[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

[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

[WEB SITE] Classification and Complications of Traumatic Brain Injury: Practice Essentials, Epidemiology, Pathophysiology

Practice Essentials

Traumatic brain injury (TBI), also known as acquired brain injury, head injury, or brain injury, causes substantial disability and mortality. It occurs when a sudden trauma damages the brain and disrupts normal brain function. TBI may have profound physical, psychological, cognitive, emotional, and social effects.

According to the Centers for Disease Control and Prevention’s National Center for Injury Prevention and Control, in the United States annually at least 1.4 million people sustain a TBI, and approximately 50,000 people die from such injuries.

See Pediatric Concussion and Other Traumatic Brain Injuries, a Critical Images slideshow, to help identify the signs and symptoms of TBI, determine the type and severity of injury, and initiate appropriate treatment.

Essential update: Metabolic biomarkers may help predict TBI severity and outcome

In a study of 256 consecutive adult patients with acute TBI and 36 control patients with acute orthopedic trauma and no acute or previous brain disorders, presented in October 2014 at the annual meeting of the Congress of Neurological Surgeons, Posti et al found 43 potential metabolic biomarkers that differed significantly in expression patterns between TBI patients and control subjects.[1] These differences were most pronounced among patients with severe TBI.

These metabolic biomarkers included small fatty acids, amino acids, and sugar derivatives.[1] Several metabolites (eg, decanoic acid, octanoic acid, glycerol serine, and 1H-indole-3-acetic acid) were significantly upregulated in cerebrospinal fluid and brain microdialysate samples from newly arrived patients with severe TBI, suggesting disruption of the blood-brain barrier. Marked intergroup differences were still evident in samples taken the day after injury. Metabolic profiles were strongly associated with outcomes, as measured by Glasgow Outcomes Scale scores.

Classification

Primary and secondary injuries

• Primary injury: Induced by mechanical force and occurs at the moment of injury; the 2 main mechanisms that cause primary injury are contact (eg, an object striking the head or the brain striking the inside of the skull) and acceleration-deceleration [2]
• Secondary injury: Not mechanically induced; it may be delayed from the moment of impact, and it may superimpose injury on a brain already affected by a mechanical injury [2]

Focal and diffuse injuries

These injuries are commonly found together; they are defined as follows:

• Focal injury: Includes scalp injury, skull fracture, and surface contusions; generally caused by contact
• Diffuse injury: Includes diffuse axonal injury (DAI), hypoxic-ischemic damage, meningitis, and vascular injury; usually caused by acceleration-deceleration forces

Measures of severity

See the list below:

• Glasgow Coma Scale (GCS): A 3- to 15-point scale used to assess a patient’s level of consciousness and neurologic functioning [3, 4] ; scoring is based on best motor response, best verbal response, and eye opening (eg, eyes open to pain, open to command)
• Duration of loss of consciousness: Classified as mild (mental status change or loss of consciousness [LOC] 6 hr)
• Posttraumatic amnesia (PTA): The time elapsed from injury to the moment when patients can demonstrate continuous memory of what is happening around them [5]

Complications

Complications include the following:

• Posttraumatic seizures: Frequently occur after moderate or severe TBI
• Hydrocephalus
• Deep vein thrombosis: Incidence as high as 54% [6]
• Heterotopic ossification: Incidence of 11-76%, with a 10-20% incidence of clinically significant heterotopic ossification [7]
• Spasticity
• Gastrointestinal and genitourinary complications: Among the most common sequelae in patients with TBI
• Gait abnormalities
• Agitation: Common after TBI

Long-term physical, cognitive, and behavioral impairments are the factors that most commonly limit a patient’s reintegration into the community and his/her return to employment. They include the following:

• Insomnia
• Cognitive decline
• Posttraumatic headache: Tension-type headaches are the most common form, but exacerbations of migraine-like headaches are also frequent
• Posttraumatic depression: Depression after TBI is further associated with cognitive decline, [8, 9] anxiety disorders, substance abuse, dysregulation of emotional expression, and aggressive outbursts

Outcome measures

The following tools are commonly used to measure outcome after TBI[10, 11] :

• Functional Independence Measure (FIM): An 18-item scale used to assess the patient’s level of independence in mobility, self-care, and cognition
• Glasgow Outcome Scale (GOS)
• Disability Rating Scale (DRS): Measures general functional changes over the course of recovery after TBI (see the image below)
• Disability Rating Scale (DRS).

Continue —>  Classification and Complications of Traumatic Brain Injury: Practice Essentials, Epidemiology, Pathophysiology.

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