Browsing by Subject "Neurologic Examination"
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Item Pupillometer Inter-Device Reliability Assessment(2015-01-26) Zhao, Weidan; Stutzman, Sonja; Olson, Daiwai; Saju, Ciji; Wilson, Margaret; Venkatesh, AiyagariINTRODUCTION: Assessment of the pupillary reflex is one of the fundamental aspects of the neurological examination. Traditionally, it comprises of a subjective assessment of the size and shape of the pupil prior to the manual application of a light source and the speed of pupil reactivity when exposed to light. We have recently shown that there is a striking degree of disagreement between trained observers in interpreting pupillary size and reactivity, partly because examiners are allowed to use a variety of non-standardized handheld light sources. Automated hand-held pupillometers are commercially available that are able to provide an objective measurement of the initial and final size of the pupil and to grade the speed of pupil contraction in response to a light stimulus. The purpose of this prospective study was to assess the inter-device reliability of the pupillary examination performed with NPiTM-100 pupillometers (NeuroOptics, Inc.). METHODS: To determine the inter-device reliability, 33 practitioners (28 RNs, 2 MDs, 1 NP, 1 medical student and 1 PhD research coordinator) obtained 210 paired pupillometer measurements from 20 patients at risk for cerebral edema. Paired pupillometer assessments were completed within a five-minute period and consisted of two separate assessments by two different clinicians using two different pupillometers. RESULTS: There was no statistically significant difference between the mean maximum pupil size at rest for both OS (p=0.27) and OD assessments (p=0.74) when measured by the different pupillometers (PM1 and PM2) prior to the light stimulation. Similarly, there was no statistically significant difference between the mean minimum pupil size for both OS (p=0.64) and OD (0.44) when measured after the light stimulation. The mean pupil reactivity for both OS (p=0.36) and OD (p=0.82) are also not statistically significantly different. In addition, Cohen's Kappa assessments of pupil size and reactivity revealed an almost perfect agreement between PM1 and PM2 for both the maximum pupil size of both OS (k=0.97) and OD observations (k=0.91) and the minimum pupil size of OS (k=0.96) and OD observations (k=0.98). Including the non-reactive pupil results, there was also a high correlation for the OS (k=0.99) and OD readings (k=0.90). DISCUSSION: The NPiTM-100 pupillometers have a high inter-device reliability, even when two different pupillometer devices are used on the same subject by different practioners. The data provide sufficient support to conclude that the use of NPiTM-100 pupillometers is likely to improve the precision of the pupillary examination.Item The Validity of Hourly Neurologic Assessments in the Intensive Care Unit for Patients with Traumatic Brain Injury(2017-01-17) Kabangu, Jean-Luc; Bedros, Nicole; Williams, Brian; Aoun, Salah; Geoffrion, Tracy; Provenzale, Natalie; Baker, Stacy; Minshall, ChristianLEARNING OBJECTIVES: Traumatic brain injury (TBI) is a leading cause of disability and mortality worldwide. The standard of care at many trauma centersis to admit patients with TBI to the Intensive Care Unit (ICU) for hourly neurologic assessments. There is a proven discrepancy between documented GCS (Glasgow Coma Scale score) and the presence of significant organic intracranial injuries and their clinical impact. Additionally, unnecessary ICU stay incurs significant financial costs to and resource utilization, and may adversely affect patient outcomes. There is no consensus regarding the optimal duration or frequency of hourly neurologic assessments. METHODOLOGY: As a feasibility study we retrospectively reviewed data from the trauma registry at our urban, level I trauma center over a 2-month period, Data points included head injury type, admission GCS, lowest GCS within 24 hours of admission, lowest GCS during hospitalization, ICU length of stay, total length of stay; and unplanned surgical, medical, or diagnostic intervention prompted by a decline in GCS. RESULTS: Twenty-two patients were admitted to the ICU based on the radiographic and clinical diagnoses of traumatic brain injury. Eighty-two percent of patients did not experience a decline in GCS within the first 24 hours of admission. Among them, 17% experienced a decline after 24 hours for non-neurological reasons. Of the 18% that did experience a decline within 24 hours, none prompted an unplanned intervention in their previously management plan. CONCLUSIONS: All patients with TBI may not require hourly neurologic assessments in the ICU. The majority of patients in our review did not experience a decline in GCS. Additionally, those that did decline did not trigger a significant change in clinical management. Further data is required to elucidate certain patient or injury criteria to separate patients that truly require hourly neurologic assessments from those that can be monitored in a lower acuity setting.