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EMJ Online First, published on October 3, 2014 as 10.1136/emermed-2013-203488 Original article
Glasgow Coma Scale is unreliable for the prediction of severe head injury in elderly trauma patients A Kehoe,1 S Rennie,1 J E Smith1,2 1
Emergency Department, Derriford Hospital, Plymouth, UK 2 Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Medical Directorate, Joint Medical Command, Birmingham, UK Correspondence to Dr J E Smith, Emergency Department, Derriford Hospital, Derriford Road Plymouth PL6 8DH, UK; [email protected] Received 7 December 2013 Revised 29 August 2014 Accepted 15 September 2014
ABSTRACT Objectives and background Elderly patients comprise an ever-increasing proportion of major trauma patients. The presenting GCS in elderly patients with traumatic brain injury (TBI) may not reflect the severity of injury as accurately as it does in the younger patient population. However, GCS is often used as part of the decision tool to define the population transferred directly to a major trauma centre. The aim of this study was to explore the relationship between age and presenting GCS in patients with isolated TBI. Methods A retrospective database review was undertaken using the Trauma Audit and Research Network database. All patients presenting to Derriford Hospital, Plymouth, between 1 January 2009 and 31 May 2014 with isolated TBI were included. Demographic, mechanistic, physiological, resource use and outcome data were collected. Abbreviated injury scale (AIS) was recorded for all patients. Patients were categorised into those older and younger than 65 years on presentation. Distribution of GCS, categorised into severe (GCS 3–8), moderate (GCS 9–12) and mild TBI (13–15), was compared between the age groups. Median GCS at each AIS level was also compared. Results The distribution of GCS differed between young and old patients with TBI (22.1% vs 9.8% had a GCS 3–8, respectively) despite a higher burden of anatomical injury in the elderly group. Presenting GCS was higher in the elderly at each level of AIS. The difference was more apparent in the presence of more severe injury (AIS 5). Conclusions Elderly patients who have sustained isolated severe TBI may present with a higher GCS than younger patients. Triage tools using GCS may need to be modified and validated for use in elderly patients with TBI.
INTRODUCTION
To cite: Kehoe A, Rennie S, Smith JE. Emerg Med J Published Online First: [please include Day Month Year] doi:10.1136/emermed2013-203488
Emerging evidence demonstrates that the elderly comprise an ever-increasing proportion of the major trauma population, with low falls becoming the predominant mechanism of injury.1 The implications of this, and challenges to the traditional approach to trauma management, are yet to be fully defined. Derriford Hospital is the major trauma centre (MTC) for the Peninsula Trauma Network. The population it serves contains a high proportion of elderly patients, and the impact of these demographic changes may therefore become apparent here first. Many trauma triage tools include the Glasgow Coma Scale (GCS) when defining those patients requiring direct transfer to an MTC rather than the nearest hospital. The reliability of the GCS to predict significant brain injury has been used as
part of several triage tools in the last few decades, from the original triage and trauma scores,2 to the triage-revised trauma score.3 Another triage tool (the Wessex trauma triage tool) is currently in use in the Peninsula Trauma Network, which uses a combination of anatomical and physiological criteria (including the motor score of the GCS) to identify those patients suitable for transfer directly to an MTC.4 It has been suggested that the presenting GCS in patients with isolated traumatic brain injury (TBI) may not reflect the severity of injury as accurately in the elderly as it does in the young.5 6 The aim of this study was to explore the relationship between age and presenting GCS in patients with isolated TBI in our population.
METHODS The Trauma Audit and Research Network (TARN) database was interrogated to identify patients attending Derriford Hospital, Plymouth, between 1 January 2009 and 31 May 2014 with significant, isolated TBI (abbreviated injury scale (AIS) head of 3, 4 and 5, with no other TARN-qualifying injury with AIS >2). The AIS gives an indication of the severity of the anatomical injury and can be broadly thought of as representing minor injury (1), moderate injury (2) and serious to critical (3– 5), with a maximal injury (6) thought to be unsurvivable.7 For example, a base of skull fracture is graded as AIS 3, a small subdural haematoma (≤50 cm3) is AIS 4, a massive extradural haematoma is AIS 5 and transection of the brain stem is AIS 6. TARN eligibility includes trauma patients of any age who are admitted to hospital for 72 h or more, are admitted to a critical care unit, die in hospital or are transferred to another hospital for specialist care. Specific patient groups, such as those aged over 65 years, who are admitted due to a fracture of the neck of femur, are excluded.8 9 Patients who did not meet TARN eligibility criteria were not included in this study. Entries with missing data were also excluded. Demographic, mechanistic, physiological, resource use and outcome data were collected. Patients were categorised into those older and younger than 65 years on presentation. Presenting GCS values were not normally distributed. The difference in distribution of presenting GCS between age groups was therefore considered by comparing medians and IQRs for the whole study population and subgroups defined by AIS score and also by categorisation into severe (GCS 3–8), moderate (GCS 9–12) and mild TBI (GCS 13–15) groups according to Teasdale and Jennett’s original classification.10–12
et al. Emerg Med2014. J 2014;0:1–3. doi:10.1136/emermed-2013-203488 Copyright Article author (orKehoe theirA, employer) Produced by BMJ Publishing Group Ltd under licence.
1
Downloaded from emj.bmj.com on October 7, 2014 - Published by group.bmj.com
Original article Categorical data were compared using χ2 analysis or Fisher’s exact test for two-by-two tables. Continuous data were not normally distributed and were therefore compared using the Mann–Whitney U test. Significance was set at p
EMJ Online First, published on October 3, 2014 as 10.1136/emermed-2013-203488 Original article
Glasgow Coma Scale is unreliable for the prediction of severe head injury in elderly trauma patients A Kehoe,1 S Rennie,1 J E Smith1,2 1
Emergency Department, Derriford Hospital, Plymouth, UK 2 Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Medical Directorate, Joint Medical Command, Birmingham, UK Correspondence to Dr J E Smith, Emergency Department, Derriford Hospital, Derriford Road Plymouth PL6 8DH, UK; [email protected] Received 7 December 2013 Revised 29 August 2014 Accepted 15 September 2014
ABSTRACT Objectives and background Elderly patients comprise an ever-increasing proportion of major trauma patients. The presenting GCS in elderly patients with traumatic brain injury (TBI) may not reflect the severity of injury as accurately as it does in the younger patient population. However, GCS is often used as part of the decision tool to define the population transferred directly to a major trauma centre. The aim of this study was to explore the relationship between age and presenting GCS in patients with isolated TBI. Methods A retrospective database review was undertaken using the Trauma Audit and Research Network database. All patients presenting to Derriford Hospital, Plymouth, between 1 January 2009 and 31 May 2014 with isolated TBI were included. Demographic, mechanistic, physiological, resource use and outcome data were collected. Abbreviated injury scale (AIS) was recorded for all patients. Patients were categorised into those older and younger than 65 years on presentation. Distribution of GCS, categorised into severe (GCS 3–8), moderate (GCS 9–12) and mild TBI (13–15), was compared between the age groups. Median GCS at each AIS level was also compared. Results The distribution of GCS differed between young and old patients with TBI (22.1% vs 9.8% had a GCS 3–8, respectively) despite a higher burden of anatomical injury in the elderly group. Presenting GCS was higher in the elderly at each level of AIS. The difference was more apparent in the presence of more severe injury (AIS 5). Conclusions Elderly patients who have sustained isolated severe TBI may present with a higher GCS than younger patients. Triage tools using GCS may need to be modified and validated for use in elderly patients with TBI.
INTRODUCTION
To cite: Kehoe A, Rennie S, Smith JE. Emerg Med J Published Online First: [please include Day Month Year] doi:10.1136/emermed2013-203488
Emerging evidence demonstrates that the elderly comprise an ever-increasing proportion of the major trauma population, with low falls becoming the predominant mechanism of injury.1 The implications of this, and challenges to the traditional approach to trauma management, are yet to be fully defined. Derriford Hospital is the major trauma centre (MTC) for the Peninsula Trauma Network. The population it serves contains a high proportion of elderly patients, and the impact of these demographic changes may therefore become apparent here first. Many trauma triage tools include the Glasgow Coma Scale (GCS) when defining those patients requiring direct transfer to an MTC rather than the nearest hospital. The reliability of the GCS to predict significant brain injury has been used as
part of several triage tools in the last few decades, from the original triage and trauma scores,2 to the triage-revised trauma score.3 Another triage tool (the Wessex trauma triage tool) is currently in use in the Peninsula Trauma Network, which uses a combination of anatomical and physiological criteria (including the motor score of the GCS) to identify those patients suitable for transfer directly to an MTC.4 It has been suggested that the presenting GCS in patients with isolated traumatic brain injury (TBI) may not reflect the severity of injury as accurately in the elderly as it does in the young.5 6 The aim of this study was to explore the relationship between age and presenting GCS in patients with isolated TBI in our population.
METHODS The Trauma Audit and Research Network (TARN) database was interrogated to identify patients attending Derriford Hospital, Plymouth, between 1 January 2009 and 31 May 2014 with significant, isolated TBI (abbreviated injury scale (AIS) head of 3, 4 and 5, with no other TARN-qualifying injury with AIS >2). The AIS gives an indication of the severity of the anatomical injury and can be broadly thought of as representing minor injury (1), moderate injury (2) and serious to critical (3– 5), with a maximal injury (6) thought to be unsurvivable.7 For example, a base of skull fracture is graded as AIS 3, a small subdural haematoma (≤50 cm3) is AIS 4, a massive extradural haematoma is AIS 5 and transection of the brain stem is AIS 6. TARN eligibility includes trauma patients of any age who are admitted to hospital for 72 h or more, are admitted to a critical care unit, die in hospital or are transferred to another hospital for specialist care. Specific patient groups, such as those aged over 65 years, who are admitted due to a fracture of the neck of femur, are excluded.8 9 Patients who did not meet TARN eligibility criteria were not included in this study. Entries with missing data were also excluded. Demographic, mechanistic, physiological, resource use and outcome data were collected. Patients were categorised into those older and younger than 65 years on presentation. Presenting GCS values were not normally distributed. The difference in distribution of presenting GCS between age groups was therefore considered by comparing medians and IQRs for the whole study population and subgroups defined by AIS score and also by categorisation into severe (GCS 3–8), moderate (GCS 9–12) and mild TBI (GCS 13–15) groups according to Teasdale and Jennett’s original classification.10–12
et al. Emerg Med2014. J 2014;0:1–3. doi:10.1136/emermed-2013-203488 Copyright Article author (orKehoe theirA, employer) Produced by BMJ Publishing Group Ltd under licence.
1
Downloaded from emj.bmj.com on October 7, 2014 - Published by group.bmj.com
Original article Categorical data were compared using χ2 analysis or Fisher’s exact test for two-by-two tables. Continuous data were not normally distributed and were therefore compared using the Mann–Whitney U test. Significance was set at p
