Elsevier

Injury

Volume 42, Issue 9, September 2011, Pages 940-944
Injury

Correlation between Glasgow coma score components and survival in patients with traumatic brain injury

https://doi.org/10.1016/j.injury.2010.09.019Get rights and content

Abstract

Background

The Glasgow coma scale (GCS) score is used in the initial evaluation of patients with traumatic brain injury (TBI); however, the determination of an accurate score is not possible in all clinical situations. Our aim is to determine if the individual components of the GCS score, or combinations of them, are useful in predicting mortality in patients with TBI.

Methods

The components of the GCS score and the receiver-operating characteristic (ROC) curves were analyzed from 27,625 cases of TBI in Taiwan.

Results

The relationship between the survival rate and certain eye (E), motor (M) and verbal (V) score combinations for GCS scores of 6, 11, 12 and 13 were statistically significant. The areas under ROC curve of E + V, M + V and M alone were 0.904, 0.903 and 0.900, respectively, representing the 3 most precise combinations for predicting mortality. The area under the ROC curve for the complete GCS score (E + M + V) was 0.885. Patients with lower E, M and V score respectively, and lower complete GCS scores had higher hazard of death than those with the highest scores.

Conclusion

The results of this study indicate that the 3 fundamental elements comprising the Glasgow coma scale, E, M, and V individually, and in certain combinations are predictive of the survival of TBI patients. This observation is clinically useful when evaluating TBI patients in whom a complete GCS score cannot be obtained.

Introduction

The Glasgow coma scale (GCS) has been universally established as a common diagnostic tool to evaluate the consciousness, clinical status, as well as the prognosis of traumatic brain injury (TBI) patients.1, 9, 16 The GCS score is based on the simple addition of the 3 components evaluated, eye (E), motor (M) and verbal (V). Multiple studies have reported the predictive value of the GCS, alone or in combination with other clinical factors, in determining the outcomes of patients who have sustained brain injury.7, 8, 10, 13 Though the score is useful in the evaluation of TBI patients, an accurate and complete GCS score is difficult to obtain in many situations, e.g., if the patient is intubated or they have excessive swelling of the eyelids, thus decreasing the ability of physicians to provide appropriate care. A simplified assessment system using fewer parameters for predicting survival of TBI patients may make training of medical professionals easier, lead to less variability in reporting, and allow more accurate assessment across a broader range of clinical scenarios. Thus, many authors have recognised the limitations of the GCS and have sought to improve its functionality and simplify its use.3, 4, 11 A report by Healey et al.5 suggested that the motor component of the GCS contains all of the information of the complete score, and the authors recommended using the motor score alone in outcome prediction models.

TBI accounts for 12.5% of all the traumatic injuries in Taiwan, and the mortality rate of the patients with moderate to severe TBI is as high as 35%. Data of patients who died from traumas indicate that 55% of deaths were caused by TBI. The Head Injury Registry is an electronic database of TBI cases in Taiwan, archived by the Injury Prevention Center at Taipei Medical University, and supported by the Department of Health. This registry provides a valuable resource for research into the causes and outcomes of TBI.

In this retrospective study we sought to determine the association of individual GCS component scores, and combinations of the scores, as predictors of mortality in TBI patients by reviewing the records of TBI cases archived in the Head Injury Registry.

Section snippets

TBI subject inclusion and exclusion criteria

A TBI patient was defined as a patient who, after having received direct or indirect trauma to the head, exhibited brain concussion, contusion, skull fracture, or any of their clinical manifestations such as loss of consciousness, amnesia, neurological deficits, and seizures. Clinical evidence of skull fractures and intracranial hemorrhage, e.g., positive findings on radiographs or computed tomography (CT) were used to define the extent of TBI. In general, a patient with one or more of these

Results

Patient characteristics and E, M, V, and GCS scores are presented in Table 1. The mean ± standard deviation (SD) of age and E, M, V and GCS score were 41.6 ± 22.8, 3.6 ± 0.8, 5.6 ± 1.0, 4.4 ± 1.2, and 14.0 ± 2.9, respectively. Most of the subjects were males (63%) and had maximum E, M, V and GCS score (above 70%), and most injuries were sustained due to a traffic accident (54%) or fall (30%). Approximately 31% of subjects had an intracranial hemorrhage, and 11% had a skull bone fracture. The mortality rate

Discussion

Simplifying predictive models of survival in TBI has significant clinical utility. Accurate and complete GCS scores are difficult to obtain in many situations and a simplified assessment system using fewer parameters may make training of medical professionals easier, lead to less variability in reporting and more accurate patient assessments. In this large, retrospective study of TBI patients, we have found that combinations of the individual components of the GCS score, and even a single

Conclusion

The results of this study indicate that the 3 fundamental elements comprising the Glasgow coma scale, E, M and V, individually, and in certain combinations are predictive of the survival of TBI patients. This observation is clinically useful when evaluating TBI patients in whom a complete GCS score cannot be obtained.

Conflict of interest statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Acknowledgements

The author(s) disclosed receipt of the following financial support for the research and/or authorship of this article: National Health Research Institute, Taiwan (Grant No. NHRI-EX99-9707PI); Department of Health, Executive Yuan, Taiwan (Grant No. DOH99-TD-B-111-003).

References (16)

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