Limitations of the Glasgow Coma Scale in predicting outcome in children with traumatic brain injury

Objective: To study the hypothesis that, in the absence of an ischemic-hypoxic state, children with severe traumatic brain injury and with unfavorable Glasgow Coma Scale scores may have good recovery. Design: Retrospective, observational, cross-sectional study with factorial design. Setting: Inpatient population in a university hospital. Patients: Seventy-nine children with traumatic brain injury admitted to the intensive care unit. Interventions: All patients received close monitoring and strict control of intracranial pressure (<20 mm Hg) and cerebral perfusion pressure (>60 mm Hg). Measurements and results: Admission Glasgow Coma Scale score, survival, need for cardiopulmonary resuscitition, presence of shock, peak intracranial pressure, duration of coma, Glasgow outcome Scale score, and the results of neuropsychologic tests were analyzed. Of 79 children, 70 (89%) survived. Although the mortality rate was higher among patients with Glasgow Coma Scale scores of 3 to 5, 14 (64%) of 22 of these children survived. Nonsurvivors had a significantly higher incidence of shock and need for cardiopulmonary resuscitation. Except for two patients who had prolonged hypoxemia, all children, including those with Glasgow Coma Scale scores of 3 to 5, had a satisfactory outcome (Glasgow Outcome Scale scores of 4 or 5). Neuropsychologic outcome was not significantly different in the survivors with Glasgow Coma Scale scores of 3 to 5 and those with Glasgow Coma Scale scores of 6 or more. Conclusions: A low Glasgow Coma Scale score does not always accurately predict the outcome of severe traumatic brain injury; in the absence of hypoxic-ischemic injury, children with traumatic brain injury and Glasgow Coma Scale scores of 3 to 5 can recover independent function.