GoodBYE GCSMark Wilson

Scale = individual componentsScore = the total

What is consciousness?

WakefulnessContent

levels of Consciousness"MetaconsciousConsciousConfusedDeliriousSomnolentObtundedStuporousComatose.

Bart Hughes 1962Children have a higher state of consciousness and since children's skulls are not fully closed one can return to an earlier child like state of consciousness by self trephination

Bryan Jennett 1926-2008Sir Graham Teasdale

cited > 6,000 times

What was it meant for?The assessment of coma and impaired conciousness

TREND MONITOR

NOT A TOTAL NUMBER

But what do we use it for now?Communication about all neuro patientsHead Injury Severity MeasurePrognostication toolSedation ScaleDepth of ComaAll cause MENTAL STATUS MONITOR

Mild - GCS 13-15Moderate - GCS 9-12Severe - GCS < 8 (trauma coma data bank)But PVS can be E4, V2, M3Brain Injury SeveritySubarachnoid SeverityWFNS scaleGradeGCSMotor Deficit115-213-14-313-14+412-7+/-53-6+/-

E1 V1 M2 = 48% E1 V2 M1 = 27%E2 V1 M1 = 19%Mortality of GCS 4Healey C, Osler TM, Rogers FB, et al. Improving the Glasgow Coma Scale score: motor score alone is a better predictor J Trauma. 2003;54:671-678.

ITU GCS 12 is not the same as Pre-Hospital 12E3, V4, M5

Scoring Systems incorporating GCSAPACHE IIRTSTRISSCRAMS

+ TBI Models eg IMPACT (motor score)

Problems WITH GCSPeople Intubated prior ArrivalNo V when intubatedNothing about Brain Stem ReflexesThe abnormal flexion bitIt is not linear - M score more importantLow Interrupter reliability (30% of paired assessments are > 2 different)

3 , 8 , 15

History of ScoresJouvet Coma ScaleMoscow Coma ScaleGlasgow Coma ScaleJapan Coma ScaleBozza-Marrumbini ScaleGrady Coma ScaleFour Score

Full Outline of UnResponsiveness Score

Simple Assessment ScalesAlertVoicePainUnresponsiveAlertConfusedDrowsyUnresponsiveObeys CommandsLocalisesLess (/ withdrawal)Simplified Motor Scales

What Causes Fixed Dilated PupilsHypoxiaSeizuresDrugsOrbital TraumaBrain Stem Injury

and pressure on the occulomotor nerve.

FUCD Meta-AnalysisEDHSDHMortalityGood OutcomeGood OutcomeMortality29%54%66%7%

It is underlying pathology that should predict outcome - not a score

Whats THE FUTURE?

NIRSUltrasoundMobile CT

Try to Look Through patients

WHY STICK WITH GCS?Its understoodDo you really want different coma scores for TBI, stroke, sedation?It is ingrained in so many scoring systems / models.

TAKE HOME MESSAGEDESCRIBE WHAT YOU SEE using the scale + pupils

But also think about the underlying pathology@markhwilson