[BLOG POST] What Is the Glasgow Coma Scale? – BrainLine

The Glasgow Coma Scale (GCS) is the most common scoring system used to describe the level of consciousness in a person following a traumatic brain injury. Basically, it is used to help gauge the severity of an acute brain injury. The test is simple, reliable, and correlates well with outcome following severe brain injury.

The GCS is a reliable and objective way of recording the initial and subsequent level of consciousness in a person after a brain injury. It is used by trained staff at the site of an injury like a car crash or sports injury, for example, and in the emergency department and intensive care units.

The GCS measures the following functions:

Eye Opening (E)

• 4 = spontaneous
• 3 = to sound
• 2 = to pressure
• 1 = none
• NT = not testable

Verbal Response (V)

• 5 = orientated
• 4 = confused
• 3 = words, but not coherent
• 2 = sounds, but no words
• 1 = none
• NT = not testable

Motor Response (M)

• 6 = obeys command
• 5 = localizing
• 4 = normal flexion
• 3 = abnormal flexion
• 2 = extension
• 1 = none
• NT = not testable

Clinicians use this scale to rate the best eye opening response, the best verbal response, and the best motor response an individual makes. The final GCS score or grade is the sum of these numbers.

Using the Glasgow Coma Scale

A patient’s Glasgow Coma Score (GCS) should be documented on a coma scale chart. This allows for improvement or deterioration in a patient’s condition to be quickly and clearly communicated.

Individual elements, as well as the sum of the score, are important. The individual elements of a patient’s GCS can be documented numerically (e.g. E2V4M6) as well as added together to give a total Coma Score (e.g E2V4M6 = 12). For example, a score may be expressed as GCS 12 = E2 V4 M6 at 4:32.

Every brain injury is different, but generally, brain injury is classified as:

• Severe: GCS 8 or less
• Moderate: GCS 9-12
• Mild: GCS 13-15

Mild brain injuries can result in temporary or permanent neurological symptoms and neuroimaging tests such as CT scan or MRI may or may not show evidence of any damage.

Moderate and severe brain injuries often result in long-term impairments in cognition (thinking skills), physical skills, and/or emotional/behavioral functioning.

Limitations of the Glasgow Coma Scale

Factors like drug use, alcohol intoxication, shock, or low blood oxygen can alter a patient’s level of consciousness. These factors could lead to an inaccurate score on the GCS.

Children and the Glasgow Coma Scale

The GCS is usually not used with children, especially those too young to have reliable language skills. The Pediatric Glasgow Coma Scale, or PGCS, a modification of the scale used on adults, is used instead. The PGCS still uses the three tests — eye, verbal, and motor responses — and the three values are considered separately as well as together.

Here is the slightly altered grading scale for the PGCS:

Eye Opening (E)

• 4 = spontaneous
• 3 = to voice
• 2 = to pressure
• 1 = none
• NT = not testable

Verbal Response (V)

• 5 = smiles, oriented to sounds, follows objects, interacts
• 4 = cries but consolable, inappropriate interactions
• 3 = inconsistently inconsolable, moaning
• 2 = inconsolable, agitated
• 1 = none
• NT = not testable

Motor Response (M)

• 6 = moves spontaneously or purposefully
• 5 = localizing (withdraws from touch)
• 4 = normal flexion (withdraws to pain)
• 3 = abnormal flexion (decorticate response)
• 2 = extension (decerebrate response)
• 1 = none
• NT = not testable

Pediatric brain injuries are classified by severity using the same scoring levels as adults, i.e. 8 or lower reflecting the most severe, 9-12 being a moderate injury and 13-15 indicating a mild TBI. As in adults, moderate and severe injuries often result in significant long-term impairments.

Posted on BrainLine February 13, 2018. Reviewed July 25, 2018.

References

Teasdale G, Allen D, Brennan P, McElhinney E, Mackinnon L. The Glasgow Coma Scale: an update after 40 years. Nursing Times 2014; 110: 12-16

Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974,2:81-84. PMID 4136544.

The Glasgow Structured Approach to Assessment of the Glasgow Coma Scale. (n.d.). Retrieved February 13, 2018, from www.glasgowcomascale.org.

via What Is the Glasgow Coma Scale? | BrainLine

[Abstract] Update on pharmacotherapy for stroke and traumatic brain injury recovery during rehabilitation

Abstract

PURPOSE OF REVIEW:

This article evaluates whether specific drugs are able to facilitate motor recovery after stroke or improve the level of consciousness, cognitive, or behavioral symptoms after traumatic brain injury.

RECENT FINDINGS:

After stroke, serotonin reuptake inhibitors can enhance restitution of motor functions in depressed as well as in nondepressed patients. Erythropoietin and progesterone administered within hours after moderate to severe traumatic brain injury failed to improve the outcome. A single dose of zolpidem can transiently improve the level of consciousness in patients with vegetative state or minimally conscious state.

SUMMARY:

Because of the lack of large randomized controlled trials, evidence is still limited. Currently, most convincing evidence exists for fluoxetine for facilitation of motor recovery early after stroke and for amantadine for acceleration of functional recovery after severe traumatic brain injury. Methylphenidate and acetylcholinesterase inhibitors might enhance cognitive functions after traumatic brain injury. Sufficiently powered studies and the identification of predictors of beneficial drug effects are still needed.

 

via Update on pharmacotherapy for stroke and traumatic brain injury recovery during rehabilitation. – PubMed – NCBI

[ARTICLE] The Relationship of the FOUR Score to Patient Outcome: A Systematic Review -Full Text

Abstract

The Full Outline of UnResponsiveness (FOUR) score assessment of consciousness replaces the Glasgow Coma Scale (GCS) verbal component with assessment of brainstem reflexes. A comprehensive overview studying the relationship between a patient’s FOUR score and outcome is lacking. We aim to systematically review published literature reporting the relationship of FOUR score to outcome in adult patients with impaired consciousness. We systematically searched for records of relevant studies: CENTRAL, MEDLINE, EMBASE, Scopus, Web of Science, ClinicalTrials.gov, and OpenGrey. Prospective, observational studies of patients with impaired consciousness were included where consciousness was assessed using FOUR score, and where the outcome in mortality or validated functional outcome scores was reported. Consensus-based screening and quality appraisal were performed. Outcome prognostication was synthesized narratively. Forty records (37 studies) were identified, with overall low (n = 2), moderate (n = 25), or high (n = 13) risk of bias. There was significant heterogeneity in patient characteristics. FOUR score showed good to excellent prognostication of in-hospital mortality in most studies (area under curve [AUC], >0.80). It was good at predicting poor functional outcome (AUC, 0.80–0.90). There was some evidence that motor and eye components (also GCS components) had better prognostic ability than brainstem components. Overall, FOUR score relates closely to in-hospital mortality and poor functional outcome. More studies with standardized design are needed to better characterize it in different patient groups, confirm the differences between its four components, and compare it with the performance of GCS and its recently described derivative, the GCS-Pupils, which includes pupil response as a fourth component.

Introduction

Clinicians’ management decisions about acute traumatic brain injury (TBI) patients are guided by assessments of the person’s current state and may also be influenced by their perceptions of its relation to the patient’s likely outcome.¹ Internationally, the Glasgow Coma Scale (GCS) is the most widely used tool for assessing and communicating about a patient’s responsiveness.² All the three components—eye, motor, and verbal responses—relate to outcome,³ as does the derived summation into the GCS score, albeit with some loss of information. Moreover, the GCS is combined with other features, such as pupil response, age, and injury characteristics, in numerous multi-variate prognostic models for predicting functional outcome and mortality.^4–6 The difficulty in assigning a verbal response in an intubated patient and the separation of assessment of brain stem features, such as pupil response, in multi-variate modeling stimulated specialists in neurological intensive care to propose an alternative approach.

The Full Outline of UnResponsiveness (FOUR) score was described by Wijdicks and colleagues. It is based on the eye and motor components of the Glasgow system, but the verbal component was removed and two new components added, namely brainstem reflexes and respiratory pattern. The FOUR score was developed for the assessment of level of consciousness in patients admitted to a neurointensive care unit.⁷ This was with the purpose of improving the standardized assessment of level of consciousness for patients who are intubated or have focal neurological deficits. Each component is a 5-point scale, ranging from 0 to 4, with combined FOUR score ranging from 0 to 16, with 16 indicating the highest level of consciousness. Unlike the GCS, the eyes must be able to track or blink to command in order to obtain the maximum score of 4 points for eye component in FOUR score. Table 1 shows the scoring criteria for all components of FOUR score and GCS. The FOUR score approach emphasizes description of a patient by the combined score and the validity of the latter as an index of acute severity through its relationship to outcome. In order to provide a comprehensive assessment of the latter, we have performed a systematic review of the reported evidence, with focus on prognostic performance in groups of patients particularly targeted by FOUR score, namely those with a neurological diagnosis, intubated patients, and those admitted to dedicated neuroscience centers.

Table 1. Components of the FOUR Score and Glasgow Coma Scale

Full Outline of UnResponsiveness Score	Glasgow Coma Scale
Eye response 4 = eyelids open or opened, tracking, or blinking to command 3 = eyelids open but not tracking 2 = eyelids closed, but open to loud voice 1 = eyelids closed, but open to pain 0 = eyelids remain closed with pain	Eye opening 4 = spontaneous 3 = to speech 2 = to pain 1 = none
Motor response 4 = thumbs-up, fist, or peace sign 3 = localizing to pain 2 = flexion response to pain 1 = extension response to pain 0 = no response to pain or generalized myoclonus status	Best motor response 6 = obeying commands 5 = localizing to pain 4 = withdrawal from pain 3 = abnormal flexion response to pain 2 = extension response to pain 1 = none
Brainstem reflexes 4 = pupil and corneal reflexes present 3 = one pupil wide and fixed 2 = pupil or corneal reflexes absent 1 = pupil and corneal reflexes absent 0 = absent pupil, corneal and cough reflex	Verbal response 5 = orientated 4 = confused 3 = inappropriate words 2 = incomprehensible sounds 1 = none
Respiration 4 = not intubated, regular breathing pattern 3 = not intubated, Cheyne-Stokes breathing pattern 2 = not intubated, irregular breathing 1 = breathes above ventilator rate 0 = breathes at ventilator rate or apnea

FOUR, Full Outline of UnResponsiveness. […]

 

Continue —>  The Relationship of the FOUR Score to Patient Outcome: A Systematic Review | Journal of Neurotrauma

[Abstract] From cortical blindness to conscious visual perception: Theories on neuronal networks and visual training strategies

Homonymous hemianopia (HH) is the most common cortical visual impairment leading to blindness in the contralateral hemifield. It is associated with many inconveniences and daily restrictions such as exploration and visual orientation difficulties. However, patients with HH can preserve the remarkable ability to unconsciously perceive visual stimuli presented in their blindfield, a phenomenon known as blindsight. Unfortunately, the nature of this captivating residual ability is still misunderstood and the rehabilitation strategies have been insufficiently exploited. This paper discusses type I and type II blindsight in a neuronal framework of altered global workspace, resulting from inefficient perception, attention and conscious networks. To enhance synchronisation and create global availability for residual abilities to reach visual consciousness, rehabilitation tools need to stimulate subcortical extrastriate pathways through V5/MT. Multisensory bottom-up compensation combined with top-down restitution training could target pre-existing and new neuronal mechanisms to recreate a framework for potential functionality.

Source: Frontiers | From cortical blindness to conscious visual perception: Theories on neuronal networks and visual training strategies | Frontiers in Systems Neuroscience

[ARTICLE] Music in Research and Rehabilitation of Disorders of Consciousness: Psychological and Neurophysiological Foundations – Full Text HTML

Abstract

According to a prevailing view, the visual system works by dissecting stimuli into primitives, whereas the auditory system processes simple and complex stimuli with their corresponding features in parallel. This makes musical stimulation particularly suitable for patients with disorders of consciousness (DoC), because the processing pathways related to complex stimulus features can be preserved even when those related to simple features are no longer available. An additional factor speaking in favor of musical stimulation in DoC is the low efficiency of visual stimulation due to prevalent maladies of vision or gaze fixation in DoC patients. Hearing disorders, in contrast, are much less frequent in DoC, which allows us to use auditory stimulation at various levels of complexity.

The current paper overviews empirical data concerning the four main domains of brain functioning in DoC patients that musical stimulation can address: perception (e.g., pitch, timbre, and harmony), cognition (e.g., musical syntax and meaning), emotions, and motor functions. Music can approach basic levels of patients’ self-consciousness, which may even exist when all higher-level cognitions are lost, whereas music induced emotions and rhythmic stimulation can affect the dopaminergic reward-system and activity in the motor system respectively, thus serving as a starting point for rehabilitation.

Continue —> Music in Research and Rehabilitation of Disorders of Consciousness: Psychological and Neurophysiological Foundations

[Blog Post] Cognitive Issues

 

 

 

 

Rebloged from

Broken Brain – Brilliant Mind

 

Cognitive issues are often the first thing people think of when they think about TBI. After all, it’s your brain, right? And that’s the source of your cognition.

Project LEARNet, which is “A Resource for Teachers, Clinicians, Parents, and Students by the Brain Injury Association of New York State”, has some great tutorials on Cognitive and Academic Issues for students after TBI, as well as Self-Regulation/Executive Function Issues. Don’t let the focus on kids / students deter you – these are great resources for anyone who is seeking to better understand TBI.Check out the tutorials on Cognitive and Academic Issues here and Self-Regulation/Executive Function Issues here. They are downloadable PDFs that you can print and take with you – great stuff!

Cognitive Issues after Brain Injury can include:

1. Altered consciousness
2. Aura or weird reverie, trance
3. Trouble concentrating
4. Trouble making decisions easily
5. Trouble reading
6. Analytical skills suffer
7. Trouble telling what’s real or not
8. Being easily distracted
9. Being forgetful, can’t remember
10. Nightmares
11. Worrisome thoughts

Source: Cognitive Issues