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Association of clinically important traumatic brain injury and Glasgow Coma Scale scores in children with head injury
  1. Amit Kochar1,2,
  2. Meredith L Borland2,3,4,
  3. Natalie Phillips2,5,6,
  4. Sarah Dalton2,7,
  5. John Alexander Cheek2,8,
  6. Jeremy Furyk2,9,10,
  7. Jocelyn Neutze2,11,
  8. Mark D Lyttle8,12,
  9. Stephen Hearps13,
  10. Stuart Dalziel2,14,15,
  11. Silvia Bressan12,16,
  12. Ed Oakley2,8,12,
  13. Franz E Babl2,8,12
  1. 1 Emergency Department, Women's and Children's Hospital, Adelaide, SA, Australia
  2. 2 PREDICT, Paediatric Research in Emergency Departments International Collaborative, Melbourne, Victoria, Australia
  3. 3 Division of Paediatrics and Emergency Medicine, School of Medicine, University of Western Australia, Perth, WA, Australia
  4. 4 Emergency Department, Perth Children's Hospital, Perth, Western Australia, Australia
  5. 5 Emergency Department, Queensland Children's Hospital, South Brisbane, Queensland, Australia
  6. 6 Child Health Research Centre, Faculty of Medicine, University of Queensland, South Brisbane, Queensland, Australia
  7. 7 Department of Emergency, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
  8. 8 Emergency Department, Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
  9. 9 Emergency Department, The Townsville Hospoital, Townsville, Queensland, Australia
  10. 10 Emergency Department, University Hospital Geelong, Geelong, Victoria, Australia
  11. 11 Emergency Department, Kidzfirst Middlemore Hospital, Auckland, New Zealand
  12. 12 Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
  13. 13 Emergency Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
  14. 14 Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand
  15. 15 Departments of Surgery and Paediatrics;Child and Youth Health, University of Auckland, Auckland, New Zealand
  16. 16 Department of Women's and Child's Health, University of Padova, Padova, Italy
  1. Correspondence to Dr Amit Kochar, North Adelaide, SA 5006, Australia; amit.kochar{at}


Objective Head injury (HI) is a common presentation to emergency departments (EDs). The risk of clinically important traumatic brain injury (ciTBI) is low. We describe the relationship between Glasgow Coma Scale (GCS) scores at presentation and risk of ciTBI.

Methods Planned secondary analysis of a prospective observational study of children<18 years who presented with HIs of any severity at 10 Australian/New Zealand centres. We reviewed all cases of ciTBI, with ORs (Odds Ratio) and their 95% CIs (Confidence Interval) calculated for risk of ciTBI based on GCS score. We used receiver operating characteristic (ROC) curves to determine the ability of total GCS score to discriminate ciTBI, mortality and need for neurosurgery.

Results Of 20 137 evaluable patients with HI, 280 (1.3%) sustained a ciTBI. 82 (29.3%) patients underwent neurosurgery and 13 (4.6%) died. The odds of ciTBI increased steadily with falling GCS. Compared with GCS 15, odds of ciTBI was 17.5 (95% CI 12.4 to 24.6) times higher for GCS 14, and 484.5 (95% CI 289.8 to 809.7) times higher for GCS 3. The area under the ROC curve for the association between GCS and ciTBI was 0.79 (95% CI 0.77 to 0.82), for GCS and mortality 0.91 (95% CI 0.82 to 0.99) and for GCS and neurosurgery 0.88 (95% CI 0.83 to 0.92).

Conclusions Outside clinical decision rules, decreasing levels of GCS are an important indicator for increasing risk of ciTBI, neurosurgery and death. The level of GCS should drive clinician decision-making in terms of urgency of neurosurgical consultation and possible transfer to a higher level of care.

  • paediatrics
  • paediatric emergency medicine
  • paediatric injury

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  • Contributors AK: conceived the study, obtained grant funding, designed the study, provided overall supervision, interpreted the data, wrote the initial draft of the paper, gave final approval to be published and agreed to be accountable for all aspects of the work. FEB, MB, NP, SD, JAC, JF, JoN, MDL, SB and SD: designed the study, obtained the data, provided supervision, interpreted the data, drafted or revised it critically, gave final approval to be published and agreed to be accountable for all aspects of the work. SH: designed the study, supervised the analysis of the data, contributed to the interpretation of the data, revised the paper critically, gave final approval to be published and agreed to be accountable for all aspects of the work.

  • Funding The study was funded by grants from the National Health and Medical Research Council (project grant GNT1046727, Centre of Research Excellence for Paediatric Emergency Medicine GNT1058560), Canberra, Australia; the Murdoch Children’s Research Institute, Melbourne, Australia; the Emergency Medicine Foundation (EMPJ-11162), Brisbane, Australia; Perpetual Philanthropic Services (2012/1140),Australia; Auckland Medical Research Foundation (No. 3112011) and the A + Trust (Auckland District Health Board), Auckland, New Zealand; WA Health Targeted Research Funds 2013, Perth, Australia; the Townsville Hospital and Health Service Private Practice Research and Education Trust Fund, Townsville, Australia; and supported by the Victorian Government’s Infrastructure Support Program, Melbourne, Australia. FEB’s time was part funded by a grant from the Royal Children’s Hospital Foundation, Melbourne, Australia, a Melbourne Children’s Clinician Scientist Fellowship, Melbourne, Australia; and an NHMRC Practitioner Fellowship, Canberra, Australia. SRD’s time was part funded by the Health Research Council of New Zealand (HRC13/556).

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.