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Fallacies of GCS and New Head Injury Scoring

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Kumar Saurabh
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43 views61 pages

Fallacies of GCS and New Head Injury Scoring

Uploaded by

Kumar Saurabh
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Fallacies of GCS and New Head

Injury Scoring Systems


Syed Yasin Shahtaz Emanee
The Lancet, July 13, 1974
Score revised in 1979 – Motor Component 6 categories – total 15,
compared with a total of 14 with the earlier system
The Lancet Neurology, August 2014

• 4 years after the original Article in The Lancet,


an editorial in the Journal of Neurosurgery
called for neurosurgical units worldwide to
adopt the Glasgow Coma Scale and
standardised outcome measures to assess
head injuries
The Lancet Neurology, August 2014

• The first edition of the Advanced Trauma


Life Support Course, which recommended its
use for the assessment of level of
consciousness
The Lancet Neurology, August 2014

• In 1988, the World Federation of


Neurosurgical Societies (WFNS) used it as the
basis for their recommendations about
grading of patients with subarachnoid
haemorrhage
Fallacies of GCS
Fallacies of Scoring
• Not originally intended to be converted into a single score
— the components (E4,V5, M6) are more important than
the total score

• M score does not factor in unilateral pathology

• Unreliable in patients in the middle range of 9-12

• Skewed towards motor component

• Timing of Assessment
• The same GCS score will predict different TBI
mortality depending on the
components
— GCS of 4 with the components 1+1+2 (E+V+M)
predicts a mortality rate of 48%
— GCS of 4 with the components 2+1+1 (E+V+M)
predicts a mortality rate of 19%
Confounders
E V M
Ocular injury Intubated Limb injuries
Neuromuscular Tracheostomised Quadriparesis /
diseases plegia
Aphasic Immobilised
Language Neuromuscular
Barriers diseases
Metabolic disorders / Under influence of Drugs /
Alcohol / Sedatives / catatonia and psychiatric illnesses
Inter observer variability
• In a study of independent paired assessments
by attending emergency physicians GCS scores
were the same in just 38% and were 2 or more
points apart in 33%
• Less than half (48%) of clinicians correctly scored
the GCS in a written clinical scenario; with
neurosurgeons correct just 56% of the time.
For perspective, the GCS sensitivity and
specificity to independently predict
outcomes are similar to the ability of
weather forecasters to predict rain and
the ability of the WBC count to predict
appendicitis
SIMPLER SCALES PERFORM JUST AS WELL

• The 6-point motor component exhibits the


best performance of the 3 subscales, and
there have been calls to adopt it as a GCS
replacement
• McNarry and Goldhill (2004) describe two 4-
point scores (AVPU, ACDU) as comparable to
the GCS
• Gill et al observed that just 3 of the 6 points
of the GCS motor score defined essentially its
total performance – the SIMPLIFIED MOTOR
SCALE
(aka TROLL – Test of
Responsiveness –
Obeys,
Localises,
Less)
Timeline of some Bedside Indices
• 1974 – GCS by teasdale
• 1984 - Comprehensive level of Consciousness
Scale (CLOCS)
• 1988 – Glasgow liege scale
• 1991 – Pittsburg Brainstem Score
• 1991 - Innsbruck Coma Scale
• 1993 – Sugiura modified Edinberg coma scale
• 2005 – FOUR score
From WFNS Newsletter 2019
Glasgow Outcome Scale –
• Sister scale of GCS to see outcomes of head
injury – originally in 1975

Nature Reviews – Neurology July 2016


• Originally 5 point – later expanded into 8
points
GCS - P
GCS – Pupils Age charts
• The Charts are derived from information
about 10,702 adult head injured patients
• Outcome at 3-6 months – mortality,
favourable
• Clinical – GCS –P
• CT – Hematoma, SAH, Absence of Basal
Cisterns
FOUR
score
• The FOUR score provides
– greater neurological detail than the GCS,
– recognizes a locked-in syndrome, and is superior
to the GCS due to the availability of
– brainstem reflexes, breathing patterns, and the
– ability to recognize different stages of herniation
• Thirty-two studies demonstrated equivalency
or superiority of the FOUR score compared to
Glasgow Coma Score in prediction of mortality
and functional outcomes
• It displays good inter-rater reliability among
physicians and nurses
Madras Head Injury Prognostic Scale
(MHIPS)
• retrospective study involved 355 patients with
severe head injury
APACHE III
• Physiological dimension – 12 items – each
scored 0-4
• Age – 0-6
• Chronic Diseases and Organ failure
• Total Score - 0-71 (higher the score, higher
the mortality)
Radiological Scales
• Marshall - 1992
• Rotterdam - 2005
• Stolkholm – 2010
• Helsinki - 2014
Radiological scales - MARSHALL
ROTTERDAM
HELSINKI
PECARN
e – TBI score
WFNS – eTBI 2019
Other Simpler Scales
• Best Motor Response
• AVPU – Alert – Verbal – Pain - Unresponsive
• ACDU – Alert – Confused – Drowsy -
Unresponsive
• Unstructured Clinical Judgement
Summary
• GCS is probably more suitable for simpler non
intubated patients without brainstem
dysfunction
• GCS has stood the test of time – convenience
and communication
• Search for a more accurate scale continues
Future Perspectives
• Responsiveness, Vitals, Brainstem reflexes
• Aim – predicting the need for intervention,
outcome
• Separate variants for pre hospital, hospital
admission and icu patients
• Variants for sub populations – paeds, geriatric,
pregnant
• Easily Validated in local languages
• Usability in multiple pathologies
THANK YOU

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