Using the Glasgow Coma Scale: analysis and limitations

Fluid-Based Protein Biomarkers in Traumatic Brain Injury: The View from the Bedside

There has been an explosion of research into biofluid (blood, cerebrospinal fluid, CSF)-based protein biomarkers in traumatic brain injury (TBI) over the past decade. The availability of very large datasets, such as CENTRE-TBI and TRACK-TBI, allows for correlation of blood- and CSF-based molecular (protein), radiological (structural) and clinical (physiological) marker data to adverse clinical outcomes. The quality of a given biomarker has often been framed in relation to the predictive power on the outcome quantified from the area under the Receiver Operating Characteristic (ROC) curve. However, this does not in itself provide clinical utility but reflects a statistical association in any given population between one or more variables and clinical outcome. It is not currently established how to incorporate and integrate biofluid-based biomarker data into patient management because there is no standardized role for such data in clinical decision making. We review the current status of biomarker research and discuss how we can integrate existing markers into current clinical practice and what additional biomarkers do we need to improve diagnoses and to guide therapy and to assess treatment efficacy. Furthermore, we argue for employing machine learning (ML) capabilities to integrate the protein biomarker data with other established, routinely used clinical diagnostic tools, to provide the clinician with actionable information to guide medical intervention.

Comparison of Glasgow Coma Scale and Full Outline of UnResponsiveness score for prediction of in-hospital mortality in traumatic brain injury patients: a systematic review and meta-analysis

BACKGROUND

Currently, Glasgow Coma Scale (GCS) is used to assess patients' level of consciousness. Although this tool is highly popular in clinical settings, it has various limitations that reduce its applicability in certain situations. This had led researchers to look for alternative scoring systems. This study aims to compare the value of GCS and Full Outline of UnResponsiveness (FOUR) score for prediction of mortality in traumatic brain injury (TBI) patients through a systematic review and meta-analysis.

METHOD

Online databases of Medline, Embase, Scopus, and Web of Science were searched until the end of July 2022 for studies that had compared GCS and FOUR score in TBI patients. Interested outcomes were mortality and unfavorable outcome (mortality + disability). Findings are reported as area under the curve (AUC) sensitivity, specificity, and diagnostic odds ratio.

RESULTS

20 articles (comprised of 2083 patients) were included in this study. AUC of GCS and FOUR score for prediction of in-hospital mortality after TBI was 0.92 (95% CI 0.80-0.91) and 0.91 (95% CI 0.88-0.93) respectively. The diagnostic odds ratio of the two scores for prediction of in-hospital mortality after TBI was 44.51 (95% CI 23.58-84.03) for GCS and 45.16 (95% CI 24.25-84.09) for FOUR score. As for prediction of unfavorable outcome after TBI, AUC of GCS and FOUR score were 0.95 (95% CI 0.93 to 0.97) and 0.93 (95% CI 0.91-0.95), respectively. The diagnostic odds ratios for prediction of unfavorable outcome after TBI were 66.31 (95% CI 35.05-125.45) for GCS and 45.39 (95% CI 23.09-89.23) for FOUR score.

CONCLUSION

Moderate level of evidence showed that the value of GCS and FOUR score in the prediction of in-hospital mortality and unfavorable outcome is comparable. The similar performance of these scores in assessment of TBI patients gives the medical staff the option to use either one of them according to the situation at hand.

Neurologic Complications of Babesiosis, United States, 2011-2021

Babesiosis is a globally distributed parasitic infection caused by intraerythrocytic protozoa. The full spectrum of neurologic symptoms, the underlying neuropathophysiology, and neurologic risk factors are poorly understood. Our study sought to describe the type and frequency of neurologic complications of babesiosis in a group of hospitalized patients and assess risk factors that might predispose patients to neurologic complications. We reviewed medical records of adult patients who were admitted to Yale-New Haven Hospital, New Haven, Connecticut, USA, during January 2011-October 2021 with laboratory-confirmed babesiosis. More than half of the 163 patients experienced >1 neurologic symptoms during their hospital admissions. The most frequent symptoms were headache, confusion/delirium, and impaired consciousness. Neurologic symptoms were associated with high-grade parasitemia, renal failure, and history of diabetes mellitus. Clinicians working in endemic areas should recognize the range of symptoms associated with babesiosis, including neurologic.

Incorporating age improves the Glasgow Coma Scale score for predicting mortality from traumatic brain injury

Background

The Glasgow Coma Scale (GCS) score has been adapted into categories of severity (mild, moderate, and severe) and are ubiquitous in the trauma setting. This study sought to revise the GCS categories to account for an interaction by age and to determine the discrimination of the revised categories compared with the standard GCS categories.

Methods

The American College of Surgeons National Trauma Data Bank registry was used to identify patients with traumatic brain injury (TBI; ICD-9 codes 850-854.19) who were admitted to participating trauma centers from 2010 to 2015. The primary exposure variables were GCS score and age, categorized by decade (teens, 20s, 30s…, 80s). In-hospital mortality was the primary outcome for examining TBI severity/prognostication. Logistic regression was used to calculate the conditional probability of death by age decade and GCS in a development dataset (75% of patients). These probabilities were used to create a points-based revision of the GCS, categorized as low (mild), moderate, and high (severe). Performance of the revised versus standard GCS categories was compared in the validation dataset using area under the receiver operating characteristic (AUC) curves.

Results

The final population included 539,032 patients with TBI. Age modified the performance of the GCS, resulting in a novel categorization schema for each age decile. For patients in their 50s, performance of the revised GCS categories mirrored the standard GCS categorization (3-8, 9-12, 13-15); all other revised GCS categories were heavily modified by age. Model validation demonstrated the revised GCS categories statistically significantly outperformed the standard GCS categories at predicting mortality (AUC: 0.800 vs 0.755, p<0.001). The revised GCS categorization also outperformed the standard GCS categories for mortality within pre-specified subpopulations: blunt mechanism, isolated TBI, falls, non-transferred patients.

Discussion

We propose the revised age-adjusted GCS categories will improve severity assessment and provide a more uniform early prognostic indicator of mortality following traumatic brain injury.

Level of evidence

III epidemiologic/prognostic.

Prediction of ICU mortality in critically ill children : Comparison of SOFA, GCS, and FOUR score

INTRODUCTION

The SOFA (Sequential Organ Failure Assessment), GCS (Glasgow Coma Scale), and FOUR (Full Outline of UnResponsiveness) scores are the most commonly used scoring systems to predict the risk of mortality and morbidity in intensive care units (ICUs). The aim of the current study was to compare the predictive ability of these three models for predicting medical/surgical ICU mortality in critically ill children.

METHODS

In the current observational and prospective study, a total of 90 consecutive patients, age ≤18 years, admitted to medical and surgical ICUs, were enrolled. The SOFA, GCS, FOUR score and demographic characteristics of all children were recorded on the first day of admission. For statistical analyses, a receiver operator characteristic (ROC) curve, the Hosmer-Lemeshow goodness of fit test, and logistic regression were used (95% confidence interval).

RESULTS

The SOFA, GCS, and FOUR scores between survivors and nonsurvivors were statistically different (p = 0.002, p < 0.001, p = 0.004, respectively). The discrimination power for SOFA, GCS, and FOUR score was moderate (area under ROC [AUC] curve: 75.1%; standard error [SE]: 6.0%, 72.9% [SE: 7.2%], 78.7% [SE: 6.6%], respectively). The only well-calibrated model was GCS (x² = 2.76, p = 0.59).

CONCLUSIONS

The performance of the three predictive models SOFA, GCS, and FOUR score for predicting outcomes in children admitted to medical and surgical ICUs was good. The discrimination was moderate for all three models, and calibration was good just for GCS. GCS was superior in predicting outcome in critically ill children; however, further studies are needed to validate these scores in the pediatric population.

Factors Influencing the Reliability of the Glasgow Coma Scale: A Systematic Review

BACKGROUND

The Glasgow Coma Scale (GCS) characterizes patients with diminished consciousness. In a recent systematic review, we found overall adequate reliability across different clinical settings, but reliability estimates varied considerably between studies, and methodological quality of studies was overall poor. Identifying and understanding factors that can affect its reliability is important, in order to promote high standards for clinical use of the GCS.

OBJECTIVE

The aim of this systematic review was to identify factors that influence reliability and to provide an evidence base for promoting consistent and reliable application of the GCS.

METHODS

A comprehensive literature search was undertaken in MEDLINE, EMBASE, and CINAHL from 1974 to July 2016. Studies assessing the reliability of the GCS in adults or describing any factor that influences reliability were included. Two reviewers independently screened citations, selected full texts, and undertook data extraction and critical appraisal. Methodological quality of studies was evaluated with the consensus-based standards for the selection of health measurement instruments checklist. Data were synthesized narratively and presented in tables.

RESULTS

Forty-one studies were included for analysis. Factors identified that may influence reliability are education and training, the level of consciousness, and type of stimuli used. Conflicting results were found for experience of the observer, the pathology causing the reduced consciousness, and intubation/sedation. No clear influence was found for the professional background of observers.

CONCLUSION

Reliability of the GCS is influenced by multiple factors and as such is context dependent. This review points to the potential for improvement from training and education and standardization of assessment methods, for which recommendations are presented.

Does history of substance use disorder predict acute traumatic brain injury rehabilitation outcomes?

BACKGROUND/OBJECTIVE

The study explored whether premorbid substance use disorder (SUD) predicts acute traumatic brain injury (TBI) outcomes.

METHODS

143 participants with moderate (34.2%) and severe (65.8%) TBI were enrolled at two Level 1 trauma center inpatient brain injury rehabilitation units. Acute outcomes were measured with the Disability Rating Scale (DRS), the FIMTM; self and informant ratings of the Patient Competency Rating Scale (PCRS); self and family rating of the Frontal Systems Behavioral Scale (FrSBe), and the Neurobehavioral Rating Scale-Revised (NRS-R).

RESULTS

Hierarchical linear modeling revealed that SUD history significantly predicted trajectories of PCRS clinician ratings, PCRS self-family and PCRS self-clinician discrepancy scores, and more negative FrSBE family ratings. These findings indicate comparatively greater post-injury executive functions (EF) impairments, particularly self-awareness (SA) of injury-related deficits, for those with SUD history. No significant SUD*time interaction effect was found for FIM or NRS-R scores.

CONCLUSIONS

SUD history and TBI are associated with impaired SA and EF but their co-occurrence is not a consistent predictor of acute post-injury functional outcomes. Pre-morbid patient characteristics and rater expectations and biases may moderate associations between SA and recovery after TBI.

Glasgow Coma Scale flow chart: a beginner's guide

The Glasgow Coma Scale (GCS) has been accepted nationally and internationally as a tool to assess depth and duration of consciousness since it was published in 1974. Although it was intended to be an easy and practical bedside tool for any grade of health professional, it is considered to be ambiguous and confusing for infrequent users. Moreover, there has been increasing concern about the accuracy and effectiveness of the GCS observation carried out by these users, which could result from lack of training and dissemination of benchmarking across non-specialist areas. This paper aims to introduce a GCS flow chart to guide users step by step when assessing a patient's level of consciousness.

Investigating nurses' knowledge, attitudes and self-confidence patterns to perform the conscious level assessment: a cluster analysis

By accurately assessing a patient's conscious level, the nurse is able to detect neurological changes in order to improve survival outcomes and minimize long-term sequelae. However, problems are encountered when using the Glasgow Coma Scale (GCS) to assess a patient's conscious level. This study aims to identify the profile of a group of nurse's knowledge, attitudes and self-confidence (KAS) to perform the conscious level assessment using the GCS. A descriptive correlational survey was conducted from January to March 2010 in one acute care hospital in Singapore. A convenience sampling was used, and 114 nursing staff (91.2% response rates) completed a self-reported questionnaire. Four main outcomes: demographic and clinical experiences, and KAS. Two-step cluster analysis yielded two clusters. Cluster A (48.2%) was labelled 'average attitudes, knowledge and self-confidence' group. Cluster B (51.8%) was labelled as 'positive attitudes, good knowledge and high self-confidence' group. Two clusters showed differences in the levels of their KAS. Findings may be used for management to improve support of nurses to ensure accurately assessing patient's conscious level. Management should formulate strategies to encourage nurses to resolve actual problems following training or mentoring and to increase the depth and breadth of nurses' KAS to perform the conscious level assessment using the GCS.

Nurses' self-confidence and attitudes in using the Glasgow Coma Scale: a primary study

AIMS

The aim of this study was to examine nurses' self-confidence and attitudes towards the Glasgow Coma Scale (GCS).

BACKGROUND

The GCS measures the depth and duration of impaired consciousness. However, there is an increasing evidence that problems are encountered in completing some aspects of the GCS.

DESIGN

This descriptive correlational study recruited 114 Registered Nurses (RNs) in one acute care hospital in Singapore.

METHODS

A set of questionnaires were given to the participants. The questionnaire had three parts, which collected data on demographics, attitudes and self-confidence.

RESULTS

Data analysis showed the type of clinical discipline (B=0.19), seniority in nursing (Staff Grade) (B=0.28) and higher attitude scores towards the GCS (B=0.41) were significant factors determining a nurse's confidence in using the GCS. A longer length of time working in a Neuroscience setting (B=0.21) and higher self-confidence scores (B=0.41) were significant factors determining a nurse's attitude towards the GCS.

CONCLUSION

To ensure patient safety, the GCS has to be performed accurately. This study has shown there are differences in attitudes and self-confidence in using the GCS between nurses of different demographics, and that there are a variety of factors influencing their attitudes and confidence.

RELEVANCE TO CLINICAL PRACTICE

Mentoring and educational interventions are suggested in order to reduce safety risks resulting from lower proficiency in using the GCS.

Glasgow coma scale and APACHE-II scores affect the liver transplantation outcomes in patients with acute liver failure

BACKGROUND

The timing and selection of patients for liver transplantation in acute liver failure are great challenges. This study aimed to investigate the effect of Glasgow coma scale (GCS) and APACHE-II scores on liver transplantation outcomes in patients with acute liver failure.

METHOD

A total of 25 patients with acute liver failure were retrospectively analyzed according to age, etiology, time to transplantation, coma scores, complications and mortality.

RESULTS

Eighteen patients received transplants from live donors and 7 had cadaveric whole liver transplants. The mean duration of follow-up after liver transplantation was 39.86+/-40.23 months. Seven patients died within the perioperative period and the 1-, 3-, 5-year survival rates of the patients were 72%, 72% and 60%, respectively. The parameters evaluated for the perioperative deaths versus alive were as follows: the mean age of the patients was 33.71 vs 28 years, MELD score was 40 vs 32.66, GCS was 5.57 vs 10.16, APACHE-II score was 23 vs 18.11, serum sodium level was 138.57 vs 138.44 mmol/L, mean waiting time before the operation was 12 vs 5.16 days. Low GCS, high APACHE-II score and longer waiting time before the operation (P<0.01) were found as statistically significant factors for perioperative mortality.

CONCLUSION

Lower GCS and higher APACHE-II scores are related to poor outcomes in patients with acute liver failure after liver transplantation.

Investigating factors that have an impact on nurses' performance of patients' conscious level assessment: a systematic review

AIM

  To identify factors that have an impact on nurses' performance of patients' conscious level assessment.

BACKGROUND

  There is a need for nurses to accurately assess a patient's conscious level to detect neurological changes and initiate prompt action.

METHODS

  Nine databases were systematically searched (1990-February 2010) to review experimental, cohort, case control, cross-sectional and descriptive studies that addressed factors which affected nurses' performance of patient conscious level assessment. Participants in the studies reviewed were nursing staff. The Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument was used for quality assessment.

RESULTS

  Eleven studies were analysed in this review. Knowledge and experience were found to be the most significant factors in determining nurses' performance of patient conscious level assessment. Formal training was found to be effective in improving assessment skills and experience greatly affected the accuracy of assessment.

CONCLUSION

  Knowledge and experience are the most significant factors on nurses' performance of consciousness level assessment. Implications for nursing management  Formal training is needed on a continual basis to maintain skills in consciousness level assessment, and nurses who are more experienced in the use of assessment should mentor those that are less experienced.

A systematic review of the factors that impact nurses' performance of conscious level assessment

EXECUTIVE SUMMARY

Background The ability to perform a conscious level assessment forms a vital part of a nurse's skill base. By accurately assessing a patient's conscious level, the nurse is able to detect neurological changes and initiate prompt action. The clinical implications of this are grave and assessment errors are serious and have potentially important clinical consequences.

OBJECTIVES

INCLUSION CRITERIA: This review considered any high quality quantitative papers that addressed factors which impacted nurses' performance of conscious level assessment. This review included data from cohort, case control, cross-sectional, and descriptive studies.The participants of this review were nursing staff working in acute hospitals, specifically working in settings, such as intensive care.Studies which examined knowledge, attitudes and demographic factors and their impact on nurses' performance of conscious level assessment were considered.Search strategy A three-step search strategy was utilised in this review. An initial limited search of MEDLINE and CINAHL was undertaken. A search strategy was then developed using identified keywords and MeSH headings. Lastly, the reference lists of all identified studies were examined. All searches were limited to English Language studies published between 1990 and 2010.Assessment of methodological quality The reviewers used the JBI Critical Appraisal Checklist for Cohort / Case Control Studies and the JBI Critical Appraisal Checklist for Descriptive / Case Series Studies to assess methodological quality.Data extraction Data were extracted using The JBI Data Extraction Form for Comparative Cohort / Case Control studies and the JBI Data Extraction Form for Descriptive/Case Series studies.Data synthesis Due to the heterogeneous nature of the study methods, the findings of this systematic review are presented in a narrative summary.Results Fifty papers were identified through the various database searches and review of reference list and bibliographies, based on their titles and abstracts. Thirteen studies were included in this review. Knowledge and experience were found to be the most significant factors in determining nurses' performance for conscious level assessment. Formal training was found to be effective in improving assessment skills and experience greatly affected the accuracy of conscious level assessment The agreement rates between healthcare staff were moderate to high, however there were still instances of disagreement.Conclusion This review demonstrated that knowledge and experience are the most significant factors to impact nurses' performance of conscious level assessment. There was variability between results of the studies found. This may have been due to differences in the setting, the target population as well as study methodology. However, these findings suggest that the factors impacting a nurses' performance of conscious level assessment may be more complex than what was initially assumed.Implications for practice It is suggested that formal training be on a continual basis to maintain skills in conscious level assessment. Secondly, nurses who are more experienced in the use of the conscious level assessment should mentor those less experienced.Implications for research The effect of training courses has not been studied comprehensively. Further research should be conducted concerning the accuracy and reliability of nurses using other conscious level assessment instruments.

The pathophysiology and causes of raised intracranial pressure

This article explains the pathophysiology and causes of raised intracranial pressure (ICP), and the significance of assessing and recording vital observations for all patients when admitted to hospital. It discusses the nursing care, treatment and management required in order to minimize the risk of further increases in ICP.

Monitoring of herpes simplex virus DNA types 1 and 2 viral load in cerebrospinal fluid by real-time PCR in patients with herpes simplex encephalitis

A quantitative polymerase chain reaction (PCR) assay was evaluated retrospectively on 92 cerebrospinal fluid (CSF) samples from 29 patients with herpes simplex virus (HSV) encephalitis with the aim to study if the concentration of HSV genomes can be used as a prognostic marker and for monitoring of antiviral therapy. The results were compared to those obtained previously by nested PCR, and the numbers of HSV genomes/ml were evaluated in correlation to patient outcome and treatment. The aims were to compare the sensitivity of a conventional nested PCR to a quantitative PCR, to investigate the range of HSV genome concentration in initial samples and to evaluate possible relationships between the HSV DNA concentrations in CSF, neopterin levels, and outcome of disease. The 29 initial samples contained between 2 x 10(2) and 42 x 10(6) HSV genomes/ml. There was no apparent correlation between the amount of HSV DNA in the initial samples and income status, initial neopterin levels, or prognosis. The number of HSV genomes/ml declined after treatment in all patients, but HSV DNA was still detectable after day 20 in 3 out of 16 patients. A long duration of genome detectability was found to correlate with poor outcome. There was no difference in sensitivity between the nested PCR and the quantitative PCR. While the quantitative PCR is more rational than a nested PCR, the quantitation of HSV genomes does not seem very useful as a prognostic marker in HSV encephalitis.

Assessment of altered conscious level in clinical practice

This article will critically appraise the literature focusing on the use and application of the Glasgow Coma Scale (GCS). Historically the GCS tool was created in a 14-point format and later revised to a 15-point format. Critical analysis of this potentially confusing aspect will be explored. The GCS tool enables the healthcare practitioner to effectively monitor the level of consciousness. The authors believe that anatomical and physiological knowledge is required to competently interpret assessment of level of consciousness. The article will review the anatomical basis of consciousness and consider some of the issues of application of GCS in practice, including painful stimuli.

Statistical Validation of the Glasgow Coma Score

BACKGROUND

To validate the predictive value of the Glasgow Coma Score (GCS) and find the best way to model the score in a logistic regression model predicting mortality.

METHODS

Analyses were based on 20,494 patients from the trauma registries of three urban Level I trauma centers in the province of Quebec, Canada. The predictive value of the GCS and its components was evaluated in logistic regression models predicting in-hospital mortality with measures of discrimination and calibration. The performance of the GCS with no transformation and as an ordered categorical variable was compared with two transformation techniques: fractional polynomials and spline regression.

RESULTS

The GCS had excellent discrimination (area under Receiving Operator Characteristic Curve=0.833 95% confidence interval=0.820-0.846) but fairly poor calibration (Pearson's Chi-squared statistic=122 on 11 df). The eye component added no predictive information to the verbal and motor components in the whole sample but was important in certain sub-populations. Using the three components separately, rather than the sum, did not improve the predictive model. Fractional polynomial transformation of the GCS improved calibration and spline regression performed even better. GCS modeled as an ordered categorical variable performed badly both in terms of discrimination and calibration.

CONCLUSIONS

The GCS in its present form is an efficient predictor of in-hospital mortality, which could benefit from statistical transformation in logistic regression models when the accuracy of estimated probabilities of mortality is important. The common use of GCS categories for modeling mortality leads to loss of information and should be discarded.