Mortality by decade in trauma patients with Glasgow Coma Scale 3

The aim of this study was to assess how increasing age affects mortality in trauma patients with Glasgow Coma Scale (GCS) 3. The Los Angeles County Trauma System Database was queried for all patients aged 20 to 99 years admitted with GCS 3. Mortality was 41.8 per cent for the 3306 GCS 3 patients. Mortality in the youngest patients reviewed, those in the third decade, was 43.5 per cent. After logistic regression analysis, patients in the third decade had similar mortality rates to patients in the sixth (adjusted OR, 0.88; CI, 0.68 to 1.14; P = 0.33) and seventh decades (adjusted OR, 0.96; CI, 0.70 to 1.31; P = 0.79). A significantly lower mortality rate, however, was noted in the fifth decade (adjusted OR, 0.76; CI, 0.61 to 0.95; P = 0.02). Conversely, significantly higher mortality rates were noted in the eighth (adjusted OR, 1.93; CI, 1.38 to 2.71; P = 0.0001) and combined ninth/tenth decades (adjusted OR, 2.47; CI, 1.71 to 3.57; P < 0.0001). Given the high survival in trauma patients with GCS 3 as well as continued improvement in survival compared with historical controls, aggressive care is indicated for patients who present to the emergency department with GCS 3.     

Glasgow Coma Scale score, mortality, and functional outcome in head-injured patients

BACKGROUND: Preresuscitation Glasgow Coma Scale (P-GCS) score is frequently obtained in injured patients and incorporated into mortality prediction. Data on functional outcome in head injury is sparse. A large group of patients with head injuries was analyzed to assess relationships between P-GCS score, mortality, and functional outcome as measured by the Functional Independence Measure (FIM). METHODS: Records for patients with International Classification of Diseases, Ninth Revision diagnosis codes indicating head injury in a statewide trauma registry between 1994 and 2002 were selected. P-GCS score, mortality, and FIM score at hospital discharge were integrated and analyzed. RESULTS: Of 138,750 patients, 22,924 patients were used for the mortality study and 7,150 patients for the FIM study. A good correlation exists between P-GCS score and FIM, as determined by rank correlation coefficients, whereas mortality falls steeply between a P-GCS score of 3 and a P-GCS score of 7 followed by a shallow fall. Although P-GCS score is related to mortality in head-injured patients, its relationship is nonlinear, which casts doubt on its use as a continuous measure or an equivalent set of categorical measures incorporated into outcome prediction models. The average FIM scores indicate substantial likelihood of good outcomes in survivors with low P-GCS scores, further complicating the use of the P-GCS score in the prediction of poor outcome at the time of initial patient evaluation. CONCLUSION: Although the P-GCS score is related to functional outcome as measured by the FIM score and mortality in head injury, current mortality prediction models may need to be modified to account for the nonlinear relationship between P-GCS score and mortality. The P-GCS score is not a good clinical tool for outcome prediction in individual head-injured patients, given the variability in mortality rates and functional outcomes at all scores.     

Problems of the Glasgow Coma Scale with early intubated patients

The Glasgow Coma Scale is probably the most common grading scale in neurotraumatology all over the world. Its validity concerning severity and prognosis of the injury has been established in the Anglo-American literature. Data derived from the German rescue system, however is different from the Anglo-American in some respects. The analysis of a well-defined group of German trauma patients with moderate and severe head injuries (n=299) shows that low Glasgow Coma Scores (GCS 3–6) established during the first two posttraumatic days must not correspond directly to the outcome after one year. Especially for the best Glasgow Coma Score during the day after the injury, GCS 4 had a poorer collective long-term prognosis than GCS 3. Therefore, German data from head injury studies based on the Glasgow Coma Scoring are difficult to compare to those cited in the Anglo-American literature. Any statistical analysis of a so called ranking scale which does not satisfy its own claims under special conditions is difficult.     

Emergency decompressive craniectomy for trauma patients with Glasgow Coma Scale of 3 and bilateral fixed dilated pupils

Background  

Trauma patients with Glasgow Coma Scale (GCS) of 3 and bilateral fixed dilated pupils (BFDP) usually have dismal outcome, and neurosurgeons are less likely to treat such patients aggressively. In this work, the authors assessed whether emergency decompressive craniectomy (EDC) can change the poor outcome of these patients.     

A comparison of the Glasgow Coma Scale and the Swedish Reaction Level Scale

The Glasgow Coma Scale (GCS) and the Swedish Reaction Level Scale (RLS85), two level-of-consciousness scales used in the assessment of patients with head injury, were compared in a prospective study of 239 patients admitted to a regional head injury unit over a 4-month period. Assessments were made by nine staff members ranging from house officer to registrar, after briefing about the two scales. Data were also collected on age, nature of injuries, surgical treatment, and condition at discharge or transfer using the Glasgow Outcome Scale. Both the GCS and the RLS85 reliably identified comatose patients and those with minor head injury, but were much less effective in defining the response level in patients considered to have a moderate head injury. Only 41% of the patients allocated to a moderate-head-injury category by the GCS and the RLS85 were common to both groups. Where a mismatch occurred, neither scale allocated patients to a 'better' or 'worse' category more frequently than the other. Assessment of patients' conscious levels using the GCS was difficult in only two cases. One patient had facial injuries, and the other was intubated. The RLS85 was reported by all users to be simpler to use than the GCS, but the latter is much more widespread in use. Both scales function well in cases of severe and minor head injury, but have weaknesses when defining moderate head injury. Level-of-consciousness scales are only an aid to assessment and the final choice between the two scales must remain a matter of personal or departmental preference.     

A practical review of the Glasgow Coma Scale and Score

Since the Glasgow Coma Scale was introduced in 1974,(1) it has become the most common method of describing a patient's level of consciousness. However, despite its almost universal use, there remain a number of misunderstandings, particularly regarding the appropriate situations in which to use the Glasgow Coma Score rather than the Scale, and also in the correct way to elicit and record the motor responses. This article, aimed at non-neurosurgeons, addresses these problems, and provides a reference for those wishing to learn or teach the Glasgow Coma Scale and Score.     

The value of the Glasgow Coma Scale and Injury Severity Score: predicting outcome in multiple trauma patients with head injury

This retrospective study of multiple trauma patients requiring SICU admission was undertaken to determine to what extent, if any, head injury affected patient outcome. One hundred seventy such patients with head injuries had further analysis. Glasgow Coma Scale (GCS) values at approximately 5 hours postinjury were evaluated, and the Glasgow Outcome Scale was determined 1 month postinjury. A good recovery was seen in 99% of the 87 patients with GCS 15-13. This fell to 71% of the 24 patients with GCS 12-9. Among 59 patients having a GCS below 9, 41% died and an additional 17% had a poor recovery, leaving only 35% with an eventual good outcome. By using both Injury Severity Score and GCS at 6 hours postinjury, physicians will be more accurate in assessing outcome of multiple trauma patients with head injuries.     

Analysis of incidence of traumatic brain injury in blunt trauma patients with Glasgow Coma Scale of 12 or less

Purpose

Early diagnosis of traumatic brain injury (TBI) is important for improving survival and neurologic outcome in trauma victims. The purpose of this study was to assess whether Glasgow Coma Scale (GCS) of 12 or less can predict the presence of TBI and the severity of associated injuries in blunt trauma patients.

Prediction of neuropsychiatric outcome following mild trauma brain injury: an examination of the Glasgow Coma Scale

The relationship between the Glasgow Coma Scale (GCS) and neuropsychiatric outcome was examined in 57 consecutive subjects with mild traumatic brain injury (TBI) attending a follow-up clinic. Subjects were grouped according to initial GCS score (15 versus 13-14) and contrasted at an average of 5-6 months post-injury. As expected, those with GCS 13-14 had longer PTA (p = 0.001) and a higher rate of abnormal brain CT scans (p = 0.005). However, no significant differences emerged for indices of neuropsychiatric status, including measures of neurobehavioural symptoms/signs, overall psychological distress, psychiatric 'caseness', functional and psychosocial outcome, frequency of common somatic complaints, and rate of return to work. Subsidiary analyses based upon the presence/absence of CT abnormalities and the duration of PTA (<1 hour versus 1-24 hours) also failed to predict outcome, although a trend associating longer PTA with lower functional outcome was observed. Thus, despite early neurosurgical differences, the results suggest that initial GCS scores do not clearly translate into neuropsychiatric sequelae at follow-up within the rubric of GCS 13-15.     

Extracranial insults and outcome in patients with acute head injury--relationship to the Glasgow Coma Scale

Hypoxia and hypotension are extracranial insults known to have an adverse effect on the outcome of patients with acute head injury. Arterial oxygen tension, blood pressure and the Glasgow Coma Score on admission of 67 patients seen over a 6-month period were correlated with the outcome at 6 months. With a given level of consciousness the presence of an extracranial insult resulted in a worse outcome than would be predicted. The combination of hypoxia and hypotension was uniformly fatal as was the presence of severe respiratory dysfunction.     

The differential mortality of Glasgow Coma Score in patients with and without head injury

ImportanceThe GCS was created forty years ago as a measure of impaired consciousness following head injury and thus the association of GCS with mortality in patients with traumatic brain injury (TBI) is expected. The association of GCS with mortality in patients without TBI (non-TBI) has been assumed to be similar. However, if this assumption is incorrect mortality prediction models incorporating GCS as a predictor will need to be revised.ObjectiveTo determine if the association of GCS with mortality is influenced by the presence of TBI.Design/setting/participantsUsing the National Trauma Data Bank (2012; N = 639,549) we categorized patients as isolated TBI (12.8%), isolated non-TBI (33%), both (4.8%), or neither (49.4%) based on the presence of AIS codes of severity 3 or greater. We compared the ability GCS to discriminate survivors from non-survivors in TBI and in non-TBI patients using logistic models. We also estimated the odds ratios of death for TBI and non-TBI patients at each value of GCS using linear combinations of coefficients.Main outcome measureDeath during hospital admission.ResultsAs the sole predictor in a logistic model GCS discriminated survivors from non-survivors at an acceptable level (c-statistic = 0.76), but discriminated better in the case of TBI patients (c-statistic = 0.81) than non-TBI patients (c-statistic = 0.70). In both unadjusted and covariate adjusted models TBI patients were about twice as likely to die as non-TBI patients with the same GCS for GCS values < 8; for GCS values > 8 TBI and non-TBI patients were at similar risk of dying.ConclusionsA depressed GCS predicts death better in TBI patients than non-TBI patients, likely because in non-TBI patients a depressed GCS may simply be the result of entirely reversible intoxication by alcohol or drugs; in TBI patients, by contrast, a depressed GCS is more ominous because it is likely due to a head injury with its attendant threat to survival. Accounting for this observation into trauma mortality datasets and models may improve the accuracy of outcome prediction.     

A comparison of the Glasgow Coma Scale and the Reaction Level Scale (RLS85)

The Glasgow Coma Scale (GCS) and the Reaction Level Scale (RLS85) were compared for rating neurosurgical patients in regard to ranking order of deficit severity, interobserver variability, and coverage for relevant factors. Four physicians, four registered nurses, and four assistant nurses performed 72 pairwise ratings on 47 neurosurgical patients. The rank correlation between the GCS sum score and the RLS85 was -0.94, suggesting the same ranking order of severity and indicating that the underlying concepts of somnolence, delirium, and motor responses in coma are evaluated in the same way. By the sign test, the RLS85 was shown to have better interobserver agreement than the GCS sum score and the eye-motor-verbal (EMV) profile. The interobserver grading disagreements in both scales were distributed over the entire range of responsiveness, and for the GCS sum score they were slanted to combined segments 9 to 15. The RLS85 showed full coverage of relevant factors, while 43 (60%) of the 72 test occasions in the GCS sum score and the EMV profiles showed untestable features, most often because of patient intubation. The pseudoscore (that is, the choice of value given to untestable features) affects interobserver agreement as well as the estimated overall patient responsiveness in the GCS sum score. Assessment by the order of applying the scales showed a significant effect on the GCS eye-opening scale (p = 0.01) and the GCS sum score (p = 0.03), indicating a sensitivity to environmental stimuli unrelated to the patient's status. This study demonstrates that basically the same information as that found in the separate eye, motor, and verbal scales of the GCS can be combined directly into the RLS85, which has better interobserver agreement and better coverage than the GCS sum score.     

Early prognosis in severe cranio-cerebral trauma using the Glasgow Coma Score and evoked potentials

During 72 h following severe head injury, 103 patients in acute posttraumatic coma were assessed by clinical examinations (documented by Glasgow Coma Score) and brain stem auditory evoked potentials (BAEP) as well as short-latency somatosensory evoked potentials (SEP) following median-nerve stimulation. Patient outcomes were classified at 6 months or more according to the following categories: good recovery, severely disabled or vegetative, and brain dead. Patients who had died of systemic complications (pneumonia, septicemia, renal failure, etc.) were excluded from the study. The Glasgow Coma Score was reliable in forecasting a favorable outcome; all patients with a Score over 9 points had a good recovery. The Glasgow Coma Score was not reliable in predicting an unfavorable outcome, however; some patients with the lowest possible Glasgow Coma Score (3 points) at the early clinical examination survived with good recovery. The BAEPs were reliable predictors of an unfavorable outcome; the outcome was unfavorable when a missing wave V or more missing waves pointed toward a secondary brainstem lesion. Normal BAEPs were not reliable, however, in predicting a favorable outcome. SEP data served as a prognostic indicator of unfavorable as well as favorable outcomes. In summary, evoked potentials add valuable information to the clinical examination in assessing a patient's outcome after severe head injury.     

Outcome and prognostic factors in head injuries with an admission Glasgow Coma Scale score of 3

HYPOTHESIS: To identify significant risk factors associated with mortality in patients with a Glasgow Coma Scale score of 3. DESIGN: Trauma registry study. SETTING: Level I urban trauma center. PATIENTS: A total of 760 patients with head injury with an admission Glasgow Coma Scale score of 3. Analysis was performed in all patients and in only patients who reached the hospital alive and had no major extracranial injuries (exclusion of patients with a chest or abdominal Abbreviated Injury Score [AIS] >3). MAIN OUTCOME MEASURES: Stepwise logistic regression analysis was used to identify independent risk factors associated with mortality. RESULTS: Blunt trauma accounted for 477 (63%) and penetrating trauma for 283 (37%) of the 760 head injuries. Penetrating trauma was significantly more likely to be associated with a lack of vital signs on admission (15% vs 9%; P = .03). Overall mortality was 76% (94% for penetrating injuries and 65% for blunt injuries; P<.001). Overall, 79% of patients had a head AIS of 4 or greater. Mortality in the subgroup was 64% (320/497) and was significantly higher in penetrating vs blunt trauma (89% vs 52%; P<.001). Penetrating trauma, high head AIS, hypotension on admission, and age older than 55 years were independent significant risk factors associated with mortality. Only 10% of the 177 survivors had good functional outcome at hospital discharge. Eighty-six patients (17% of those with vital signs on admission) became organ donors. CONCLUSIONS: Patients with head injury with an admission Glasgow Coma Scale score of 3 have a poor prognosis. Mechanism of injury, head AIS, hypotension on admission, and age play a critical role in outcome. These patients are an important source of organ donation and should be evaluated and resuscitated aggressively.     

A prospective population-based study of pediatric trauma patients with mild alterations in consciousness (Glasgow Coma Scale score of 13-14)

OBJECTIVE: Considerable controversy surrounds the appropriate evaluation of children with mild alterations in consciousness after closed head trauma (Glasgow Coma Scale [GCS] score of 13-14). The objective of the current study was to determine the incidence of intracranial lesions in pediatric patients with a field GCS score of 13 or 14 after closed head injuries. METHODS: The current study is a population-based, multicenter prospective study of all patients to whom emergency medical services responded during a 12-month period. The setting was urban Los Angeles County, encompassing a patient population of 2.3 million children, 13 designated trauma centers, and 94 receiving hospitals. RESULTS: In the pediatric age group (<15 yr old), 8488 patients were transported by emergency medical services for injuries. Of these, 209 had a documented field GCS score of 13 or 14. One hundred fifty-seven patients were taken to trauma centers, and 135 (86%) underwent computed tomography. Forty-three patients (27.4%) had abnormal results on computed tomographic scans, 30 (19.1%) had an intracranial hemorrhage, and 5 required an operative neurosurgical procedure for hematoma evacuation. Positive and negative predictive values of deteriorating mental status (0.500 and 0.844, respectively), loss of consciousness (0.173 and 0.809), cranial fracture (0.483 and 0.875, and extracranial injuries (0.205 and 0.814) were poor predictors of intracranial hemorrhage. CONCLUSION: Pediatric patients who have mild alterations in consciousness in the field have a significant incidence of intracranial injury. The great majority of these patients will not require operative intervention, but the implications of missing these hemorrhages can be severe for this subgroup of head-injured patients. Because clinical criteria and cranial x-rays are poor predictors of intracranial hemorrhage, it is recommended that all children with a GCS score of 13 or 14 routinely undergo screening via non-contrast-enhanced computed tomography.     

Glasgow Coma Scale and laboratory markers are superior to COHb in predicting CO intoxication severity

Carbon monoxide (CO) intoxications can affect several organ systems and lead to coma or death in severe cases. To date, COHb is routinely used as a marker for detecting CO intoxication. In this retrospective study, we investigated 173 patients admitted with CO intoxication to our intensive care unit (ICU) over a period of 8 years. Standardised blood tests, chest X-ray and neurological status evaluation were performed on admission and throughout the inpatient treatment. The duration of inpatient treatment was considered to be an indication of the severity of CO-related illness. Interestingly, the data did not reveal a significant correlation between initial COHb level and the duration of inpatient treatment. Instead, a significant inverse correlation was found between the initial Glasgow Coma Scale and the duration of inpatient treatment. Furthermore, significant correlations were found between the duration of inpatient treatment and the occurrence of elevated leucocyte numbers, elevated C-reactive protein (CRP) serum concentrations and the presence of lung infiltrates. In conclusion, we postulate that clinical parameters, such as the Glasgow Coma Scale and the laboratory markers CRP and leucocyte count are adequate supportive tools for evaluating the severity of CO-related illness, and further, that the measurement of COHb alone is insufficient for this purpose.     

Diagnostic value of the Glasgow Coma Scale for traumatic brain injury in 18,002 patients with severe multiple injuries

Although patients with severe multiple injuries may have other reasons for unconsciousness, traumatic brain injury (TBI) in these patients is frequently defined by the Glasgow Coma Scale (GCS). Nevertheless, the diagnostic value of GCS for severe TBI in the multiple-injured patient is unknown. Therefore, we investigated the diagnostic value of GCS to identify severe TBI in multiple-injured patients. The records of 18,002 severely injured adult (ISS >16) patients from the Trauma Register of the German Society for Trauma Surgery were analyzed and initial GCS and Abbreviated Injury Scale (head) (AIS(head)) were recorded. A severe TBI was defined by an AIS(head) ≥ 3. On the other hand, unconsciousness was defined by an initial GCS ≤ 8. By these criteria, 6546 patients (36.3%) were unconscious, and 8746 patients (48.6%) had severe TBI. Nine percent of all cases (n=1643) had a GCS ≤ 8 without severe TBI. Only 56.1% of patients with severe TBI (n=4903) had been unconscious. Decreasing levels of unconsciousness (as defined by GCS) showed consistent rising prevalence of severe TBI (correlation coefficient r=-0.52). Approximately 20% of all multiple-injured patients arriving in the emergency department with an initial GCS of 15 had severe TBI (AIS(head) ≥ 3). The diagnostic value of GCS ≤ 8 for severe TBI in patients with multiple injuries has low sensitivity (56.1%) but higher specificity (82.2%). Our study indicates that the GCS (as defined ≤ 8) in unconsciousness patients with multiple injuries shows only a moderate correlation with the diagnosis of severe TBI. Nevertheless, the main reason for unconsciousness in patients with multiple injuries is TBI, since only 9% of these patients had another reason for unconsciousness. However, due to the poor sensitivity of GCS, we suggest the use of the anatomical scoring system with AIS(head) ≥ 3 to define severe TBI in patients with multiple injuries.