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Emerg Med J. 2020 Feb 12. pii: emermed-2018-208154. doi: 10.1136/emermed-2018-208154. [Epub ahead of print]

Association of clinically important traumatic brain injury and Glasgow Coma Scale scores in children with head injury.

Kochar A1,2, Borland ML2,3,4, Phillips N2,5,6, Dalton S2,7, Cheek JA2,8, Furyk J2,9,10, Neutze J2,11, Lyttle MD8,12, Hearps S13, Dalziel S2,14,15, Bressan S12,16, Oakley E2,8,12, Babl FE2,8,12.

Author information

Emergency Department, Women's and Children's Hospital, Adelaide, SA, Australia
PREDICT, Paediatric Research in Emergency Departments International Collaborative, Melbourne, Victoria, Australia.
Division of Paediatrics and Emergency Medicine, School of Medicine, University of Western Australia, Perth, WA, Australia.
Emergency Department, Perth Children's Hospital, Perth, Western Australia, Australia.
Emergency Department, Queensland Children's Hospital, South Brisbane, Queensland, Australia.
Child Health Research Centre, Faculty of Medicine, University of Queensland, South Brisbane, Queensland, Australia.
Department of Emergency, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.
Emergency Department, Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.
Emergency Department, The Townsville Hospoital, Townsville, Queensland, Australia.
Emergency Department, University Hospital Geelong, Geelong, Victoria, Australia.
Emergency Department, Kidzfirst Middlemore Hospital, Auckland, New Zealand.
Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia.
Emergency Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia.
Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand.
Departments of Surgery and Paediatrics;Child and Youth Health, University of Auckland, Auckland, New Zealand.
Department of Women's and Child's Health, University of Padova, Padova, Italy.



Head injury (HI) is a common presentation to emergency departments (EDs). The risk of clinically important traumatic brain injury (ciTBI) is low. We describe the relationship between Glasgow Coma Scale (GCS) scores at presentation and risk of ciTBI.


Planned secondary analysis of a prospective observational study of children<18 years who presented with HIs of any severity at 10 Australian/New Zealand centres. We reviewed all cases of ciTBI, with ORs (Odds Ratio) and their 95% CIs (Confidence Interval) calculated for risk of ciTBI based on GCS score. We used receiver operating characteristic (ROC) curves to determine the ability of total GCS score to discriminate ciTBI, mortality and need for neurosurgery.


Of 20 137 evaluable patients with HI, 280 (1.3%) sustained a ciTBI. 82 (29.3%) patients underwent neurosurgery and 13 (4.6%) died. The odds of ciTBI increased steadily with falling GCS. Compared with GCS 15, odds of ciTBI was 17.5 (95% CI 12.4 to 24.6) times higher for GCS 14, and 484.5 (95% CI 289.8 to 809.7) times higher for GCS 3. The area under the ROC curve for the association between GCS and ciTBI was 0.79 (95% CI 0.77 to 0.82), for GCS and mortality 0.91 (95% CI 0.82 to 0.99) and for GCS and neurosurgery 0.88 (95% CI 0.83 to 0.92).


Outside clinical decision rules, decreasing levels of GCS are an important indicator for increasing risk of ciTBI, neurosurgery and death. The level of GCS should drive clinician decision-making in terms of urgency of neurosurgical consultation and possible transfer to a higher level of care.


paediatric emergency medicine; paediatric injury; paediatrics

Conflict of interest statement

Competing interests: None declared.

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