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