Glasgow Coma Scale : What is new

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Information about Glasgow Coma Scale : What is new

Published on September 25, 2018

Author: drvenugopalpp


slide 1: Glasgow Coma Scale What is new Dr.Venugopalan P P Director and Lead consultant in Emergency Medicine Aster DM Healthcare slide 2: What is GCS The Glasgow Coma Scale provides a practical method for assessment of impairment of conscious level in response to defined stimuli. slide 3: “The Glasgow Coma Scale is an integral part of clinical practice and research across the World. The experience gained since it was first described in 1974 has advanced the assessment of the Scale through the development of a modern structured approach with improved accuracy reliability and communication in its use.” Sir Graham Teasdale Emeritus Professor of Neurosurgery University of Glasgow slide 4: When looking back... ● The Scale was described in 1974 ● Graham Teasdale and Bryan Jennett ● Way to communicate about the level of consciousness of patients with an acute brain injury. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974 2:81-4 slide 5: GCS Score What was our Understanding slide 6: What is new slide 7: One slide 8: Two slide 9: Three slide 11: Where and how to stimulate slide 12: No Painful stimuli Only pressure stimuli slide 13: Four slide 14: Check Observe Stimulate Rate 4 systematic steps in GCS assessment slide 15: ● Spontaneous ● To Sound ● To pressure ● None slide 16: Mnemonic E- Eye opening Spontaneous S- Sound P- Pressure N- None slide 17: Eye opening slide 18: ● Oriented ● Confused ● Words ● Sounds ● None slide 19: Mnemonic FIVErbal slide 20: Verbal Response slide 21: ● Obey commands ● Localizing ● Normal flexion ● Abnormal flexion ● Extension ● None slide 22: Best motor response slide 24: Charts slide 25: Confounding factors rendering one or more components of the Glasgow Coma Scale untestable ○ Drugs anaesthetics sedatives neuromuscular blockade etc ○ Cranial nerve injuries ○ Intoxication alcohol or drugs ○ Hearing impairment ○ Intubation or tracheostomy Use NT whenever such factors are existing slide 26: Confounding factors rendering one or more components of the Glasgow Coma Scale Untestable ○ Limb or spinal-cord injuries ○ Dysphasia ○ Pre-existing disorders dementia or psychiatric disorders ○ Ocular trauma ○ Language and culture ○ Orbital swelling Use NT whenever such factors are existing slide 30: Paediatric GCS slide 31: Few areas of confusions…. GCS slide 32: Prevention and management of missing components ● Avoid missing values ❖ Temporary stop sedation wake-up test ● Simple imputation same value for each patient ❖ Record the verbal scale in patients intubated or with tracheostomy as VTube ❖ We advise against assigning a score of 1 to eye and verbal components in sedated or untestable patients slide 33: Prevention and management of missing components ● Statistical imputation single or multiple imputation based on data ❖ Imputation of verbal score from eye and motor components ❖ Imputation based on other patient characteristics slide 34: Strategies to improve GCS ● Describe the responses of each of the components in individual patients ● Use the extended six-point motor subscale and 15-point score ● Do not assign 1 for imputation of missing values ● Chart and display changes over time slide 35: Strategies to improve GCS ● Limit the use of the score to classification and research ● Improve standardisation in assessment of patients ● Develop training instruments and implement quality improvement programmes ● Use the scale for prognosis only in combination with other prognostic factors eg Age Pupil reactivity and Imaging slide 36: GCS -P Pupil Reaction Scale PRS slide 38: GCS P The GCS Pupils Score GCS-P was described by Paul Brennan Gordon Murray and Graham Teasdale in 2018 as a strategy to combine the two key indicators of the severity of traumatic brain injury into a single simple index slide 39: How do I score GCS-P ● GCS-P is calculated by subtracting the Pupil Reactivity Score PRS from the Glasgow Coma Scale GCS total score GCS-P GCS minus PRS GCS-P is Ranging from 15 to 1 slide 40: How do I assess PRS slide 41: Advantage of GCS P ● GCS and the pupil response to light are both related to outcome ● Combining the information together in the GCS-P extends the information provided about outcome to an extent comparable to more complex methods of combination of the data ● Improve decision making about patient care and assist in stratification of patients into clinical trials. slide 42: Advantage of GCS P ● GCS-P Score may also be a useful platform onto which information about other key prognostic features can be added in a simple format likely to be useful in clinical practice slide 43: Evidence based exercise In the first paper Brennan Murray and Teasdale describe the development of the Glasgow Coma Scale-Pupils score GCS-P a simple but elegant tool that extends the information collected by the GCS score on the severity of TBI. slide 44: Evidence based exercise The authors examined 1. Relationships between GCS scores and pupils’ reaction to light 2. Relationships between these factors and patient outcome 6 months after injury slide 45: Evidence based exercise They examined data from ● CRASH1 and IMPACT2 ● The two largest databases containing information on individual patients with TBI slide 46: GCS P Case study Imagine that you are asked to assess a patient who has been ejected from the passenger seat of a car at high velocity. They make no eye verbal or motor movements spontaneously or in response to your spoken requests. slide 47: GCS P Case study ● When stimulated their eyes do not open ● Make only incomprehensible sounds ● Flex arms abnormally ● Scored as E1V2M3 using the Glasgow Coma Scale ● Sum score of 6. slide 48: GCS P Case study ● Now test their pupil reactivity to light ● Neither pupil is reactive to light. ● Pupil Reactivity Score PRS of 2. ● GCS-P can then be determined as GCS-PRS ● In this case it 6-2 4. slide 49: GCS P Case study ● GCS 6 there is a 29 chance of death at 6 months ● When the pupil reactivity and GCS are combined to give a GCSP the mortality increases to 39 slide 51: GCS -P and Mortality slide 52: GCS -P ● Used as an index of ‘overall’ brain damage ● Distinguishing head injuries of differing severities ● Monitoring their progress and prognosis slide 53: GCS -P ‘Brain stem’ features were not incorporated into the scale but were expected to be assessed separately There have nevertheless been views that more complex scores with extra features would be useful. slide 54: GCS- P A Age slide 56: GCS PA ● GCS Pupils Age prognostic charts ● Developed by Gordon Murray Paul Brennan and Graham Teasdale and published by the Journal of Neurosurgery in 2018 ● The charts provide a simple graphical presentation of the probabilities of outcome from traumatic brain injury based on GCS Pupil reactivity Age and CT scan findings. slide 57: GCS Pupils Age prognostic charts ● Four prognostic factors contain much of the information about prognosis of people with an acute head injury ● GCS pupil reactivity to light age and the findings on ● Computer Tomography CT scan are the most useful investigative index slide 58: GCS Pupils Age prognostic charts ● Combining them to convey information graphically about risks of mortality or the prospects for independent recovery after head injury. 1. GCS 2. Pupil reactivity 3. Age 4. CT Scan finding slide 59: GCS PA ● Observed the additive effect on outcome that occurs when age is added to the patient’s admission GCS-P ● The risk of death after TBI increases as patient age advances ● At all ages the risk of death increases as the GCS-P decreases. slide 60: GCS - PA ● Probability of favourable outcome is greater in younger patients and in patients with higher GCS-P slide 61: GCS -PA Charts ● The authors created two prediction charts based on the GCS-P and patient age stratified into 5-year increments GCS-PA charts ● One chart clearly shows risks of death ● Other chart probabilities of favourable outcomes in patients 6 months after TBI. slide 62: 6 month mortality slide 63: 6 months favorable outcome slide 64: GCS Pupil Age slide 65: These factors have been validated in earlier studies to be the most important prognostic characteristics in head-injured patients. slide 66: GCS-P A CT Abnormalities slide 67: GCS P A plus CT findings ● CT findings are the other important predictor of patient outcome ● CT scan findings showed the differences in outcome are very similar between patients with or without either a haematoma or absent cisterns or subarachnoid haemorrhage slide 68: GCS P A plus CT findings Taken in combination there is a gradation in risk with increasing numbers of any of these abnormalities A simple extension of the prognostic charts can then be made by stratifying the original charts into three CT groupings: ● No ● Only One ● Two or more CT Abnormalities slide 69: GCS-PA CT charts ● Simplify three different abnormal CT findings into scores based solely on the number of abnormalities ● Created two sets of three predictive charts based on the GCS-P plus patient age and number of CT abnormalities GCS-PA CT charts ● Charts for No CT abnormalities Only one abnormalities Two or More abnormalities slide 70: GCS-PA CT charts 1. One chart follows probabilities of death 6 months after injury 2. Other set follows probabilities of favourable outcome at the same time point. ● Charts can be used by clinicians in decision making ● Communicating predictive information to other clinicians patients and caregivers. slide 71: GCS PA CT Prediction Charts slide 72: GCS PA CT- prediction charts 6 months Mortality No CT findings slide 73: GCS PA CT prediction charts 6 months mortality Only One CT findings slide 74: GCS-PA CT prediction charts 6 month mortality Two or more CT findings slide 75: GCS PA CT Prediction chart 6 months Favorable outcome No CT Findings slide 76: GCS PA CT Prediction chart 6 months Favorable outcome Only One CT Findings slide 77: GCS PA CT Prediction chart 6 months Favorable outcome Two or More CT Findings slide 78: GCS-P- A - CT prognostic Tables ● Developed from data created by the IMPACT and CRASH studies ● These studies include patients exhibiting a wide spectrum of haematoma. ● The size of the haematoma or severity of subarachnoid haemorrhage does not need to be separately considered ● Size and severity will influence the GCS and pupil reactivity slide 79: Summary slide 80: Authors response on the studies “Decisions about patient care in the immediate aftermath of a head injury are influenced by physician perceptions of the patient’s likely outcome so it’s important that assumptions that underlie these decisions are correct. slide 81: Authors response on the studies “Working together between Glasgow and Edinburgh we have developed the GCS-P and associated prognostic charts. These simple and easy to use tools provide reliable estimates of outcomes at 6 months and will support clinician decision making in neurotrauma.” slide 82: How to assess GCS Video slide 83: You can search here …. slide 84: Resources slide 85: Thanks a lot

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