NEUROLOGICAL SCALES FOR ASSESSMENT OF CONSCIOUSNESS.pptx

Various scales for assessment of coma

1. NEUROLOGICAL SCALES FOR ASSESSMENT OF CONSCIOUSNESS DR. VIJAY PRAKASH HAWA SR NEUROLOGY GOVT. MEDICAL COLLEGE KOTA

2. Consciousness defined as a state of awareness of self and surroundings. Alterations in consciousness are conceptualized into two types. The first type affects arousal The second type involves cognitive and affective mental function, sometimes referred to as the “ content” of mental function.

3. Alterations in arousal, although often referred to as altered levels of consciousness Four points on the continuum of arousal are often used in describing the clinical state of a patient: Alert refers to a perfectly normal state of arousal. Lethargy lies between alertness and stupor. Patient Often Aroused By Verbal Stimuli Stupor is a state of baseline unresponsiveness that requires repeated application of vigorous stimuli to achieve arousal. Coma is a state of complete unresponsiveness to arousal.

4. Neurological scales Glasgow coma scale

5. Teasdale g, jennet b assessment of coma and impaired consciousness; A practical scale : the lancet:1974 July 13;304 (7872) 81:4

6. The GCS uses a triple criteria scoring system: best eye opening (maximum 4 points) best verbal response (maximum 5 points) best motor response (maximum 6 points) These scores are added together to provide a total score between 3 and 15

7. Eye responses in the Glasgow coma scale. Adapted from Teasdale G. Forty years on: updating the Glasgow coma scale. Nursing Times 2014;110:42;12-16

8. Eye opening response- pain stimuli should be given over nail /shoulder pinch to avoid grimace causes closure of eyes.

9. Verbal responses in the Glasgow coma scale. Adapted from Teasdale G. Forty years on: updating the Glasgow coma scale. Nursing Times 2014;110:42;12-16

10. Motor responses in the Glasgow coma scale. Adapted from Teasdale G. Forty years on: updating the Glasgow coma scale. Nursing Times 2014;110:42;12-16

11. Motor responses in the Glasgow coma scale. Adapted from Teasdale G. Forty years on: updating the Glasgow coma scale. Nursing Times 2014;110:42;12-16

12. M3 vs M4

13. Confounding factors rendering one or more components of the Glasgow Coma Scale untestable • Drugs (anaesthetics, sedatives, neuromuscular blockade, etc) • Cranial nerve injuries • Intoxication (alcohol or drugs) • Hearing impairment • Intubation or tracheostomy • Limb or spinal-cord injuries • Dysphasia • Pre-existing disorders (dementia or psychiatric disorders) • Ocular or maxilla facial trauma • Language and culture • Orbital swelling

14. Other Limitations of the GCS A GCS score relies on the skill of the observer The GCS can only be carried out if scores for all three elements can be completed The GCS is non-parametric The clinical significance of the GCS outside of trauma and neurosurgery is debatable

15. ADVANTAGES: A SIMPLE AND STANDARIZED SYSTEM TO DETECT IN CHANGE IN LOC QUICK, EASY, OBJECTIVE, ACCURATE NUMERICAL, EASY TO CHART AND ANALYZE IS DESIGNED TO REDUCE OBSERVER VARIABILITY HELP TO MAKE MANAGEMENT DECISION GCS CAN PREDICT OUTCOME

16. GCS Pupils Score (GCS-P) The GCS-P is calculated by subtracting the Pupil Reactivity Score (PRS) from the Glasgow Coma Scale (GCS) total score:   Pupils Unreactive to Light Pupil Reactivity Score Both Pupils 2 One Pupil 1 Neither Pupil GCS-P = GCS - PRS

17. Sessler et al, AM J Repir Crit Care Med 2002 166 : 1338-1344

18. Neurological scales F OUR SCORE .  . 

19. In 2005, Wijdicks et al.devised a new coma score, the Full Outline of UnResponsiveness (FOUR) score, which addressed the pitfalls of the GCS. FOUR stands  for  F ull  O utline of  U n R esponsiveness , and it measures four domains of neurological function:  eye responses, motor responses, brainstem reflexes, and respiratory patterns .  The FOUR Score is calculated by adding the scores of each domain, which range from  0 to 4.  The lowest possible score is 0, indicating no neurological function, and the highest possible score is 16, indicating normal neurological function.

20. Eye Responses (E) Eyelids open or opened, tracking, or blinking to command: 4 points Eyelids open but not tracking: 3 points Eyelids closed but open to loud voice: 2 points Eyelids closed but open to pain: 1 point Eyelids remain closed with pain: 0 points Motor Responses (M) Thumbs-up, fist, or peace sign: 4 points Localizing to pain: 3 points Flexion response to pain: 2 points Extension response to pain: 1 point No response to pain or generalized myoclonus status: 0 points

21. Brainstem Reflexes (B) Pupil and corneal reflexes present: 4 points One pupil wide and fixed: 3 points Pupil OR corneal reflex absent: 2 points Pupil AND corneal reflexes absent: 1 point Absent pupil, corneal, and cough reflexes: 0 points Respiration Pattern (R) Not intubated, regular breathing pattern: 4 points Not intubated, Cheyne-Stokes breathing pattern: 3 points Not intubated, irregular breathing: 2 points Breathes above ventilatory rate: 1 point Breathes at ventilator rate or apnea: 0 points

22. Criteria FOUR Score GCS Domains Eye responses, motor responses, brainstem reflexes, respiratory pattern Eye responses, motor responses, verbal responses Range 0-16 3-15 Verbal responses Not required Required Brainstem reflexes Included Not included Respiratory pattern Included Not included Locked-in syndrome Can detect Cannot detect Brain herniation Can detect Cannot detect Validation Less widely used and validated More widely used and validated Complexity More complex and time-consuming Less complex and time-consuming Difference Between FOUR Score Vs GCS

23. The FOUR Score has several advantages over the GCS: It does not require verbal responses, which may be impaired by intubation, aphasia, or language barriers. It evaluates brainstem reflexes and respiratory patterns, which may reflect the location and severity of brain lesions. It can differentiate between locked-in syndrome and vegetative state, which have different prognoses and ethical implications. It can detect signs of brain herniation, which may require immediate treatment. It can better discriminate between different levels of coma, especially in the lower range of scores.

24.   The FOUR Score also has some limitations : It is not widely used or validated in different populations and settings, unlike the GCS, which has been extensively studied and standardized. It may be influenced by external factors that affect the neurological examination, such as sedation, hypothermia, metabolic disturbances, or drug intoxication. It may be more complex and time-consuming to perform than the GCS, which may limit its feasibility and reliability in busy or resource-limited settings. It may not capture some aspects of neurological function that are assessed by other scales, such as the  Glasgow Outcome Scale (GOS) , which measures the level of disability and dependence.

25. A New Approach in Intensive Care Unit Consciousness Assessment: FIVE Score F ull I ntracranial V alidity E valuation Score FOUR score + MEAN ARTERIAL PRESSURE between 60-130mmHg - 2 points patients under inotropic support with a mean arterial pressure between 60-130mmHg - 1 point patients with a mean arterial pressure below 60mmHg or above 130mmHg - 0 points. Additionally,, GAG REFLEX (for patients with infratentorial mass) If the reflex is absent,-0 points are given if it is unilateral-1 point if it is preserved- 2 points .

26. REFERENCES: Bradley’s Neurology in clinical practice, Eighth edition Assessment of coma and impaired consciousness; A practical scale, Teasdale g, jennet b : the lancet:1974 July 13;304 (7872) 81:4 The Glasgow Coma Scale at 40 years: standing the test of time Graham Teasdale, Andrew Maas, Fiona Lecky, Geoff rey Manley, Nino Stocchetti , Gordon Murray; Lancet Neurol 2014; 13: 844–54 Jennett & Teasdale. Lancet 1977;i:878-881. James & Trauner . Brain insults in infants and children. Orlando: Grune & Stratton, 1985:179-182. Tatman , Warren, Williams, Powell, Whitehouse. Archives of Disease in Childhood 1997;77:519-521 The Full Outline of UnResponsiveness (FOUR) Score and Its Use in Outcome Prediction: A Scoping Systematic Review of the Adult Literature: Neurocrit care 2019 aug 31(1) 162-175 Sessler et al, AM J Repir Crit Care Med 2002 166 : 1338-1344 A New Approach in Intensive Care Unit Consciousness Assessment: FIVE Score, Clinical trials. Gov .in ,14 sept. 2023 .

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