GCS 15: when mild TBI isn’t so mild

Abstract

Objective: The present study characterizes patients with the mildest of mild traumatic brain injury (TBI), as defined by a Glasgow coma score (GCS) of 15. Methods: This is an IRB approved observational cohort study of adult patients who presented to the emergency department of a Level-1 trauma center, with the primary diagnosis of TBI and a GCS score of 15 on arrival. Data collected included demographic variables such as age, gender, race, mechanisms of injury, signs and symptoms including associated vomiting, seizures, loss of consciousness (LOC), alteration of consciousness (AOC), and posttraumatic amnesia (PTA).Pre-hospital GCS, Emergency Department (ED) GCS, and results of brain CT scans were also collected as well as patient centered outcomes including hospital or intensive care unit (ICU) admission, neurosurgical intervention, and in hospital death. Data were stored in REDCap (Research Electronic Data Capture), a secure, web-based application. Descriptive and inferential analysis was done using JMP 14.0 for the Mac. Results: Univariate predictors of hospital admission included LOC, AOC, and PTA, all p < 0.0001. Patients admitted to ICU were significantly more likely to be on an antiplatelet or anticoagulant (P < 0.0001), have experienced PTA (p = 0.0025), LOC (p < 0.0001), or have an abnormal brain CT (p < 0.0001). Patients who died in the hospital were significantly more likely to be on an antiplatelet or anticoagulant (P = 0.0005. All who died in the hospital had intracranial hemorrhage on ED head CT, despite having presented to the ED with GCS of 15. Patients were also significantly more likely to have had vomiting (p < 0.0001). Patients who underwent neurosurgical intervention were significantly more likely to be male (P = 0.0203), to be on an antiplatelet or anticoagulant (P = < 0.0001) likely to have suffered their TBI from a fall (P = 0.0349), and experienced vomiting afterwards (P = 0.0193). Conclusions: This study underscores: 1) the importance of neuroimaging in all patients with TBI, including those with a GCS 15. Fully 10% of our cohort was not imaged. Extrapolating, these would represent 2.5% bleeds, and 1.47% fractures. 2) The limitations of GCS in classifying TBI, as patients with even the mildest of mild TBI have a high frequency of gross CT abnormalities.

Prospective observational cohort study on epidemiology, treatment and outcome of patients with traumatic brain injury (TBI) in German BG hospitals

“… 34 It also supports the opinion that TBI with CGS 13 is substantially different from TBI with GCS 15, although both are classified as ‘mild TBI’. 34 35 Recently attempts have been made to subclassify patients with mild TBI (eg, complicated vs uncomplicated mild TBI) according to their prognosis. 35 36 Although these subclassifications are not widely accepted so far, our results strongly encourage such a subclassification of mild TBI, including imaging and biomarker findings as well as certain sociodemographic and psychologic factors, which have also been found to predict mild TBI outcome in other studies.…”

“…This finding highlights the problem linked to the GCS-based diagnosis of mild TBI, including a heterogenous group of patients ranging from a mild concussion to a potentially life-threatening structural damage revealed by CCT. 34 It also supports the opinion that TBI with CGS 13 is substantially different from TBI with GCS 15, although both are classified as 'mild TBI'. 34 35 Recently attempts have been made to subclassify patients with mild TBI (eg, complicated vs uncomplicated mild TBI) according to their prognosis.…”

Infected open depressed skull fracture complicated with tetanus grade I in an unimmunized child: a rare case report with literature review

“…The most common mechanism of injury was fall at 48%, followed by motor vehicle collision at 34%, and assault or being struck in the head at 30%. The most common location of injury reported was on the road (39%), followed by inside a home (21%) [3,4]. There are several factors in our society that play role in the incidence of tetanus.…”

Craniotomies following acute traumatic brain injury in Finland—a national study between 1997 and 2018

“…Intracranial abnormalities, visible on day-of-injury computed tomography (CT), are relatively common and occur in a substantial proportion of people presenting to the emergency department (ED) following acute head trauma [ 49 ]. The rate of abnormalities increases in association with the severity of injury, as measured by the Glasgow Coma Scale (GCS), whereby those with a GCS score of 15 have fairly low rates [ 13 , 17 ] but those with GCS scores of 14, 13, and lower have much higher rates [ 15 ]. The large majority of those cases, however, do not require neurosurgery [ 12 ].…”