Global Research Review: Issue 10

Published on January 9, 2014
Abstracts Curated by the Global Emergency Medicine Literature Review Group


Is the Simplified Motor Scale (SMS) as good as GCS?

Thompson DO, Hurtado TR, Liao MM, Byyny RL, Gravitz C, Haukoos JS. Validation of the Simplified Motor Score in the out-of-hospital setting for prediction of outcomes after traumatic brain injury. Ann Emerg Med. 2011;58:417-25.

This study is a secondary analysis of an urban trauma registry that sought to validate a previous finding that the out-of-hospital simplified motor score (SMS) was comparable to the Glasgow Coma Scale (GCS) to predict 4 outcomes of interest: emergency tracheal intubation, clinically meaningful brain injury, need for neurosurgical intervention, and mortality. The authors analyzed a trauma registry composed of all trauma patients over a 9-year period (January 1, 1999 to June 30, 2008) who met any of the following criteria: required hospital admission, required ED observation unit admission for more than 12 hours, were transferred from an outlying hospital, died in the ED.

This study compared the GCS and the SMS of the subgroup transported by EMS. The analysis included 19,408 patients from the registry who had complete outcome data. The need for emergent intubation, brain injury, mortality, and the composite of the four outcomes had significant differences (i.e. GCS better), however the confidence intervals were not significantly different. These results indicated the SMS is comparable to the GCS in the out-of-hospital setting to predict the need for clinically meaningful outcomes.

When evaluated by prehospital providers, the Simplified Motor Score (SMS) may perform as well as the Glasgow Coma Scale (GCS) for predicting negative outcomes in patients with traumatic brain injury. The strengths of this article include the consecutive nature of the patient selection and the large sample size. The authors make a clear argument for simplifying the score used by out-of-hospital providers given the poor inter-rater reliability of the GCS. The limitations center around missing data, as 34% of the out-of-hospital GCS scores were absent. Additionally, this study was conducted in a large urban Level I trauma system in the United States, and patients were scored by paramedics and emergency medical technicians with considerable trauma experience. While the SMS appears to be easier to calculate then the GCS, these results need to be validated in resource-limited settings before adoption of the SMS scoring system can be recommended in these settings.

EPI Note: If validated for use in low- and middle-income countries, the SMS has the potential advantage of being easier to teach and use, and could be utilized at community health centers or district hospitals to determine which trauma patients should be transferred to a higher level facility



Managing pediatric procedural pain without medications

Pillai Riddell RR, Racine NM, Turcotte K, et al. Non-pharmacological management of infant and young child procedural pain. Cochrane Database Syst Rev. 2011;(10):CD006275.

Infant pain management has improved in recent years, however evidence shows that it is still undermanaged. The authors of this Cochrane review assessed the efficacy of non-pharmacological interventions for acute pain in infants and children. Analyses were grouped by age (preterm, neonate and older), accounting for altered responses with developmental stage, and by pain response (immediate pain reactivity and delayed pain-related regulation). This review is the first comprehensive meta-analysis of non-pharmacologic pain management in children under 3 years of age.

The authors searched 7 databases for randomized controlled trials (RCTs) and RCT crossover studies with a non-treatment control group. A total of 51 studies with 3,396 participants met inclusion criteria. For preterm infants, the following interventions were found effective and recommended: kangaroo care, non-nutritive sucking-related interventions, and swaddling. For neonates, non-nutritive sucking-related interventions were found effective. For older infants, evidence was limited, but both non-nutritive sucking-related interventions and video-mediated distractions may reduce pain response. There was significant heterogeneity in the primary literature, which limited the authors’ ability to confidently make further conclusions.

Emergency care often necessitates painful procedures for young children, including blood draws, sutures, and injections. Non-pharmacologic interventions to reduce pain are particularly important in resource-poor settings where limitations in availability, safety, and monitoring make analgesia and anesthesia difficult. This Cochrane review represents the most comprehensive data currently available on non-pharmacologic interventions for children younger than 3 years. Non-pharmacological interventions can reduce acute pain perception in infants and children. While more research is needed, global EM practitioners can utilize the authors’ recommendations to manage pain perception in young children.



Dengue Management Update

Thomas L, Moravie V, Besnier F, et al. Clinical presentation of dengue among patients admitted to the adult emergency department of a tertiary care hospital in Martinique: implications for triage, management, and reporting. Ann Emerg Med. 2012;59(1):42-50.

This prospective observational study aimed at improving the triage algorithms and appropriate reporting systems for Dengue fever. The authors analyzed the clinical presentations for 715 Dengue fever patients admitted to a local adult ED. Among them were 332 patients with severe illness, including Dengue hemorrhagic fever or Dengue shock syndrome (104 of 332), severe bleeding (9 of 332), acute organ failure (56 of 332), and dehydration and electrolytes imbalance (171 of 332). The dehydration and electrolytes imbalance group had no evidence of plasma leakage and responded well to normal saline infusion. The results suggested that hematological presentations may help differentiate uncomplicated Dengue fever from more severe forms, i.e., those who exhibit plasma leakage. Such patients require more aggressive treatment.

This is a promising study to improve triage, management and reporting for Dengue fever on the international level. Several factors may have biased the results, such as limited ethno-geographic origin, no exclusion of comorbidities, or a short observation time in ED. The study emphasized the diagnostic and therapeutic significance of plasma leakage, as the presence or absence of plasma leakage remains an important factor in directing treatment for patients with Dengue fever. The results could assist in the development of a Dengue fever classification system for adult patients. -GJ, XL


GJ: Gabrielle A. Jacquet, MD, MPH | MB: Mark Bisanzo, MD, DTM&H | RM: Regan Marsh, MD, MPH | XL: Xiaoguong LI, MD

This article originally appeared in issue 10 of Emergency Physicians International

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