Glasgow Coma Scale matters for children with head trauma

In emergency medicine, the Glasgow Coma Scale (GCS) serves as a crucial tool for assessing the consciousness level of patients with head injuries. But how reliable is the GCS in determining the need for head imaging or neurosurgical intervention in children? A groundbreaking study by Johnson, Nishijima, and Kuppermann examines the link between GCS scores and the occurrence of clinically important traumatic brain injuries (ciTBIs) in pediatric patients following blunt head trauma [1].

Study question

Does the patient’s GCS on arrival to the ED correlate with the need for neurosurgery or clinically important traumatic brain injuries (ciTBIs)?

Study design

The authors used a 2004-2006 dataset from the Pediatric Emergency Care Applied Research Network (PECARN) of more than 40,000 children under 18 years presenting to 25 pediatric emergency departments (EDs) with nontrivial blunt head trauma. In the parent study, data were collected by ED clinicians, including a comprehensive history and physical examination, plus documentation of GCS scores used to categorize trauma severity. In this secondary analysis they looked at ciTBI and the need for neurosurgical intervention in all patients with a documented GCS.

PECARN defines a ciTBI as an injury resulting from blunt trauma to the head that leads to any of the following:

  1. Death from the brain injury
  2. Neurosurgical intervention (such as craniotomy, intracranial pressure monitoring)
  3. Intubation for more than 24 hours due to the head injury
  4. Hospitalization for two or more nights [2]

Result

  • ciTBIs was rare (1.8%) and neurosurgery even less frequent (0.05%).
  • Most children (98.5%) had initial ED GCS scores between 13 to 15. 
  • The lower the GCS score, the higher the frequency of ciTBIs and neurosurgical interventions. 
  • Children with a GCS score of 4 had the highest incidence of ciTBIs (95.5%) and neurosurgical interventions (72.2%).
  • Conversely, children with a GCS score of 15 had the lowest incidence of ciTBIs (0.7%) and a minimal rate of neurosurgical interventions (0.1%).
  • There was a nearly linear decrease in the frequency of ciTBI as GCS scores improved from 4 to 15.
  • Children with GCS scores of 14 still showed a significant prevalence of ciTBIs (8.0%) and some required neurosurgical interventions (1.3%).

Caution

  • Variability in GCS Score Assessment: GCS scores were determined by ED physicians post-arrival, which could differ from assessments made by prehospital providers. This variability may impact the study’s applicability to prehospital settings and the overall accuracy of ciTBI and neurosurgical intervention predictions.
  • Definition of ciTBI: The study’s ciTBI criteria, based on expert consensus from the PECARN study, lack direct correlation with long-term neurological outcomes. This gap could affect the utility of the study’s findings in predicting long-term recovery and outcomes.

Despite these limitations, the study offers valuable insights into the relationship between initial GCS scores and the incidence of ciTBIs and neurosurgical interventions, underscoring the GCS score’s potential utility in clinical decision-making for pediatric head trauma. It emphasizes the need for further research, including how GCS scores might be integrated into broader clinical assessments and triage algorithms, particularly in the context of long-term patient outcomes.

Take home messages

  1. The GCS predicts clinically important traumatic brain injuries and the need for neurosurgical intervention. The lower the GCS the more likely the patient will need interventions.
  2. For GCS less than 14: Imaging is warranted.
  3. For GCS=14: Because 8% of children were found to have ciTBIs, strongly consider imaging or transfer to a pediatric trauma center.

Why is this important for patients and caregivers

  • Doctors and caregivers need to identify which children with head injuries need to have brain imaging done, like a head CT or MRI. Imaging comes with risks to the patient and can be expensive. We examined cases from 25 hospitals to see if a commonly used score evaluating a child’s mental condition could predict the severity of head injuries. Their findings showed that children with lower (poorer) scores are more likely to have a serious head injury. This helps doctors know which patients may require imaging.

References

  1. Johnson M, Nishijima D, Kuppermann N. The Association of Glasgow Coma Scale Score With Clinically Important Traumatic Brain Injuries in Children. Pediatric Emergency Care. 2020; 36 (11): e610-e613. doi: 10.1097/PEC.0000000000001701.
  2. Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374:1160–1170. doi: 10.1016/S0140-6736(09)61558-0

Julia Magaña, Associate Professor of Emergency Medicine

Julia Magaña, Associate Professor of Emergency Medicine

University of California, Davis

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