The relationship of Injury Severity Score and Glasgow Coma Score to rehabilitative potential in patients suffering traumatic brain injury

The predictive utility of the Injury Severity Score (ISS) and Glasgow Coma Score (GCS) in relation to rehabilitative potential and functional outcome in traumatic brain injury (TBI) is untested. The purpose of this study was to define the relationship of ISS and GCS to rehabilitative potential using the functional independence measure (FIM) score. Trauma and inpatient rehabilitation (IR) registries were queried for demographic, disposition, and injury scoring data. FIM scores at admission (A) and discharge (D) were assessed including IR FIM gain (G). Analysis of variance was used to examine the relationship of ISS and GCS to FIM with predictive utility investigated through bivariate analysis. Of 5488 patients admitted to a Level I trauma center (1999-2000) 1437 suffered TBI with 285 (20%) entering IR. Compared with low-ISS patients the high-ISS patients had significantly lower FIM-A and FIM-D, but FIM-G was static. GCS results were similar, excluding FIM-G which was significantly higher for GCS < or = 8 compared with GCS > 8. Bivariate analysis revealed no ISS correlation with FIM-G (r = 0.16) and a weak GCS correlation (FIM-G r = -0.15). As prospective predictive measures ISS and GCS correlate weakly with rehabilitative potential in TBI patients. Severely injured patients including those with severe TBI have a rehabilitative gain toward functional independence that is similar to that of when compared with those less severely injured.     

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.     

Mortality prediction of head Abbreviated Injury Score and Glasgow Coma Scale: analysis of 7,764 head injuries

BACKGROUND: We assessed the prognostic value and limitations of Glasgow Coma Scale (GCS) and head Abbreviated Injury Score (AIS) and correlated head AIS with GCS. STUDY DESIGN: We studied 7,764 patients with head injuries. Bivariate analysis was performed to examine the relationship of GCS, head AIS, age, gender, and mechanism of injury with mortality. Stepwise logistic regression analysis was used to identify the independent risk factors associated with mortality. RESULTS: The overall mortality in the group of head injury patients with no other major extracranial injuries and no hypotension on admission was 9.3%. Logistic regression analysis identified head AIS, GCS, age, and mechanism of injury as significant independent risk factors of death. The prognostic value of GCS and head AIS was significantly affected by the mechanism of injury and the age of the patient. Patients with similar GCS or head AIS but different mechanisms of injury or ages had significantly different outcomes. The adjusted odds ratio of death in penetrating trauma was 5.2 (3.9, 7.0), p < 0.0001, and in the age group > or = 55 years the adjusted odds ratio was 3.4 (2.6, 4.6), p < 0.0001. There was no correlation between head AIS and GCS (correlation coefficient -0.31). CONCLUSIONS: Mechanism of injury and age have a major effect in the predictive value of GCS and head AIS. There is no good correlation between GCS and head AIS.     

Reliability of Glasgow Coma Score in pediatric trauma patients

Background

Discordant assessments of Glasgow Coma Score (GCS) following trauma can result in inappropriate triage. This study sought to determine the reliability of prehospital GCS compared to emergency department (ED) GCS.

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.     

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.     

Factors influencing pediatric Injury Severity Score and Glasgow Coma Scale in pediatric automobile crashes: results from the Crash Injury Research Engineering Network

Background/Purpose

Motor vehicle crashes account for more than 50% of pediatric injuries. Triage of pediatric patients to appropriate centers can be based on the crash/injury characteristics. Pediatric motor vehicle crash/injury characteristics can be determined from an in vitro laboratory using child crash dummies. However, to date, no detailed data with respect to outcomes and crash mechanism have been presented with a pediatric in vivo model.

Methods

The Crash Injury Research Engineering Network is comprised of 10 level 1 trauma centers. Crashes were examined with regard to age, crash severity (ΔV), crash direction, restraint use, and airbag deployment. Multiple logistic regression analysis was performed with Injury Severity Score (ISS) and Glasgow Coma Scale (GCS) as outcomes. Standard age groupings (0-4, 5-9, 10-14, and 15-18) were used. The database is biases toward a survivor population with few fatalities.

Results

Four hundred sixty-one motor vehicle crashes with 2500 injuries were analyzed (242 boys, 219 girls). Irrespective of age, ΔV > 30 mph resulted in increased ISS and decreased GCS (eg, for 0-4 years, ΔV < 30: ISS = 10, GCS = 13.5 vs ΔV > 30: ISS = 19.5, GCS = 10.6; P < .007, < .002, respectively). Controlling for ΔV, children in lateral crashes had increased ISS and decreased GCS versus those in frontal crashes. Airbag deployment was protective for children 15 to 18 years old and resulted in a lower ISS and higher GCS (odds ratio, 2.1; 95% confidence interval, 0.9-4.6). Front-seat passengers suffered more severe (ISS > 15) injuries than did backseat passengers (odds ratio, 1.7; 95% confidence interval, 0.7-3.4). A trend was noted for children younger than 12 years sitting in the front seat to have increased ISS and decreased GCS with airbag deployment but was limited by case number.

Conclusion

A reproducible pattern of increased ISS and lower GCS characterized by high severity, lateral crashes in children was noted. Further analysis of the specific injuries as a function and the crash characteristic can help guide management and prevention strategies.     

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.     

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.     

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.     

Usefulness of the abbreviated injury score and the injury severity score in comparison to the Glasgow Coma Scale in predicting outcome after traumatic brain injury

BACKGROUND: Assessment of injury severity is important in the management of patients with brain trauma. We aimed to analyze the usefulness of the head abbreviated injury score (AIS), the injury severity score (ISS), and the Glasgow Coma Scale (GCS) as measures of injury severity and predictors of outcome after traumatic brain injury (TBI). METHODS: Data were prospectively collected from 410 patients with TBI. AIS, ISS, and GCS were recorded at admission. Subjects' outcomes after TBI were measured using the Glasgow Outcome Scale (GOS-E) at 12 months postinjury. Uni- and multivariate analyses were performed. RESULTS: Outcome information was obtained from 270 patients (66%). ISS was the best predictor of GOS-E (rs = -0.341, p < 0.001), followed by GCS score (rs = 0.227, p < 0.001), and head AIS (rs = -0.222, p < 0.001). When considered in combination, GCS score and ISS modestly improved the correlation with GOS-E (R = 0.335, p < 0.001). The combination of GCS score and head AIS had a similar effect (R = 0.275, p < 0.001). Correlations were stronger from patients 8). CONCLUSIONS: GCS score, AIS, and ISS are weakly correlated with 12-month outcome. However, anatomic measures modestly outperform GCS as predictors of GOS-E. The combination of GCS and AIS/ISS correlate with outcome better than do any of the three measures alone. Results support the addition of anatomic measures such as AIS and ISS in clinical studies of TBI. Additionally, most of the variance in outcome is not accounted for by currently available measures of injury severity.     

Median nerve somatosensory evoked potentials and the Glasgow Coma Scale as predictors of outcome in comatose patients with head injuries

Median nerve somatosensory evoked potential (SSEP) grades and Glasgow Coma Scale (GSC) scores were obtained from 51 patients with head injuries within 1 week after the injury to determine the relationship of these scores, both individually and combined, to outcome scores obtained more than 6 months after the injury. SSEP grading was based on the presence or absence of the cortical evoked potential, the amplitude of the early cortically generated P22 wave form, and the conduction time through the brain (P/N13-N20 interpeak latency). SSEP responses from both sides of the brain were combined and graded from 1 to 6. The GCS was graded without the verbal component (maximum score, 10), because all patients were intubated. All patients were unresponsive to commands. Median SSEP grades correlated better with Glasgow Outcome Scale and Barthel Index scores (R = 0.57 and 0.64, respectively; P less than 0.00001) than GCS scores did (R = 0.35 and 0.37, respectively, P less than 0.00001), and combining SSEP grades and GCS scores did not improve the predictive power of the model (R = 0.57 and 0.64, respectively; P less than 0.00001). All SSEP Grade 1 patients (n = 13) either died or remained in a vegetative state. In contrast, all SSEP Grade 6 patients (n = 7) had a moderate disability or good recovery. This study demonstrates the prognostic value of early quantitative median nerve SSEP grading for patients with head injuries who are unresponsive to commands within 1 week after the injury.     

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.

Use of admission Glasgow Coma Score, pupil size, and pupil reactivity to determine outcome for trauma patients

BACKGROUND: Determination of nonsurvival in trauma patients is difficult because valid prognostic indicators are lacking. It was hypothesized that patients presenting with a Glasgow Coma Score (GCS) of 3 as well as fixed and dilated (FD) pupils do not have a reasonable chance of survival. METHODS: From 1999 through 2001, adult trauma patients (age, >14 years) admitted with a GCS of 3 were reviewed. Patients receiving paralytic agents before initial assessment were excluded from analysis. Fixed and dilated pupils were defined as being 4 mm or more in diameter bilaterally and nonreactive to light. In this study, the FD patients were evaluated for survival, resuscitative measures, surgical procedures, length of hospital stay, and organ donation. The non-FD patients were evaluated for survival and length of hospital stay. RESULTS: Of the 137 patients evaluated with a GCS of 3, 104 had FD pupils and 33 did not. In the FD group, there were no survivors. On arrival, 28 (37.3%) of the patients were declared dead, and no further interventions were undertaken. Of the 76 patients (62.7%) who underwent further resuscitation, which included 53 surgical procedures, 30 died in the resuscitation bay, 39 within 24 hours, 4 within 48 hours, 2 within 72 hours, and 1 on day 6. There were 18 (23.7%) organ donors. Of the 33 patients without FD pupils, 11 (33%) survived to discharge (mean hospital stay, 21.4 days). Of the 22 nonsurvivors (67%), 10 died in the resuscitation bay, 8 within 24 hours, 1 within 48 hours, 1 on day 4, and 2 on day 6. CONCLUSIONS: Patients presenting with a GCS of 3 and FD pupils have no reasonable chance for survival. A significant percentage of these patients can be salvaged for organ donation. This information should be used in deciding to pursue aggressive resuscitation efforts and in discussing prognosis with family. Patients with a GCS of 3 who are not FD should be aggressively resuscitated because many of these patients survive to discharge.     

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.     

Abbreviated Injury Scale and Injury Severity Score: a scoring chart

The Abbreviated Injury Scale and the Injury Severity Score are important tools for grading the severity of injury to trauma patients. The Trauma Chart provided is a simple and concise guide for scoring and recording this useful information. The chart is useful in both a large wall-mounted form and in the reduced two-page form included in this article.     

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.     

Early prediction of outcome following head injury in children: an assessment of the value of Glasgow Coma Scale score trend and abnormal plantar and pupillary light reflexes.

A retrospective study of 95 children less than 15 years of age with significant head injury was made to assess the value of Glasgow Coma Scale (GCS) score trend and plantar and pupillary light reflexes during the first 24 hours after injury, in predicting eventual outcome. GCS score trend or reflexes used alone were significantly correlated to outcome. There was also a statistically significant correlation when these parameters in combination were related to outcome. However, the clinical value of the combined use of GCS score trend and reflexes was only slightly greater than the use of GCS score trend alone.     

Post-traumatic amnesia and Glasgow Coma Scale related to outcome in survivors in a consecutive series of patients with severe closed-head injury

A consecutive series of 93 severe closed-head injury (SCHI) patients, discharged from hospital in a conscious state, were rated on the Glasgow Outcome Scale at 6 and 12 months post-injury. Patients were included in this study if they had a period of post-traumatic amnesia (PTA) exceeding 24 h. Approximately 80% of patients had made a good recovery by 12 months post-injury; a better outcome than has been found in studies using the presence of coma during the first 6 h post-admission to hospital to define severe head injury. When analysed individually, duration of PTA and Glasgow Coma Scale scores on admission to hospital were both strongly correlated with outcome. Only duration of PTA, however, contributed significantly to outcome variance when potential outcome predictors were assessed using a stepwise multiple regression analysis. The definition of severe head injury, the higher than usual incidence of good recovery in the present study, and the relationship between injury severity and outcome are discussed.