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Limitations of the Glasgow Coma Scale in predicting outcome in children with traumatic brain injury
M W Lieh-Lai1, A A Theodorou, A P Sarnaik
1Division of Pediatric Neurosurgery, Children's Hospital of Michigan, Detroit 48201.
Insights
Severe traumatic brain injury in children can have good outcomes even with low Glasgow Coma Scale scores, provided there is no hypoxic-ischemic injury. Aggressive management ensures many children with severe TBI and low scores achieve independent function.
Area of Science:
- Pediatric critical care medicine
- Neurotraumatology
- Pediatric neurology
Background:
- Severe traumatic brain injury (TBI) in children often leads to poor prognoses.
- The Glasgow Coma Scale (GCS) is a common tool for assessing TBI severity and predicting outcomes.
- However, the predictive accuracy of GCS in the absence of secondary insults like hypoxia requires further investigation.
Purpose of the Study:
- To test the hypothesis that children with severe TBI and low GCS scores can achieve good recovery without ischemic-hypoxic conditions.
- To evaluate the relationship between initial GCS scores and functional outcomes in pediatric TBI patients.
Main Methods:
- Retrospective, observational, cross-sectional study of 79 children admitted to a university hospital's intensive care unit with TBI.
- Patients underwent intensive monitoring with controlled intracranial pressure (<20 mm Hg) and cerebral perfusion pressure (>60 mm Hg).
Main Results:
- 89% of the 79 children survived.
- Among children with GCS scores of 3-5, 14 out of 22 (64%) survived.
- Most survivors, including those with initial GCS scores of 3-5, achieved satisfactory functional outcomes (GCS scores of 4 or 5) and comparable neuropsychological results to those with higher initial GCS scores, provided no prolonged hypoxemia occurred.
Conclusions:
- Low GCS scores do not invariably predict poor outcomes in pediatric severe TBI.
- In the absence of hypoxic-ischemic injury, children with severe TBI and low GCS scores (3-5) can achieve independent functional recovery.
- Aggressive management of intracranial and cerebral perfusion pressures is crucial for favorable outcomes.
Objective:
To study the hypothesis that, in the absence of an ischemic-hypoxic state, children with severe traumatic brain injury and with unfavorable Glasgow Coma Scale scores may have good recovery.
Design:
Retrospective, observational, cross-sectional study with factorial design.
Setting:
Inpatient population in a university hospital.
Patients:
Seventy-nine children with traumatic brain injury admitted to the intensive care unit.
Interventions:
All patients received close monitoring and strict control of intracranial pressure (less than 20 mm Hg) and cerebral perfusion pressure (greater than 60 mm Hg).
Measurements And Results:
Admission Glasgow Coma Scale score, survival, need for cardiopulmonary resuscitation, presence of shock, peak intracranial pressure, duration of coma, Glasgow Outcome Scale score, and the results of neuropsychologic tests were analyzed. Of 79 children, 70 (89%) survived. Although the mortality rate was higher among patients with Glasgow Coma Scale scores of 3 to 5, 14 (64%) of 22 of these children survived. Nonsurvivors had a significantly higher incidence of shock and need for cardiopulmonary resuscitation. Except for two patients who had prolonged hypoxemia, all children, including those with Glasgow Coma Scale scores of 3 to 5, had a satisfactory outcome (Glasgow Outcome Scale scores of 4 or 5). Neuropsychologic outcome was not significantly different in the survivors with Glasgow Coma Scale scores of 3 to 5 and those with Glasgow Coma Scale scores of 6 or more.
Conclusions:
A low Glasgow Coma Scale score does not always accurately predict the outcome of severe traumatic brain injury; in the absence of hypoxic-ischemic injury, children with traumatic brain injury and Glasgow Coma Scale scores of 3 to 5 can recover independent function.