Original articleCritical Score of Glasgow Coma Scale for Pediatric Traumatic Brain Injury
Introduction
Pediatric brain injury, which is a dominant cause of pediatric hospital emergency room visits, frequently requires extensive treatment and often results in disability or death [1]. Mortality and morbidity rates among patients with traumatic brain injuries remain significant, despite progress in prevention, diagnosis, and treatment [2]. The major causes of pediatric brain injury are falls, recreational activities, and motor vehicle crashes [3]. Prolonged intensive care and rehabilitation are often necessary, even in the face of uncertain outcome. This uncertainty has resulted in the development of scoring systems that can determine prognosis [2]. Previous studies have demonstrated that the following factors are correlated with patient outcome: age, coma duration, systemic hypertension, brain lesion type, injury severity score, abnormal motor patterns, abnormal pupillary response, Glasgow Coma Scale, hypoxia, hypotension, and impaired brainstem reflexes [4], [5], [6]. Various electrophysiologic techniques, such as somatosensory evoked potentials, brainstem auditory evoked potentials, and cognitive event-related potentials have been used as predictors [7]. For example, somatosensory evoked potentials were used to assess outcome for traumatic brain injury patients with consciousness disturbances [7]. Event-related potentials such as N400 were used to assess the subcortical and cortical systems involved in language processing for patients with traumatic brain injury [7].
There has been significant variation in results of studies examining outcomes of patients with traumatic brain injury [2], [8], [9], [10], [11]. Children with severe head injuries typically have better prognosis than adults [8], [9], [10]. Most children with head injuries recover well [9], [11]. This situation is likely a result of the different patterns of injury in children and adults [8], [9]. There is also some controversy over whether the outcome of young children with closed head injury is superior to that of older children. In some studies, the outcomes of the younger children were discouraging [4], [12]. Children 6 years of age and older had better cognitive and motor outcomes than younger patients [4], [12]. The incomplete myelinization in young children may result in greater sensitivity to shearing injury [13]. Numerous mechanisms of injury are unique to children. With growth and maturation of the central nervous system, traumatic brain lesions vary depending on a patient’s age at injury. Therefore the ability to predict accurately which children will make a good recovery would be useful for physicians when reassuring distraught parents who frequently blame themselves for their child’s injury [11].
The Glasgow Coma Scale is the most commonly used prognostic indicator [5], [6], [14], [15], [16], [17], [18], [19], [20] and the most commonly used tool to evaluate injury severity [21], [22]. A low Glasgow Coma Scale score indicates severe traumatic brain injury and is considered highly predictive of death or poor recovery. In adults, a Glasgow Coma Scale score ≤8 indicates coma and the traumatic brain injury is classified as a severe injury [21], [22]. However, the critical predictive Glasgow Coma Scale score of 8 for adult patients may be not applicable to children. The established severity grading system for adults with traumatic brain injury facilitates comparisons of outcomes among studies. However, few studies identified the predictive critical Glasgow Coma Scale score for pediatric traumatic brain injury patients.
Hypoxic-ischemic insult at the time of injury is a devastating confounding variable in traumatic brain injury patients that needs to be considered separately when predicting outcome for traumatic brain injury children on the basis of Glasgow Coma Scale scores [2]. Scan variables of computed tomography are independent prognostic variables which might assist in identifying patients at high risk of death at hospital admission [17]. Some studies have demonstrated that less favorable recovery rates were associated with mass-occupying lesions [6]. The computed tomographic findings related to abnormal intracranial pressure and death in a study by Eisenberg were midline shift, compression or obliteration of mesencephalic cisterns, and the presence of subarachnoid hemorrhage [23]. Other studies also suggested that traumatic brain injury outcome was indicated by the morphologic features of computed tomographic scans [17], [23], [24], [25]. Hence, this study employed computed tomography for determination of injury severity and outcome predictions.
Studies of traumatic brain injuries in children a decade ago identified a high variability in individual outcomes. The difficulties remaining may be due in part to the dynamic nature of the pediatric nervous system and, perhaps, to limitations in the ability to quantify the complexity of an injury and measure its full impact on neurodevelopment [20]. To determine outcome predictions for pediatric traumatic brain injury cases, an injury severity grading system needs to be established. First, an attempt is made to identify the critical Glasgow Coma Scale score for initial injury severity grading in children with traumatic brain injuries. Then, the clinical variables, computed tomographic findings, and Glasgow Coma Scale scores in injury severity determinations and outcome predictions are determined.
Section snippets
Subjects
A total of 309 children admitted to Chang Gung Memorial Hospital with traumatic brain injuries (at the age of injury, 2-10 years) were enrolled in this study. Enrollment criterion was that case diagnosis was intracranial injury, excluding those with skull fracture alone, with the code range of 850-854 of the International Classification of Diseases, 9th Revision (ICD-9) (850, cerebral concussion; 851, cerebral laceration and contusion; 852, subdural, subarachnoid, or extradural hemorrhage; 853,
Glasgow Coma Scale and Glasgow Outcome Scale
The receiver operating characteristic curve indicated that the sensitivity was increased when the Glasgow Coma Scale increased; however, the specificity was decreased when the Glasgow Coma Scale increased. From the Youden index (J), The optimum cutoff point of the Glasgow Coma Scale set at 5 had both good sensitivity and specificity (Fig 1). The area under the operating characteristic curve was equal to 0.991, indicating that the Glasgow Coma Scale is a good marker to differentiate the Glasgow
Discussion
Glasgow Coma Scale score is the most important predictor for outcome for pediatric traumatic brain injuries. Furthermore, the critical Glasgow Coma Scale score should be set at 5 for pediatric traumatic brain injury. This threshold for neurophysiologic dysfunction is lower in children than adults. Although the critical Glasgow Coma Scale score has been set at 8 for adult traumatic brain injuries [21], [22], the receiver operating characteristic curve in this study found that a critical Glasgow
Conclusion
The Glasgow Coma Scale is the most effective predictor for prognosis of traumatic brain injury in children. The critical Glasgow Coma Scale score should be set at 5 in children with traumatic brain injury, rather than 8 as that in adults. In the present study, the computed tomographic findings were also important in determining injury severity and predicting outcome in children. For diffuse brain lesions, brain swelling/edema, whether combined with subarachnoid hemorrhage or not, was associated
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