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Application and Clinical Utility of the Glasgow Coma Scale Over Time: A Study Employing the NIDRR Traumatic Brain Injury Model Systems Database

Barker, Marie D. PhD; Whyte, John MD, PhD; Pretz, Christopher R. PhD; Sherer, Mark PhD; Temkin, Nancy PhD; Hammond, Flora M. MD; Saad, Zabedah MS; Novack, Thomas PhD

Section Editor(s): Caplan, Bruce PhD, ABPP; Bogner, Jennifer PhD, ABPP; Brenner, Lisa PhD, ABPP

The Journal of Head Trauma Rehabilitation: September/October 2014 - Volume 29 - Issue 5 - p 400–406
doi: 10.1097/HTR.0b013e31828a0a45
Original Articles

Objective: To examine possible changes in Glasgow Coma Scale (GCS) scores related to changes in emergency management, such as intubation and chemical paralysis, and the potential impact on outcome prediction.

Participants: 10 228 patients from the Traumatic Brain Injury Model Systems national database.

Design: Retrospective study examining 5-year epochs from 1987 to 2012.

Main Measures: GCS score assessed in the Emergency Department (GCS scores for intubated, but not paralyzed, patients were estimated with a formula using 2 of the 3 GCS components), Outcome: Functional Independence Measure (FIM) assessed at rehabilitation admission.

Results: The rate of intubation prior to GCS scoring averaged 43% and did not increase across time. However, a clear increase over time was observed in the use of paralytics or heavy sedatives, with 27% of patients receiving this intervention in the most recent epoch. Estimated GCS scores classified 69% of intubated patients as severely brain injured and 8% as mildly injured. The GCS accounted for a modest, yet consistent, amount of variability (approximately 5%-7%) in FIM scores during most epochs.

Conclusions: Given the frequency of intubation and/or paralysis following brain injury in this sample, estimating GCS or exploring other means to gauge injury severity is beneficial, particularly because a portion likely did not sustain severe brain injury. There is no evidence for declining predictive utility of the GCS over time.

Supplemental Digital Content is Available in the Text.

University of Alabama at Birmingham (Drs Barker and Novack); Moss Rehabilitation Research Institute, Elkins Park, Pennsylvania (Dr Whyte); Craig Hospital (Dr Pretz) and Traumatic Brain Injury National Data and Statistical Center (Dr Pretz), Englewood, Colorado; TIRR Memorial Hermann, Houston, Texas (Dr Sherer); University of Washington, Seattle (Dr Temkin); Indiana University School of Medicine, Indianapolis (Dr Hammond); Carolinas Rehabilitation, Charlotte, North Carolina (Dr Hammond); and University of Northern Colorado, Greeley, Colorado (Ms Saad).

Corresponding Author: Thomas Novack, PhD, University of Alabama at Birmingham, SRC 520, 619 19th St S, Birmingham, AL 35249 (

This research was supported in part by the Traumatic Brain Injury Model Systems (Grants H133A070039, H133A070040, H133A070042, H133A070043, H133A980023, and H133A110006) from the National Institute on Disability and Rehabilitation Research (NIDRR), US Department of Education. However, those contents do not necessarily represent the policy of the Department of Education, and you should not assume endorsement by the Federal Government.

Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (

The authors declare no conflicts of interest.

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