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J Neurotrauma. 2017 Feb 27. doi: 10.1089/neu.2016.4793. [Epub ahead of print]

Tripartite Stratification of the Glasgow Coma Scale in Children with Severe Traumatic Brain Injury and Mortality: An Analysis from a Multi-Center Comparative Effectiveness Study.

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1 Department of Pediatrics, Massachusetts General Hospital , Boston, Massachusetts.
2 Department of Pediatrics, Pennsylvania State University College of Medicine , Hershey, Pennsylvania.
3 Department of Pediatrics, Hackensack University Medical Center , Hackensack, New Jersey.
4 Department of Pediatrics, Starship Children's Hospital , Auckland, New Zealand .
5 Department of Epidemiology, University of Pittsburgh , Pittsburgh, Pennsylvania.
6 Department of Critical Care Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania.
7 Office of Clinical Research, National Institute of Neurological Disorders and Stroke , Bethesda, Maryland.
8 Departments of Anesthesia (Pediatrics) and Neurology, Harvard Medical School , Boston, Massachusetts.


The Glasgow Coma Scale (GCS) score has not been validated in children younger than 5 years and the clinical circumstances at the time of assignment can limit its applicability. This study describes the distribution of GCS scores in the population, the relationship between injury characteristics with the GCS score, and the association between the tripartite stratification of the GCS on mortality in children with severe traumatic brain injury (TBI). The first 200 children from a multi-center comparative effectiveness study in severe TBI (inclusion criteria: age 0-18 years, GCS ≤8 at the time of intracranial pressure [ICP] monitoring) were analyzed. After tripartite stratification of GCS scores (Group A, GCS 3; Group B, GCS 4 - 5; and Group C, GCS 6 - 8), analyses of variance and chi-square testing were performed. Mean age was 7.61 years ±5.33 and mortality was 19.1%. There was no difference in etiology or type/mechanism of injury between groups. However, groups demonstrated differences in neuromuscular blockade, endotracheal intubation, pre-hospital events (cardiac arrest and apnea), coagulopathy, and pupil response. Mortality between groups was different (42.2% Group A, 22.6% Group B, and 3.8% Group C; p < 0.001), and adding pupil response improved mortality associations. In children younger than 5 years of age, a similar relationship between GCS and mortality was observed. Overall, GCS score at the time of ICP monitor placement is strongly associated with mortality across the pediatric age range. Development of models with GCS and other factors may allow identification of subtypes of children after severe TBI for future studies.


Glasgow Coma Scale (GCS) score; comparative effectiveness research; pediatric neurocritical care; pediatric traumatic brain injury; secondary injuries

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