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Glasgow coma scale.ppt

This slide talks about the Glasgow Coma Scale and Pupillary assessment.

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Glasgow coma scale.ppt

  1. 1. Glasgow Coma Scale and Pupillary assessment Dr Sumit Sinha Asstt Prof Neurosurgery JPNATC, AIIMS
  2. 2. Clinical Scenario ● A 20 year old white male presents to the team physician unconscious 5 minutes after missing the pole vault pit and landing with the occipital region of his head hitting asphalt. After assessing the ABC’s and finding them intact, the patient’s level of consciousness was evaluated. The patient’s eyes, initially closed, opened to the sound of his name, and when asked where he was, the patient responded with “my shoes to change.” The patient moved all of his fingers and toes when prompted. ● What is this patient’s score on the Glasgow Coma Scale?
  3. 3. Clinical correlate (revisited) ● The patient’s eyes, initially closed, opened to the sound of his name. ● Eye opening ● 3 ● When asked where he was, the patient said “my shoes to change.” ● Verbal response ● 3 ● The patient moved all of his fingers and toes when prompted. ● Motor response ● 6 ● Score ● GCS 12 = E3 V3 M6 at 16:34 ● Head injury severity ● Moderate
  4. 4. ● Developed by neurosurgeons in 1974 ● Quantifies level of consciousness ● Acute brain damage: traumatic and/or vascular injuries or infections ● Metabolic disorders: hepatic or renal failure, hypoglycemia, diabetic ketosis, toxic ingestion ● Assess initial level of consciousness ● Assess changes in level of consciousness ● Helps guide treatment and predict outcome Glasgow Coma Scale: What is it?
  5. 5. Glasgow scoring 2Incomprehensible speech PointsResponseCategory 1No response 2Extensor (rigid) response, decerebrate posture 3Abnormal (spastic) flexion, decorticate posture 4Withdraws from pain 5Purposeful movement to painful stimulus 6Obeys commands for movement Motor response 1TIntubated 1No response 3Inappropriate responses, words discernible 4Disoriented, confused conversation, able to answer questions 5Oriented conversation Verbal response 1No response 2Opens to pain, not applied to face 3Opens to verbal command, speech, or shout 4Spontaneous, open with blinking at baseline Eye opening
  6. 6. Verbal response in children 3Persistent cries and/or screamsPersistent inappropriate crying and/or screaming 4Inappropriate wordsCries and consolable 2GruntsGrunts or is agitated or restless 5Appropriate words or phrasesSmiles or coos appropriately 1No responseNo response PointsVerbal ageNon-verbal age
  7. 7. Prognosis 12%82%11-15 27%68%8-10 53%34%5-7 87%7%3-4 Vegetative or DeadGood recovery or Moderate disability Highest score observed during 1st 24 hours after injury
  8. 8. Glasgow Coma Scale ● (Teasdale & Jennett (1974)
  9. 9. Glasgow Coma Scale (GCS) • Used in acute situations to assess patient’s level of consciousness • Need to record initial examination results accurately • This is only achieved using the same questions each time patient is assessed ! • Treatment decision may depend on whether subsequent examinations show improvement/ deterioration
  10. 10. Components of the GCS ● There are three components to the GCS: • Best eye opening • Best motor response • Best verbal response ● Each is evaluated independently of the other two ● components. ● ALWAYS SCORE THE BEST RESPONSE FOR THE PATIENT
  11. 11. Best Eye Opening (4 – 1) • Assessment of eye opening shows that arousal mechanisms located in the brain stem are functioning. • If patients have their eyes closed, their state of arousal can be assessed by the degree of stimulation needed to get them to open their eyes.
  12. 12. Eye Opening Response 4 = eyes open spontaneously when a person approaches the bedside. Indicates intact arousal mechanism. 3 = eyes open to either spoken or shouted verbal stimulation. 2 = eyes open to a painful stimuli (to be used only when it is clear patient will not open eyes to verbal stimuli). 1 = failure to open eyes regardless of stimuli.
  13. 13. Eye Opening • If there is damage to the occulomotor nerve from trauma, the patient may not be physically able to open his or her eye. • The occulomotor nerve is responsible for movement of the eyelid and causes the eye to open.
  14. 14. Best Motor Response (6 – 1) • Obeys commands (6) • Localises to pain (5) • Withdraws from pain (4) • Abnormal flexion (3) • Extension (2) • No response (1)
  15. 15. Obeys Commands (6) • Patients are aware of their environment, have understood the observer's instructions, and are able to carry them out. • Examples of possible commands are 'lift up your arms' or 'hold up your thumb'. • If patients are asked to 'squeeze my hands', they must also be asked to release their grip.
  16. 16. Localises to Pain (5) • This is a response to a central painful stimulus. • It involves the higher centres of the brain, the cerebral hemispheres or cerebrum. • It tells the body to do something about removing the source of the pain - usually a motor response such as moving an arm towards the source of the pain in order to remove it and stop the pain from continuing
  17. 17. Withdraws from pain (4) • Patients flex or bend their arm towards the source of the pain, but do not actually localise or try to remove the source of the pain.
  18. 18. Abnormal Flexion (3) • Patients flex or bend the arm at the elbow and rotate the wrist, resulting in a spastic posture in response to a central painful stimulus. • It is an abnormal response and indicates severe cerebral damage and an interruption of nerve pathways from the brain's cortex to the spine. Mesencephalic region or corticospinal tract damage
  19. 19. Extension (2) • In response to a central painful stimulus, patients will extend or straighten an arm at the elbow, or may rotate the arm inwards. • Abnormal response and emanates from the brain stem. • It shows that patients are not able to send information to and from the cerebrum due to damage to the brain stem. ● Brainstem damage below the red nucleus
  20. 20. Best Verbal Response (5 - 1) • Verbal response assesses consciousness by determining whether a person is aware of him/herself and the environment. • It involves the second aspect of consciousness - cognition.
  21. 21. Orientation There are six specific questions in the original GCS • What is your name • Where are you • Why are you here • What month are we in? • What year are we in? • What season are we in?
  22. 22. Confusion (4) • A patient may be able to hold a conversation with the observer but responses are inappropriate or disoriented. • This category is sometimes referred to as 'sentences', which is a more specific assessment used by neurocentres. • A patient who talks in sentences, is confused but not orientated, and will score four.
  23. 23. Inappropriate Speech (3) • Does not carry on conversation, poor attention span, uses inappropriate words and phrases. • Random/confused/repetitive.
  24. 24. Incomprehensible Speech (2) • Patients are less aware of their environment and their verbal response is in the form of incomprehensible sounds. • Moan or cry, unable to articulate. • The observer may now have to use both a painful and verbal stimulus to get a response.
  25. 25. Levels of Consciousness GCS ratings correlate with brainstem and higher cortical functioning: • GCS 13 - 15: mild traumatic brain injury • GCS 9 -12: moderate traumatic brain injury • GCS 3 – 8: severe traumatic brain injury