■格拉斯哥昏迷量表(GCS)评分是评估创伤性脑损伤(TBI)后意识的主要方法,和TBI严重程度分类的临床标准。很少有文献了解昼夜节律或急诊科(ED)到达时间对这一重要临床工具的影响。
■使用国家创伤数据库的国家样本计划对患有钝性TBI的成年患者进行回顾性队列分析,2003-2006年。ED到达GCS评分的特征是中午(上午10点至下午4点)和午夜(上午12点至上午6点)队列(N=24548)。报告描述性数据的比例和标准误差。使用优势比(OR)的多变量回归,平均差异(B),和他们相关的95%置信区间[CI]被用来评估ED到达小时和GCS评分之间的关联.在p<0.05时评估统计学显著性。
■患者为42.48±0.13岁,69.5%为男性。GCS评分12.68±0.13(77.2%轻度,5.2%适度,17.6%严重-TBI)。总的来说,患者主要因机动车事故(52.2%)和跌倒(24.2%)受伤,85.7%住院(33.5%ICU)。白天和夜间入院的伤害严重程度评分没有差异。夜间入院与全身合并症减少(p<0.001)和酗酒和药物中毒的可能性增加(p<0.001)相关。GCS评分显示昼夜节律,峰值在下午12点(13.03±0.08),最低点在凌晨4点(12.12±0.12)。午夜患者表现出更低的GCS(上午12点-上午6点:12.23±0.04;上午10点-下午4点:12.95±0.03,p<0.001)。调整人口统计学和伤害因素的多变量回归证实,午夜小时数与GCS降低独立相关(B=-0.29[-0.40,-0.19])。在没有死于ED或直接去手术的患者中(N=21862),午夜小时数(多变量OR1.73[1.30-2.31])与ICU入院可能性增加相关;GCS评分增加(单位OR0.82[0.80-0.83])与赔率降低相关.值得注意的是,交互因子EDGCS评分*ED到达小时独立显示OR0.96[0.94-0.98],提示GCS评分对ICU入院几率的影响在夜间不如在白天重要。
■夜间TBI患者出现GCS评分下降,并以更高的比率进入ICU,但先前的合并症和类似的全身性损伤较少。夜间工作时间和ICU入院时GCS评分降低之间的相互作用对临床评估/分诊具有重要意义。
BACKGROUND: The Glasgow Coma Scale (GCS) score is the primary method of assessing consciousness after traumatic brain injury (TBI), and the clinical standard for classifying TBI severity. There is scant literature discerning the influence of circadian rhythms or emergency department (ED) arrival hour on this important clinical tool.
METHODS: Retrospective cohort analysis of adult patients suffering blunt TBI using the National Sample Program of the National Trauma Data Bank, years 2003-2006. ED arrival GCS score was characterized by midday (10 a.m.-4 p.m.) and midnight (12 a.m.-6 a.m.) cohorts (N=24548). Proportions and standard errors are reported for descriptive data. Multivariable regressions using odds ratios (OR), mean differences (B), and their associated 95% confidence intervals [CI] were performed to assess associations between ED arrival hour and GCS score. Statistical significance was assessed at p<0.05.
RESULTS: Patients were 42.48±0.13-years-old and 69.5% male. GCS score was 12.68±0.13 (77.2% mild, 5.2% moderate, 17.6% severe-TBI). Overall, patients were injured primarily via motor vehicle accidents (52.2%) and falls (24.2%), and 85.7% were admitted to hospital (33.5% ICU). Injury severity score did not differ between day and nighttime admissions.Nighttime admissions associated with decreased systemic comorbidities (p<0.001) and increased likelihood of alcohol abuse and drug intoxication (p<0.001). GCS score demonstrated circadian rhythmicity with peak at 12 p.m. (13.03±0.08) and nadir at 4am (12.12±0.12). Midnight patients demonstrated lower GCS (12 a.m.-6 a.m.: 12.23±0.04; 10 a.m.-4 p.m.: 12.95±0.03, p<0.001). Multivariable regression adjusted for demographic and injury factors confirmed that midnight-hours independently associated with decreased GCS (B=-0.29 [-0.40, -0.19]).In patients who did not die in ED or go directly to surgery (N=21862), midnight-hours (multivariable OR 1.73 [1.30-2.31]) associated with increased likelihood of ICU admission; increasing GCS score (per-unit OR 0.82 [0.80-0.83]) associated with decreased odds. Notably, the interaction factor ED GCS score*ED arrival hour independently demonstrated OR 0.96 [0.94-0.98], suggesting that the influence of GCS score on ICU admission odds is less important at night than during the day.
CONCLUSIONS: Nighttime TBI patients present with decreased GCS scores and are admitted to ICU at higher rates, yet have fewer prior comorbidities and similar systemic injuries. The interaction between nighttime hours and decreased GCS score on ICU admissions has important implications for clinical assessment/triage.