BENGKEL PENGURUSAN PESAKIT “HEAD INJURY” UNTUK JURURAWAT DI HOSPITAL KKM NEGERI SELANGOR 25 JUN 2010 DI HOSPITAL SUNGAI BULOH GLASGOW COMA SCALE
Assessment of the initial severity and late outcome play a key role in the management and understanding of a wide range of acute injuries and insults to the brain WHY WAS THE SCALE DEVELOPED?
Graham M. Teasdale was Professor and Head of the Department of Neurosurgery, University of Glasgow (1981 to 2003). What were the main factors in the design of the scale? The approach should be simple and practicable , useable in a wide range of hospitals by staff without special training. GLASGOW COMA SCALE
The Glasgow Coma Scale (GCS) was developed to assess the level of neurologic injury , and includes assessments of movement, speech , and eye opening Brain injury is often classified as Severe (GCS ≤ 8), Moderate (GCS 9–12), Mild (GCS ≥ 13) <ul><li>Quick neurologic assessment for </li></ul><ul><li>Prognosis </li></ul><ul><li>Victim’s ability to maintain patent airway on own </li></ul>This avoids the need to make arbitrary distinctions between consciousness and different levels of coma GLASGOW COMA SCALE
The Glasgow Coma Scale has proved a practical and consistent means of monitoring the state of head injured patients. GCS does not entail assumptions of specific underlying anatomical lesions or physiological mechanisms In the acute stage, changes in conscious level provide the best indication of the development of complications such as intracranial haematoma whilst the depth of coma and its duration indicate the degree of ultimate recovery which can be expected. GLASGOW COMA SCALE
Useful as a reflection of the intensity of impairment of activating functions Spontaneous eye opening <ul><li>It indicates arousal mechanisms brain stems are active </li></ul><ul><li>It does not imply awareness . </li></ul>In the persistent vegetative or minimally conscious state, eye opening is characteristically dissociated from evidence of intellectual function. GCS: EYE OPENING
<ul><li>It is sought by speaking or shouting at the patient. </li></ul><ul><li>Any sufficiently loud sound can be used, not necessarily a command to open the eyes. </li></ul>Eye opening in response to speech <ul><li>This should be assessed before the patient is physically stimulated. </li></ul>GCS: EYE OPENING
Eye opening response to pain <ul><li>It is assessed if the person is not opening their eyes to sound. </li></ul><ul><li>It is should not causes unnecessary injury to the patient. </li></ul><ul><li>The stimulus should be pressure on the bed of a fingernail or supraorbital nerve . </li></ul>Options such as rubbing the sternum or pinching the chest or arm do not offer advantages. GCS: EYE OPENING
<ul><li>It implies substantial impairment of brain stem arousal mechanisms. </li></ul><ul><li>Substantial effort should be made earlier to ensure that this is not due to an inadequate stimulation. </li></ul>An absence of eye opening It is also important to identify if a lack of eye opening is a consequence of local injury, for example fronto-basal fractures , or sedative and paralysing medication GCS: EYE OPENING
Orientation <ul><li>It is the highest level of response and implies awareness of self and environment . </li></ul><ul><li>The person should be able to provide answers to at least three questions, </li></ul><ul><li>1. who they are </li></ul><ul><li>2. where they are </li></ul><ul><li>3. the date – at least in terms of the year the month and day of the week. </li></ul>A person who can answer some but not all these questions can be subcategorised as partially orientated , either specifying what information that they are able to give or how many out of the three components they can provide. GCS: VERBAL RESPONSE
<ul><li>It is recorded if the patient engages in conversation but is unable to provide any of the foregoing three points of information. </li></ul><ul><li>The key factor is that the person can produce appropriate phrases or sentences. </li></ul>Confused conversation GCS: VERBAL RESPONSE
Inappropriate speech <ul><li>It is assigned if the person produces only one or two words , in an exclamatory way, often swearing. </li></ul><ul><li>It is commonly produced by stimulation and does not result in sustained conversation exchange. </li></ul>GCS: VERBAL RESPONSE
<ul><li>It is consist of moaning and groaning but without any recognisable words . </li></ul><ul><li>It is commonly produced by stimulation and does not result in sustained conversation exchange. </li></ul>Incomprehensible sounds GCS: VERBAL RESPONSE
<ul><li>No verbal response upon pain stimulus. </li></ul><ul><li>Substantial effort should be made earlier to ensure that this is not due to an inadequate stimulation. </li></ul>No verbal response The verbal responses may be affected as a result of focal brain damage rather than a general impairment of function. For example, an impaired verbal response in an otherwise apparently alert person should raise the suspicion of dysphasia. The use of endotrachial intubation clearly precludes a verbal response GCS: VERBAL RESPONSE
Obeying commands The assessment of motor responsiveness becomes important in a person not conversing to at least a confused level <ul><li>It is the best response possible. </li></ul><ul><li>Confirmation of the specificity of the response by squeezing and releasing the fingers or holding up the arms or other movement elicited by verbal command. </li></ul>It is important to be aware that motor responses can occur as a primitive grasp reflex or a startle response or a even simple posture adjustment GCS: MOTOR RESPONSES
Localisation <ul><li>It is done with the application of pressure on the supraorbital notch </li></ul><ul><li>Localising should be recorded only if the person’s hand reaches above the clavicle in an attempt to remove the stimulus. </li></ul><ul><li>If in doubt, stimulation can be applied to more than one site to ensure that the hand attempts to remove it </li></ul>Stimulus to the trunk may result in the arms moving across the chest in a way that does not represent a specific localised response. GCS: MOTOR RESPONSES
A withdrawal response <ul><li>It is recorded if the elbow bends away from pain stimulus but the movement is not sufficient to achieve localisation </li></ul>GCS: MOTOR RESPONSES
An abnormal flexion response (decorticate) <ul><li>It is recorded if the elbow bends in decorticate posturing and the movement is not sufficient to achieve localisation </li></ul>GCS: MOTOR RESPONSES
An extension response (decerebrate) <ul><li>It is recorded if the elbow only straightens and the movement should not sufficient to achieve localisation. </li></ul>GCS: MOTOR RESPONSES
Before recording that someone has no motor response, vigorous and varied efforts should be made. Absence of motor response. <ul><li>It is recorded if no limb movement upon pain stimulus </li></ul>GCS: MOTOR RESPONSES
What kind of flexion movements can be recognised? <ul><li>It is clearly present when the response is slow, stereotyped </li></ul><ul><ul><li>– that is repeated time after time </li></ul></ul><ul><ul><li>– and results in the arm moving to an adducted internally rotated position, </li></ul></ul><ul><ul><li>characteristic of the hemiplegic or so called decorticate posture </li></ul></ul>normal flexion movement <ul><li>It is characterised by rapid withdrawal, abduction of the shoulder , and external rotation which varies from stimulation to stimulation </li></ul>abnormal flexion movement Inexperienced staff, particularly working outside neurosurgical centres, find the distinction very difficult to make with consistency. For this reason, in the acute stage, it is sufficient in monitoring most patients to record simply that flexion is present The distinction is useful prognostically GCS: MOTOR RESPONSES
Why is it the best motor response? <ul><li>The scale is based upon taking account of the best response of the better limb . </li></ul><ul><li>The highest level of response achieved provides the most consistent assessment of the patient’s state and the best guide to the integrity of brain function remaining . </li></ul>A difference between the two sides may indicate focal brain damage. The worst or most abnormal response also should be noted in order to identify the site of focal damage GCS: MOTOR RESPONSES
What needs to be checked if there is apparently no response? <ul><li>An absence of motor response clearly equates to a severe depression of function . </li></ul><ul><li>Before ascribing this to structural damage it is important to exclude other causes </li></ul><ul><ul><li>– for example the effects of systemic insults such as hypoxia , hypotension or the use of drugs . </li></ul></ul><ul><li>Comparison should be made of the responses in the legs and arms with those in head and neck injury in order to alert the examiner to the possibility of spinal cord or brain stem injury . </li></ul><ul><li>It is also important to ensure a stimulus of adequate intensity has been applied. </li></ul>GCS: MOTOR RESPONSES
Inter-observer consistency has been examined by many investigators and has been shown to be robust in a wide, relevant range of circumstances including emergency departments, intensive care units and in pre-hospital care. However, consistency cannot be assumed and should be confirmed and enhanced by training and communication between staff. GCS: CONSISTENCY
In the acute stage , the sooner an observation is made, the more useful it is as a guide to predict the ultimate outcome . In the acute state where patient’s state of consciousness is influenced by remedial disorders – for example hypoxia or hypotension, prognosis have been based upon an assessment after sufficient time has passed . Post resuscitation GCS usually assess after 6 hours , in a well resuscitated patient. Post resuscitation GCS GCS: HOW SOON ?
<ul><li>The shorter the time between an injury or other event and the assessment , the more the security about the stability of a patient’s condition. </li></ul><ul><li>Observations at frequent intervals are appropriate for example every few minutes and at least several times within an hour . </li></ul><ul><li>As time passes the frequency can be reduced, and related to whether or not there are reasons for considering the patient needs continuing observation and care. </li></ul>GCS: HOW OFTEN ?
<ul><li>Questions are asked about the extent of change that should take place in order to trigger action . </li></ul><ul><li>It may determine transfer to another unit e.g. from a general to a specialist neurosurgical department. </li></ul><ul><li>Again, hard and fast rules are not appropriate. </li></ul>The general guidance is that it depends upon where the patient is showing change from and the extent of the change <ul><li>Generally significant changes when total score reduces by 2 points or motor response reduces by single point </li></ul>There is a greater degree of consistency in the assessment of the motor component of the scale than the verbal and eye features GCS: HOW MUCH CHANGE MATTER ?
The total or sum score (coma score) was initially used as a way of summarising information, in order to make it easier to present group data. However, the resulting score proved a useful and powerful summary of the extent of brain dysfunction and showed a strong relationship with prognosis When describing an individual patient, especially when communicating with colleagues, it is always preferable to refer to the responses observed and not to rely upon communication through the intermediary of numbers or a total score . GCS: RELATIONSHIP BETWEEN THE SCALE AND THE SCORE?
A major limitation of the total score is the difficulty to translate the score into a clear picture of the patient’s actual condition . This is particularly a risk in telephone exchanges. The lowest score is not 0, nor even, 1 but 3 GCS: RELATIONSHIP BETWEEN THE SCALE AND THE SCORE?
It is a result of the differences in the approaches to assessment of flexion motor responses In the simpler system , recommended for routine use in patient monitoring, no attempt is made to distinguish between normal and abnormal flexion . This results in a system summing to a total of 14 Distinction between normal and abnormal flexion important in assessing the significant deterioration from normal to abnormal brain responses – Important prognostic factor GCS: IS THE TOTAL SCORE 14 OR 15?
The Glasgow Coma Scale (GCS) as an objective assessment of neurological function, is of Limited usefulness in children under 3 years of age One of the components of the Glasgow coma scale is the best verbal response which cannot be assessed in nonverbal small children A modification of the original Glasgow coma scale was created for children too young to talk CHILDREN COMA SCALE
Children coma scale = = (score for eye opening) + (score for best nonverbal or verbal response) + (score for best motor response) CHILDREN COMA SCALE
Interpretation: • minimum score is 3 which has the worst prognosis • maximum score is 15 which has the best prognosis <ul><li>• Scores of 7 or above have a good chance for recovery. </li></ul><ul><ul><li>Scores of 3-5 are potentially fatal especially if accompanied by fixed pupils or absent oculovestibular responses or elevated intracranial pressure. </li></ul></ul><ul><ul><li>Normal children under 5 years may have lower scores than adults because of reduced best verbal and motor responses. </li></ul></ul>CHILDREN COMA SCALE
Simpson and Reilly (1982) PAEDIATRIC COMA SCALE
British Paediatric Neurology Association CHILD’S GLASGOW COMA SCALE
It remains the standard for acute assessment Although initially described four decades ago, the Glasgow approaches to assessment of initial severity and outcome of brain damage have weathered the test of time. Alternatives to and adaptations of the Glasgow Scales have been described. Some of these have clear advantages, for example in relation to children CONCLUSIONS