Research Review - Final – Jan. 12, 2017
Glasgow Coma Scale for Field Triage of Trauma: A Systematic Review
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Structured Abstract
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, and effects on clinical decisionmaking and clinical outcomes.
Data sources
MEDLINE®, CINAHL®, PsycINFO®, HaPI (Health and Psychosocial Instruments), the Cochrane Databases (January 1995 through June 2016), and reference lists.
Study selection
Studies on predictive utility of the tGCS versus the mGCS or Simplified Motor Scale (SMS), 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.
Data extraction
One investigator abstracted study characteristics and results; a second checked data for accuracy. Two investigators independently applied prespecified criteria to rate study quality. Data on discrimination were pooled using a random effects model. The strength of evidence was graded using published methods.
Results
Thirty-two 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 correctly discriminates 1 to 3 more cases of in-hospital mortality from cases without in-hospital mortality than the mGCS or 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 from 0.03 to 0.05; SOE: Moderate). Differences in discrimination between mGCS and SMS were very small.
Findings were robust in sensitivity and subgroup analyses. Differences among the tGCS, mGCS, and SMS in diagnostic accuracy (sensitivity, specificity) using standard thresholds were small, based on limited evidence (SOE: Low). Evidence was insufficient to determine if there were differences between the tGCS and the mGCS in interrater reliability (SOE: Insufficient). Three studies found that the tGCS was associated with lower proportions of correct scores than the mGCS; differences ranged from 6 percent to 27 percent (SOE: Low).
Limitations
Evidence on comparative predictive utility was primarily restricted to effects on discrimination. All predictive utility studies were retrospective, and mGCS and SMS were taken from tGCS rather than independently assessed. Most studies had methodological limitations. We included only 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.
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.
Key Messages
- The tGCS is associated with slightly greater discrimination than the mGCS or Simplified Motor Score (SMS) for in-hospital mortality, receipt of neurosurgical interventions, severe brain injury, and emergency intubation. For every 100 trauma patients, the tGCS is able to correctly discriminate 1 to 5 more patients than the mGCS or the SMS.
- Limited evidence suggests that the mGCS is easier to score correctly than the tGCS.
- The clinical significance of differences in discrimination is likely to be small and could be offset by factors such as convenience and ease of use.
- Future 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.
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