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Original Investigation |

Glasgow Coma Scale Score in Survivors of Explosion With Possible Traumatic Brain Injury in Need of Neurosurgical Intervention ONLINE FIRST

Itamar Ashkenazi, MD1; William P. Schecter, MD2; Kobi Peleg, PhD3,4; Adi Givon, BA3; Oded Olsha, MB, BS5; Fernando Turegano-Fuentes, MD6; Ricardo Alfici, MD1 ; and the Israeli Trauma Group
[+] Author Affiliations
1Department of Surgery, Hillel Yaffe Medical Center, Hadera, Israel
2Department of Surgery, University of California, San Francisco
3National Center for Trauma and Emergency Medicine Research, Gertner Institute, Tel Hashomer, Israel
4Disaster Medicine Department, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
5Department of Surgery, Shaare Zedek Medical Center, Jerusalem, Israel
6Emergency Surgery Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
JAMA Surg. Published online July 13, 2016. doi:10.1001/jamasurg.2016.1742
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Importance  Head injury following explosions is common. Rapid identification of patients with severe traumatic brain injury (TBI) in need of neurosurgical intervention is complicated in a situation where multiple casualties are admitted following an explosion.

Objective  To evaluate whether Glasgow Coma Scale (GCS) score or the Simplified Motor Score at presentation would identify patients with severe TBI in need of neurosurgical intervention.

Design, Setting, and Participants  Analysis of clinical data recorded in the Israel National Trauma Registry of 1081 patients treated following terrorist bombings in the civilian setting between 1998 and 2005. Primary analysis of the data was conducted in 2009, and analysis was completed in 2015.

Main Outcomes and Measures  Proportion of patients with TBI in need of neurosurgical intervention per GCS score or Simplified Motor Score.

Results  Of 1081 patients (median age, 29 years [range, 0-90 years]; 38.9% women), 198 (18.3%) were diagnosed as having TBI (48 mild and 150 severe). Severe TBI was diagnosed in 48 of 877 patients (5%) with a GCS score of 15 and in 99 of 171 patients (58%) with GCS scores of 3 to 14 (P < .001). In 65 patients with abnormal GCS (38%), no head injury was recorded. Nine of 877 patients (1%) with a GCS score of 15 were in need of a neurosurgical operation, and fewer than 51 of the 171 patients (30%) with GCS scores of 3 to 14 had a neurosurgical operation (P < .001). No difference was found between the proportion of patients in need of neurosurgery with GCS scores of 3 to 8 and those with GCS scores of 9 to 14 (30% vs 27%; P = .83). When the Simplified Motor Score and GCS were compared with respect to their ability to identify patients in need of neurosurgical interventions, no difference was found between the 2 scores.

Conclusions and Relevance  Following an explosion in the civilian setting, 65 patients (38%) with GCS scores of 3 to 14 did not experience severe TBI. The proportion of patients with severe TBI and severe TBI in need of a neurosurgical intervention were similar in patients presenting with GCS scores of 3 to 8 and GCS scores of 9 to 14. In this study, GCS and Simplified Motor Score did not help identify patients with severe TBI in need of a neurosurgical intervention.

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Figure 1.
Proportion of Patients With Traumatic Brain Injury According to Glasgow Coma Scale Score Category
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Figure 2.
Number of Patients in Need of Operation for Traumatic Brain Injury in Each Glasgow Coma Scale Score Category

aNumber of patients with Glasgow Coma Scale score of 15 and no traumatic brain injury.

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Figure 3.
Reliability of Glasgow Coma Scale Score and Simplified Motor Score (SMS) in Identifying Severe Traumatic Brain Injury and Need of Neurosurgery

Bars represent percentage of patients in the specific category who had either severe traumatic brain injury or were in need of neurosurgical operation.

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