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Published on: November 9, 2018
Performance of the Pediatric Glasgow Coma Scale Score in the Evaluation of Children With Blunt Head Trauma
Dominic A Borgialli1,2, Prashant Mahajan3, John D Hoyle4,5
1Department of Emergency Medicine, Hurley Medical Center, Flint, MI.
Insights
The pediatric Glasgow Coma Scale (GCS) is less accurate for detecting traumatic brain injuries (TBIs) on CT scans in preverbal children compared to older children. However, both scales show equal accuracy in identifying clinically important TBIs (ciTBIs).
Area of Science:
- Pediatric Emergency Medicine
- Neurotrauma
- Clinical Assessment Tools
Background:
- Traumatic brain injuries (TBIs) are a significant concern in pediatric blunt head trauma.
- Accurate and timely assessment of TBI severity is crucial for appropriate management.
- The standard Glasgow Coma Scale (GCS) is widely used, but its application in preverbal children requires adaptation (pediatric GCS).
Purpose of the Study:
- To compare the diagnostic accuracy of the pediatric GCS in preverbal children (<2 years) versus the standard GCS in older children (≥2 years).
- To evaluate the effectiveness of these scales in identifying traumatic brain injuries (TBIs) and clinically important TBIs (ciTBIs) following blunt head trauma.
Main Methods:
- Secondary analysis of a prospective, observational, multicenter cohort study involving 42,041 children with blunt head trauma.
- Pediatric GCS applied to children <2 years; standard GCS applied to children ≥2 years.
- Outcomes included TBI visible on CT and clinically important TBI (ciTBI); accuracy assessed using receiver operating characteristic (ROC) curves.
Main Results:
- The pediatric GCS demonstrated lower accuracy (Area Under Curve [AUC] 0.61 for TBI on CT) compared to the standard GCS (AUC 0.71 for TBI on CT) in children <2 years.
- For clinically important TBIs (ciTBI), the pediatric GCS (AUC 0.77) and standard GCS (AUC 0.81) showed comparable accuracy between the age groups.
- A significant proportion of patients <2 years (9.4%) and ≥2 years (6.5%) had TBIs on CT.
Conclusions:
- The pediatric GCS is less accurate than the standard GCS for detecting TBI on CT scans in preverbal children.
- Both the pediatric GCS and standard GCS exhibit similar accuracy in identifying clinically important TBIs (ciTBIs) in their respective age groups.
- Further refinement of TBI assessment tools for preverbal children may be warranted.
Objective:
The objective was to compare the accuracy of the pediatric Glasgow Coma Scale (GCS) score in preverbal children to the standard GCS score in older children for identifying those with traumatic brain injuries (TBIs) after blunt head trauma.
Methods:
This was a planned secondary analysis of a large prospective observational multicenter cohort study of children with blunt head trauma. Clinical data were recorded onto case report forms before computed tomography (CT) results or clinical outcomes were known. The total and component GCS scores were assigned by the physician at initial emergency department evaluation. The pediatric GCS was used for children <2 years old and the standard GCS for those ≥2 years old. Outcomes were TBI visible on CT and clinically important TBI (ciTBI), defined as death from TBI, neurosurgery, intubation for more than 24 hours for the head injury, or hospitalization for 2 or more nights for the head injury in association with TBI on CT. We compared the areas under the receiver operating characteristic (ROC) curves between age cohorts for the association of GCS and the TBI outcomes.
Results:
We enrolled 42,041 patients, of whom 10,499 (25.0%) were <2 years old. Among patients <2 years, 313/3,329 (9.4%, 95% confidence interval [CI] = 8.4% to 10.4%) of those imaged had TBIs on CT and 146/10,499 (1.4%, 95% CI = 1.2% to 1.6%) had ciTBIs. In patients ≥2 years, 773/11,977 (6.5%, 95% CI = 6.0% to 6.9%) of those imaged had TBIs on CT and 572/31,542 (1.8%, 95% CI = 1.7% to 2.0%) had ciTBIs. For the pediatric GCS in children <2 years old, the area under the ROC curve was 0.61 (95% CI = 0.59 to 0.64) for TBI on CT and 0.77 (95% CI = 0.73 to 0.81) for ciTBI. For the standard GCS in older children, the area under the ROC curve was 0.71 (95% CI = 0.70 to 0.73) for TBI on CT scan and 0.81 (95% CI = 0.79 to 0.83) for ciTBI.
Conclusions:
The pediatric GCS for preverbal children was somewhat less accurate than the standard GCS for older children in identifying those with TBI on CT. However, the pediatric GCS for preverbal children and the standard GCS for older children were equally accurate for identifying ciTBI.
