Who here uses the Glascow Coma Scale?

[Just Plain Ruff]

Come on Dwayne, at least a 4 year bachelors and a 2 year masters in EMS. That's the minimum you need to understand the gcs.

I use it but mostly to make sure my narrative is in linewith the requirements for my service on documentation.

Its that little sound in the back of my head that let's me know that I need to make sure this patient is watched a little closer but its a number and I tend to rely on my patient rather than a number.

Its an adjunct in your treatment plan, and your treatment should not be based solely on the advertisement of this number.

Treat your patient not the number!!!!!!

Sent from my SPH-D700 using Tapatalk

What about the old guy who always presents with a 7 or 8. Do you intubate him or go with what you see????

Sent from my SPH-D700 using Tapatalk

[Paramagic]

So you're saying that to ignore the GCS is to be ignorant of basic pt assessment skills? Not trying to put words in your mouth, but it sounds as if you are one of the few here defending it's value..I'd love to hear your justification.

Dwayne

That certainly is putting words in my mouth,but you are clearly already aware of that. I'm interested that the question of justifying the exclusion of GCS has not been asked. On what basis do provides decide that a long-standing, clinical useful, reproducible, standardized scale to determine level of consciousness, degree and to some extent, location of neurological dysfunction and prognosis from neurosurgical events like trauma or hemorrhage? If GCS isn't used, what is?

GCS is not perfect; there are problems with interrater reliability to begin with, but proper training and education can minimize this. This is important given the increasing level of prehospital management of neurosurgical emergencies as initial GCS is an important in determining prognosis. Change in GCS from the prehospital situation to in-hospital (assuming it has been obtained) is strongly predictive of outcome. GCS was initially and is still fundamentally, designed for use in patients with traumatic brain injuries, but it has been widely used and is accepted as appropriate for the se in any patient with an acute neurosurgical issue.

However there are more accurate methods of determining outcome, using age, presence of hypoxia or hypotension and pupil response and so on, but GCS, and in particular the motor score (which is less susceptible to being confounded) is still an important part of these other systems. GCS is most accurate when it is at either extreme (which stands to reason) but still has value in the entire range.

Understanding the pros and cons of the GCS lets us realise that GCS isn't just a random number, or collection of random numbers put together so people can parrot "GCS less than 8, intubate" at every opportunity. It is an important part of assessment and monitoring of range of patient presentation, and an important predictor of outcome in head injured patients.

[DwayneEMTP]

I really like many of your posts Magic, but on this one it appears that you chose a side, became insulting in your defense of it, and despite your own post putting the lie to your logic, are going to simply continue to swear that there is in fact a pink elephant in the room.

I've not seen you quite so moody and defensive before. But I'm willing to bet that if you reread the above post that you will see that you have made the exact point that you showed such disdain for me making earlier.

Dwayne

[tcripp]

What about the old guy who always presents with a 7 or 8. Do you intubate him or go with what you see????

Got a better one for you, Ruff. I have run on a patient with a GCS of 3...no obvious signs of trauma...vital signs all within normal limits...and aside from the fact that you can't wake this person...his color is good and breathing is normal.

Yes...treat the patient, not the number. I TOTALLY agree with that statement.

OH...the patient above? He has basilar migraines that drop him hard. First few times we ran on him, we intubated and flew him out. Now, we load him up and transport him to the closest facility for observations...as is.

[Paramagic]

I really like many of your posts Magic, but on this one it appears that you chose a side, became insulting in your defense of it, and despite your own post putting the lie to your logic, are going to simply continue to swear that there is in fact a pink elephant in the room.

I've not seen you quite so moody and defensive before. But I'm willing to bet that if you reread the above post that you will see that you have made the exact point that you showed such disdain for me making earlier.

Dwayne

I'm not sure why you think I'm moody or defensive, something must have come across in my post that was not intended. I'm also not sure why you think that my first post was directed at you. I agree entirely with your first post that just using one number is meaningless without a breakdown and a context, but if that is how it has been taught, then that represents a deficiency in the teaching of using the GCS.

The post that prompted me to reply was the "Honestly I could care less" post, partly because I think that is a sad indictment on EMS education and to some extent attitudes, and also because that comment is non-sensical given the context. It should be "I couldn't care less." But that is a discussion for another time.

Nonetheless, you asked for my justification of why I think the GCS is important, and I gave it. I stand by the fact that although there are flaws in the GCS it is still a valuable tool for assessing, monitoring and prognosticating when used properly.

[DwayneEMTP]

I'm not sure why you think I'm moody or defensive, something must have come across in my post that was not intended. I'm also not sure why you think that my first post was directed at you. I agree entirely with your first post that just using one number is meaningless without a breakdown and a context, but if that is how it has been taught, then that represents a deficiency in the teaching of using the GCS.

The post that prompted me to reply was the "Honestly I could care less" post, partly because I think that is a sad indictment on EMS education and to some extent attitudes, and also because that comment is non-sensical given the context. It should be "I couldn't care less." But that is a discussion for another time.

Nonetheless, you asked for my justification of why I think the GCS is important, and I gave it. I stand by the fact that although there are flaws in the GCS it is still a valuable tool for assessing, monitoring and prognosticating when used properly.

Gotcha man. I didn't think you meant me specifically, but only that I had seemed to have made the argument that you were commenting on.

As sometimes happens in text, I'm afraid I completely mistook the tone of your posts. I'll ask you to believe that it was an honest mistake and not an attempt to skew point of your posts.

Thanks for taking the time to participate brother...

Dwayne

[paramedicmike]

I disagree. And seeing as you've presented your opinion with nothing to support your argument I'm going to present my opinion with nothing to support my argument. We'll both think each other is wrong. We'll both think each is reading the scenario/question incorrectly. We'll move on from there.

That certainly is putting words in my mouth,but you are clearly already aware of that. I'm interested that the question of justifying the exclusion of GCS has not been asked. On what basis do provides decide that a long-standing, clinical useful, reproducible, standardized scale to determine level of consciousness, degree and to some extent, location of neurological dysfunction and prognosis from neurosurgical events like trauma or hemorrhage? If GCS isn't used, what is?

Who said anything of the sort? It looks like many of the arguments here are saying that treating a patient based on your physical exam findings was preferable to treating a number.

GCS is not perfect; there are problems with interrater reliability to begin with, but proper training and education can minimize this. This is important given the increasing level of prehospital management of neurosurgical emergencies as initial GCS is an important in determining prognosis. Change in GCS from the prehospital situation to in-hospital (assuming it has been obtained) is strongly predictive of outcome. GCS was initially and is still fundamentally, designed for use in patients with traumatic brain injuries, but it has been widely used and is accepted as appropriate for the se in any patient with an acute neurosurgical issue.

However there are more accurate methods of determining outcome, using age, presence of hypoxia or hypotension and pupil response and so on, but GCS, and in particular the motor score (which is less susceptible to being confounded) is still an important part of these other systems. GCS is most accurate when it is at either extreme (which stands to reason) but still has value in the entire range.

I considered breaking this down but decided it was best left in its entirety.

Everything you have just argued (with no supporting sources, by the way) leaves the GCS as nothing more than a tool for documentation. You haven't argued for any type of treatment or intervention to be performed on behalf of the GCS. So it's a prognosticating tool. That sounds like something that's important for documentation to me. It gives the docs an idea of how well the patient will do in the long run.

As such, I don't have to think specifically about it on scene. My assessment, which will be as complete and thorough as I can make it on each and every patient encompassing, among other things, all the components of the GCS, will provide the necessary information for documentation purposes. (It will also provide the necessary information for treatment... which the GCS by itself will not do.) Then the docs can take our findings and document their findings and plug their numbers into their calculators and come up with another number that may, or may not depending on what they're doing, predict both long term outcome and short term interventions for their patients.

Understanding the pros and cons of the GCS lets us realise that GCS isn't just a random number, or collection of random numbers put together so people can parrot "GCS less than 8, intubate" at every opportunity. It is an important part of assessment and monitoring of range of patient presentation, and an important predictor of outcome in head injured patients.

Your assessment is an important part of your assessment and is the sum of all its parts... not the sum of one tiny slice. If you do your assessment thinking, "...his eyes open so his eye score for GCS is 4..." then I would argue you're assessing the skill and not assessing the patient.

[mobey]

Paramagic

Understanding the pros and cons of the GCS lets us realise that GCS isn't just a random number, or collection of random numbers put together so people can parrot "GCS less than 8, intubate" at every opportunity. It is an important part of assessment and monitoring of range of patient presentation, and an important predictor of outcome in head injured patients.

I hereby request evidence to back this up.

To be honest this thread is filled with opinions but no one has yet to post any good science behind GCS, or debunking it

The GCS was used accurately by experienced and highly trained users, but inexperienced users made consistent errors. The errors were such that they would not be detectable by studies that examine only interobserver agreement, and they were substantial, averaging in some cases more than one point on the four-point and five-point scales of the GCS. Also, the error rates were highest at the intermediate levels of consciousness, for which the detection of changes in condition is vital. The findings support the continued use of the GCS by appropriately qualified personnel, but call into question much of the conventional wisdom about its reliability when used by untrained or inexperienced staff.

link

Edit: Mike was posting at the same time...

Edited April 4, 2011 by mobey

[Paramagic]

Dwayne, no offense taken, and my apologies if I caused any; none was intended.

Everything you have just argued (with no supporting sources, by the way) leaves the GCS as nothing more than a tool for documentation. You haven't argued for any type of treatment or intervention to be performed on behalf of the GCS. So it's a prognosticating tool. That sounds like something that's important for documentation to me. It gives the docs an idea of how well the patient will do in the long run.

Stephen Bernard and colleagues published in Annals of Surgery in 2010 the only well controlled study into pre-hospital RSI that showed a benefit in functional outcome in patients who recieve pre-hospital as opposed to in hospital RSI. In this study it was patients with a GCS <10 who recieved benefit. So if we want to provide validated scientific treatment to these patients following traumatic brain injury we need to be able to assess GCS in the field.

As for it being a prognosticating tool, this is indeed true. Surely we are interested in the prognosis of out patients? It's prognostic value has been demonstrated in many different conditions, not least of which is head injuries. However, with increased intervention for these patients in the field, the prognostic value is clouded if a GCS is not accurately recorded, so again, we need to be able to assess and record GCS accurately so Doctors can provide appropriate treatment with reference to their expected outcomes (Problems with initial Glasgow Coma Scale assessment caused by prehospital treatment of patients with head injuries: results of a national survey. J Trauma, 1994)

Your assessment is an important part of your assessment and is the sum of all its parts... not the sum of one tiny slice. If you do your assessment thinking, "...his eyes open so his eye score for GCS is 4..." then I would argue you're assessing the skill and not assessing the patient.

If a patient has their eyes open (actually open) then their GCS score for eyes is 4. I'm not sure why you would think otherwise. However, no-one has suggest that GCS is taken in isolation; it has to be taken in context, but this doesn't diminsh it's value. Nobody has suggested that it should be used without context, that is just a strawman.

I would ask again, if this well studied, well understood (for all it's pros and cons) internationally recognized, reproducible and validated tool is not being used, then what is?

Paramagic

I hereby request evidence to back this up.

To be honest this thread is filled with opinions but no one has yet to post any good science behind GCS, or debunking it

link

Edit: Mike was posting at the same time...

Certainly. With regards to the study you have linked to, I am aware of this, hence my comment "there are problems with interrater reliability to begin with, but proper training and education can minimize this" Paramedics should not be the inexperienced or poorly trained providers that confound this.

Other references for the validity of the GCS include (but are not limited to):

Bishara, S. N., Partridge, F. M., Godfrey, H. P., & Knight, R. G. (1992). Post-traumatic amnesia and Glasgow Coma Scale related to outcome in survivors in a consecutive series of patients with severe closed-head injury. Brain Injury, 6(4), 373380.

Bush, B. A., Novack, T. A., Malec, J. F., Stringer, A. Y., Millis, S. R., & Madan, A. (2003). Validation of a model for evaluating outcome after traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 84(12), 18031807.

Changaris, D. G., McGraw, C. P., Richardson, J. D., Garretson, H. D., Arpin, E. J., & Shields, C. B. (1987). Correlation of cerebral perfusion pressure and Glasgow Coma Scale to outcome. Journal of Trauma, 27(9), 10071013.

Demetriades, D., Kuncir, E., Murray, J., Velmahos, G., Rhee, P., Chan, L. (2004). Mortality prediction of head abbreviated injury score and Glasgow Coma Scale: Analysis of 7,764 head injuries. Journal of the American College of Surgeons, 199(2), 216222.

Diringer, M. N., & Edwards, D. F. (1997). Does modification of the Innsbruck and the Glasgow Coma Scales improve their ability to predict functional outcome? Archives of Neurology, 54(5), 606611.

Gill, M., Windemuth, R., Steele, R., & Green, S. M. (2005). A comparison of the Glasgow Coma Scale score to simplified alternative scores for the prediction of traumatic brain injury outcomes. Annals of Emergency Medicine, 45(1), 3742.

Healey, C., Osler, T. M., Rogers, F. B., Healey, M. A., Glance, L. G., Kilgo, P. D., et al. (2003). Improving the Glasgow Coma Scale score: Motor score alone is a better predictor. Journal of Trauma, 54(4), 671678.

Lieberman, J. D., Pasquale, M. D., Garcia, R., Cipolle, M. D., Mark Li, P., & Wasser, T. E. (2003). Use of admission Glasgow Coma Score, pupil size, and pupil reactivity to determine outcome for trauma patients. Journal of Trauma, 55(3), 437442; discussion 442433.

Mamelak, A., Pitts, L., & Damron, S. (1996). Predicting survival from head trauma 24 hours after injury: A practical method with therapeutic implications. Journal of Trauma: Injury, Infection, and Critical Care, 41(1), 9199.

Meredith, W., Rutledge, R., Hansen, A., Oller, D., Thomason, M., Cunningham, P., et al. (1995). Field triage of trauma patients based upon the ability to follow commands: A study in 29,573 patients. Journal of Trauma, 38, 129135.

Novack, T. A., Bush, B. A., Meythaler, J. M., & Canupp, K. (2001). Outcome after traumatic brain injury: Pathway analysis of contributions from premorbid, injury severity, and recovery variables. Archives of Physical Medicine and Rehabilitation, 82(3), 300305.

Pal, J., Brown, R., & Fleiszer, D. (1989). The value of the Glasgow Coma Scale and Injury Severity Score: Predicting outcome in multiple trauma patients with head injury. Journal of Trauma, 29(6), 746748.

Poon, W. S., Zhu, X. L., Ng, S. C., & Wong, G. K. (2005). Predicting one year clinical outcome in traumatic brain injury at the beginning of rehabilitation. Acta Neurochirurgica, 93 (Suppl.), 207208.

Ross, S., Leipold, C., Terregino, C., & O'Malley, K. (1998). Efficacy of the motor component of the Glascow Coma Scale in trauma triage. Journal of Trauma, 45, 4244.

Wellons, J., & Tubbs, R. (2003). The management of pediatric traumatic brain injury. Seminars in Neurosurgery, 14(2), 111118. Young, B., Rapp, R. P., Norton, J. A., Haack, D., Tibbs, P. A., & Bean,

J. R. (1981). Early prediction of outcome in head-injured patients. Journal of Neurosurgery, 54(3), 300303.

Zafonte, R. D., Hammond, F. M., Mann, N. R., Wood, D. L., Black, K. L., & Millis, S. R. (1996). Relationship between Glasgow Coma Scale and functional outcome. American Journal of Physical Medicine & Rehabilitation, 75(5), 364369.

[DwayneEMTP]

...

Dwayne, no offense taken, and my apologies if I caused any; none was intended...

No man, not even in the ballpark.

...However, no-one has suggest that GCS is taken in isolation;

...it has to be taken in context, but this doesn't diminsh it's value.

...Nobody has suggested that it should be used without context, that is just a strawman.

See, I think that this is where myself, and perhaps others split the sheets. I was not taught to give the GCS as value/value/value/ but as a single number and, when I used it as sprite medic, was never questioned as to the values. I have also heard the GCS relayed within the hospital setting many times as a single value and recorded as a single value there as well.

I don't believe that it is a strawman, but that perhaps where you were educated/work gave it significantly more consideration that did those where many of the rest of us have been.

...I would ask again, if this well studied, well understood (for all it's pros and cons) internationally recognized, reproducible and validated tool is not being used, then what is?

I'm not being a smartass when I say that I believe a concise and thorough hand-off report. I've been running these through my head this morning trying to think what is missing in a good hand off report that is salvaged if I add a GCS...I truly can't think of anything.

Maybe you can give some scenarios/examples that would show us more clearly what you mean. I'm confident that I have a grasp on the significant neurological markers as they pertain to my practice and scope and certainly make sure that they are highlighted within my hand-off so I don't see the advantage is presenting them again in isolation.

It had never occurred to me that you weren't just being a shithead when you took up this argument. But your argument has been intelligent and passionate and got me to wondering what the hell I may be missing.

I must admit..that I try to mold my treatment to best blend with the in hospital treatment when I can see possible ways to do so, but other than ETCO2 when considering cessation of resusc attempts in arrests, I don't really consider outcome potentials of my patients when considering treatment plans yet that seems to carry a lot of weight in your argument of the GCS value, unless I'm misunderstanding. Maybe that's why I'm having a hard time grasping your argument.

This debate has not gone anywhere near where my crystal ball predicted that it was going to go...that is cool as hell!

Dwayne