Glasgow Coma Scale

[Ace844]

(The Predictive Value of Field versus Arrival Glasgow Coma Scale Score and TRISS Calculations in Moderate-to-Severe Traumatic Brain Injury

[Original Articles)

Davis, Daniel P. MD, FACEP; Serrano, Jennifer A. MD; Vilke, Gary M. MD, FACEP; Sise, Michael J. MD, FACS; Kennedy, Frank MD, FACS; Eastman, A Brent MD, FACS; Velky, Thomas MD, FACS; Hoyt, David B. MD, FACS

From the Departments of Emergency Medicine (D.P.D., J.A.S., G.M.V.) and Surgery (D.B.H.), University of California San Diego, San Diego, California; Mercy Air Medical Services (D.P.D.), San Diego, California; Scripps Mercy Hospital (M.J.S.), San Diego, California; Sharp Memorial Hospital (F.K.), San Diego, California; Scripps La Jolla Hospital (A.B.E.), La Jolla, California; Palomar Hospital (T.V.), Escondido, California.

Submitted for publication August 2, 2005.

Accepted for publication January 6, 2006.

Presented as a poster at the 64th Annual Meeting of the American Association for the Surgery of Trauma, September 22–24, 2004, Atlanta, Georgia.

Address for reprints: Daniel Davis, MD, UCSD Emergency Medicine, 200 West Arbor Drive, #8676, San Diego, CA 92103-8676; email: davismd@cox.net]

Abstract

Background: Glasgow Coma Scale (GCS) scores are widely used to quantify level of consciousness in the prehospital environment. The predictive value of field versus arrival GCS is not well defined but has tremendous implications with regard to triage and therapeutic decisions as well as the use of various predictive scoring systems, such as Trauma Score and Injury Severity Score (TRISS). This study explores the predictive value of field GCS (fGCS) and arrival GCS (aGCS) as well as TRISS calculations using field (fTRISS) and arrival (aTRISS) data in patients with moderate-to-severe traumatic brain injury (TBI).

Methods: Major trauma victims with head Abbreviated Injury Scores of 3 or greater were identified from our county trauma registry over a 16-year period. The predictive ability of fGCS with regard to aGCS was explored using univariate statistics and linear regression modeling. The difference between aGCS and fGCS was also modeled against mortality and the composite endpoint using logistic regression, adjusting for fGCS. The predictive value of preadmission GCS (pGCS), defined as either fGCS or aGCS in nonintubated patients without a documented fGCS, with regard to mortality and a composite endpoint representing the need for neurosurgical care (death, craniotomy, invasive intracranial pressure monitoring, or intensive care unit care >48 hours) was determined using receiver-operator curve (ROC) analysis. Finally, fTRISS and aTRISS predicted survival values were compared with each other and to observed survival.

Results: A total of 12,882 patients were included. Mean values for fGCS and aGCS were similar (11.4 and 11.5, respectively, p = 0.336), and a strong correlation (r2 = 0.67, 95% CI 0.66–0.69, p < 0.0001) was observed between them. The difference between fGCS and aGCS was also predictive of outcome after adjusting for fGCS. Good predictive ability was observed for pGCS with regard to both mortality and neurosurgical intervention. Both fTRISS and aTRISS predicted survival values were nearly identical to observed survival. Observed and fTRISS predicted survival were nearly identical in patients undergoing prehospital intubation

Conclusions: Values for fGCS are highly predictive of aGCS, and both are associated with outcome from TBI. A change in GCS from the field to arrival is highly predictive of outcome. The use of field data for TRISS calculations appears to be a valid methodological approach, even in severely injured TBI patients undergoing prehospital intubation.

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Since its original description by Teasdale and Jennett in 1974, the Glasgow Coma Scale (GCS) score has become ubiquitous as a measure of level of consciousness in the assessment of traumatic brain injury (TBI) patients.1–15 Its simplicity has made it popular in emergency medical services (EMS) systems to assist with triage and therapeutic decision making.8–15 In addition, GCS score is incorporated into various trauma scoring systems, which are used for benchmarking and research applications. The most popular of these is the Revised Trauma Score (RTS), which can then be used to estimate the probability of survival as part of the Trauma Score and Injury Severity Score (TRISS) methodology.16–19 The TRISS methodology has since been used to evaluate prehospital treatment strategies as an alternative to randomized controlled trials.17–27

There are several potential problems with the use of GCS score by EMS personnel. First, GCS was originally described as a prognostic tool when measured several hours following admission, in the post-resuscitative phase of TBI.1 In addition, GCS was intended for use as a dynamic measure of level of consciousness rather than as a single measurement.1,28,29 Furthermore, RTS and TRISS prediction equations were derived from GCS scores calculated by physicians upon arrival at the trauma center rather than by EMS personnel in the field, where its predictive value has not been validated.16–19 Even among physicians, GCS has demonstrated poor interobserver reliability, and the accuracy and predictive value of prehospital GCS and TRISS is unknown.30 Several smaller studies have documented discrepancies between field and arrival GCS calculations, either due to inaccuracies in calculations by EMS personnel or to dynamic changes in level of consciousness during the early phase of TBI.4,6,7,30,31 Finally, although the association between GCS and mortality is well documented, the ability of early GCS to predict the need for advanced neurosurgical care remains undetermined but may have utility for triage decisions in the prehospital environment. The objectives of this analysis were to evaluate the predictive value of fGCS with regard to arrival GCS score (aGCS) as well as eventual outcome in patients with moderate-to-severe traumatic brain injury (TBI). In addition, the use of field versus arrival clinical data to calculate TRISS survival predictions was explored.

PATIENTS AND METHODS

This was a retrospective, registry-based analysis. Waiver of informed consent was granted by our Institutional Review Board. Adult patients with moderate-to-severe TBI, defined as a Head/Neck Abbreviated Injury Score (AIS) of 3 or greater, were identified from the county trauma registry over a 16-year period. Patients in whom the Head/Neck AIS was defined by a neck injury were excluded.

EMS System

San Diego County has a population of about 3 million in an area of 4,200 square miles. The vast majority of major trauma victims (MTVs) receive an advanced life support (ALS) response by paramedics. In addition, air medical crews, consisting of a flight nurse and either an emergency medicine resident or flight paramedic, respond from two locations at the request of ground providers. All prehospital personnel receive training in GCS score calculations.5 Adult MTVs are taken to one of five designated trauma centers, all of which are designated Level I or II.

Data Collection

Prehospital and hospital data for each admitted trauma patient are entered into the country trauma registry. For this analysis, age, prehospital and arrival systolic blood pressure (SBP), prehospital and arrival respiratory rate (RR), fGCS and aGCS, Injury Severity Score (ISS), prehospital intubation status, intensive care unit (ICU) length of stay, craniotomy, invasive intracranial pressure (ICP) monitoring, and survival to hospital discharge were abstracted from the county trauma registry. In addition, a preadmission GCS score (pGCS) was defined for each patient as either the fGCS score or the aGCS score in patients not intubated in the field in whom fGCS was not recorded.

Data Analysis

The first objective of this analysis was to compare the predictive value of fGCS with regard to aGCS. Mean values for fGCS and aGCS were compared using Student’s t test. This was performed for all patients and separately for those with a head AIS value of 4 or greater. Of note, comparisons of fGCS and aGCS required that both values be recorded; this excluded patients undergoing prehospital intubation because aGCS could not be calculated with an endotracheal tube in place. The association between fGCS and aGCS was also modeled using linear regression, and aGCS based on fGCS was explored graphically, with GCS stratified into 3, 4 to 8, 9 to 12, 13 to 14, and 15. Finally, the significance of a change in GCS from the field to arrival was explored using logistic regression, adjusting for fGCS. Mortality and the need for neurosurgical intervention were used as the outcome variables for the logistic regression models. Neurosurgical intervention was defined by a composite endpoint, which included mortality, craniotomy, invasive intracranial pressure monitoring, or ICU admission >48 hours.

The second objective was to explore the predictive value of fGCS, aGCS, and pGCS with regard to outcome. Both mortality and the need for neurosurgical intervention as defined above were explored as outcome measures using receiver-operator curve (ROC) analysis. In this analytic approach, sensitivity is plotted against 1 - specificity, with predictive ability quantified using the area under the curve (AUC). Optimal predictive ability is indicated by an AUC that approaches 1.0, whereas a poor test has an AUC approaching 0.5. An optimized value can be determined as the point on the ROC curve that maximizes sensitivity and specificity. Total fGCS, aGCS, and pGCS scores, as well as the individual pGCS components (eye, verbal, motor), were included in the analyses.

The final objective was to validate the use of field versus arrival data for TRISS predicted survival calculations. Field values for GCS, SBP, and RR were used to calculate a field TRISS score (fTRISS), while the first recorded hospital vital signs were used to calculate an arrival TRISS score (aTRISS). Each TRISS survival prediction was compared with the other and to observed survival. A separate comparison between fTRISS predicted survival and observed survival was performed for intubated patients. This represents a different use of TRISS predictions than the original descriptions.16–19

RESULTS

A total of 12,882 patients in whom pGCS scores could be defined were included in this analysis. This included 10,396 patients with a documented fGCS score and 9,158 non-intubated patients with a documented aGCS score. The mean values for fGCS and aGCS were similar (11.4 and 11.5, respectively, p = 0.336) and a strong correlation (r2 = 0.67, 95% CI 0.66–0.69, p < 0.0001) was observed between them. For patients with severe TBI (head AIS 4 or greater), mean values for fGCS and aGCS were identical (10.1 for both, p = 0.769). The values for aGCS stratified by fGCS are displayed in Figure 1. The difference between fGCS and aGCS was associated with both mortality (adjusted OR 1.25, 95% CI 1.21–1.29, p < 0.0001) and neurosurgical intervention (adjusted OR 1.27, 95% CI 1.23–1.30, p < 0.0001) after adjusting for fGCS using logistic regression. The distribution of pGCS scores is displayed in Figure 2. The relationship between pGCS and both survival and prehospital intubation is displayed in Figure 3.

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Fig. 1. Arrival GCS calculations based on field GCS stratifications.

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Fig. 2. Histogram for preadmission GCS scores.

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Fig. 3. Survival and field intubation by preadmission GCS score.

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The ROC analyses for fGCS, aGCS, and pGCS for both in-hospital mortality and neurosurgical intervention, including the individual components for pGCS (eye, verbal, motor), are displayed in Figures 4 to 6. Optimized threshold points and AUCs are displayed in Table 1.

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Fig. 4. Receiver-operator curve for preadmission GCS, including individual components, as predictive of mortality.

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Fig. 5. Receiver-operator curve for preadmission GCS, including individual components, as predictive of a composite endpoint of mortality, craniotomy, invasive intracranial pressure monitoring, or ICU stay >48 hours.

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Fig. 6. Receiver-operator curve for field GCS scores as predictive of either mortality or a composite endpoint of mortality, craniotomy, invasive intracranial pressure monitoring, or ICU stay >48 hours versus arrival GCS scores as predictive of either mortality or a composite endpoint of mortality, craniotomy, or ICU stay >48 hours.

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Table 1 Area under the Curve and Optimized Threshold Values for Preadmission GCS, Field GCS, and Arrival GCS using Receiver-Operative Curve (ROC) Analyses

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A total of 9,018 patients had complete data to allow calculation of preadmission TRISS scores (fTRISS or aTRISS if field vitals not recorded in nonintubated patients); predicted and observed survival values were similar (77.8% versus 78.6%, 95% CI for difference –1.9% to 0.3%, p = 0.155). A total of 5,735 patients had complete data to allow calculation of fTRISS scores; predicted and observed survival values were also similar (75.1% versus 74.5%, 95% CI for difference –0.8% to 2.0%, p = 0.415). A total of 1,276 intubated patients had complete data to allow calculation of fTRISS scores; predicted and observed survival values were again similar (39.9% versus 40.2%, 95% CI for difference –3.6% to 3.0%, p = 0.862). These data are displayed in Figure 7. Finally, a total of 4,118 patients had complete data to allow calculation of both fTRISS and aTRISS scores, which were similar to each other and to observed survival (86.5% versus 87.0% versus 85.9%; 95% CI for scene-arrival difference –1.5% to 0.5%, p = 0.325; 95% CI for scene-observed difference –0.7% to 1.9%, p = 0.350; 95% CI for arrival-observed difference –0.1% to 2.4%, p = 0.083). These data are displayed in Figure 8. The predicted and observed survival values were higher in this group, as patients undergoing prehospital intubation were excluded due to the inability to calculate aGCS values.

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Fig. 7. Predicted versus observed survival. TRISS methodology was used to calculate predicted survival, using either field or preadmission clinical data (using arrival data in non-intubated patients if field data incomplete). The final comparison used field data only for intubated patients. Standard error bars are indicated.

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Fig. 8. Predicted versus observed survival. TRISS methodology was used to calculate predicted survival, using either field or arrival clinical data. Standard error bars are indicated.

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DISCUSSION

Here we explore the predictive value of fGCS scores in relation to aGCS as well as patient outcome, including mortality and the need for neurosurgical intervention. Values for fGCS were highly predictive of aGCS, and TRISS scores calculated using either field or arrival data were nearly identical to each other and to observed patient outcome. This was even true for patients undergoing prehospital intubation, who represent the most critically injured of all patients. These data support the predictive value of fGCS and the use of prehospital data for TRISS calculations. It is notable, however, that any change in GCS from the field to hospital arrival was highly predictive of outcome, underscoring the dynamic nature of level of consciousness and the need to perform serial GCS assessments in the early phase of resuscitation. Overall predictive ability of GCS was good, but use of GCS alone in making prehospital triage decisions involves a substantial tradeoff between sensitivity and specificity as reflected by the ROC analyses. Additional studies are necessary to develop a better tool to efficiently determine the need for advanced neurosurgical care for patients with potential TBI.

Previous studies have investigated the level of agreement between prehospital and hospital GCS scores. Bazarian et al. observed lower fGCS versus aGCS values in 60 TBI patients with a fGCS of 8 to 13.4 This would suggest that use of fGCS to calculate TRISS predicted survival would lead to lower predicted survival, erroneously inflating the observed–predicted survival differential. Arbabi et al. compared fGCS to aGCS in 7,823 MTVs and observed discordant values in 1,441 (18%).7 Most of these had higher aGCS values, which would again result in a lower fTRISS versus aTRISS. Udekwu et al. observed a nonlinear relationship between aGCS and outcome, including mortality and Functional Independence Measure, in almost 23,000 MTVs.9 The study population used in these studies is important to consider when considering our data. We selected a population of patients with moderate-to-severe TBI. This results in a higher overall mortality and increases the probability that an alteration in consciousness was related to a significant head injury. Using all MTVs increases the proportion of patients with higher GCS values and decreases overall mortality.7,9 This may also increase the likelihood that factors such as alcohol or drug intoxication or a mild concussion without structural brain injury would result in a rapid rise in GCS score from the field to arrival at the hospital. On the other hand, focusing on patients with moderate GCS scores may select for a group with more dynamic levels of consciousness, magnifying an fGCS–aGCS difference.4

The ability of paramedics to calculate GCS scores is not well documented. Our previous experience during the San Diego Paramedic RSI Trial suggests that paramedics can be taught to accurately perform this assessment.5 However, Gill et al. observed poor interobserver reliability for GCS score among physicians performing assessments only minutes apart.30 In addition, the short response intervals observed in many EMS systems may result in the fGCS being obtained during an early “concussive” phase, which may not predict eventual outcome. This was perhaps best demonstrated during the San Diego Paramedic RSI Trial, where almost a quarter of patients enrolled for “traumatic coma” did not have significant injury, experiencing a rapid return to full consciousness and extubation in the ED.5,32,33 It is worth noting that the prognostic value of GCS was originally described with assessments performed after the initial resuscitation phase.1 Ultimately, new technologies may give a more accurate and continuous measure of consciousness that will replace clinical examination during the initial assessment of TBI patients.

Several limitations to this analysis must be considered when interpreting these data. Although a strong association between fGCS and aGCS was observed, there is no other way to verify the accuracy of paramedic GCS assessments. Even if an investigator were present on the scene, the high interobserver variability would call into question the “gold standard” for GCS scoring. In addition, a single fGCS value is entered into our trauma registry. This makes it difficult to determine whether this represents the initial GCS, as is the intent of this parameter, or instead represents an assessment taken immediately before arrival in the trauma resuscitation suite. Similarly, the predictive value of a change in GCS from the field to arrival is difficult to validate; however, the strong correlation with outcome suggests that this represents a true dynamic alteration in consciousness rather than a calculation error. Furthermore, the inability to perform GCS assessments on intubated patients prevents validation efforts in these critically injured patients, although the relationship between pGCS and prehospital intubation status as well as the agreement between fTRISS predicted survival and observed survival in intubated patients supports the validity of these calculations. Finally, we selected a population of patients with TBI as defined by head AIS. As discussed above, this may artificially improve the predictive ability of fGCS and fTRISS scores by making the likelihood that an alteration in level of consciousness represented a true injury.

CONCLUSIONS

Prehospital GCS calculations appear to be valid as they are correlated with both aGCS and patient outcome. In addition, a change in GCS from the field to arrival is highly predictive of survival as well as the need for neurosurgical intervention. The use of prehospital data for TRISS predicted survival calculations also appears to be valid, even in patients requiring prehospital intubation.

REFERENCES

1. Teasdale G, Jennett B. Assessment of coma and impaired consciousness: a practical scale. Lancet. 1974;2:81–82. Bibliographic Links [Context Link]

2. Wall RL. Rapid-sequence intubation in head trauma. Ann Emer Med. 1993;22:1008–1013. [Context Link]

3. Moskopp D, Stahle C, Wassmann H. Problems of the Glasgow Coma Scale with early intubated patients. Neurosurg Rev. 1995;18:253–257. Bibliographic Links [Context Link]

4. Bazarian JJ, Eirich MA, Salhanick SD. The relationship between pre-hospital and emergency department Glasgow coma scale scores. Brain Inj. 2003;17:553–560. Bibliographic Links [Context Link]

5. Davis DP, Vadeboncoeur TF, Ochs M, et al. The association between field Glasgow Coma Scale score and outcome in patients undergoing paramedic rapid sequence intubation. J Emerg Med. 2005;29:391–397. Bibliographic Links [Context Link]

6. Marion DW, Carlier PM. Problems with initial Glasgow Coma Scale assessment caused by prehospital treatment of patients with head injuries: results of a national survey. J Trauma. 1994;36:89–95. Bibliographic Links [Context Link]

7. Arbabi S, Jurkovich GJ, Wahl WL, et al. A comparison of prehospital and hospital data in trauma patients. J Trauma. 2004;56:1029–1032. Ovid Full Text Bibliographic Links [Context Link]

8. Norwood SH, McAuley CE, Berne JD, et al. A prehospital glasgow coma scale score < or = 14 accurately predicts the need for full trauma team activation and patient hospitalization after motor vehicle collisions. J Trauma. 2002;53:503–507. Ovid Full Text Bibliographic Links [Context Link]

9. Udekwu P, Kromhout-Schiro S, Vaslef S, Baker C, Oller D. Glasgow Coma Scale score, mortality, and functional outcome in head-injured patients. J Trauma. 2004;56:1084–1089. Ovid Full Text Bibliographic Links [Context Link]

10. Lieberman JD, Pasquale MD, Garcia R, et al. Use of admission Glasgow Coma score, pupil size, and pupil reactivity to determine outcome for trauma patients. J Trauma. 2003;55:437–442. Ovid Full Text Bibliographic Links [Context Link]

11. Pal J, Brown R, Fleiszer D. The value of the Glasgow Coma Scale and Injury Severity Score: predicting outcome in multiple trauma patients with head injury. J Trauma. 1989;29:746–748. Bibliographic Links [Context Link]

12. Amin AP, Kulkarni HR. Improvement in the information content of the Glasgow Coma Scale for the prediction of full cognitive recovery after head injury using fuzzy logic. Surgery. 2000;127:245–253. Bibliographic Links [Context Link]

13. Healey 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. Ovid Full Text Bibliographic Links [Context Link]

14. Rutledge R, Lentz CW, Fakhry S, Hunt J. Appropriate use of the Glasgow Coma Scale in intubated patients: a linear regression prediction of the Glasgow verbal score from the Glasgow eye and motor scores. J Trauma. 1996;41:514–522. Ovid Full Text Bibliographic Links [Context Link]

15. Teoh LS, Gowardman JR, Larsen PD, Green R, Galletly DC. Glasgow Coma Scale: variation in mortality among permutations of specific total scores. Intensive Care Med. 2000;26:157–161. Bibliographic Links [Context Link]

16. Boyd CR, A. TM, Copes WS. The TRISS method. J Trauma. 1987;27:370–378. [Context Link]

17. Copes WS, Champion HR, Sacco WJ, et al. The injury severity score revisited. J Trauma. 1988;28:69–77. [Context Link]

18. Champion HR, Sacco WJ, Carnazzo AJ, et al. The trauma score. Crit Care Med. 1981;9:672–676. Bibliographic Links [Context Link]

19. Champion HR, Sacco WJ, Copes WS, et al. A revision of the trauma score. J Trauma. 1989;29:623–629. Bibliographic Links [Context Link]

20. Baxt WG, Moody P. The impact of a rotorcraft aeromedical emergency care service on trauma mortality. JAMA. 1983;249:3047–3051. Bibliographic Links [Context Link]

21. Baxt WG, Moody P. The differential survival of trauma patients. J Trauma. 1987;27:602–606. Bibliographic Links [Context Link]

22. Baxt WG, Moody P. The impact of a physician as part of the aeromedical prehospital team in patients with blunt trauma. JAMA. 1987;257:3246. Bibliographic Links [Context Link]

23. Baxt WG, Moody P. The impact of advanced prehospital emergency care on the mortality of severely brain-injured patients. J Trauma. 1987;27:365–369. Bibliographic Links [Context Link]

24. Baxt WG, Moody P, Cleveland HC, et al. Hospital-based rotorcraft aeromedical emergency care services and trauma mortality: a multicenter study. Ann Emerg Med. 1985;14:859–864. Bibliographic Links [Context Link]

25. Boyd CR, Corse KM, Campbell RC. Emergency interhospital transport of the major trauma patient: air versus ground. J Trauma. 1989;29:789–793. Bibliographic Links [Context Link]

26. Jacobs LM, Gabram SG, Sztajnkrycer MD, Robinson KJ, Libby MC. Helicopter air medical transport: ten-year outcomes for trauma patients in a New England program. Conn Med. 1999;63:677–682. Bibliographic Links [Context Link]

27. Larson JT, Dietrich AM, Abdessalam SF, Werman HA. Effective use of the air ambulance for pediatric trauma. J Trauma. 2004;56:89–93. Ovid Full Text Bibliographic Links [Context Link]

28. Teasdale GM, Murray L. Revisiting the Glasgow Coma Scale and Coma Score. Intensive Care Med. 2000;26:153–154. Bibliographic Links [Context Link]

29. Teasdale G, Gentleman D. The description of “conscious level”: a case for the Glasgow Coma Scale. Scott Med J. 1982;27:7–9. Bibliographic Links [Context Link]

30. Gill MR, Reiley DG, Green SM. Interrater reliability of Glasgow Coma Scale scores in the emergency department. Ann Emerg Med. 2004;43:215–223. Bibliographic Links [Context Link]

31. Buechler CM, Blostein PA, Koestner A, et al. Variation among trauma centers’ calculation of Glasgow Coma Scale score: results of a national survey. J Trauma. 1998;45:429–432. Ovid Full Text Bibliographic Links [Context Link]

32. Davis DP, Ochs M, Stern J, et al. Factors associated with head-injury mortality following paramedic rapid sequence intubation: a final analysis of the San Diego Paramedic RSI Trial. J Trauma. 2005;59:484–488. Ovid Full Text Bibliographic Links [Context Link]

33. Davis DP, Hoyt DB, Ochs M, et al. The effect of paramedic rapid sequence intubation on outcome in patients with severe traumatic brain injury. J Trauma. 2003;54:444–453. Ovid Full Text Bibliographic Links [Context Link]

[Just Plain Ruff]

I for one as a ER paramedic who took reports, it wasnt really important to us to know the gcs unless it was less than 8. Sure go ahead and give the components if that is what you need to do.

I've also been involved in many ER's across the country and in each of the departments you could see the reactions of nurses to different types of reports.

Long winded reports got glazed looks from the nurses unless the patient was critical. I listened to one paramedic give his report and when he got 3 minutes into and started on all the patients med hx and medications taken along with dosages the nurse walked away. At the end of his report he requested lasix and morphine yet did he get the order approved Heck no - there was no one listening to his report at that time.

So I followed the KISS rule - keep it simple stupid

BUT with that said - do what you are required if you have to give each component of the gcs then go ahead but as for your way is better, I say my way is better. but then again that's whats great about this country My way is better than yours.

[FireGuard69]

When I give a radio report, if the GCS is anything but 15 (unless a lower number is the baseline, as with a dementia patient for example) I give the components.

I worked as a Communications Specialist for a medivac helo, and if GCS was less then 15, they wanted to know why. And the RNs and Medics usually told us why. It can help with calling in appropiate staff (Level II Trauma Centre)

This is our way of doing things.

[paramedicmike]

This is our way of doing things.

Yeah...but Jersey's just....shall we say...."special"!

[Mark3743]

I am reading all this and am impressed with the depth of knowledge I am seeing in this thread, however I do have to make one comment. The GCS score seems to be important in a small category of pts such as those with a traumatic brain injury (TBI), but for most of the pt's GCS just doesn't seem that important. I would have to agree that a total GCS score of less than 8 is nesscary before anyone really is going to care at the recieving hospital, But that kind of a score requires severe motor impairment and that is the more important finding!! I also think that the GCS should be revised so as to be able to assign a zero score. Our PCR requires a GCS score and I am tired of explaining to a lawyer or manager why this person scored a three and had been dead for two days and a pt alive and seriously injured scored no better.

[AZCEP]

There are some alternatives out there, but you really are pinned to what your local protocol wants you to use.

The motor response has been studied to be the most important of the three sections of the GCS.

Like most other assessment tools, if your receiving facility doesn't understand the scale you use, you can bet you won't be getting the attention that you need.

[Mark3743]

There are some alternatives out there, but you really are pinned to what your local protocol wants you to use.

The motor response has been studied to be the most important of the three sections of the GCS.

Like most other assessment tools, if your receiving facility doesn't understand the scale you use, you can bet you won't be getting the attention that you need.

Any reccomendations on alternatives to GCS?? I don't see too many TBI where I work!

[Ace844]

Any reccomendations on alternatives to GCS?? I don't see too many TBI where I work!

The Revised Trauma score is great for some patients I have also been known to use the TRISS, or APACHE scores as well.

Hope this helps,

ACE844

[AZCEP]

Actually, the TRISS, APACHE, and ISS all have their own issues. Most common is the depth of the score, and the ability to remember what each section is for.

The one I've found to be the easiest is the F-O-U-R score.

When using the FOUR Score, evaluators assign a score of zero to fourin each of four categories, including eye, motor, brain stem andrespiratory function. A score of four represents normal functioning ineach category, while a score of zero indicates nonfunctioning.

Comatose patients remain fully testable even if a tube is inserted to enable breathing, which applies to almost half of all comatose patients

Brain stem reflexes, indicators of the entire brain's health emanating from the underside portion of the brain that controls breathing and consciousness, are tested, providing information for immediate intervention and prognosis

More precise measurements and higher agreement between evaluators than the Glasgow Coma Scale

Recognition of a locked-in syndrome

Attention to stages of brain herniation and breathing as indicators of coma depth

Scores have better correlation with outcomes, e.g., in the comatose patients with lower scores on the FOUR Score and the Glasgow Coma Scale, more patients with low FOUR Score ratings died

www.sciencedaily.com/releases/2005/09/050908080323.htm