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The Efficacy of Glasgow Coma Scale (GCS) Score and Acute Physiology
and Chronic Health Evaluation (APACHE) II for Predicting Hospital
Mortality of ICU Patients with Acute Traumatic Brain Injury
Amir Nik1, Mohammad Sobhan Sheikh Andalibi1, Mohammad Reza Ehsaei2*, Ahmadreza Zarifian1, Ehsan
Ghayoor Karimiani3, Gholamreza Bahadoorkhan2
1
Student Research Committee, School of Medicine, Mashhad University of medical sciences, Mashhad, Iran
2
Department of Neurosurgery, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
3
Department of Education and Research, Razavi Hospital, Mashhad, Iran
Objective: To compare the efficacy and functional outcome of Glasgow Coma Scale (GCS) score with that
of Acute Physiology and Chronic Health Evaluation Score II (APACHE II) in patients with multiple trauma
admitted to the ICU.
Methods: This cross-sectional study included 125 patients with traumatic brain injury associated with systemic
trauma admitted to the ICU of Shahid Kamyab Hospital, Mashhad, between September 2015 and December
2016. On the day of admission, data were collected from each patient to calculate GCS and APACHE II scores.
Sensitivity, specificity, and correct outcome prediction was compared between GCS and APACHE II.
Results: Positive predictive value (PPV) at the cut-off points was higher in APACHE II (80.6%) compared with
GCS (69.2%). However, negative predictive value (NPV) of GCS was slightly higher in comparison with APACHE
II. Moreover, the area under the receiver operating characteristic (ROC) curve for sensitivity and specificity of
GCS and APACHE II showed no significant difference (0.81±0.04 vs. 0.83±0.04; p=0.278 respectively).
Conclusion: Our study suggested that there was no considerable difference between GCS and APACHE II
scores for predicting mortality in head injury patients. Both scales showed acceptable PPV, while APACHE II
showed better results. However, the utilization of GCS in the initial assessment is recommended over APACHE
II as the former provides higher time- and cost-efficiency.
Journal compilation © 2018 Trauma Research Center, Shiraz University of Medical Sciences
Nik A et al.
Table 2. Comparison of GSC and APACHE II scores for hospital mortality prediction
Scale CPa Sensitivity Specificity YIb AUCc PPVd NPVe 95%CIf
GCS 6 61.4% 85.1% 0.46 0.81±0.04 69.2 80.2 0.73-0.87
APACHE II 19 56.9.72% 92.6.0% 0.50 0.83±0.03 80.6 79.8 0.75-0.89
a
CP: Cut-off Point; YI: Youden Index; AUC: area under the ROC curve; PPV: Positive Predictive Value; NPV: Negative Predictive
b c d e
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Nik A et al.
Fig. 1. ROC curves drawn at different cut-off values for GCS and APACHE II scales. The area under the curve for APACHE II is
larger, but there is no statistically significant difference when compared with that of GCS.
whom were excluded from this study to minimize On the one hand, in the developing countries, the
the researcher bias [18]. rate of accidents and subsequent head injuries are
APACHE II scale has been shown to have promising higher, compared to the developed countries. On
outcomes in evaluating patients in emergency units the other hand, the healthcare budgets are usually
[19, 20]. APACHE II not only includes GCS but also lower in the developing countries, compared to the
uses 11 other physiologic factors that include both developed ones. This discrepancy highlights the
clinical and laboratory data. need for an initial assessment method that is less
ISS is an anatomical scoring system that is costly and more time-efficient, since it is important
associated with mortality, morbidity, hospital stay, to reduce the costs of management and treatment in
and overall severity of injuries. There are several emergency units and hospitals.
downsides to the use of ISS in the initial evaluation of The findings of this study demonstrated that there
critically injured patients in emergency department. was no significant difference between GCS and
First, since ISS is directly related to AIS, any APACHE II scales for predicting hospital mortality
error in AIS increases the chance of error in ISS. in patients with head injury. Although both of the
Moreover, different patterns of injury on different scales showed desirable PPV, APACHE II yielded
sites and organs can result in same ISS scores. Most better results. However, t it is important to reduce the
importantly, since complete description of injuries expenses of management and treatment in hospitals.
require thorough investigation and examination of Considering all aspects, it seems that in comparison
the patient, anatomical scoring systems like ISS with APACHE II, GCS is a more accessible method
are not efficacious tools for initial evaluation and particularly for quick initial evaluation of critically
screening in an emergency setting, especially in ICU injured patients with head trauma.
patients [12]. One of our limitations was that the follow-up
In the current study, we found the most frequent cause was limited to the period of hospital stay. Due to
of ICU admission to be road traffic accidents. Similar the lack of trained staff, limited budget, and low
results have been previously reported by Majdan et al., socioeconomic status in most of the patients, the
who showed traumatic brain injuries are significantly patients were not followed for long-term outcomes
associated with road traffic accidents [15]. after their discharge. In addition, this study was
Our results showed that APACHE II had higher carried out in a single center. Although our hospital
specificity but lower sensitivity compared with is the main referral center for traumatic patients in
GCS. This finding suggests that APACHE II scale the Northeast of Iran, further multicenter studies
has more power in recognizing critically ill patients would be of help in order to achieve results that are
with higher chances of survival, who are in greater more reliable.
need for ICU care. In conclusion, our study suggested that there
The ROC curve results showed no significant was no considerable difference between GCS and
difference between the GCS and APACHE II scales, APACHE II scores for predicting mortality in head
suggesting that APACHE II is not necessarily a injury patients. Both scales showed acceptable PPV,
better mortality predictor in patients with head while APACHE II showed better results. However,
trauma. Measuring the APACHE II score demands the utilization of GCS in the initial assessment
more time and budget, the items that are of utmost is recommended over APACHE II as the former
importance in emergency care. provides higher time- and cost-efficiency.
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