Stalin Ramprakash¹, Bhavani M H^2*

{¹Assistant Professor, Department of Paediatrics} {²Associate Professor, Department of Obstetrics and Gynaecology}

Shridevi Institute of Medical Sciences and Research hospital, NH-4, Bypass Road, Tumkur- 572106, INDIA.

Email: hrbs2006@yahoo.co.in

 RESULTS

Table 1: Age and sex distribution, N=148

Table 2: Etiology and mortality.

In our study we have observed that the mortality is higher in hepatic encephalopathy (61.9%) and hypoxic ischemic encephalopathy (85.7%) most often following revival from cardiac arrest.

Table 3: Association between the score and mortality

Chi-Square = 57.31, P – < 0.000001

It was observed that when the scores were between 3‐ 5 mortality rate was 67.0%, it was 17% when the minimal observed score was between 6-8. The group in which the minimal score never decreased be1ow 9 had no mortality.

Table 4: Association between the score at presentation and mortality.

Chi-Square = 55.45, p = 0.00001

When the relationship between the scores at presentation and final outcome were analysed it was found that those with a score of 5 or less had a mortality of 69% whereas the mortality was only 16.9% in those who had the presentation score as 6 and above. There is significant association between the scores at presentation and final outcome (p < 0.00001)

Table 5: Association between the score after 24 hours and mortality.

Chi-Square = 60.63, p < 0.00001

Those who had scores less than or equal to 5 had a mortality rate of 70.3%. Whereas those with a score above or equal to 6 had only 5.6% mortality.

Table 6:Association between coma score after 48 hrs of admission and mortality

Chi-Square = 63.1, p < 0.00001

From our observations it can be made out that those with a score 5 or less at 48 hrs had 72%mortality whereas mortality for the group with score of 6 or more at 48 hrs was only 7.5%.

Table 7: Association between the coma scores at 72 hrs and mortality

Chi-Square = 72.1, p < 0.00000001

Those who had scores less than or equal to 5 at 72hrs had a mortality of 66.7% but those with 6 and above at 72 hrs had a mortality of about 7.1%. Analysis shows that there is highly significant association between the scores at 72 hrs and mortality (p < 0.00000001).

Table 8: Association between coma score trends and mortality

Chi-square = 38.8, P <0.000001

When the coma score remained static or showed deterioration the mortality was 55.7% and it was 8.9% when the scores improved by atleast one. When there was no change or deterioration in coma score over 48 hrs the mortality was 57.1% and it was 7.4 % when there was improvement in the score by atleast one.

When coma score remained static or showed deterioration by 72 hrs the mortality was 59.3% and when there was improvement by atleast one during the same period the mortality was 7.4%. There was high degree of association between the change in scores over 72 hrs and the mortality.           

Among those children in whom score deteriorated or did not improve over first five day period or till death, mortality was 80.0% and it was 7.7% for the group which showed an improvement in score by atleast one.

Table 9: Sensitivity and Specificity of the different scores at presentation as predictors of mortality

Coma score of 5 Predicts the mortality with optimum sensitivity (79.0%) and specificity (74.4%). By using receiver operating characteristic (ROC) curve the optimum score that has the maximum sensitivity and specificity can be arrived. Score 5 is the optimum cut off point for the prediction of mortality at presentation. Score 5 or less at presentation has increased mortality.

Table 10: Sensitivity and Specificity of different scores at 24 hrs as predictors of mortality

The optimum score which predicts the mortality at 24 hrs with high sensivity 91.8% and specificity 79.06% is 5 or less. A score of 5 or less at 24 hrs is associated with poor outcome.

Table 11: Sensitivity and Specificity of different scores at 48 hrs as predictors of mortality

At 48 hrs score 5 or less predicts the mortality with high sensitivity 83.8% and specificity 86%. Score 5 or less at 48 hrs can be taken as optimum cutoff point below which the prognosis is poor.

Table 12: Sensitivity and Specificity of different scores at 72 hrs as predictors of mortality

The optimum score with high sensitivity and specificity is score 6 (86.3% and 80.27% respectively). Score 6 or less of 72 predicts the mortality with high sensitivity and specificity.

DISCUSSION

Coma scale is a simple clinical tool which can be applied by any trained person. But inter observer variations are likely to occur. When uniform training is given to all those who would be applying the scale the variations can be minimized to a large event. The association between the coma score at various time points, change in scores with time and the mortality were studied using chi-square test. In our study we found that there is highly statistically significant association between the GSC score levels and outcome. As the score increases the proportion of death decreases and the proportion having good recovery increases and vice versa. This type of association has been observed at different time points (Initial, 24 hrs, 48 hrs and 72 hrs). The significance of this association increases with the progression of time since admission. P value for the degree of association at various time points are: At presentation P < 0.00001, 24hrs - P < 0.000001, 48 hrs - P < 0.000001 and 72 hrs P < 0.00000001. This high degree of association is in accordance with the study conducted by Soustiel et al.⁴ who reported that among the clinical parameters GCS provided the most accurate prognosis (in 80%). Study done by Grewal et al.⁵ who found that GCS trend or brain stem reflexes used alone were significantly correlated with outcome. Their study is with comatose children following head injury where as we have conducted the study in non- traumatic coma in children. We have studied the ability of different scores to predict the final outcome using their sensitivity and specificity at various time points viz. initial, 24hrs, 48hrs and72 hrs. We have arrived at the optimum scores that form a cutoff point in prediction of mortality and good recovery at various time points. Optimum scores that predict mortality, at presentation- Score 5 and below predicts increased mortality. Score 5 predicts mortality with sensitivity 79% and specificity 74.4%. At 24 hrs of admission - Score 5 and below predicts increased mortality. Score 5 predicts mortality with sensitivity 91.8% and specificity 79.06%. At 48 hrs of admission - Score 5 and below predicts increased mortality. Score 5 predicts mortality with sensitivity 83.8% and specificity 86.0%. At 72 hrs of admission - Score 6 and below predicts increased mortality. Score 6 predicts mortality with sensitivity 86.3% and specificity 80.2%. It can be seen that the optimum scores that predict mortality increase with time since admission. Longer a patient remains in a lower score poorer is the prognosis. The finding that the score of 5 or less within 24 hrs of hospitalization if associated with poor prognosis is in accordance with the study done by Awasthi et al. ⁶ from Lucknow. Rober H AHaslam⁷ in Nelson textbook of pediatrics also reports that score 5 or less is associated with grave prognosis. In the study conducted by Reddy AM et al.⁸ they concluded that a low total Glagow coma scale score was found to be associated with adverse short-term outcome. The likelihood of death in patients with GCS less than 8 was much higher than when the GCS was >8 i.e., 6 (15%) cases expired out of 38 cases with GCS ≤8 and 2 (4%) cases expired out of 42 cases with GCS >8. In a study by Cicero MX et al. ⁹on pediatric trauma victims they concluded that the Glasgow coma scale is predictive of mortality and injury outcomes, as well as both Emergency Department and hospital length of stay, and has excellent prognostic accuracy. The Glasgow motor component has predictive value for injury and mortality that is nearly equivalent to the full Glagow coma scale.Though many studies have analysed the scores at presentation, cutoff points for different time intervals after admission were not analysed.

CONCLUSION

In our study we found that there is highly statistically significant association between the GSC score levels and outcome. As the score increases the proportion of death decreasesand the proportion having good recovery increases and vice versa. This type of association has been observed at different time points (Initial, 24 hrs, 48 hrs and 72 hrs). The significance of this association increases with the progression of time since admission.

REFERENCES

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