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Trauma patients with prehospital Glasgow Coma Scale less than nine: not a homogenous group



Prehospital guidelines stratify and manage patients with Glasgow Coma Scale (GCS) less than nine and any sign of head injury as affected by severe traumatic brain injury (STBI). We hypothesized that this group of patients is so inhomogeneous that uniform treatment guidelines cannot be advocated.


Patients (2005–2012) with prehospital GCS below nine and abbreviated injury scale head and neck above two were identified from trauma registry. Patients with acute lethal injuries, isolated neck injuries, extubated within 24 h or transferred interhospitally were excluded. Patients were dichotomized based on the worst prehospital GCS (recorded before sedatives) into two groups: GCS 3–5 and GCS 6–8. These were statistically compared using univariate analysis.


The GCS 3–5 group (99 patients) when compared with the GCS 6–8 group (49 patients) had shorter prehospital times (63 vs. 79 min; p < 0.05), more frequent episodes of both hypoxia (30.3% vs. 7.7%; p < 0.05) and hypotension (26.7% vs. 6.4%; p < 0.05), more often required craniectomy (15.1% vs. 4.0%; p = 0.05) and higher mortality (33.3% vs. 2%; p < 0.05). In the GCS 3–5 group, prehospital endotracheal intubation was attempted more often (57.5% vs. 28.6%, p < 0.05) and was more often successful (39.3% vs. 10.2%; p = 0.05). Length of stay in ICU did not differ.


STBI patients are fundamentally different based on whether their initial GCS falls into 3–5 or 6–8 category. Recommendations from trials investigating trauma patients with GCS less than nine as one group should be translated with caution to clinical practice.

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Fig. 1
Fig. 2



Abbreviated injury score head and neck


Glasgow Coma Scale


Emergency department


Endotracheal intubation


External ventricular drain


Intracerebral pressure monitor


Intensive care unit


Injury severity score


Severe traumatic brain injury


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Author information

Authors and Affiliations



CB contributed to data interpretation and writing. DK performed data collection, data analysis and data interpretation and writing. KK helped in data collection and data interpretation. SN performed literature search and data collection. ZJB contributed to study design, writing and critical revision. All authors have read and approved the manuscript

Corresponding author

Correspondence to Zsolt Janos Balogh.

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Conflict of interest

Cino Bendinelli, Dominic Ku, Kate Louise King, Shane Nebauer, Zsolt Janos Balogh declare that they have no conflict of interest.

Ethics approval and consent to participate

The protocol was approved by the Hunter New England Human Research Ethics Committee (09/12/16/5.01). Being a retrospective study with de-identified data, the need for patient approval to participate was waived.

Availability of data and material

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

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Bendinelli, C., Ku, D., King, K.L. et al. Trauma patients with prehospital Glasgow Coma Scale less than nine: not a homogenous group. Eur J Trauma Emerg Surg 46, 873–878 (2020).

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  • Glasgow Coma Scale
  • Traumatic brain injury
  • Prehospital
  • Paramedic
  • Intubation