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Inter observer variability in gcs scoring in a level i trauma centre


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Inter observer variability in gcs scoring in a level i trauma centre

  1. 1. Vivek Tandon, Deepak Agrawal Dept of Neurosurgery. JPNATC AIIMS – New Delhi Inter-observer variability in GCS scoring in a Level I Trauma Centre Do we now need GCS independent protocols?
  2. 2. Introduction <ul><li>Frykberg and Tepas showed in mass casualty CNS injury is frequent and specially in terrorist bombings. </li></ul><ul><li>Head injury being the most common cause – 71% for immediate and 52% for the late fatality. </li></ul><ul><li>GCS charting is an integral part of assessment in the ER by any physician/ surgeon . </li></ul><ul><li>HI Protocols are usually implemented in ER based on the initial GCS </li></ul>
  3. 3. GCS effectiveness <ul><li>Motor component of GCS and systolic blood pressure are the strongest physiological predictors of severe injury. </li></ul><ul><li>Sensitivity and specificity of GCS score less than 6 were 72.6 % and 96.2%. AND for systolic BP of < 80 mm were 30.4 and 99.2%. </li></ul>
  4. 4. Objective <ul><li>This study was to assess whether there was any interobserver variability in GCS recording by doctors & nurses during the initial management of patient in the ER and ICU/ward </li></ul>
  5. 5. Materials and methods <ul><li>Only those patients which were admitted under neurosurgery through casualty were studied. </li></ul><ul><li>We analyzed the GCS score awarded to the patient by the resident doctor (emergency team) in casualty, by the neurosurgeon in casualty and by the neurosurgeon at the time of admission in ward /ICU / or before operating. GCS scores awarded by the nursing staff were also studied. </li></ul><ul><li>No. of years of post MBBS experience for doctors and no. of years of service was also analyzed. </li></ul>
  6. 6. Results Total no. of patients 100 GCS score - <8 24 GCS score - <9 - 13 32 GCS score - 14 - 15 44
  7. 7. Results Total no. of patients with discrepancy 42 % Discrepancy in score =1 15 35% Discrepancy in score =2 11 26% Discrepency in score =3 9 22% Discrepency in score = >4 7 17%
  8. 8. results 26 22
  9. 9. Results Scoring discrepancies Scoring difference in eye score 15 Scoring difference in verbal score 28 Scoring difference in motor score 24
  10. 10. Results continued Mean year of experience of JR Difference in score , compared with S/R neurosurgery % less than 1 year 25 59.5% More than one year 17 40.5%
  11. 11. Discussion <ul><li>If There is variability in GCS recording patients with severe HI may be labeled as moderate HI or vice-versa </li></ul><ul><li>Protocols for HI management are usually developed based on the GCS assessment. </li></ul><ul><li>At JPNATC GCS independent protocol for cervical spine & HI screening has been developed where all pts of suspected HI irrespective of GCS undergo CT of head & Cx spine (upto C7) </li></ul>
  12. 12. Conclusions <ul><li>GCS scoring can not be a gold standard for assessing the level of consciousness in patients with significant brain injury. </li></ul><ul><li>There is need to devise simpler and GCS independent protocols for triage. </li></ul><ul><li>In spite of proper training there remains significant inter-observer variability in GCS recordings even among neurosurgeons. </li></ul>