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 Table of Contents  
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


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 Submission23-Feb-2018
Date of Decision18-Dec-2018
Date of Acceptance05-Aug-2019
Date of Web Publication25-Nov-2019

Correspondence Address:
Dr. Amit Agrawal
Department of Neurosurgery, Narayana Medical College Hospital, Chinthareddypalem, Nellore - 524 003, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_16_18

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  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 2019 Dec 11];14:94-8. Available from: http://www.journaldmims.com/text.asp?2019/14/2/94/271547




  Introduction Top


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 Top


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 Top


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

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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

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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

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  Discussion Top


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 Top


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.



 
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