Major Trauma and GCS of 3: Do Pupillary Characteristics Give Prognostic Clues?

Abstract & Commentary

Source: Lieberman JD, et al. Use of admission Glasgow coma score, pupil size, and pupil reactivity to determine outcome for trauma patients. J Trauma 2003;55:437-43.

The ability to reliably predict fatal outcomes of major trauma patients on arrival to the emergency department (ED) would help to determine the need for further resuscitative efforts, allow for early mobilization of organ procurement agencies, and give the treating physicians the ability to convey accurate information when counseling families. This study from Lehigh Valley Hospital in Pennsylvania sought to determine whether admission Glasgow Coma Scale score (GCS), pupil size, and pupil reactivity are sufficient to predict outcomes of major trauma patients. The authors hypothesized that patients with an admission GCS of 3 as well as fixed and dilated pupils have no reasonable chance of survival to hospital discharge.

This retrospective chart review included all patients older than 14 years admitted to the ED with a GCS of 3. Patients were excluded if they had received paralytics, sedatives, pain medication, atropine, or eye drops in the prehospital setting, or if they had a blood ethanol concentration greater than 100 mg/dL or known drug use prior to injury. Enrolled patients had records reviewed for the presence of fixed and dilated pupils (FD) (defined as pupils greater than 4 mm in diameter bilaterally and nonreactive to light) or absence of fixed and dilated pupils (NFD), survival to hospital discharge, length of hospital stay, resuscitative and surgical procedures performed, discharge destination, and functional status at discharge. For nonsurvivors, data was collected on cause of death and whether or not organ donation occurred.

During the study period, 274 adults were admitted with a GCS of 3. After exclusions, the study group consisted of 137 patients. Of the 137 patients, 104 (63%) had FD pupils and 33 (37%) had NFD pupils. No patient admitted with a GCS of 3 and FD pupils survived to hospital discharge (95% CI 0-3.38%). Of the 46 patients in the FD group who survived their initial resuscitation, almost all died on hospital day one, with all patients dying by hospital day six. Of these 46 patients, 18 (30.5%) went on to organ donation.

In the NFD group, 11 of 33 patients (33%) survived to hospital discharge. The functional status at discharge ranged from complete dependence to complete independence. Nine of the 11 were discharged to rehabilitation facilities, and two to home. Twelve patients survived the initial resuscitation, but died while in the intensive care unit. Of these 12, two (17%) went on to donate organs.

The authors conclude that trauma patients presenting with a GCS of 3 and FD pupils have no reasonable chance of functional recovery. They recommend that these patients may be resuscitated for the possibility of organ procurement. The authors also conclude that for patients with a GCS of 3 and NFD pupils, the prognosis is considerably better.

Commentary by Jacob W. Ufberg, MD

This study highlights the dismal prognosis of trauma patients presenting to the ED with a GCS of 3 and FD pupils. However, there are several hurdles to clear before we start applying this decision rule to stop the resuscitation efforts for people meeting these criteria. First and most importantly, this study is far too small to realistically place the odds of survival at zero. With only 104 patients in the FD group, the 95% confidence interval for survival ranges from 0 to 3.38%. I would not feel comfortable withholding resuscitation efforts for a patient who may have a 3% chance of survival. A much larger study is warranted.

Also, several of the exclusions would be a problem in implementing this rule for real-time decision making. Many trauma patients already have undergone a major resuscitation effort prior to obtaining the blood alcohol concentration results. Many other patients would be excluded from this decision rule due to drug use or the possibility of drug use, as the frequency of concurrent alcohol or drug use and major trauma is well known.

However, this study does provide very useful guidance for physicians speaking with family members, allowing for some early risk stratification for discussing prognosis with families. These findings also will help to mobilize organ procurement agencies early, and will help guide physicians when to discuss the possibility of organ donation with families of trauma patients who arrive with a GCS of 3 and FD pupils.

Dr. Ufberg, Assistant Professor of Emergency Medicine, Assistant Residency Director, Department of Emergency Medicine, Temple University School of Medicine, Philadelphia, PA, is on the Editorial Board of Emergency Medicine Alert.