Optic nerve sheath diameter as a predictor of altered mental status in drug intoxication patients

Objectives: As far as we know, proposed the predictive performance of optic nerve sheath diameter measured (ONSD) from brain computed tomography to predict poor prognosis in drug intoxication patients. The aim of our study was to evaluate the predictive performance of ONSD for predicting mortality and admission in patients with altered mental status among drug intoxication patients.

Method: We retrospectively enrolled patients with drug intoxication patients who underwent brain computed tomography due to altered mental status between January 2018 and December 2019.

Two emergency physicians independently measured ONSD at 3 mm behind the globe in each patients. Statistical analysis including multivariate logistic regression analysis were yielded to estimate predictive performance.

Results: A total of 18 patients (8.7%) were death and 57 patients (24%) were admitted out of 206 patients. ONSD was independently predictive factors for predicting mortality and admission. ONSD (cut-off = 4.35) had 69.05% sensitivity and 53.33% specificity with area under the receiver operating characteristic curve of 0.824 (95% CI = 0.803–0.927) for predicting mortality among drug intoxication patients while the ONSD (cut-off = 3.96) had 100% sensitivity and 51.5% specificity with area under the receiver operating characteristic curve of 0.824 (95% CI, 0.722–0.927) for predicting admission among patients. There were excellent inter- and intra-observer agreements for measuring ONSD on brain CT.

Conclusion: ONSD was demonstrated as feasible predictive marker for predicting admission and mortality among drug intoxication patients with altered mental status. This information can help decision making for emergency physicians to provide prompt treatment in drug intoxication patients.

Drug overdose; Computed tomograhy; Mortality; Outcome; Prognostic marker

[1] Warner M, Chen LH, Makuc DM, Anderson RN, Miniño AM. Drug poisoning deaths in the United States, 1980-2008. NCHS Data Brief. 2011; 1–8.

[2] Rudd RA, Seth P, David F, Scholl L. Increases in drug and opioid-involved overdose deaths - United States, 2010-2015. Morbidity and Mortality Weekly Report. 2016; 65: 1445–1452.

[3] Erickson TB, Thompson TM, Lu JJ. The approach to the patient with an unknown overdose. Emergency Medicine Clinics of North America. 2007; 25: 249–281.

[4] Taheri MS, Noori M, Shakiba M, Jalali AH. Brain CT-scan findings in unconscious patients after poisoning. International Journal of Biomedical Science. 2011; 7: 1–5.

[5] Eizadi Mood N, Sabzghabaee AM, Yadegarfar G, Yaraghi A, Ramazani Chaleshtori M. Glasgow coma scale and its components on admission: are they valuable prognostic tools in acute mixed drug poisoning? Critical Care Research and Practice. 2011; 2011: 952956.

[6] Manini AF, Nair AP, Vedanthan R, Vlahov D, Hoffman RS. Validation of the prognostic utility of the electrocardiogram for acute drug overdose. Journal of the American Heart Association. 2017; 6: e004320.

[7] Manini AF, Kumar A, Olsen D, Vlahov D, Hoffman RS. Utility of serum lactate to predict drug-overdose fatality. Clinical Toxicology. 2010; 48: 730–736.

[8] Yates C, Manini AF. Utility of the electrocardiogram in drug overdose and poisoning: theoretical considerations and clinical implications. Current Cardiology Reviews. 2012; 8: 137–151.

[9] Kimberly HH, Shah S, Marill K, Noble V. Correlation of optic nerve sheath diameter with direct measurement of intracranial pressure. Academic Emergency Medicine. 2008; 15: 201–204.

[10] Waheed S, Baig MA, Siddiqui E, Jamil D, Bashar M, Feroze A. Prognostic significance of optic nerve sheath diameter on computed tomography scan with severity of blunt traumatic brain injury in the emergency department. The Journal of the Pakistan Medical Association. 2019; 68: 268–271.

[11] Park JS, Cho Y, You Y, Min JH, Jeong W, Ahn HJ, et al. Optimal timing to measure optic nerve sheath diameter as a prognostic predictor in post-cardiac arrest patients treated with targeted temperature management. Resuscitation. 2019; 143: 173–179.

[12] Fluss R, Faraggi D, Reiser B. Estimation of the Youden Index and its associated cutoff point. Biometrical Journal. Biometrische Zeitschrift. 2005; 47: 458–472.

[13] Sporer KA. Acute heroin overdose. Annals of Internal Medicine. 1999; 130: 584–590.

[14] Kiyatkin EA, Sharma HS. Acute methamphetamine intoxication: brain hyperthermia, blood-brain barrier, brain edema, and morphological cell abnormalities. International Review of Neurobiology. 2009; 88: 65–100.

[15] Andersen GO, Ritland S. Life threatening intoxication with sodium valproate. Journal of Toxicology: Clinical Toxicology. 1995; 33: 279–284.

[16] Sekhon MS, Ainslie PN, Griesdale DE. Clinical pathophysiology of hypoxic ischemic brain injury after cardiac arrest: a “two-hit” model. Critical Care. 2017; 21: 90.

[17] Leinonen V, Vanninen R, Rauramaa T. Raised intracranial pressure and brain edema. Handbook of Clinical Neurology. 2017; 145: 25–37.

[18] Vaiman M, Gottlieb P, Bekerman I. Quantitative relations between the eyeball, the optic nerve, and the optic canal important for intracranial pressure monitoring. Head & Face Medicine. 2014; 10: 32.

[19] Hossein-Nejad H, Bahreini M, Rasooli F. Bias in the measurement of optic nerve sheath diameter. The American Journal of Emergency Medicine. 2018; 36: 323–324.