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GCS-Pupil Score Is a Better Predictor of
Mortality Than GCS Alone in
Pediatric Severe Traumatic Brain Injury
Binod Balakrishnan MD, Sheila J. Hanson MD, Heather Trimmer, Irene Kim MD,
Liyun Zhang, Pippa Simpson PhD, and Raquel Farias-Moeller, MD
Pediatric Trauma Society Annual Meeting November 14, 2019
No Disclosures
Introduction sTBI is the leading cause of pediatric death and disability.
• 475,000 children/yr
• 5,000 new disability
• 2,600 deaths
• Huge economic burden (2.6B)
• Interest in models predicting
outcomes early post injury.
-Dewan MC et al. Epidemiology of Global Pediatric Traumatic Brain Injury: Qualitative Review. World Neurosurg 2016
-Langlois JA et al. The incidence of traumatic brain injury among children in the United States: differences by race. J Head Trauma Rehabil 2005
-Stanley RM et al. US estimates of hospitalized children with severe traumatic brain injury: implications for clinical trials. Pediatrics 2012
Introduction • The GCS is the most widely used tool but:
• Affected by sedation, neuromuscular blockade, ETT
• Does not account for brainstem function.
• Patients without pupillary response have worse
outcomes
• What if the GCS and the # of non-reactive pupils were
combined?
• Brennan et al published GCS-P in large adult
cohort.
• GCS-P proved better to predict mortality and
functional outcome
• GCS-P = GCS - PRS 0 non reactive pupils = 0
1 non reactive pupil = 1
2 non reactive pupils =2
Brennan PM et al. Simplifying the use of prognostic information in traumatic brain injury. Part 1: The GCS-Pupils
score: an extended index of clinical severity. J Neurosurg 2018
Objectives / Methods
To apply the GCS-P score to a large pediatric sTBI cohort.
VPS database of severe TBI patients 0-18 years from 2010-2015
GCS and PRS were extracted from PRISM3 score
Data collected: Demographics, abusive head trauma, cardiac arrest,
ICP monitor, mechanical ventilation, mortality, discharge PCPC score.
1ary outcome: PICU mortality
2ary outcome: functional outcome
at PICU discharge
Favorable: PCPC 1-3
Unfavorable: PCPC 4&5, or 2 above baseline
Statistical Analysis
• Chi-square or Fisher’s exact test for categorical variables
• Mann-Whitney U test for continuous or ordinal variables
• Multivariable classification and regression tree analysis (CART) to examine important predictors of death and functional outcomes
• Predictors considered - age, gender, race, cardiac arrest, abusive head trauma, intracranial pressure monitor, craniotomy, ventilation/intubation, patients’ origin, GCS-P score, GCS and PRS.
Results - Demographics Severe TBI cohort N=2682
Age, n (%)
0-1 month
1-23 month
2-5 years
6-12 years
13-18 years
24 (0.9)
580 (21.6)
701 (26.1)
772 (28.8)
605 (22.6)
Male, n (%) 1754 (65.4)
Prior Cardiac Arrest, N (%) 245 (9.1)
Abusive head trauma diagnosis 418 (15.6%)
Mortality, n (%) 618 (23.0)
Intervention, n (%)
Ventilation
ICP monitor
Craniotomy
2429 (95.8)
629 (24.8)
403 (15.9)
Institution, n (%)
Free standing Hospital
24 hours attending
1569 (58.5)
1894 (70.6)
Patient Origin, n (%)
ED
OR/PACU
2280 (85.0)
402 (15.0)
Initial Scores
GCS, median (IQR)
GCS-P, median (IQR)
PRS, n (%)
0
1
2
6 (3, 7)
6 (3,7)
1954 (72.9)
108 (4.0)
620 (23.1)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
3 4 5 6 7 8M
OR
TALIT
Y
GCS
PRS = 2 PRS = 1 PRS = 0
Association of pupil
reactivity with mortality
across the range of GCS
Mortality and functional outcome across the range of GCS and GCS-P scores
GCS-P Mortality
N=618
Unfavorable PCPC
n = 79
1 462/525 (88%) 17/25 (68%)
2 39/81 (48%) 11/15 (73.3%)
3 62/370 (17%) 18/77 (23.3%)
4 15/114 (13%) 3 /24(12.5%)
5 14/181 (8%) 13/45 (28.9%)
6 16/481 (3%) 11/110 (10%)
7 7/469 (1.5%) 4/104 (3.8%)
8 3/461 (0.6%) 2/97 (2%)
GCS Mortality
N= 618
Unfavorable PCPC
N=79
3 538/909 (59%) 34/102 (33.3)
4 23/121 (19%) 11/30 (36.7%)
5 19/194 (9.8%) 17/50 (34%)
6 24/498 (4.8%) 10/112 (8.9)
7 10/486 (2.1%) 4/102 (3.9)
8 4/474 (0.8%) 3/101 (2.97%)
GCS-P ≤ 2
Deathn = 618/2682 (23%)
n = 117/2076 (5.6%)
n = 88/2019 (4.4%)OR = 22.8*
YesNo
Cardiac arrestYesNo
GCS-P ≤ 5No Yes
n = 41/531 (7.7%) n = 23/90 (25.6%)
AHTNo Yes
OR = 79.9*
OR = 6.6*
OR = 4.1*
n = 24/1398 (1.7%) n = 64/621 (10.3%)
n = 29/57 (50.9%)
n = 501/606 (82.7%)
Classification and Regression Tree analysis of factors associated with mortality
*p<0.0001
GCS ≤ 5
Unfavorable PCPCn = 79/497 (15.9%)
n = 17/315 (5.4%)
YesNo
AHTYesNo
Cardiac arrest
No
n = 27/131 (20.6%)
PRS= 0 PRS=1 or 2
n = 8/51 (15.7%)
Yes
OR = 9.1*
OR = 5.3*
OR = 8.4*
n = 23/125 (18.4%)
OR = 8.9*
n = 62/182 (34.1%)
n = 35/51 (68.6%)n = 9/264 (3.4%)
n = 4/6 (66.7%)
Classification and Regression Tree analysis of factors associated with
unfavorable functional outcome in survivors
*p<0.0001
Comparison between GCS <5 and GCS-P ≤ 2 as predictors of outcome
Death
Conditions Sensitivity, 95%C.I. Specificity, 95%C.I. PPV, 95%C.I. NPV, 95%C.I.
GCS ≤ 5 0.94 (0.92, 0.96) 0.69 (0.67, 0.71) 0.47 (0.45, 0.50) 0.97 (0.96, 0.98)
GCS-P ≤ 2 0.81 (0.78, 0.84) 0.95 (0.94, 0.96) 0.83 (0.8, 0.86) 0.94 (0.93, 0.95)
Unfavorable discharge PCPC
GCS ≤ 5 0.78 (0.69, 0.86) 0.71 (0.67, 0.76) 0.34 (0.27, 0.41) 0.95 (0.92, 0.97)
GCS-P ≤ 2 0.35 (0.25, 0.46) 0.97 (0.96, 0.99) 0.70 (0.56, 0.84) 0.89 (0.86, 0.92)
Conclusions
GCS-P improves the ability to predict mortality and poor functional
outcome at ICU discharge in children with severe TBI.
Inclusion of GCS-P for risk stratification in future studies is important to
assess effectiveness of interventions as outcomes in this most severely
injured population vary greatly
Future studies that assess long term outcomes should be considered.
Thank you
Association of pupil reactivity with mortality and unfavorable outcome for GCS 3-8
No reactive Pupils (PRS=2)
N = 620
One reactive Pupil (PRS=1)
N = 108
Two reactive pupils (PRS=0)
N= 1954
GCS
Mortality
n = 496 (80%)
Unfavorable
PCPC
n = 27/40 (68%)
Mortality
n = 30 (27.7%)
Unfavorable
PCPC
n = 9/19 (47.3%)
Mortality
n = 92 (4.7%)
Unfavorable PCPC
n = 43/438 (9.8%)
3 462/525 (88%)** 17/25 (68%)** 24/47 (51%)** 5/7 (71.4%) a 52/337 (15.4%) 12/70 (17.1%)
4 15/34 (44%)** 6/8 (75%) a 2/12 (17%) ns 3/4 (75%) b 6/75 (8%) 2/18 (11%)
5 8/21 (38%)** 3/3 (100%) b 1/13 (7.7%) ns 1/4 (25%) ns 10/160 (6.2%) 13/43 (30.2%)
6 8/26 (31%)** 0/2 ns 1/11 (9%) ns 0/1 ns 15/461 (3.2%) 10/109 (9.2%)
7 3/10 (30%)** 0/1 ns 1/16 (6%) ns 0/0 6/460 (1.3%) 4/101 (3.9%)
8 0/4 (0%) ns 1/1 (100%) b 1/9 (11%) ns 0/3 ns 3/461 (0.6%) 2/97 (2.1%)
Compared to PRS = 0, “**” = p<0.0001; “a” = p<0.01; “b” = p<0.05; “ns” = p>0.05