Glasgow Coma Scale for Field Triage of Trauma: A Systematic Review [Entered Retrospectively]

Project Summary Title and Description

Title
Glasgow Coma Scale for Field Triage of Trauma: A Systematic Review [Entered Retrospectively]
Description
Objectives. To assess the predictive utility, reliability, and ease of use of the total Glasgow Coma Scale (tGCS) versus the motor component of the Glasgow Coma Scale (mGCS) for field triage of trauma, as well as comparative effects on clinical decisionmaking and clinical outcomes. Data Sources. MEDLINE®, CINAHL, PsycINFO, HAPI (Health & Psychosocial Instruments), and the Cochrane Databases (January 1995 through June, 2016). Additional studies were identified from reference lists and technical experts. Study Selection. Studies on the predictive utility of the tGCS versus the mGCS or Simplified Motor Scale (SMS) (a simplified version of the mGCS), randomized trials and cohort studies on effects of the tGCS versus the mGCS on rates of over- or under-triage, and studies on interrater reliability and ease of use of the tGCS, mGCS, and/or SMS. Data Extraction. One investigator abstracted details about study characteristics and results; a second investigator checked data for accuracy. Two investigators independently applied prespecified criteria to rate study quality. Data on discrimination of tGCS versus mGCS and tGCS versus SMS were pooled using a random effects model. The strength of evidence was determined based on the overall risk of bias, consistency, directness, precision, and reporting bias. Results. 33 studies met inclusion criteria; 24 studies addressed predictive utility and 10 addressed interrater reliability or ease of use. No study assessed comparative effects on over- or under-triage or clinical outcomes. For in-hospital mortality, the tGCS is associated with slightly greater discrimination than the mGCS (pooled mean difference in area under the receiver operating characteristic curve [AUROC] 0.015, 95% confidence interval [CI] 0.009 to 0.022, I2=85%, 12 studies; strength of evidence [SOE]: Moderate) or the SMS (pooled mean difference in AUROC 0.030, 95% CI 0.024 to 0.036, I2=0%, 5 studies; SOE: Moderate). This means that for every 100 trauma patients, the tGCS is able to correctly discriminate 1 to 3 more cases of in-hospital mortality from cases without in-hospital mortality than the mGCS or the SMS . The tGCS is also associated with greater discrimination than the mGCS or SMS for receipt of neurosurgical interventions, severe brain injury, and emergency intubation (differences in AUROC ranged from 0.03 to 0.05; SOE: Moderate). Differences in discrimination between the mGCS versus the SMS were small (differences in the AUROC ranged from 0.000 to 0.01; SOE: Moderate). Findings were robust in sensitivity and subgroup analyses based on age, type of trauma, study years, assessment setting (out-of-hospital vs. emergency department), risk of bias assessment, and other factors. Differences between the tGCS, mGCS, and SMS in diagnostic accuracy (sensitivity, specificity) based on standard thresholds (scores of ≤15, ≤5, and ≤1) were small, based on limited evidence (SOE: Low). The interrater reliability of tGCS and mGCS appears to be high, but evidence was insufficient to determine if there were differences between scales (SOE: Insufficient). Three studies found the tGCS associated with a lower proportion of correct scores than the mGCS (differences in proportion of correct scores ranged from 6% to 27%), though the difference was statistically significant in only one study (SOE: Low). Limitations. Evidence on comparative predictive utility was primarily restricted to effects on discrimination. All studies on predictive utility were retrospective and the mGCS and SMS were taken from the tGCS rather than independently assessed. Most studies had methodological limitations. We restricted inclusion to English-language studies and were limited in our ability to assess publication bias. Studies on ease of use focused on scoring of video or written patient scenarios; field studies and studies on other measures of ease of use such as time required and assessor satisfaction were not available. Conclusions. The tGCS is associated with slightly greater discrimination than the mGCS or SMS for in-hospital mortality, receipt of neurosurgical interventions, severe brain injury, and emergency intubation. The clinical significance of small differences in discrimination is likely to be small, and could be offset by factors such as convenience and ease of use. Research is needed to understand how use of the tGCS versus the mGCS or SMS impacts clinical outcomes and risk of over- or under-triage.
Attribution
N/A
Authors of Report
N/A
Methodology description
Data Sources. MEDLINE®, CINAHL, PsycINFO, HAPI (Health & Psychosocial Instruments), and the Cochrane Databases (January 1995 through June, 2016). Additional studies were identified from reference lists and technical experts. Study Selection. Studies on the predictive utility of the tGCS versus the mGCS or Simplified Motor Scale (SMS) (a simplified version of the mGCS), randomized trials and cohort studies on effects of the tGCS versus the mGCS on rates of over- or under-triage, and studies on interrater reliability and ease of use of the tGCS, mGCS, and/or SMS. Data Extraction. One investigator abstracted details about study characteristics and results; a second investigator checked data for accuracy. Two investigators independently applied prespecified criteria to rate study quality. Data on discrimination of tGCS versus mGCS and tGCS versus SMS were pooled using a random effects model. The strength of evidence was determined based on the overall risk of bias, consistency, directness, precision, and reporting bias.
PROSPERO
CRD42016035944
DOI
10.26300/p7we-zk98
Notes
This project was entered retrospectively. Data Abstraction is available in the attached documents.
Funding Source
Agency for Healthcare Research and Quality. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-2015-00009-I.) AHRQ Publication No.16(17)-EHC041-EF.

Key Questions

1. Key Question 1. In patients with known or suspected trauma, what is the predictive utility of the tGCS compared with the mGCS for predicting in-hospital mortality, morbidity, Injury Severity Score of 16 or greater, head Abbreviated Injury Scale score greater than 2 or greater than 3, presence of intracranial hemorrhage, and utilization indicators of severe injury (e.g., receipt of intracranial monitoring within 48 hours of admission, receipt of a neurosurgical intervention within 12 hours of admission, or early intubation [in the field or immediately upon presentation to the ED])? Key Question 1a. How does predictive utility vary according to patient age or other patient characteristics (e.g., TBI vs. unspecified or other trauma, systolic blood pressure, level of intoxication, type of trauma, intubation or receipt of medications in the field), the training and background of the person administering the instrument, and the timing/setting of assessment (i.e., in the field vs. upon presentation to the ED or urban vs. rural location)?
2. Key Question 4. In patients with known or suspected trauma, what is the comparative reliability (e.g., interrater and intra-rater kappa) and ease of use (e.g., time to complete, amount of missing data, user reported satisfaction) of the tGCS compared with the mGCS score? Key Question 4a. How do comparative reliability and ease of use vary according to patient age or other patient characteristics (e.g., TBI vs. unspecified or other trauma, systolic blood pressure, level of intoxication, type of trauma, intubation or receipt of medication in the field), the training and background of the person administering the instrument, and the timing/setting of assessment (i.e., in the field vs. upon presentation to the ED or urban vs. rural location)?

Associated Extraction Forms

Associated Studies (each link opens a new tab)

TitleAuthorsYear
Send severely head-injured children to a pediatric trauma center.1996
Efficacy of the motor component of the Glasgow Coma Scale in trauma triage.1998
Improving the Glasgow Coma Scale score: motor score alone is a better predictor.2003
Initial emergency department trauma scores from the OPALS study: the case for the motor score in blunt trauma.
A comparison of the Glasgow Coma Scale score to simplified alternative scores for the prediction of traumatic brain injury outcomes.2005
The predictive value of field versus arrival Glasgow Coma Scale score and TRISS calculations in moderate-to-severe traumatic brain injury.2006
A comparison of five simplified scales to the out-of-hospital Glasgow Coma Scale for the prediction of traumatic brain injury outcomes.2006
Validation of the Simplified Motor Score for the prediction of brain injury outcomes after trauma.2007
Assessing the level of consciousness in children: a plea for the Glasgow Coma Motor subscore.2008
Comparison of the Full Outline of Unresponsiveness Score Coma Scale and the Glasgow Coma Scale in an emergency setting population.2009
The prehospital simplified motor score is as accurate as the prehospital Glasgow coma scale: analysis of a statewide trauma registry.2012
Validation of the Simplified Motor Score in the out-of-hospital setting for the prediction of outcomes after traumatic brain injury.2011
Modification of Glasgow Coma Scale criteria for injured elders.2011
Predictive value of initial Glasgow coma scale score in pediatric trauma patients.2013
Injury pattern, hospital triage, and mortality of 1250 patients with severe traumatic brain injury caused by road traffic accidents.2014
A comparison of the prehospital motor component of the Glasgow coma scale (mGCS) to the prehospital total GCS (tGCS) as a prehospital risk adjustment measure for trauma patients.-- Not Found --
Prehospital heart rate and blood pressure increase the positive predictive value of the Glasgow Coma Scale for high-mortality traumatic brain injury.2014
Components of traumatic brain injury severity indices.2014
Evidence-based improvement of the National Trauma Triage Protocol: The Glasgow Coma Scale versus Glasgow Coma Scale motor subscale.2014
Glasgow motor scale alone is equivalent to Glasgow Coma Scale at identifying children at risk for serious traumatic brain injury.2014
Glasgow coma scale motor score and pupillary reaction to predict six-month mortality in patients with traumatic brain injury: comparison of field and admission assessment.2015
Glasgow Coma Scale Motor Component ("Patient Does Not Follow Commands") Performs Similarly to Total Glasgow Coma Scale in Predicting Severe Injury in Trauma Patients.2016
Performance of the pediatric glasgow coma scale in children with blunt head trauma.2005
Does a prehospital Glasgow Coma Scale score predict pediatric outcomes?2012
Effectiveness of a Glasgow Coma Scale instructional video for EMS providers.-- Not Found --
A comparison of prehospital and hospital data in trauma patients.
Agreement between prehospital and emergency department glasgow coma scores.2007
Knowledge of Glasgow coma scale by air-rescue physicians.
A simple and useful coma scale for patients with neurologic emergencies: the Emergency Coma Scale.
Level of agreement between prehospital and emergency department vital signs in trauma patients.2013
Randomized controlled trial of a scoring aid to improve Glasgow Coma Scale scoring by emergency medical services providers.
Glasgow Coma Scale Scoring is Often Inaccurate.2015

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