317: Glasgow Coma Scale of 15 Excludes Need for Immediate Neurosurgical Care but Not Presence of Intracranial Hemorrhage In EMS-Transported Trauma Patients

Abstract

Accurate triage of head injured patients is an essential function of EMS systems. Identification of critical injuries in otherwise well-appearing patients is challenging and complicated by underlying co-morbidities and patient medication use. 1) To assess whether a normal Glasgow Coma Scale (GCS=15) may be used to exclude need for emergent treatment for intracranial injury in patients without physiologic or anatomic criteria for emergent triage in EMS transported patients; 2) To assess whether use of anti-coagulants or anti platelet drugs impact this triage decision. A secondary analysis of a cohort of EMS patients transported to a single Level 1 trauma Center. As part of a multicenter trial, EMS providers who transported injured patients were interviewed immediately after hospital arrival during a two-year period. The interview collected patient physiologic condition, apparent anatomic injury, mechanism of injury (MOI), medical history and medications. Initial GCS on scene was used for analysis. Our outcome was need for neurosurgical care within 4 hours, or administration of blood products (FFP, platelets or concentrated clotting factors) within 8 hours for intracranial injury. Odds ratios and 95% CI are presented. During this study period, there were 2310 patients transported by EMS, 1872 had a GCS =15 on EMS arrival, and a completed interview. Of this 1872, 118 met physiological or anatomic criteria for emergent triage and were excluded. Of the remaining 1753, 121(6.9%) patients were on coumadin, and 357(20.3%) were on one or more anti-platelet drugs ( aspirin, 305, clopidogrel 101 aggrenox, 15). Overall, 27 (1.5%) patients had intracranial hemorrhages, of which two required craniotomy: one at 8 hours; and a second at 30 hours. Of those with intracranial hemorrhage, 16 (64%) received blood products within 8 hours. There was an increased incidence of intracranial hemorrhage in patients on coumadin (OR 4.3, 95% CI 1.5, 12.4) and antiplatelet drugs (OR 3.2, 95% CI 1.4, 7.2) versus patients on no medications. In this population, an initial GCS =15, excluded the need for rapid neurosurgical intervention but not emergent care (reversal of anti-coagulation) for intracranial injury. We cannot assess whether early treatment with blood products may have obviated the need for neurosurgical intervention. Triage decisions regarding these patients must balance the low rate for injury and potential need for treatment in this population