Glasgow Coma Scale in traumatic brain injury

Even 30 years after its first publication the Glasgow Coma Scale (GCS) is still used worldwide to describe and assess coma. The GCS consists of three components, the ocular, motor and verbal response to standardized stimulation, and is used as a severity of illness indicator for coma of various origins. The GCS facilitates information transfer and monitoring changes in coma. In addition, it is used as a triage tool in patients with traumatic brain injury. Its prognostic value regarding the outcome after a traumatic brain injury still lacks evidence. One of the main problems is the evaluation of the GCS in sedated, paralysed and/or intubated patients. A multitude of pseudoscores exists but a universal definition has yet to be defined.     

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.     

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.     

Utility of Glasgow Coma Scale-Extended in symptom prediction following mild traumatic brain injury

Study objective: To examine the efficacy of the Glasgow Coma Scale-Extended (GCS-E) for the prediction of symptoms commonly associated with mild traumatic brain injury (TBI).

Method: Three hundred and sixty-one participants with a mild TBI were evaluated using the GCS-E and the Standardized Assessment of Concussion. A sub-group of 185 participants took part in a more extensive evaluation, which also included measures of depression and vestibular symptoms. All participants had a Glasgow Coma Scale score of 15, but experienced varying lengths of post-traumatic amnesia (PTA) as measured by the GCS-E.

Results: Use of the GCS-E for assessment of PTA duration revealed that longer lengths of amnesia following mild TBI were associated with greater incidence of dizziness, depression and cognitive impairments during the first weeks after injury.

Conclusion: Results suggest that the GCS-E is a useful tool for the prediction of symptoms associated with mild TBI.     

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.

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.     

Classification of a traumatic brain injury: the Glasgow Coma scale is not enough

Background: Classifying the severity of a traumatic brain injury (TBI) solely by means of the Glasgow Coma scale (GCS) is under scrutiny, because it overlooks other important clinical signs. Clinicians treating patients with acute TBI are well placed to suggest which variables, in addition to the GCS, should concur in a new classification of TBI. Methods: In Italy, acute TBI patients are treated by anaesthetists, and so we asked them, in a questionnaire survey, to rate the weight they give to the GCS and to other clinical variables in their approach to TBI. Because sedation may underestimate GCS scores, we also inquired whether anaesthetists select sedatives that allow drug‐free GCS scores. The questionnaire was distributed to 1334 anaesthetists attending courses on neurotrauma; the response rate was 63%. Results: Two thirds of the respondents believe that the definition of severe TBI should include, in addition to GCS scores, pupil reactivity to light and computer tomogram (CT) findings, the variables that guide Italian anaesthetists in TBI management. Most respondents (68.2%) administer sedation which allows prompt neurological evaluation and reliable GCS scoring. A minority of respondents (9.3%) withhold or antagonize sedation, delay tracheal intubation or allow patient–ventilator asynchrony. Conclusions: Italian anaesthetists would welcome a definition of TBI severity that includes CT findings and pupil reactivity in addition to the GCS.     

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.     

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.

The predictive value of field versus arrival Glasgow Coma Scale score and TRISS calculations in moderate-to-severe traumatic brain injury

BACKGROUND: Glasgow Coma Scale (GCS) scores are widely used to quantify level of consciousness in the prehospital environment. The predictive value of field versus arrival GCS is not well defined but has tremendous implications with regard to triage and therapeutic decisions as well as the use of various predictive scoring systems, such as Trauma Score and Injury Severity Score (TRISS). This study explores the predictive value of field GCS (fGCS) and arrival GCS (aGCS) as well as TRISS calculations using field (fTRISS) and arrival (aTRISS) data in patients with moderate-to-severe traumatic brain injury (TBI). METHODS: Major trauma victims with head Abbreviated Injury Scores of 3 or greater were identified from our county trauma registry over a 16-year period. The predictive ability of fGCS with regard to aGCS was explored using univariate statistics and linear regression modeling. The difference between aGCS and fGCS was also modeled against mortality and the composite endpoint using logistic regression, adjusting for fGCS. The predictive value of preadmission GCS (pGCS), defined as either fGCS or aGCS in nonintubated patients without a documented fGCS, with regard to mortality and a composite endpoint representing the need for neurosurgical care (death, craniotomy, invasive intracranial pressure monitoring, or intensive care unit care >48 hours) was determined using receiver-operator curve (ROC) analysis. Finally, fTRISS and aTRISS predicted survival values were compared with each other and to observed survival. RESULTS: A total of 12,882 patients were included. Mean values for fGCS and aGCS were similar (11.4 and 11.5, respectively, p = 0.336), and a strong correlation (r = 0.67, 95% CI 0.66-0.69, p < 0.0001) was observed between them. The difference between fGCS and aGCS was also predictive of outcome after adjusting for fGCS. Good predictive ability was observed for pGCS with regard to both mortality and neurosurgical intervention. Both fTRISS and aTRISS predicted survival values were nearly identical to observed survival. Observed and fTRISS predicted survival were nearly identical in patients undergoing prehospital intubation CONCLUSIONS: Values for fGCS are highly predictive of aGCS, and both are associated with outcome from TBI. A change in GCS from the field to arrival is highly predictive of outcome. The use of field data for TRISS calculations appears to be a valid methodological approach, even in severely injured TBI patients undergoing prehospital intubation.     

Comparison of the New Injury Severity Score and the Injury Severity Score

BACKGROUND: The New Injury Severity Score (NISS) was proposed in 1997 to replace the Injury Severity Score (ISS) because it is more sensitive for mortality. We aim to test whether this is true in our patients. METHODS: This study was a retrospective review of data from 6,231 consecutive patients over 3 years in the trauma registry of a Level I trauma center studying outcome, ISS, and NISS. RESULTS: Misclassification rates were 3.97% for the NISS and 4.35% for the ISS. The receiver operating characteristic curve areas were 0.936 and 0.94, respectively. Neither the ISS nor the NISS were well calibrated (Hosmer-Lemeshow statistic, 36.11 and 49.28, respectively; p < 0.001). CONCLUSION: The NISS should not replace the ISS, as they share similar accuracy and calibration.     

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.     

Glasgow Coma Scale score at intensive care unit discharge predicts the 1-year outcome of patients with severe traumatic brain injury

Objective

To analyse the association between the Glasgow Coma Scale (GCS) score at intensive care unit (ICU) discharge and the 1-year outcome of patients with severe traumatic brain injury (TBI).

Design

Retrospective analysis of prospectively collected observational data.

Patients

Between 01/2001 and 12/2005, 13 European centres enrolled 1,172 patients with severe TBI. Data on accident, treatment and outcomes were collected. According to the GCS score at ICU discharge, survivors were classified into four groups: GCS scores 3–6, 7–9, 10–12 and 13–15. Using the Glasgow Outcome Scale (GOS), 1-year outcomes were classified as “favourable” (scores 5, 4) or “unfavourable” (scores <4). Factors that may have contributed to outcomes were compared between groups and for favourable versus unfavourable outcomes within each group.

Main results

Of the 538 patients analysed, 308 (57 %) had GCS scores 13–15, 101 (19 %) had scores 10–12, 46 (9 %) had scores 7–9 and 83 (15 %) had scores 3–6 at ICU discharge. Factors significantly associated with these GCS scores included age, severity of trauma, neurological status (GCS, pupils) at admission and patency of the basal cisterns on the first computed tomography (CT) scan. Favourable outcome was achieved in 74 % of all patients; the rates were significantly different between GCS groups (93, 83, 37 and 10 %, respectively). Within each of the GCS groups, significant differences regarding age and trauma severity were found between patients with favourable versus unfavourable outcomes; neurological status at admission and CT findings were not relevant.

Conclusion

The GCS score at ICU discharge is a good predictor of 1-year outcome. Patients with a GCS score <10 at ICU discharge have a poor chance of favourable outcome.     

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.     

Serum neuron-specific enolase as a predictor of short-term outcome and its correlation with Glasgow Coma Scale in traumatic brain injury

Elevated serum neuron-specific enolase levels are correlated with brain cell damage. Low scores according to Glasgow Coma Scale are also considered as serious poor prognostic factor. The aims of the study were to investigate whether there is a correlation between the two measurements in patients with traumatic brain injury and whether serum neuron-specific enolase levels have potential as a screening test to predict outcome. A total of 169 consecutive patients with traumatic brain injury admitted to our clinic between 2002 and 2005 are included in this study. Those patients, who had any major health problem before trauma, were excluded from the study. However, patients with isolated head injury were included in the study. Serial serum neuron-specific enolase concentrations taken at the first 2, 24, and 48 h after traumatic brain injury were analyzed. A computed tomography was performed on each patient on admission. Their Glasgow Coma Scale scores were recorded serially. The relationship between Glasgow Coma Scale scores and the serum neuron-specific enolase levels were assessed by statistical methods. There was a significant negative correlation between the serum neuron-specific enolase levels and Glasgow Coma Scale scores. The levels of neuron-specific enolase were significantly higher in the patients who died in 30 days after trauma and whose scores were lower than or equal to 8 points in Glasgow Coma Scale. Although there are several serious limitations of the use of neuron-specific enolase as a biomarker in traumatic brain injury (i.e., hypoperfusion, extracranial trauma, bleeding, liver, or kidney damage also increase the level of neuron-specific enolase), its concentrations may be useful as a practical and helpful screening test to identify neurotrauma patients who are at increased risk and may provide supplementary estimation with radiological and clinical findings.     

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.