatment at the right time, initiating disability limitation and rehabilitation measures like Physiotherapy also play an important role. ● The possibility of variations in inter rater reliability was not examined in this study. ● The patients were not followed up beyond 3 months post discharge.
| Item Type: | Thesis (Masters) |
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| Additional Information: | 201911018 |
| Uncontrolled Keywords: | Comparison, Glasgow Coma Scale, Unresponsiveness Score, Predicting, Mortality Neurological Patients, Altered Sensorium, Intensive Care Unit. |
| Subjects: | MEDICAL > General Medicine > MEDICAL > General Medicine |
| Depositing User: | Thavamani K |
| Date Deposited: | 09 Apr 2022 01:01 |
| Last Modified: | 10 Jan 2024 16:48 |
| URI: | http://repository-tnmgrmu.ac.in/id/eprint/19167 |
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