Glasgow coma scale evaluation and clinical considerations

GCS EVALUATION

1. GLASGOW COMA SCALE AND OTHER SCALES - EVALUATION AND CLINICAL CONSIDERATIONS ZIKRULLAH

2. Neurological scales Glasgow coma scale Pediatric GCS Glasgow coma scale – E Glasgow outcome scale FOUR Score Coma Scale Hunt and Hess scale World Federation of Neurologic Surgeons Scale (WFNS) Blantyre coma scale Rancho Los Amigos Scale

3. INTRODUCTION Glasgow Coma Scale (GCS) was introduced in 1974 by Teasdale and Jennett , aiming at standardizing the assessment of level of consciousness in head injured patients. In 1976, addition of a sixth point in the motor response subscale was made for “withdrawal from painful stimulus” Reliable, objective way of recording the conscious state of a person.

4. it is simple enough to be utilized by physicians, nurses, and other care providers for initial and continuing assessment. important part of the primary survey Designed for the evaluation of severe HT, the GCS is used in assessment of coma due to any etiology .

5. EYE OPENING Spontaneous (4) : is indicative of activity of brainstem arousal mechanisms. To speech (3) : tested by any verbal approach (spoken or shouted). To pain (2) : tested by a stimulus in the limbs ( supraorbital pressure may cause grimacing and eye closure). None (1) : no response to speech or pain.

6. Scores of 3 and 4 imply that cerebral cortex is processing information Score of 2 shows that lower levels of brain are functioning .

7. BEST VERBAL RESPONSE Oriented (5) : awareness of the self and the environment (who / where / when). Confused (4) : responses to questions with presence of disorientation and confusion. Inappropriate words (3) : speech in a random way, no conversational exchange.

8. Incomprehensible sounds (2) : moaning,groaning . None (1) : no response. Presence of speech indicates a high degree of integration in the nervous system even though lack of speech could be attributed to other factors, i.e : dysphasia, tracheostomy .

9. BEST MOTOR RESPONSE Obeying commands (6) Localizing (5) : movement of limb as to attempt to remove the stimulus, the arm crosses midline. Normal flexor response (4) : rapid withdrawal and abduction of shoulder.

10. Abnormal flexor response (3) : adduction of upper extremities, flexion of arms, wrists and fingers, extension and internal rotation of lower extremities, plantar flexion of feet, and assumption of a hemiplegic or decorticate posture. Extensor posturing (2) : adduction and hyperpronation of upper extremities, extension of legs, plantar flexion of feet, progress to opisthotonus ( decerebration ).

11. None (1) : rule out an inadequate stimulus or spinal transection . Motor 3 lesion is located in the internal capsule or cerebral hemispheres. Score of 2 describes a midbrain to upper pontine damage The motor response is considered a good indicator of the ability of central nervous system (CNS) to function properly .

12. Record best response from any limb when assessing altered consciousness Arms are more useful to test since they present a wider range of responses, while a spinal reflex may cause flexion of legs if pain is applied locally.

13. EVALUATION OF CHILDREN The GCS predicts outcome in children with HT. It also predicts outcome of intracranial hemorrhage in children with cancer. A decrease in GCS of more than 3 points at the time of intracranial hemorrhage is an indicator of increased mortality .

14. The GCS is inapplicable to infants and children below the age of 5 years. Using the standard GCS for adults, the normal aggregate scores are 9 (at six months), 11 (at twelve months), and 13-14 (at sixty months) . As for adults, emphasis should be placed on the accurate measurement of the motor score before intubation by physicians or paramedics.

15. CLINICAL OBSTACLES Several clinical conditions that have great impact on GCS rating with sedation and intubation being of great importance. Patient with a spinal cord injury will make the motor scale invalid Use of paralytics and sedatives in rapid sequence intubation introduces confounding factors . High blood alcohol concentrations (> 240 mg / 100 ml) are associated with a 2-3 point reduction in GCS.

16. Tracheal intubation and severe facial/eye swelling or damage make it impossible to test the verbal and eye responses. The score is given as 1 with a modifier attached e.g. "E1c" where "c" = closed, or "V1t" where t = tube. A composite might be "GCS 5tc". This would mean, for example, eyes closed because of swelling = 1, intubated = 1, leaving a motor score of 3 for "abnormal flexion". Often the 1 is left out, so the scale reads Ec or Vt

17. Patients who are hypoxic, hypotensive , hypothermic, or hypoglycemic , have depressed mental status due to a poor environment for the brain and not due to brain pathology. These conditions should be corrected prior to relying on the GCS for management decisions. The initial score should be assigned six hours after HT had been sustained. GCS score recorded before giving sedation is preferable.

18. Caregivers cannot score the person's body movements if an injury causes pain with movement, or makes the person unable to move. The GCS does not check if the person can learn and remember new things. A person's ability to form new memories is important in helping caregivers predict his recovery after a TBI.

19. APPLICATIONS The GCS describes and assesses coma, Monitors changes in depth of coma, Indicator of severity of illness Facilitates information transfer Used as a triage tool in patients with HT .

20. It facilitates monitoring in the early stages after injury, Allows rapid detection of complications even among patients with a GCS score of 13 to 15, Discriminates between those more or less likely to be at risk of complications. Aids in clinical decisions, such as intubation, for total GCS score 8 or motor score 4.

21. Classification of severity of HT

22. Skull Radiography, CT scans and MRI Patients with GCS scores of 13-14 have a significantly higher incidence of skull fracture, abnormal CT findings, need for hospital admission, delayed neurological deterioration and need for operation than patients with a GCS score of 15 . Patients with score 14 , with score of 15 with amnesia or of advanced age should undergo MRI / CT scans.

23. Evaluation of hemorrhage The GCS is utilized in the comparative study of traumatic and spontaneous intracerebral hemorrhage. Younger age and higher GCS scores at presentation related to favorable outcome . Evaluation of surgical or intensive care demand

24. Evaluation of acute stroke & aneurysmal SAH In patients with acute stroke , Eye and motor subscales has 87% accuracy compared to 88% for the total GCS, for initial period(< 14 days). Patients who underwent surgery for ruptured cerebral aneurysms, in those with a GCS score of 14, a “confused” verbal response indicated poorer prognosis.

25. Assessment of meningitis and CNS infections Most meningitis patients with a GCS score > 12 had a good neurological outcome, while most patients with GCS score 8 had a poor outcome . Evaluation of carotid artery injuries These injuries should only be repaired in patients with GCS score > 9, since comatose patients with GCS score < 8 do poorly regardless of management.

26. GCS in motor vehicle accidents It predicts hospitalization after motor vehicle collisions. Values of field GCS and arrival GCS scores were associated with outcome of HT . Evaluation of risk of aspiration pneumonia Prediction of hospital mortality in ICU pts

27. Limitations Collectors’ experience and the inter-rater variability in recording of GCS. LACK OF BRAINSTEM REFLEXES AND PUPILLARY RESPONSE EVALUATION The Glasgow Liège Scale combined the GCS with five brainstem reflexes ( pupillary , fronto -orbicular, oculocardiac , horizontal and vertical oculocephalic ) .

28. Does not measure concussion severity Many patients who are diagnosed with mild traumatic brain injury have diminished brain function, headaches and other symptoms that last for weeks or even months. Alternatively, some patients diagnosed with 'moderate' traumatic brain injury will recover completely within days to weeks.

29. Glasgow Coma Scale-Extended The Glasgow Coma Scale-Extended (GCS-E), was introduced for helping the acute assessment and prognostication. GCS was not intended to distinguish among different types of milder injury (13- 14 ), since many patients are orientated by the time they are first assessed and therefore score at the top of the GCS.

30. Also some patients have a period of altered consciousness as evidenced by their inability to recall events immediately after injury. A numeric value between 0-7 was assigned based on the duration of the posttraumatic amnesia .

31. Glasgow Outcome Score The GCS is often used in conjunction with Glasgow Outcome Score (1975). Score applies to patients with brain damage allowing the objective assessment of their recovery in five categories. This allows a prediction of the long-term course of rehabilitation to return to work and everyday life.

32. FOUR Score Coma Scale GCS is not fully reliable in predicting patient outcomes FOUR score includes measurement of brainstem reflexes; determination of eye opening, blinking, and tracking motor responses presence of abnormal breath rhythms and a respiratory drive. 

33. The HUNT AND HESS SCALE when applied to patients with SAH offers classification and prognostication of mortality.

34. The World Federation of Neurologic Surgeons Scale (WFNS) is the preferable rating because it uses the more prevalent GCS but with a modifying component of focal deficit .

35. Advanced Trauma Life Support AVPU Scale Alert, Response to Verbal Response to painful stimuli, Unresponsive scale ACDU Scale Alert, Confused Drowsy Unresponsive

36. Blantyre coma scale The Blantyre coma scale is a modification of the  Pediatric Glasgow Coma Scale, designed to assess malarial coma in children The score assigned by the Blantyre coma scale is a number from 0 to 5 The minimum score is 0 which indicates poor results while the maximum is 5 indicating good results

37. Eye movement 1 - Watches or follows 0 - Fails to watch or follow Best motor response 2 - Localizes painful stimulus 1 - Withdraws limb from painful stimulus 0 - No response or inappropriate response Best verbal response 2 - Cries appropriately with pain, or, if verbal, speaks 1 - Moan or abnormal cry with pain 0 - No vocal response to pain

38. Rancho Los Amigos Scale The Rancho Los Amigos Scale a.k.a. the Rancho Los Amigos Levels of Cognitive Functioning Scale (LOCF) or Rancho Scale Used to assess individuals after a closed head injury, including traumatic brain injury, based on cognitive and behavioural presentations as they emerge from coma. Individuals with brain injury will receive a score from one to eight. A score of one represents non-responsive cognitive functioning, whereas a score of eight represents purposeful and appropriate functioning

39. Each of the eight levels represents the typical sequential progression of recovery from brain damage. These patients will be scored based on combinations of the following criteria responsiveness to stimuli ability to follow commands presence of non-purposeful behavior cooperation confusion Attention to environment focus coherence of verbalization appropriateness of verbalizations and actions memory recall orientation Judgement  and  reasoning

40. CONCLUSION The GCS carries valuable information about the neurological status of patients and constitutes an element of surveillance of their evolution. But it should not replace a thorough neurological examination. Full knowledge of this scale’s strengths and limitations is essential in order to assure its proper use. Above all, uniform scoring is imperative and should be pursued.

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