Predictive value of glasgow coma score and its components in interpreting outcome in trauma patients

V Anil Kumar; Prashant Bhandarkar; Nobhojit Roy; Vineet Kumar; Jyoti Kamble; Amit Agrawal

doi:10.4103/jdmimsu.jdmimsu_16_18

ORIGINAL ARTICLE

Year : 2019 | Volume : 14 | Issue : 2 | Page : 94-98

Predictive value of glasgow coma score and its components in interpreting outcome in trauma patients

V Anil Kumar¹, Prashant Bhandarkar², Nobhojit Roy³, Vineet Kumar⁴, Jyoti Kamble⁵, Amit Agrawal⁶
¹ Department of Anesthesia and Neurocritical Care, Narayana Medical College Hospital, Nellore, Andhra Pradesh, India
² Department of Statistics, Bhabha Atomic Research Centre, Mumbai, Maharashtra, India
³ Department of Surgery, Bhabha Atomic Research Centre, Mumbai, Maharashtra, India
⁴ Department of Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India
⁵ Department of Social Sciences, Tata Institute of Social Sciences, Mumbai, Maharashtra, India
⁶ Department of Neurosurgery, Narayana Medical College Hospital, Nellore, Andhra Pradesh, India

Date of Submission	23-Feb-2018
Date of Decision	18-Dec-2018
Date of Acceptance	05-Aug-2019
Date of Web Publication	25-Nov-2019

Correspondence Address:
Dr. Amit Agrawal
Department of Neurosurgery, Narayana Medical College Hospital, Chinthareddypalem, Nellore - 524 003, Andhra Pradesh
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/jdmimsu.jdmimsu_16_18

Abstract

Background: Glasgow coma score (GCS) are widely used as primary diagnostic tool in trauma cases. In literature study of GCS is seen to be addressed in specific trauma context such as traumatic brain injury, ischemic trauma, and neurotrauma. GCS score on admission is said to be associated with survival of trauma patients. Aims: This study aims to evaluate the efficacy of GCS and its components, eye, verbal, and motor response in all types of trauma in multicenter trauma database in India. Settings: Towards Improved Trauma Care Outcome (TITCO) registry conducted in four city government hospitals in India. Materials and Methods: TITCO database contains information of 16,047 patients, we included 13,836 patients with valid GCS and its components score in this study. The total GCS score is classified as mild (>12), moderate (9–12), and severe (<9). Logistic regression is applied considering GCS and components as independent with overall mortality as a dependent variable. Receivers operating characteristic (ROC) curve is drawn to evaluate the efficacy of GCS and components. Results: Compared to severe GCS score, moderate and mild GCS score is found to have better chances of survival with odds of 6.45 and 17.25, respectively. Similar results are found to be replicated in cases eye, verbal, and motor response. Motor component appeared as a better predictor than eye and verbal response. Area under the curve of ROC was 0.813, 0.775, 0.791, and 0.798 for GCS total, eye, verbal, and motor response, respectively. Conclusions: GCS and components are appeared as the best indicator of predicting overall mortality in all the trauma cases.

Keywords: Glasgow coma scale, Glasgow scale components, outcome

How to cite this article:
Kumar V A, Bhandarkar P, Roy N, Kumar V, Kamble J, Agrawal A. Predictive value of glasgow coma score and its components in interpreting outcome in trauma patients. J Datta Meghe Inst Med Sci Univ 2019;14:94-8

How to cite this URL:
Kumar V A, Bhandarkar P, Roy N, Kumar V, Kamble J, Agrawal A. Predictive value of glasgow coma score and its components in interpreting outcome in trauma patients. J Datta Meghe Inst Med Sci Univ [serial online] 2019 [cited 2023 Mar 28];14:94-8. Available from: http://www.journaldmims.com/text.asp?2019/14/2/94/271547

Introduction

Glasgow coma scale (GCS) was introduced by Teasdale and Jennett in 1974 at Glasgow Institution Hospital in the US.^[1] Due to the simplicity of GCS, attempts of modification in it have not been successful in the past. GCS is widely accepted to assess, monitor, and communicate the level of consciousness and predict clinical outcome across a varied spectrum of neurological conditions and in different clinical settings (inclusion in prehospital care and in in-hospital management protocols).^{[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21]} The GCS score range between 3 and 15 and comprises with three components eye, verbal, and motor response, depending on the total of all individual components.^{[1],[22],[23],[24]} In international literature, many studies have analyzed the prognostic value of total GCS and its individual components in different neurological and neurosurgical conditions.^{[3],[6],[21],[22],[25],[26],[27]} Studies based on the GCS score are often found to address specific types of trauma which restricts the generalizability of results in common trauma patients. Single institution-based study may possibly get biased with recording practices or protocols. From India, very few studies have described the significance of the total GCS and/or its individual components or their combination in predicting the outcome in different neurological conditions.^[28] Taking this fact into consideration, we started this study with research question, what is a predictive value of GCS and its components in predicating overall trauma mortality at Indian hospitals?

Materials and Methods

Study design

We used data from the Towards Improved Trauma Care Outcomes (TITCO) project from India. TITCO was prospective, observational, multicenter trauma registry contains data of trauma patients admitted to four public university hospitals in Mumbai, Delhi, and Kolkata.^[29] TITCO data were collected from October 1, 2013, to September 30, 2015. The patient details of trauma cases were recorded by trained data collectors at each identified center of TITCO.

Patients characteristics

For this study, all the patients from TITCO database were included with life and/or limb-threatening injury. Patients presenting with a history of trauma and admitted or died before admission to study hospitals were included. Patients with isolated limb injury and brought dead cases were excluded. Patients other than trauma admission were excluded. We considered GCS and its components, motor, eye, and verbal response as primary variables. GCS system of measuring severity is developed by Teasdale and Jennett ^[1] to evaluate the level of consciousness of patients. GCS ranges from 3 to 15 depending on high-to-low severity. GCS up to 8 is considered severe, between 9 and 12 treated as moderate and above 12 as mild GCS. The component of GCS has different ranges such as verbal response range is 1–5, eye response 1–4, and motor response 1–6. The GCS was classified into three different qualitative groups as mild, moderate, and severe depending on their severity. Association or effect of each of this subgroup was compared with survival status of patient dead or alive. Data analyzed to evaluate GCS, its components, and their combinations on mortality of trauma patients.

Bias

Only one center recorded GCS information for all the patients. However, in overall TITCO dataset, GCS on arrival data was missing for 2211 (13.77%) of patients, and hence, concerned cases are excluded from the further consideration.

Statistical analysis

GCS and its component eye, verbal, motor are tested as an indicator of trauma severity. Logistic regression analysis was performed with trauma survival as dependent variables and assuming independent variables as GCS total, eye, verbal, and motor score. Adjusted and unadjusted odds with 95% confidence interval (CI) were calculated. Receivers operating characteristic (ROC) curve of GCS, its component and their combinations are drawn to check its efficacy in predicting mortality among trauma patients.

Data analysis

Data were analyzed using SPSS version 20.0 (SPSS Inc., Chicago, IL, USA) for Windows and Microsoft Excel version 2013. Primary and secondary variables under consideration were analyzed to estimate statistical parameters, including mean, standard deviation, and percentages.

Results

Participants

TITCO registry contains 16,047 records of trauma cases from four Indian city hospitals. Two thousand two hundred and eleven (13.77%) patients with missing GCS or component score were excluded from further consideration. We found 13,836 (86.22%) patient records with valid GCS and its component score recorded in TITCO, all these are included in the study. Males were 11,000 (80%) of trauma patients while females were 2836 (20%). Overall, deaths were reported among 21.37% of patients. Gender wise no significant (P = 0.149) difference was found with 2379 (22%) and 578 (20%) deaths among males and females, respectively. The total GCS score on arrival, eye, verbal, and motor responses was found significantly different among survived and patients expired during the study. Increase in GCS or its components value found to increase chances of survival. Among severe GCS and lowest eye and verbal response score patients, mortality was in the range of 56%–58%. While, among lowest motor response, patients 80% died [Table 1].

Table 1: Life outcome-wise distribution of gender, Glasgow Coma Scale, eye, verbal, and motor response score among total trauma patients

Click here to view

Logistic regression analysis with GCS and components shows higher chance of survival with higher GCS and components value. Significant difference was found between adjusted and unadjusted odds. For GCS total with other components (unadjusted) were not significant (P = 0.763) while adjusted moderate (9–12) and mild (>12) GCS score shows 6.45 (95% CI 5.65–4.95) and 17.25 (95% CI 15.5–13.9) times more chance of survival. Eye, verbal, and motor response show obviously increasing odds of survival adjusted and unadjusted odds are significantly different. Higher range of predicting survival is shown by motor response score and among three components of GCS motor response appears significantly important parameter [Table 2].

Table 2: Adjusted and unadjusted effect of Glasgow Coma Scale, eye, verbal, and motor response on predicting mortality in trauma patients

Click here to view

ROC curve of GCS score, eye, verbal, and motor components shows very good effectiveness for predicting mortality respective area under the curve (AUC) found for these categories are 0.813, 0.775, 0.791, and 0.798, respectively [Figure 1]. Sum of components appears better than the parts of GCS. Conversely, the combination of eye-verbal, eye-motor, and verbal-motor appeared as very poor predictor of mortality with AUC 0.501, 0.499, and 0.499, respectively. This shows that, GCS can either be used as sum of all three components or individual of them but, not as a combination of any two of them.

Figure 1: Receiver operating characteristic curve of Glasgow coma scale score, eye, verbal, and motor response among trauma patients

Click here to view

Discussion

Since its invention GCS has been widely used indicator of trauma severity across health-care professionals. Different indicators, with or without modification in GCS, are studied across globe. There are total 120 combinations of GCS components, while only 15 are clinically valid and routinely used.^[30] However, the efficacy of GCS and its component has continued. The present study adds an evidence of GCS score in performance to predict trauma fatality. The total GCS score has been shown to predict outcome with 88% accuracy in acute stroke patients, particularly early mortality after the event.^[27] The present study addresses GCS used in different city hospital with all trauma cases. In such a diverse database, AUC of overall GCS and its components is found in the range of 0.775–0.813, which is good marker for predicting early trauma mortality. Summed up the value of the verbal and eye GCS scores in acute stroke patients found to be significant but did not reach a level where it could help in clinical decision making.^[27] Hence, it was recommended to use a total sum of the GCS to decide the management and to predict the outcome.^[27]

Among eye, verbal, and motor components, predictive value of motor component has been shown to highly specific, but its value in predicting outcome is not greater than the total sum of GCS hence motor component alone is not recommended to predict the outcome.^[31] Different traumas such as traumatic brain injury (TBI), neurological disorder, and ischemic stroke (please check/modified) have shown varied responses. However, the present study considers all types of traumas together. The present study documents AUC value for motor response of 0.798, while TBI-specific study has documented the AUC of 0.937.^[3]

The verbal component can help to predict prognosis particularly when a language deficit is absent in stroke patients.^[27] The assessment of speech component can be difficult particularly in patients who underwent endotracheal intubation or a tracheostomy.^[32] In another situation where the patient has sustained focal injury to the brain which has resulted in focal deficits (i.e., aphasia); verbal component shall not reflect the true consciousness level and can be erroneously underestimated.^[27] In the present registry data, 542 (3%) patients were intubated; however, verbal response might possible to be collected before intubation as a part of the initial examination.

Eye component cater 20% of weight in overall GCS score, and the eye component of the GCS has been shown to be the weakest predictor for outcome in TBI patients.^[17],[31] It will be difficult to assess the eye-opening in cases where there is associated periorbital swelling, and a false lower score can be calculated.^[32]

Limitations

Although the GCS has high inter/intra-rater reliability ^{[33],[34],[35]} still there shall be a need for training of the individuals to get the uniform recording and comparable results.^{[36],[37],[38],[39],[40]} While eliciting the response; one should keep in mind that the painful stimuli should be gently applied in the distribution of a cranial nerve and to avoid eliciting the spinal reflex.^[41] Following this, a best should response for each component should be noted ^[42] The GCS does not take into consideration the abnormal vital parameters, if the patient is intubated and if the patient is on medication (particularly muscle relaxant), the patient is aphasic or a patient who has associated cervical spine injury (conscious but quadriplegic).^[6],[43]

GCS is a simple, easy to perform tool to assess the level of consciousness which can be used both bedside and peripheral setting (at no cost) to make clinical decisions. As previously have been recommended GCS possible to be used in resources limited settings ^[28] (as it can be learned with a basic training and no recurring cost) by both clinical as well-supporting paramedical personnel's in trauma patients. It is important to understand that GCS components are not equivalent and should not be written as summed.^[19] However, each component should separately be noted in the records.^[44]

Conclusions

The present study has shown efficient predictive value of GCS score and its components eye, verbal, and motor response in trauma patients at India. GCS along with components help to predict overall hospital mortality among trauma patients, and GCS has better AUC than its components. However, a comprehensive training and resource investment are needed for uniformity to assess and interpretation of GCS in trauma patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974;2:81-4.
2.	Waterhouse C. The glasgow coma scale and other neurological observations. Nurs Stand 2005;19:55-64.
3.	Appachi MS, Mahadevan D, Eswaran VP. Assessing the motor component of the GCS scoring system as a better predictor of outcome. Natl J Emerg Med 2012;1:41-51.
4.	Kim H, Kim JH. Evaluation of the clinical usefulness of critical patient severity classification system and glasgow coma scale for neurological patients in intensive care units. Asian Nurs Res (Korean Soc Nurs Sci) 2013;7:8-15.
5.	McNett M. A review of the predictive ability of glasgow coma scale scores in head-injured patients. J Neurosci Nurs 2007;39:68-75.
6.	Wijdicks EF. Clinical scales for comatose patients: The glasgow coma scale in historical context and the new FOUR score. Rev Neurol Dis 2006;3:109-17.
7.	Chiara O, Cimbanassi S. Organized trauma care: Does volume matter and do trauma centers save lives? Curr Opin Crit Care 2003;9:510-4.
8.	Durham R, Pracht E, Orban B, Lottenburg L, Tepas J, Flint L, et al. Evaluation of a mature trauma system. Ann Surg 2006;243:775-83.
9.	Härtl R, Gerber LM, Iacono L, Ni Q, Lyons K, Ghajar J, et al. Direct transport within an organized state trauma system reduces mortality in patients with severe traumatic brain injury. J Trauma 2006;60:1250-6.
10.	Meldon SW, Reilly M, Drew BL, Mancuso C, Fallon W Jr. Trauma in the very elderly: A community-based study of outcomes at trauma and nontrauma centers. J Trauma 2002;52:79-84.
11.	Ma MH, MacKenzie EJ, Alcorta R, Kelen GD. Compliance with prehospital triage protocols for major trauma patients. J Trauma 1999;46:168-75.
12.	Zimmer-Gembeck MJ, Southard PA, Hedges JR, Mullins RJ, Rowland D, Stone JV, et al. Triage in an established trauma system. J Trauma 1995;39:922-8.
13.	The brain trauma foundation. The American association of neurological surgeons. The joint section on neurotrauma and critical care. Glasgow coma scale score. J Neurotrauma 2000;17:563-71.
14.	Bahloul M, Chelly H, Ben Hmida M, Ben Hamida C, Ksibi H, Kallel H, et al. Prognosis of traumatic head injury in south tunisia: A multivariate analysis of 437 cases. J Trauma 2004;57:255-61.
15.	Murray GD, Teasdale GM, Braakman R, Cohadon F, Dearden M, Iannotti F, et al. The European brain injury consortium survey of head injuries. Acta Neurochir (Wien) 1999;141:223-36.
16.	Signorini DF, Andrews PJ, Jones PA, Wardlaw JM, Miller JD. Predicting survival using simple clinical variables: A case study in traumatic brain injury. J Neurol Neurosurg Psychiatry 1999;66:20-5.
17.	Al-Salamah MA, McDowell I, Stiell IG, Wells GA, Perry J, Al-Sultan M, et al. Initial emergency department trauma scores from the OPALS study: The case for the motor score in blunt trauma. Acad Emerg Med 2004;11:834-42.
18.	Bouillon B, Krämer M, Tiling T, Neugebauer E. Trauma score systems as instruments in quality control. A prospective study on validation of 7 trauma score systems with 612 trauma patients. Unfallchirurg 1993;96:55-61.
19.	Teasdale GM, Pettigrew LE, Wilson JT, Murray G, Jennett B. Analyzing outcome of treatment of severe head injury: A review and update on advancing the use of the glasgow outcome scale. J Neurotrauma 1998;15:587-97.
20.	Kerby JD, MacLennan PA, Burton JN, McGwin G Jr., Rue LW 3^rd. Agreement between prehospital and emergency department glasgow coma scores. J Trauma 2007;63:1026-31.
21.	Caterino JM, Raubenolt A, Cudnik MT. Modification of glasgow coma scale criteria for injured elders. Acad Emerg Med 2011;18:1014-21.
22.	Teasdale G, Jennett B. Assessment and prognosis of coma after head injury. Acta Neurochir (Wien) 1976;34:45-55.
23.	Teasdale G, Jennett B, Murray L, Murray G. Glasgow coma scale: To sum or not to sum. Lancet 1983;2:678.
24.	Teasdale G, Knill-Jones R, van der Sande J. Observer variability in assessing impaired consciousness and coma. J Neurol Neurosurg Psychiatry 1978;41:603-10.
25.	Mood NE, Sabzghabaee AM, Yadegarfar G, Yaraghi A, Chaleshtori MR. Glasgow coma scale and its components on admission: Are they valuable prognostic tools in acute mixed drug poisoning? Crit Care Res Pract 2011;2011:952956.
26.	Starke RM, Komotar RJ, Otten ML, Schmidt JM, Fernandez LD, Rincon F, et al. Predicting long-term outcome in poor grade aneurysmal subarachnoid haemorrhage patients utilising the glasgow coma scale. J Clin Neurosci 2009;16:26-31.
27.	Weir CJ, Bradford AP, Lees KR. The prognostic value of the components of the glasgow coma scale following acute stroke. QJM 2003;96:67-74.
28.	Balaji M, Shaji S, Sreedevi N. Modifid Glasgow coma scale and brainstem reflxes in predicting survival and outcome in children with non-traumatic coma: A descriptive study. Int J Prev Ther Med 2014;2: 1-6.
29.	Roy N, Gerdin M, Ghosh S, Gupta A, Kumar V, Khajanchi M, et al. 30-day in-hospital trauma mortality in four urban university hospitals using an Indian trauma registry. World J Surg 2016;40:1299-307.
30.	Bhatty GB, Kapoor N. The Glasgow coma scale: A mathematical critique. Acta Neurochir 1993;120:132-5.
31.	Gill M, Steele R, Windemuth R, Green SM. A comparison of five simplified scales to the out-of-hospital glasgow coma scale for the prediction of traumatic brain injury outcomes. Acad Emerg Med 2006;13:968-73.
32.	Marmarou A, Lu J, Butcher I, McHugh GS, Murray GD, Steyerberg EW, et al. Prognostic value of the glasgow coma scale and pupil reactivity in traumatic brain injury assessed pre-hospital and on enrollment: An IMPACT analysis. J Neurotrauma 2007;24:270-80.
33.	Rosen DS, Macdonald RL. Subarachnoid hemorrhage grading scales: A systematic review. Neurocrit Care 2005;2:110-8.
34.	Takagi K, Tamura A, Nakagomi T, Nakayama H, Gotoh O, Kawai K, et al. How should a subarachnoid hemorrhage grading scale be determined? A combinatorial approach based solely on the glasgow coma scale. J Neurosurg 1999;90:680-7.
35.	Teasdale GM, Drake CG, Hunt W, Kassell N, Sano K, Pertuiset B, et al. A universal subarachnoid hemorrhage scale: Report of a committee of the world federation of neurosurgical societies. J Neurol Neurosurg Psychiatry 1988;51:1457.
36.	Rowley G, Fielding K. Reliability and accuracy of the glasgow coma scale with experienced and inexperienced users. Lancet 1991;337:535-8.
37.	Menegazzi JJ, Davis EA, Sucov AN, Paris PM. Reliability of the glasgow coma scale when used by emergency physicians and paramedics. J Trauma 1993;34:46-8.
38.	Heim C, Schoettker P, Gilliard N, Spahn DR. Knowledge of glasgow coma scale by air-rescue physicians. Scand J Trauma Resusc Emerg Med 2009;17:39.
39.	Chen LM, Martin CM, Morrison TL, Sibbald WJ. Interobserver variability in data collection of the APACHE II score in teaching and community hospitals. Crit Care Med 1999;27:1999-2004.
40.	Marion DW, Carlier PM. Problems with initial glasgow coma scale assessment caused by prehospital treatment of patients with head injuries: Results of a national survey. J Trauma 1994;36:89-95.
41.	Fischer J, Mathieson C. The history of the glasgow coma scale: Implications for practice. Crit Care Nurs Q 2001;23:52-8.
42.	Matis G, Birbilis T. The glasgow coma scale a brief review. Past, present, future. Acta Neurol Belg 2008;108:75-89.
43.	Servadei F, Nasi MT, Cremonini AM, Giuliani G, Cenni P, Nanni A, et al. Importance of a reliable admission glasgow coma scale score for determining the need for evacuation of posttraumatic subdural hematomas: A prospective study of 65 patients. J Trauma 1998;44:868-73.
44.	Teoh LS, Gowardman JR, Larsen PD, Green R, Galletly DC. Glasgow coma scale: Variation in mortality among permutations of specific total scores. Intensive Care Med 2000;26:157-61.