Glasgow Coma Scale Case Study

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Despite the fact that we are now approaching the 44th anniversary of the publication of the Glasgow Coma Scale (GCS)1, there is still a debate that exists for the indication and yield of neuroimaging for minor head trauma. Head trauma in children is one of the most common reasons for visiting emergency department with more than 95% of these constitute minor head trauma, defined as Glasgow Coma Scale (GCS) score greater than or equal to 13. Among these patients, less than 10% have traumatic brain injuries (TBI), less than 1% need neurosurgery and approximately 25% of the visits for blunt head trauma are in children younger than 24 months. In the diagnosis of TBI, cranial CT scan is the diagnostic standard for identifying the presence
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The reason for this is perhaps most clearly shown by looking at the prevalence of intracranial haemorrhage. This varied from 0.9% to 35% among the 16 studies (Table 2). The variation in the ICH prevalence rates is mainly explained by the variability in the inclusion criteria. Those studies that had low prevalence rates studied every patient that was treated for head injury attending the emergency department, whereas the studies with high prevalence rates used criteria such as ‘all children admitted for observation with loss of consciousness’.
A second reason that may have contributed to the heterogeneity is the definition of intracranial haemorrhage used in each study. In the adult literature Stiell et al.8 used a standardised definition after formally surveying 129 academic neurosurgeons, neuroradiologists, and emergency physicians. All brain injuries were judged to be clinically important unless the patient was neurologically intact and had one of: solitary contusion less than 5 mm in diameter; localised subarachnoid blood less than 1 mm thick; smear subdural hematoma less than 4 mm thick; isolated pneumocephaly; or closed depressed skull fracture not through the inner table. However, in the childhood head injury literature there was no single definition of a clinically significant brain injury and therefore some papers with higher rates of reported abnormalities on CT scanning may have been using more liberal definition than others. Also, several studies were not included because of the lack of ability to break down the data presented into child and adult

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