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Early prediction of outcome following head injury in children: An assessment of the value of Glasgow Coma Scale score trend and abnormal plantar and pupillary light reflexes
Early Prediction of Outcome Following Head Injury in Children: An Assessment of the Value of Glasgow Coma Scale Score Trend and Abnormal Plantar and Pupillary Light Reflexes By M. Grewal and Anne J. Sutcliffe Birmingham, 0 A retrospective
study of 95 children less than 15 years of
age with significant head injury was made to assess the value of Glasgow Coma Scale (GCS) score trend and plantar and pupillary light reflexes during the first 24 hours after injury, in predicting eventual outcome. GCS score trend or reflexes used alone were significantly correlated to outcome. There was also a statistically significant correlation when these parameters in combination were related to outcome. However, the clinical value of the combined use of GCS score trend and reflexes was only slightly greater than the use of GCS score trend alone. Copyright o 1991 by W.B. Saunders Company INDEX WORDS:
Head injury. children.
T
HE GLASGOW Coma Scale (GCS) score (Table 1) is used widely as a guide to the severity of brain injury.’ The score is affected by other factors apart from the primary brain injury. These include hypoxia, hypovolemia, cerebral swelling, and the presence of an intracranial hematoma. These factors are most likely to occur in the first 24 hours after injury and influence not only the GCS score at that time but also the eventual outcome as assessed by the Glasgow Outcome Scale (GOS).’ The trend in GCS score has been shown to be valuable in predicting outcome for children with severe head injury.3.4In a previous study performed at the Birmingham Accident Hospital, Wags@ et al4
England
showed that GCS score trend could be used not only to predict outcome, but that plantar and pupillary light reflexes on admission had prognostic significance. The present study was designed to confirm these results and to assess whether the combined use of GCS score trend and reflexes could be used to improve the accuracy of outcome predictions. MATERIALS
AND METHODS
Ninety-five children admitted consecutively to the Major Injuries Unit of Birmingham Accident Hospital between September 1983 and December 1988, with a significant head injury and for whom complete notes were available, were studied retrospectively. Only patients with trauma to the head and a history of impairment of consciousness or radiological evidence of skull fracture were included in the study. The GCS score on admission and in the following 24 hours was recorded. The reaction of the pupils to light and the plantar reflexes on admission and after 24 hours were noted, The pupillary reflex was considered abnormal if there was no reaction or sluggish reaction to light in one or both pupils. The plantar reflex was considered abnormal if one or both reflexes were unequivocally extensor. The administration of crystalloid fluids to all children was restricted, but blood loss was replaced with colloidal solutions or whole blood. Controlled mechanical ventilation. full muscle paralysis, and mannitol were used for more severe cases. The persistence or absence of disability was noted in the survivors for up to 1 year after injury. Using GOS, they were classified into vegetative state, severe disability, moderate disability, or good recovery. In this study none of the children who survived were in vegetative state.
Table 1. Glasgow Coma Scale Scores
RESULTS
Eyes open Spontaneously
4
To speech
3
To pain
2
Never
Best verbal
1 response
Oriented
5
Confused
4
Inappropriate words
3
Incomprehensible
2
sounds
Silent
The age range of the group was 4 months to 15 years (mean, 8 years 4 months). Eleven patients (11.6%) died. Table 2 shows the relationship between GCS score trend in the first 24 hours and outcome. All the children with a GCS score of 5 or more on admission who did not deteriorate survived, although one was severely handicapped. Only 3 children with a
1
Best motor response Obey commands
6
Localizes pain
5
Flexion withdrawal
4
@cerebrate
3
flexion
Decerebrate extension
2
No response
1
JoournalofPediatricSurgery,
Vol26, No 10 (October), 1991: pp 1161-1163
From the Birmingham Accident Hospital, Birmingham. England. Date accepted: June 12, 1990. Address reprint requests to Anne J. Sutcliffe, FFARCS, Birmingham Accident Hospital, Bath Row, Birmingham B15 INA, England. Copyright o 1991 by W.B. Saunders Company 0022-3468/91/2610-0004$03.00/O
1161
1162
GREWAL AND SUTCLIFFE
This study confirmed previous results4 from the Birmingham Accident Hospital that GCS score trend is a useful predictor of outcome, particularly in the group of children who are admitted with a GCS score of 5 or more and who subsequently do not deteriorate. However, the GCS score trend is less useful for those children admitted with a GCS score of 3 or 4, and of no value at all for those admitted with a score of 5 or more who subsequently deteriorate. In this study, the presence of abnormal plantar and pupillary light reflexes predicted an outcome of death or severe disability with only 80% accuracy, compared with 99% in the previous study. Other parameters such as the presence of flaccidity6 or presence of midline shift3 are equally unhelpful. The combined use of two parameters such as GCS score trend and reflexes might improve the accuracy of outcome prediction. Using the x2 test of statistical significance, there is no doubt that there is a relationship among a low or deteriorating GCS score, abnormal reflexes, and a poor outcome. Using the data presented, the following predictions can reasonably be made: death or severe disability for children with a GCS score of 3 or 4 on admission and both reflexes abnormal after 24 hours; death or severe disability for children admitted with a GCS score of 5 or more but who subsequently deteriorate and have both reflexes abnormal after 24 hours; and a good outcome for children admitted with a GCS score of 5 or more and no deterioration. These predictions can be made for 83 (87%) of the children in this study and would be wrong in only 2.4% of cases. The outcome would be worse than predicted in only 1.2% of cases. Although there is a statistically significant relationship among GCS score trend, reflexes, and outcome, the percentage of children for whom predictions can be made and the accuracy of predictions are similar to the results obtained previously by Wagstyl et al4 using GCS score trend alone. However, the practicing clinician may find that the combined use of GCS score trend and reflexes is helpful in assessing the probability of recovery for individual children, particularly those who deteriorate after admission and those who are admitted with a GCS score of 3 or 4.
Table 2. The Relationship Between GCS Score Trend and Outcome Outcome GCS Score on Admission
SWWi3
Moderate
Good
Disability
Disability
Recovery
and
Trend in First 24 Hours After Injury
Death
5 or more with no deterioration
0
1
0
73
5 or more with deterioration
3
1
0
6
3 or 4
8
0
1
2
NOTE. x’ = 66.4: P < ,001.
Table 3. The Relationship Between Plantar Pupillary Light Reflexes 24 Hours After Admission and Outcome Outcome Plantar and Pupillary Death
Light Reflexes
SWW3
Moderate
Good
Disability
Disability
Recoven/
Both normal
0
0
0
54
One abnormal
3
2
0
26
Both abnormal
8
0
1
1
NOTE. x2 = 65.6; P < ,001.
GCS score of 3 or 4 survived. Two made a good recovery. One of these improved rapidly and had a GCS score of 15 after 24 hours. Table 3 shows the relationship between outcome and the plantar and pupillary reflexes 24 hours after injury. Of 10 children with both reflexes abnormal, 8 died. Table 4 shows the relationship between outcome, GCS score trend, and reflexes at 24 hours. Five children of 6 with both reflexes abnormal and a GCS score of 3 or 4 died. All children with both reflexes abnormal after 24 hours and an admission GCS score of 5 or more with subsequent deterioration died. DISCUSSION
Children with severe head injury are known to have better prognosis than adults.5,6 This is probably because the pattern of injury is different’ and children are less likely than adults to die of extracranial complications.6 Most head-injured children make a good recovery. The ability to predict accurately which children will make a good recovery would be useful for physicians wishing to reassure distraught parents, who often blame themselves for their child’s injury.
Table 4. The Relationship Between GCS Score Trend, Plantar and Pupillary Reflexes, and Outcome
and
Trend in First 24 Hours After Injury
Death
Both Reflexes Normal
One Reflex Abnormal
Both Reflexes Abnormal GCS Score on Admission
SlWere
Moderate
Good
Disability
Disability
Recovery
Death
Sl?vere
Moderate
Good
Disability
Disability
Recovery
Death
Sl?WW
Moderate
Good
Disability
Disability
Recovery
5 or more with no deterioration
0
0
0
1
0
1
0
19
0
0
0
53
5 or more with deterioration
3
0
0
0
0
1
0
6
0
0
0
0
30r4
5
0
1
0
3
0
0
1
0
0
0
1
NOTE. x2 = 79.3; P < ,001.
1163
PEDIATRIC HEAD INJURY OUTCOME
REFERENCES 1. Jennett B, Teasdale G: The Management of Head Injuries. Philadelphia, PA, Davies, 1981,78 2. Jennett B, Snoek J, Bond MR, et al: Disability after severe head injury: Observations on the use of the Glasgow Outcome Scale. J Neural Neurosurg Psych 44:285-893,198l 3. Young B, Rapp RP, Norton JA, et al: Early prediction of outcome in head injured patients. J Neurosurg 54:300-303,198l 4. Wagstyl J, Sutcliffe AJ, Alpar EK: Early prediction of
outcome following head injury in children. J Pediatr Surg 22:127129,1987 5. Heiskanen 0, Sipponen P: Prognosis of severe brain injury. Acta Neurol Stand 46:343-348,197O 6. Bruce DA, Schut L, Bruno LA, et al: Outcome following severe head injuries in children. J Neurosurg 48:679-688,1978 7. Pascucci RC: Head trauma in the child. Intensive Care Med 14:185-195,1988
study of 95 children less than 15 years of
age with significant head injury was made to assess the value of Glasgow Coma Scale (GCS) score trend and plantar and pupillary light reflexes during the first 24 hours after injury, in predicting eventual outcome. GCS score trend or reflexes used alone were significantly correlated to outcome. There was also a statistically significant correlation when these parameters in combination were related to outcome. However, the clinical value of the combined use of GCS score trend and reflexes was only slightly greater than the use of GCS score trend alone. Copyright o 1991 by W.B. Saunders Company INDEX WORDS:
Head injury. children.
T
HE GLASGOW Coma Scale (GCS) score (Table 1) is used widely as a guide to the severity of brain injury.’ The score is affected by other factors apart from the primary brain injury. These include hypoxia, hypovolemia, cerebral swelling, and the presence of an intracranial hematoma. These factors are most likely to occur in the first 24 hours after injury and influence not only the GCS score at that time but also the eventual outcome as assessed by the Glasgow Outcome Scale (GOS).’ The trend in GCS score has been shown to be valuable in predicting outcome for children with severe head injury.3.4In a previous study performed at the Birmingham Accident Hospital, Wags@ et al4
England
showed that GCS score trend could be used not only to predict outcome, but that plantar and pupillary light reflexes on admission had prognostic significance. The present study was designed to confirm these results and to assess whether the combined use of GCS score trend and reflexes could be used to improve the accuracy of outcome predictions. MATERIALS
AND METHODS
Ninety-five children admitted consecutively to the Major Injuries Unit of Birmingham Accident Hospital between September 1983 and December 1988, with a significant head injury and for whom complete notes were available, were studied retrospectively. Only patients with trauma to the head and a history of impairment of consciousness or radiological evidence of skull fracture were included in the study. The GCS score on admission and in the following 24 hours was recorded. The reaction of the pupils to light and the plantar reflexes on admission and after 24 hours were noted, The pupillary reflex was considered abnormal if there was no reaction or sluggish reaction to light in one or both pupils. The plantar reflex was considered abnormal if one or both reflexes were unequivocally extensor. The administration of crystalloid fluids to all children was restricted, but blood loss was replaced with colloidal solutions or whole blood. Controlled mechanical ventilation. full muscle paralysis, and mannitol were used for more severe cases. The persistence or absence of disability was noted in the survivors for up to 1 year after injury. Using GOS, they were classified into vegetative state, severe disability, moderate disability, or good recovery. In this study none of the children who survived were in vegetative state.
Table 1. Glasgow Coma Scale Scores
RESULTS
Eyes open Spontaneously
4
To speech
3
To pain
2
Never
Best verbal
1 response
Oriented
5
Confused
4
Inappropriate words
3
Incomprehensible
2
sounds
Silent
The age range of the group was 4 months to 15 years (mean, 8 years 4 months). Eleven patients (11.6%) died. Table 2 shows the relationship between GCS score trend in the first 24 hours and outcome. All the children with a GCS score of 5 or more on admission who did not deteriorate survived, although one was severely handicapped. Only 3 children with a
1
Best motor response Obey commands
6
Localizes pain
5
Flexion withdrawal
4
@cerebrate
3
flexion
Decerebrate extension
2
No response
1
JoournalofPediatricSurgery,
Vol26, No 10 (October), 1991: pp 1161-1163
From the Birmingham Accident Hospital, Birmingham. England. Date accepted: June 12, 1990. Address reprint requests to Anne J. Sutcliffe, FFARCS, Birmingham Accident Hospital, Bath Row, Birmingham B15 INA, England. Copyright o 1991 by W.B. Saunders Company 0022-3468/91/2610-0004$03.00/O
1161
1162
GREWAL AND SUTCLIFFE
This study confirmed previous results4 from the Birmingham Accident Hospital that GCS score trend is a useful predictor of outcome, particularly in the group of children who are admitted with a GCS score of 5 or more and who subsequently do not deteriorate. However, the GCS score trend is less useful for those children admitted with a GCS score of 3 or 4, and of no value at all for those admitted with a score of 5 or more who subsequently deteriorate. In this study, the presence of abnormal plantar and pupillary light reflexes predicted an outcome of death or severe disability with only 80% accuracy, compared with 99% in the previous study. Other parameters such as the presence of flaccidity6 or presence of midline shift3 are equally unhelpful. The combined use of two parameters such as GCS score trend and reflexes might improve the accuracy of outcome prediction. Using the x2 test of statistical significance, there is no doubt that there is a relationship among a low or deteriorating GCS score, abnormal reflexes, and a poor outcome. Using the data presented, the following predictions can reasonably be made: death or severe disability for children with a GCS score of 3 or 4 on admission and both reflexes abnormal after 24 hours; death or severe disability for children admitted with a GCS score of 5 or more but who subsequently deteriorate and have both reflexes abnormal after 24 hours; and a good outcome for children admitted with a GCS score of 5 or more and no deterioration. These predictions can be made for 83 (87%) of the children in this study and would be wrong in only 2.4% of cases. The outcome would be worse than predicted in only 1.2% of cases. Although there is a statistically significant relationship among GCS score trend, reflexes, and outcome, the percentage of children for whom predictions can be made and the accuracy of predictions are similar to the results obtained previously by Wagstyl et al4 using GCS score trend alone. However, the practicing clinician may find that the combined use of GCS score trend and reflexes is helpful in assessing the probability of recovery for individual children, particularly those who deteriorate after admission and those who are admitted with a GCS score of 3 or 4.
Table 2. The Relationship Between GCS Score Trend and Outcome Outcome GCS Score on Admission
SWWi3
Moderate
Good
Disability
Disability
Recovery
and
Trend in First 24 Hours After Injury
Death
5 or more with no deterioration
0
1
0
73
5 or more with deterioration
3
1
0
6
3 or 4
8
0
1
2
NOTE. x’ = 66.4: P < ,001.
Table 3. The Relationship Between Plantar Pupillary Light Reflexes 24 Hours After Admission and Outcome Outcome Plantar and Pupillary Death
Light Reflexes
SWW3
Moderate
Good
Disability
Disability
Recoven/
Both normal
0
0
0
54
One abnormal
3
2
0
26
Both abnormal
8
0
1
1
NOTE. x2 = 65.6; P < ,001.
GCS score of 3 or 4 survived. Two made a good recovery. One of these improved rapidly and had a GCS score of 15 after 24 hours. Table 3 shows the relationship between outcome and the plantar and pupillary reflexes 24 hours after injury. Of 10 children with both reflexes abnormal, 8 died. Table 4 shows the relationship between outcome, GCS score trend, and reflexes at 24 hours. Five children of 6 with both reflexes abnormal and a GCS score of 3 or 4 died. All children with both reflexes abnormal after 24 hours and an admission GCS score of 5 or more with subsequent deterioration died. DISCUSSION
Children with severe head injury are known to have better prognosis than adults.5,6 This is probably because the pattern of injury is different’ and children are less likely than adults to die of extracranial complications.6 Most head-injured children make a good recovery. The ability to predict accurately which children will make a good recovery would be useful for physicians wishing to reassure distraught parents, who often blame themselves for their child’s injury.
Table 4. The Relationship Between GCS Score Trend, Plantar and Pupillary Reflexes, and Outcome
and
Trend in First 24 Hours After Injury
Death
Both Reflexes Normal
One Reflex Abnormal
Both Reflexes Abnormal GCS Score on Admission
SlWere
Moderate
Good
Disability
Disability
Recovery
Death
Sl?vere
Moderate
Good
Disability
Disability
Recovery
Death
Sl?WW
Moderate
Good
Disability
Disability
Recovery
5 or more with no deterioration
0
0
0
1
0
1
0
19
0
0
0
53
5 or more with deterioration
3
0
0
0
0
1
0
6
0
0
0
0
30r4
5
0
1
0
3
0
0
1
0
0
0
1
NOTE. x2 = 79.3; P < ,001.
1163
PEDIATRIC HEAD INJURY OUTCOME
REFERENCES 1. Jennett B, Teasdale G: The Management of Head Injuries. Philadelphia, PA, Davies, 1981,78 2. Jennett B, Snoek J, Bond MR, et al: Disability after severe head injury: Observations on the use of the Glasgow Outcome Scale. J Neural Neurosurg Psych 44:285-893,198l 3. Young B, Rapp RP, Norton JA, et al: Early prediction of outcome in head injured patients. J Neurosurg 54:300-303,198l 4. Wagstyl J, Sutcliffe AJ, Alpar EK: Early prediction of
outcome following head injury in children. J Pediatr Surg 22:127129,1987 5. Heiskanen 0, Sipponen P: Prognosis of severe brain injury. Acta Neurol Stand 46:343-348,197O 6. Bruce DA, Schut L, Bruno LA, et al: Outcome following severe head injuries in children. J Neurosurg 48:679-688,1978 7. Pascucci RC: Head trauma in the child. Intensive Care Med 14:185-195,1988