Who here uses the Glascow Coma Scale?

[uglyEMT]

I have been following this thread after my initial every call every patient statment. Yes that still holds true, its part of my "bag o' tricks" that I use to see the status of my patient. Especially during my normally long transport times from scene.

I want to add something here. I see both Paramagic and Dwaynes side of the coin. Yes in my area we use it as one number (yes each of the three get their own value but it is reported as one) so telling a nurse GCS 10 doesnt really say anything BUT during your handoff saying what is depressed gives the complete picture. So in Dwaynes case the number doesn't even need to be given but what does is a proper handoff to the ED staff and a complete write up on the PCR. On Paramagics side it is a useful tool when seeing trends in patients status. If you are running the numbers in your head while doing your vitals and notice a depression in one of the areas it could change your course of treatment.

As far as patient outcome I know there is a begining of a paradigm shift twords pre-hospital providers thinking of patient outcome and factoring that into their interventions. I am not there yet personally. Yes I want all my patients to leave the hospital don't get me wrong. But long term doesn't equateinto my interventions, I concuntrate on giving my patient what they need at that moment. (OK I have a limited playbook but hell I work with what I got)

I will still use my GCS and give spot on handoff reports (both verbal and PCR) and using it as a tool and not just a number.

Oh and to Tcripp I know what you mean, I had a patient with a glucose of 12 yes TWELVE and a GCS of 15 going on and on about her grand daughters new boyfriend. Needless to say 2 tubes of glucose and a push of D50 the medics got it to 72 and still not GCS change.

[paramedicmike]

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.

Actually, they based it on a GCS of less than or equal to nine (with head trauma, older than 15 yrs and intact airway reflexes). What they're leaving out of the study methods, however, are the indications that lead them to move towards RSI in the first place. This isn't so much a need to be able to calculate GCS in the field as a driver towards RSI as it is we need to be able to assess our patient's need for an airway in the field.

You'll probably disagree on that last statement. But that's ok.

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)

Absolutely we're interested in patient outcome! That's why we're interested in what the studies will show us.

With that being said, *recording* a GCS can legitimately come after the fact. A complete and thorough assessment will provide all the information needed to compile an accurate GCS. Documenting that score will satisfy the needs of the statisticians who crunch the numbers.

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.

I didn't think or say 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.

No strawman and that is exactly my point! Nobody is saying use it in isolation. You commented that it's an important part of the assessment. I was simply trying to point out that it's the total assessment that counts... specifically meaning that a good assessment will provide the information regardless if you sit and check off GCS boxes or not. Then, when we sit down to do our paperwork, we can document appropriately and move on from there.

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?

Who's arguing against it? As far as you and I are concerned I think we're just arguing over when it's calculated for documentation purposes.

That being said, reading back over this I think we're both on the same page. We're just approaching the situation a little differently. I don't actively think of a patient's GCS while assessing or treating. However, I *do* get the necessary information that can be used to later check off the boxes to keep whoever wants the info happy. I don't think it unimportant in the grand scheme of things. I just don't approach it with the same mental organization you do.

Thanks, too, for the references you posted. It'll give me something to read when I'm not reading.

[HellsBells]

"I couldn't care less." But that is a discussion for another time.

Sorry to highjack the subject of this thread, but I was a little irked by the pseudo-intellectual smarminess in the pointless correction of a members grammer.

The expression " I could care less," while grammatically incorrect, is in fact an acceptable slang term, quite common in the North American lexicon. Its usage is interchangable with "I couldn't care less," rendering your correction moot, yet pretentious.

The Oxford English Dictionary does tell us that (I, etc.) could care less is a "colloq. phr." -- but so is (I, etc.) couldn't care less. The only difference is that (I, etc.) could care less is a "U.S. colloq. phr."

Now as for the GCS... I find it a useful tool for those with neurological deficits, in so far as it provides a starting point for a pts neurological status at a point in time. But, as has been previously noted, its only one part of a complete assessment.

[Paramagic]

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'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.

I have no doubt that nothing would be missed in your handover. However, what taking and recording the GCS in this instance will do, is quantify your observations in a manner that is easily transmissable, reproducible and useful to the Docs in determining their course of action. I also personally find it easier to say "GCS 5: 1, 2, 2" than "Eyes closed, groaning incoherently to painful stimuli, with extension of the arms and hyperpronation of the hands"

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

We are encouraged strongly to consider the long-term outcomes of patients when we are devising a treatment plan, and in those we assess as having a poor likelihood of good outcome, we are supported in electing to withhold treatment such as intubation. One of the ways we determine this is obviously the GCS. I realise that this is not the way most EMS approach these things.

Actually, they based it on a GCS of less than or equal to nine (with head trauma, older than 15 yrs and intact airway reflexes). What they're leaving out of the study methods, however, are the indications that lead them to move towards RSI in the first place. This isn't so much a need to be able to calculate GCS in the field as a driver towards RSI as it is we need to be able to assess our patient's need for an airway in the field.

You'll probably disagree on that last statement. But that's ok.

GCS less than or equal to 9 = GCS less than 10. But I do agree to some extent, GCS is not just a "do we intubate or not" tool. Last week I carried out an RSI in a patient with a GCS of 15, because he needed his airway protected. The week before I elected not to intubate a patient with a GCS of 6.

However, Bernards trial was not primarily about managing the airway, it was about mitigating the effects of secondary brain injury through elimination of reflexes and good sedation/pain relief, along with managing EtCO2 to minimize hyper/hypocapnia, and examining whether this improved neurological outcome at 6 months.

Sorry to highjack the subject of this thread, but I was a little irked by the pseudo-intellectual smarminess in the pointless correction of a members grammer.

The expression " I could care less," while grammatically incorrect, is in fact an acceptable slang term, quite common in the North American lexicon. Its usage is interchangable with "I couldn't care less," rendering your correction moot, yet pretentious.

Your phrases "irked by the pseudo-intellectual smarminess" and "It's usage is interchangable with "I couldn't care less" rendering your correction moot, yet pretentious" not to mention the reference to the Oxford English Dictionary, to me smacks of smarmy, pretentious pseudo-intellectualism.

[DwayneEMTP]

...We are encouraged strongly to consider the long-term outcomes of patients when we are devising a treatment plan, and in those we assess as having a poor likelihood of good outcome, we are supported in electing to withhold treatment such as intubation.

Who is 'we' in the above sense, as well as those that followed?

Thank you for your response. I have no time to give a considered rebuttal, if in fact that would be my desire...tonight.

Dwayne

[Paramagic]

Who is 'we' in the above sense, as well as those that followed?

Thank you for your response. I have no time to give a considered rebuttal, if in fact that would be my desire...tonight.

Dwayne

Sorry, 'we' being the service I work for. It's a Third Service model that is reasonably well integrated into the health system as a whole (although it could be better), and the research we carry out looks not just at how well we get people to hospital, but the overall, long term outcomes, both in terms of the patient, and the benefit (or cost) to the community at large.