NATIONAL JOURNAL OF EMERGENCY MEDICINE

ASSESSING THE MOTOR COMPONENT OF THE GCS SCORING SYSTEM

AS A BETTER PREDICTOR OF OUTCOME
Meyei S Appachi*1, Mahadevan D2, Eswaran VP3

ABSTRACT Conclusions: The motor component of GCS scoring

Background: Components of the Glasgow Coma Scale system is a better predictor of 3 month outcome while
[GCS] alone are simpler and can predict outcome in TBI the GCS in its summed form is a better indicator for
and acute stroke [AS]. requirement of endotracheal intubation in TBI and AS.

Objectives: To assess whether motor component of the
GCS on initial presentation is enough as a better predictor
of outcome and better indicator of endotracheal
intubation [ETI] in patients with TBI and AS.
Methods: Patients aged above 14 years diagnosed of
having TBI and AS presenting within 24 hours were
included. Patient's arrival GCS in Emergency Room and
GCS during ETI either on arrival or during course of
hospital stay were recorded. The outcomes were
determined in terms Glasgow Outcome Scale [GOS] at 3
months and requirement of ETI. The ability of total GCS
and its Components to predict outcome using receiver
operating characteristic [ROC] analysis was carried out.
Results: Of 375 patients, 68.8% were TBI and 31.2% were
AS. 65.1% of all patients had a good outcome at 3 months
and 45.1% was intubated. For outcome at 3 months, area
under curve [AUC] was greatest for motor component in
all patients [0.937] as well as in TBI [0.959]. But in AS, AUC
was greatest for total GCS [0.909] with similar magnitude
for motor component [0.908]. Among AS, AUC was
greatest for motor component in ischemic stroke [0.892]
and greatest for total GCS [0.944] followed by motor
component [0.919] in haemorrhagic stroke. For
requirement of ETI, AUC was greatest for total GCS in all
patients [0.977], TBI [0.982] and AS [0.967]. Among AS,
AUC was greatest for eye component [0.969] in ischemic
stroke and greatest for total GCS [0.981] in haemorrhagic
stroke.
Keywords: Acute Stroke, Endotracheal intubation,
Glasgow coma scale, Outcome predictors, Traumatic
brain injury.
INTRODUCTION
The Glasgow Coma Scale [GCS] also known as the
Glasgow Coma Score is a neurological scale which aims to
give a reliable, objective way of recording the conscious
state of a person, for initial as well as continuing
assessment (1). Teasdale and Jennett in 1974 wrote
Impaired consciousness is an expression of dysfunction
in the brain as a whole that may be due to agents acting
diffusely . . . or to the combination of remote and local
effects produced by brain damage which was initially
focal (2). The GCS is typically praised for its ease of use
and has been used to grade individual levels of
consciousness, compare effectiveness of treatment, and
as a prognostic indicator.
GCS has enjoyed universal acceptance as an important
standard tool for communication of mental status in both
traumatized and non-traumatized patients, and in the
care of trauma patients (3, 4). It is incorporated into many
scoring systems due to the ease and appeal of the GCS.
GCS is used as part of several intensive care unit [ICU]
scoring systems, including Acute Physiology and Chronic
Health Evaluation II [APACHE II], Simplified Acute
Physiology Score II [SAPS II], and Sepsis-related Organ
Failure Assessment [SOFA], to assess the status of the
central nervous system and is a component of the Trauma

1
Assistant Professor, Department of Accident, Emergency & Critical Care Medicine, Vinayaka Mission's Kirupananda Variyar Medical College & Hospitals,
Vinayaka Mission University, Sankari Main Road [NH-47], Veerapondi-Post, Salem-636308, Tamilnadu,India. Email: docmeyei@gmail.com
2
Associate Professor, Department of Neurology, Vinayaka Mission's Kirupananda Variyar Medical College & Hospitals,
Vinayaka Mission University, Sankari Main Road [NH-47], Veerapondi-Post, Salem-636308, Tamilnadu,India. Email: drdmahadevan@gmail.com
3
Prof of General Medicine, Academic Director Dept of Accident, Emergency & Critical Care Medicine, Vinayaka Mission's Kirupananda Variyar
Medical College & Hospitals, Vinayaka Mission University, Sankari Main Road [NH-47], Veerapondi-Post, Salem-636308, Tamilnadu,India.
Email: info@vinayakahospital.com mailto:drvpchandru@gmail.com

August - October 2012, Vol : 1, Issue : 1 41


and Injury Severity Score [TRISS], the Circulation,
Respiration, Abdomen, Motor, Speech [CRAMS] Scale
and the Revised Trauma Score (1, 4, 5, 6).
Traumatic Brain Injuries [TBI] are a major public health
problem in India, resulting in deaths, injuries and
disabilities of young and productive people of our society.
India has the rather unenviable distinction of having the
highest rate of head injury in the world. In India, more
than 100,000 lives are lost every year with over 1 million
suffering from serious head injuries and 1 out of 6 trauma
victims die. Most road traffic accident victims are in the
20- to 40-year age group, the main bread-earners of the
family, putting the whole family below the poverty line,
while depriving society of vital drivers of economy as in
many cases these are entrepreneurs or professionals (7).
The economic losses to India are phenomenal, though
unmeasured. As India progresses to greater growth and
development in terms of motorization, urbanization, TBIs
would increase in India. By 2050, India would have the
greatest number of automobiles on the planet,
overtaking the United States (8).
Stroke is defined as a sudden loss of brain function
resulting from an interference with blood supply to the
brain. It limits stroke to an acute vascular phenomenon
that includes ischemic strokes and haemorrhagic strokes
(9). Brain stroke is the third largest killer in India and the
second largest in the world, and the incidence in India is
around 130 per 100,000 population every year according
to the World Health Organization (10). The last few
decades have seen a rise in the incidence and prevalence
of stroke in India, attributable to increasing life span,
urbanization, and better survival, and the rates are now
matching western figures (11).
As a result of both TBI and Stroke, there is an increase in
mortality and long-term or lifelong disability that will
need for help in performing activities of daily living (12). A
patient's condition during the first few weeks after a TBI is
extremely unstable and life-threatening. During such
critical periods, accurate neurological assessment is
essential for predicting recovery (13). The GCS is a quick,
simple, and objective tool widely used and accepted
prognostic score for both traumatic and non-traumatic
altered conscious level (14, 15, 16). The ability to predict
the outcome in TBI and stroke can influence clinical
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NATIONAL JOURNAL OF EMERGENCY MEDICINE
decisions and also helps in the efficient use of resources and
communicating with the families of the victims (17, 18).
As stroke may cause localized motor, speech or language
deficits, the accuracy of GCS to measure the level of
consciousness as well as its prognostic predictability may
be affected (3). Similarly in head injury, there could be
inaccuracy in GCS measurement due to un-testable
components due to sedation paralysis, intubation,
alcohol or illicit drug intoxication or in facial injury causing
periorbital swelling (19, 20, 21, 22).
Simplicity of the GCS was the principle concern with the
goal to provide a method to quantify and communicate
with other members of the health care system describing
the degree of altered consciousness or coma (23, 24). The
correct assessment of the GCS shows variability among
health care providers and it is unnecessarily complex for
the initial assessment in the out-of-hospital setting (3,
25). The GCS is most often reported as a single and overall
score, although the scale authors did not recommend the
summary score for use in clinical practice. The use of a
global summary score may result in a loss of information
that adversely affects the predictive accuracy of the GCS
(26, 27, 28).
Various simplified scoring systems have been formulated
to predict the outcome in TBI and stroke (3, 29). As the
motor response forms the major component of the GCS
scoring system and due to the complexity of GCS, the
motor component alone could replace The Glasgow
Coma Scale in prediction of outcome in TBI and stroke.
Motor component is a simpler, quicker and easier
method of measurement.
The aim of this study is to assess the components of the
GCS on initial presentation and to see if motor score
alone is enough as a better predictor of outcome and as a
better indicator of endotracheal intubation [ETI] in
patients with TBI and acute stroke [AS].
MATERIALS AND METHODOLOGY
Study Design:-
The proposed study was submitted to the institutional
review board of our hospital. Following approval we
performed a prospective observational study from
October 2009 to July 2011.
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 NATIONAL JOURNAL OF EMERGENCY MEDICINE
Study Setting and Population:-
Vinayaka Mission Hospitals is the one of the Level 1
trauma centers located in Salem, in the southern part of
India. The hospital has got a well equipped and
sophisticated thirty bedded emergency room with a good
quantum of varied cases with agile emergency
physicians, vigilant staff nurses and paramedics round
the clock. The Emergency Department [ED] treats about
5000 patients per year from a population of
approximately over thirty lakh inhabitants in an area of
5200 square kilometers, 50% of the population live in an
urban environment. Our 450 bedded hospital treats
more than 20,000 patients per year, with 3000
admissions to intensive care units.
All the patients aged above 14 years diagnosed of having
TBI and AS presenting within 24 hours were included.
Patients who are intubated and/or sedated on
presentation, patients with hypoxia [SpO2 < 92%],
hypotension [Systolic Blood Pressure < 90 mm Hg],
alcohol or illicit drug intoxication on presentation,
patients with bilateral orbital edema, traumatic paralysis
[high spinal cord injury], previous functional/cognitive
disabilities, causes of mortality other than TBI and AS,
and patients who are unable to be followed-up at 3
months were excluded from the study.
Methods:-
All consecutive patients attending the ED of our Hospital
with TBI or AS included in the study were treated
according to Advanced Trauma Life Support [ATLS] and
American Stroke Association [ASA] guidelines
respectively. Data collected on all patients on admission
included age, sex, GCS [eye, motor and verbal], vital signs,
pupil size and response, time and cause of injury, and
Computed Tomography [CT] brain result. The CT brain
scanning in stroke was performed to exclude any non-
vascular cause of neurological deficit (29). The GCS
during ETI either on arrival or during course of hospital
stay was also recorded.
The Glasgow Coma Scale:
GCS is the sum of three coded values that describe a
patient's best motor [16], verbal [15] and eye [14]
response to speech or pain [TABLE 1]. The patient is
August - October 2012, Vol : 1, Issue : 1
assessed against the criteria of the scale and the resulting
points give a score between 3 being the lowest [worst]
and 15 being the highest [best] score. The patient's best
initial summed GCS score as well as the GCS score that is
broken down in to components [eye, motor and verbal],
after fluid resuscitation and stabilization of the patient,
are recorded by experienced emergency physician at the
time of arrival to the ED. The GCS score calculated by
paramedics on the scene is not considered as it had no
prognostic value (30). For AS patients presenting with
aphasia, the GCS verbal score is arbitrarily assigned as
'one' (31). When assessing the motor sub-score, the best
location for applying a painful stimulus is the nail bed and
the best response is recorded from either arm. For those
with more experience, supraorbital pressure was used as
a painful stimulus (32).
Outcome Measures:-
The main outcome considered in this study was
measurement of functional disability by the five-point
Glasgow Outcome Scale [GOS] score at 3 months (33)
[TABLE 2]. For ease of analysis and reporting, the five-
point GOS score was modified into broader outcome
categories as good outcome [good recovery or moderate
disability] and bad outcome [severe disability, persistent
vegetative state or dead] (34, 35) [TABLE 3]. The follow up
GOS was rated by an expert physician unaware of the
study protocol, on the basis of the response to a
structured telephone call or neurological examination at
3 months (36). Additionally, the requirement for ETI was
also assessed.
Data Analysis:-
All data were compiled into Microsoft Excel 2007 spread
sheet and statistical analysis was accomplished using
statistical method for calculations provided within
Statistical package for social science software [version
11.5]. The logistic regression analysis was performed and
classifications of observed and predicted outcomes were
identified. The Receiver Operating Characteristic [ROC]
analysis was carried out by Non-parametric Receiver
Operating Characteristic Analysis Software [Version 2.5]
for GCS and its components, and measured the areas
under these curves [AUCs] to compare the predictive
valve for outcome at 3 months in TBI and AS patients. The
43

same method was used for analysis of GCS and its
components in predicting requirement for ETI in TBI and
AS patients. p < 0.05 was considered statistically
significant.
RESULTS
The study sample analyzed consisted of 375 cases, of
which 81.33% were male and 18.67% were female. The
median age was 40 years [IOR = 29 years]. Of 375 patients
in the study, 68.8% were TBI and 31.2% were AS. Out of
258 cases of TBI, 36.4% were due to mild TBI, 17.4% were
due to moderate TBI and 46.1% were due to severe TBI.
Out of 117 cases of AS, 53.8% were due to ischemic stroke
and 46.2% were due to haemorrhagic stroke. At
admission, median of total GCS score was 10 [TBI - 9 and
AS - 10]. Highest frequency of total GCS occurred for 15 in
81 [21.6%] patients followed by 7 in 43 [11.5%] patients.
45.1% of patients were intubated either on arrival or
during the course of hospital stay [TABLE 4]. The median
GCS for requirement of ETI was 6 [TBI - 7 and AS - 6].
65.1% of patients had a good outcome as per GOS at 3
months [67.8% for TBI and 59% for AS].
From the classification of observed and predicted cases
for overall patients, it is found that 80.9% correctly
classified the bad outcome, 96.3% correctly classified the
good outcome and 90.9% correctly classified overall
outcome by the logistic regression. For TBI, it is found that
85.5% correctly classified the bad outcome, 96%
correctly classified the good outcome and 92.6%
correctly classified overall outcome by the logistic
regression. For AS, it is found that 75% correctly classified
the bad outcome, 94.2% correctly classified the good
outcome and 86.3% correctly classified overall outcome
by the logistic regression. The ROC curve analysis showed
the AUC was greatest for motor component in all patients
[AUC = 0.937] {95% confidence interval [CI] = 0.909 to
0.965} as well as in TBI [AUC = 0.959, 95% CI = 0.936 to
0.982] with p < 0.001. In AS, the AUC was greatest for total
GCS [AUC = 0.909, 95% CI = 0.854 to 0.964] with similar
magnitude for motor component [AUC = 0.908, 95% CI =
0.847 to 0. 0.968], with p < 0.001 [GRAPH 1, 2, 3, TABLE 5].
From the classification of observed and predicted cases
for acute ischemic stroke, it is found that 72.2% correctly
classified the bad outcome, 100% correctly classified the
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NATIONAL JOURNAL OF EMERGENCY MEDICINE
good outcome and 92.1% correctly classified overall
outcome by the logistic regression. For acute
haemorrhagic stroke, it is found that 90% correctly
classified the bad outcome, 83.3% correctly classified the
good outcome and 87% correctly classified overall
outcome by the logistic regression. The ROC curve
analysis showed the AUC was greatest for motor
component in acute ischemic stroke [AUC = 0.892, 95% CI
= 0.783 to 1.001] with p < 0.001. In acute haemorrhagic
stroke, the AUC was greatest for total GCS [AUC = 0.944,
95% CI = 0.886 to 1.001] followed by motor component
[AUC = 0.919, 95% CI = 0.845 to 0.993] with p < 0.001
[GRAPH 4, 5, TABLE 6].
From the classification of observed and predicted cases
for overall patients, it is found that 91.1% correctly
classified the non intubated cases, 96.7% correctly
classified the intubated cases and 93.3% correctly
classified the overall requirement of ETI by the logistic
regression. For TBI, it is found that 92.7% correctly
classified the non intubated cases, 94.1% correctly
classified the intubated cases and 93.3% correctly
classified the overall requirement of ETI by the logistic
regression. For AS, it is found that 91.5% correctly
classified the non intubated cases, 87% correctly
classified the intubated cases and 89.7% correctly
classified the overall requirement of ETI by the logistic
regression. The ROC curve analysis showed the AUC was
greatest for total GCS [AUC = 0.977, 95% CI = 0.964 to
0.991] in all patients with p < 0.001. In TBI and AS, the AUC
was greatest for total GCS [AUC = 0.982, 95% CI = 0.968 to
0.997 and 0.967, 95% CI = 0.938 to 0.996 respectively]
with p < 0.001 [GRAPH 6, 7, 8, TABLE 7].
From the classification of observed and predicted cases
for acute ischemic stroke, it is found that 93.2% correctly
classified the non intubated cases, 84.2% correctly
classified the intubated cases and 90.5% correctly
classified the overall requirement of ETI by the logistic
regression. For acute haemorrhagic stroke, it is found
that 92.6% correctly classified the non intubated cases,
92.6% correctly classified the intubated cases and 92.6%
correctly classified the overall requirement of ETI by the
logistic regression. The ROC curve analysis showed the
AUC was greatest for eye component [AUC = 0.969, 95%
CI = 0.933 to 1.006] followed by total GCS [AUC = 0.944,
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95% CI = 0.882to 1.006] in acute ischemic stroke with p < Good/Favourable Bad/Unfavourable
0.001. In acute haemorrhagic stroke, the AUC was
greatest for total GCS [AUC = 0.981, 95% CI = 0.952 to Severe Disability
1.009] with p < 0.001 [GRAPH 9, 10, TABLE 8]. Good recovery
Persistent Vegetative State
Moderate Disability
Dead
Parameter Response Score
Spontaneous 4 TABLE 3 : Broader outcome categories of GOS
Eye To speech 3
opening To pain 2
None 1
Variables Details n [%]
Oriented 5
Best Confused conversation 4 Mean - 41.47
verbal Inappropriate words 3
response Age Median - 40
Incomprehensible sounds 2
None 1 IQR - 29
Obeys commands 6 Male 305 [81.3%]
Localizes pain 5 Sex
Best Female 70 [18.7%]
Withdrawal (normal flexion) 4
motor
response Abnormal flexion (decorticate) 3 Traumatic Brain Injury 258 [68.8%]
Extension (decerebrate) 2 Diagnosis
None 1 Acute Stroke 117 [31.2%]

TABLE 1 : GLASGOW COMA SCALE Mild Head Injury 94 [36.4%]

Severity of TBI Moderate Head Injury 45 [17.4%]
1 Dead Non-survival Severe Head Injury 119 [46.1%]

Vegetative Nature of Ischemic Stroke 63 [53.8%]

2 Minimal responsiveness
state acute stroke
Haemorrhagic Stroke 54 [46.2%]
Conscious and able to follow
Severe commands Endotracheal
3 Traumatic Brain Injury 115 [44.6%]
disability Dependent on others for daily intubation
support 54 [46.2%]
Acute stroke
Able to live independently
Moderate Unable to return to work or All Patients 169 [45.1%]
4
disability school TABLE 4: Demographic and injury characteristics
Can work in sheltered setting
Able to return to work or school
5 Good recovery Resumption of normal life
despite minor deficits
TABLE 2 : The Five-Point GOS

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Asymptotic Asymptotic
95% 95%
Confidence Patient Test Result Std. Confidence
Patient Test Result Std. Area p Interval
Area p Interval Groups Variable[s] Error
Groups Variable[s] Error
Lower Upper
Lower Upper Bound Bound
Bound Bound
Eye
Eye component 0.804 0.071 <0.001 0.665 0.942
0.829 0.023 <0.001 0.784 0.873
component
Ischemic Verbal
0.677 0.070 0.029 0.540 0.814
Verbal stroke component
All 0.833 0.021 <0.001 0.792 0.874
component [n=63] Motor
Patients 0.892 0.056 <0.001 0.783 1.001
component
[n=375] Motor
0.937 0.014 <0.001 0.909 0.965 Total GCS 0.869 0.055 <0.001 0.760 0.978
component
Total GCS 0.931 0.013 <0.001 0.906 0.956 Eye
component 0.860 0.054 <0.001 0.753 0.966

Eye Haemorrhagic Verbal

0.843 0.026 <0.001 0.792 0.893 0.881 0.051 <0.001 0.780 0.982
component stroke component
[n=54] Motor
Verbal 0.919 0.038 <0.001 0.845 0.993
TBI 0.866 0.022 <0.001 0.823 0.909 component
component
[n=258] Total GCS 0.944 0.029 <0.001 0.886 1.001
Motor
0.959 0.012 <0.001 0.936 0.982
component TABLE 6 : AUCS FOR TOTAL AND INDIVIDUAL GCS COMPONENTS
Total GCS 0.948 0.012 <0.001 0.924 0.972 ROC CURVES FOR OUTCOME AT 3 MONTHS ACCORDING TO
NATURE OF ACUTE STROKE: [N=258]
Eye
0.839 0.040 <0.001 0.760 0.917
component Asymptotic 95%
Confidence
Acute Verbal Patient Test Result Std. Interval
0.760 0.044 <0.001 0.672 0.847 Groups Variable[s]
Area
Error
p
Stroke component Lower Upper
[n=117] Motor Bound Bound
0.908 0.031 <0.001 0.847 0.968
component
Eye component 0.942 0.013 <0.001 0.917 0.968
Total GCS 0.909 0.028 <0.001 0.854 0.964
All Verbal
Patients 0.899 0.017 <0.001 0.866 0.931
component
TABLE 5 : AUCS FOR TOTAL AND INDIVIDUAL GCS [n=375]
Motor
COMPONENTS ROC CURVES FOR OUTCOME AT component
0.938 0.011 <0.001 0.916 0.961
3 MONTHS
Total GCS 0.977 0.007 <0.001 0.964 0.991

Eye component 0.938 0.017 <0.001 0.905 0.971

Verbal
TBI 0.950 0.014 <0.001 0.923 0.976
component
[n=258]
Motor
0.945 0.012 <0.001 0.921 0.970
component
Total GCS 0.982 0.008 <0.001 0.968 0.997

Eye component 0.956 0.018 <0.001 0.921 0.990

Acute Verbal
0.808 0.040 <0.001 0.731 0.886
Stroke component
[n=117] Motor
0.928 0.025 <0.001 0.880 0.976
component

Total GCS 0.967 0.015 <0.001 0.938 0.996

TABLE 7 : AUCS FOR TOTAL AND INDIVIDUAL GCS COMPONENTS

ROC CURVES FOR REQUIREMENT OF ENDOTRACHEAL INTUBATION

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Asymptotic
95%
Patient Test Result Std. Confidence
Area p Interval
Groups Variable[s] Error
Lower Upper
Bound Bound
Eye
0.969 0.019 <0.001 0.933 1.006
component

Ischemic Verbal
0.770 0.058 0.001 0.655 0.884
stroke component
[n=63] Motor
0.880 0.047 <0.001 0.787 0.973
component
Total GCS 0.944 0.032 <0.001 0.882 1.006

Eye
0.930 0.038 <0.001 0.856 1.004
component
GRAPH 2 : AUCS FOR TOTAL AND INDIVIDUAL GCS COMPONENTS
Haemorrhagic Verbal
0.874 0.052 <0.001 0.773 0.976 ROC CURVES FOR OUTCOME AT 3 MONTHS IN TBI : [N=258]
stroke component
[n=54] Motor
0.968 0.019 <0.001 0.930 1.006
component
Total GCS 0.981 0.015 <0.001 0.952 1.009

TABLE 8 : AUCS FOR TOTAL AND INDIVIDUAL GCS

COMPONENTS ROC CURVES FOR REQUIREMENT OF
ENDOTRACHEAL INTUBATION ACCORDING TO NATURE
OF ACUTE STROKE: [N=258]

GRAPH 3 : AUCS FOR TOTAL AND INDIVIDUAL GCS

COMPONENTS ROC CURVES FOR OUTCOME AT 3 MONTHS
IN ACUTE STROKE:[N=117]

GRAPH 1 : AUCS FOR TOTAL AND INDIVIDUAL GCS

COMPONENTS ROC CURVES FOR OUTCOME AT 3 MONTHS
IN ALL PATIENTS: [N=375]

GRAPH 4 : AUCS FOR TOTAL AND INDIVIDUAL GCS

COMPONENTS ROC CURVES FOR OUTCOME AT 3
MONTHS IN ACUTE ISCHEMIC STROKE: [N=63]
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GRAPH 5 : AUCS FOR TOTAL AND INDIVIDUAL GCS GRAPH 8 : AUCS FOR TOTAL AND INDIVIDUAL GCS
COMPONENTS ROC CURVES FOR OUTCOME AT 3 MONTHS COMPONENTS ROC CURVES FOR REQUIREMENT OF
IN ACUTE HEMORRHAGIC STROKE: [N=54] ENDOTRACHEAL INTUBATION IN ACUTE STROKE:[N=117]

GRAPH 6 : AUCS FOR TOTAL AND INDIVIDUAL GCS GRAPH 9 : AUCS FOR TOTAL AND INDIVIDUAL GCS COMPONENTS
COMPONENTS ROC CURVES FOR REQUIREMENT OF ROC CURVES FOR REQUIREMENT OF ENDOTRACHEAL
ENDOTRACHEAL INTUBATION IN ALL PATIENTS:[N=375] INTUBATION IN ACUTE ISCHEMIC STROKE: [N=63]

GRAPH 10 : AUCS FOR TOTAL AND INDIVIDUAL GCS

GRAPH 7 : AUCS FOR TOTAL AND INDIVIDUAL GCS
COMPONENTS ROC CURVES FOR REQUIREMENT OF
COMPONENTS ROC CURVES FOR REQUIREMENT OF
ENDOTRACHEAL INTUBATION IN ACUTE HAEMORRHAGIC
ENDOTRACHEAL INTUBATION IN TBI: [N=258]
STROKE:[N=54]
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DISCUSSION
The main issues ensuing from TBI are cognitive and
personality problems, rather than physical disability (37).
TBI and AS patients with poor prognosis receiving an
effective treatment may benefit only by surviving and
become completely dependent with poor quality of life
resulting in a huge burden of care, largely borne by the
immediate relatives (29). Continuous efforts are being
made by researchers to identify the prognostic indicators
in these patients that would help the family for an
efficient planning of their income and funds. Unlike many
other studies, we assessed the outcome predictive ability
of GCS and its components in both TBI and AS patients.
We also carried out a similar analysis in subgroup of AS
patients according to the nature of stroke [hemorrhagic
and ischemic stroke].
In this study, we found that the motor component of the
GCS scoring system performed better than the total GCS,
eye and verbal components of GCS in predicting outcome
in all patients [both TBI and AS together] as well as in TBI
patients alone. In AS patients alone, the total GCS and the
motor component accurately predicted outcome in an
equivalent manner. Our findings were similar to the
results of previous studies by Healey et al, Kameshwar
Prasad et al, Gill et al and Al-Salamah et al using ROC
curves that reported the motor component of the GCS
occupied nearly the same area under an ROC curve as did
the total GCS score in their ability to predict outcome (28,
38, 39, 40). Similarly, Diringer et al, Meredith et al and
Ross et al also reported that the motor component of the
GCS score accurately predicted outcome which is also
comparable to our result (41, 42, 43). It appears that the
motor response being the largest component of the GCS
scoring system practically contains all the information of
the GCS itself and thereby better outcome predictive
value. In contrast, a study using ROC analysis by C J Weir
et al in assessing AS patients and a study by Moore et al in
TBI patients reported that the total GCS accurately
predicts outcome than the individual GCS components
(29, 44).
Data analysis from our study showed that the eye
component was the weakest predictor for TBI similar to
the results of studies by Michelle Gill et al and Al-Salamah
August - October 2012, Vol : 1, Issue : 1
et al (3, 40). In AS patients, the verbal component was the
weakest predictor which was a comparable with the
results of Diringer et al and Kameshwar Prasad et al but is
different to findings of C J Weir et al (29, 38, 41). The
components of the GCS may be affected due to focal
deficits in these patients misjudging the actual level of
consciousness. Another explanation to the varied results
may be the false recording of the best motor and verbal
response due to paralysis and dysphasia respectively
(29).
Further in AS patients, the performance of the GCS and its
components according to the nature of the stroke in
predicting outcome were not studied earlier. The results
of this subgroup analysis obtained in our study for
hemorrhagic stroke showed that the total GCS yields
equivalent prediction rates as the motor component
since they occupied similar magnitude of AUC when
compared to the eye and verbal components. But in
ischemic stroke patients, the motor component
performed greatest with a marginal difference from that
of the total GCS. There was no evidence to support or
refute this finding from the literature.
Very few studies have used ETI as TBI outcome measure
(3, 39, 40, 45). This outcome measure was not considered
in any of the previous studies in AS patients. The
requirement of ETI was analyzed to determine which
components of the GCS will display similar, better, or
worse associations. Our data analysis reveals that the
total GCS scoring system performed better than the
individual components of GCS in predicting ETI in all
patients [both TBI and AS] as well as in patients with TBI
and AS separately. In agreement with our finding, studies
by Michelle Gill et al and Haukoos JS et al also found the
total GCS was accurate in predicting the requirement of
ETI in TBI patients (3, 45). However this finding differed
from the end result of a study by Al-Salamah et al in which
they reported eye component was the best predictor of
ETI followed by the total GCS (40).
While studying the requirement of ETI according to the
nature of the stroke, the greatest predictive ability was
retained by the total GCS in hemorrhagic stroke patients.
But observations in ischemic stroke patients showed that
the ability to correctly predict ETI by the eye component
49

was the best followed by the total GCS when compared to
the motor and verbal components. This was similar to
findings of Al-Salamah et al in their study which was
described as an isolated finding requiring further
validation (40).
By evaluating the GCS and its individual components in
both TBI and AS patients, we have shown that the motor
response has a good or better predictive value in
assessing GOS. Due to simplicity of measuring the motor
response as well as its applicability in intubated patients,
the variability of its assessment among healthcare
workers would reduce (3, 25). Hence, we believe that the
total GCS could simply be replaced by the motor
component in predicting outcome of TBI and AS patients
while maintaining higher specificity. Since the
predictability of ETI by the motor score is not greater than
total GCS, we suggest the GCS in its summed form should
not be replaced by the motor component in both TBI and
AS patients. The application of these findings could be
extended to out-of-hospital environment as well (3).
CONCLUSION
In the assessment of TBI and AS patients, the motor
component of GCS scoring system is a better predictor of
3 month outcome while the GCS in its summed form is a
better indicator for requirement of endotracheal
intubation.
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