GCS; Roadside to Resus

So hi, and welcome back to the Recess Room Podcast. I'm Simon Lang. I'm Rob Fenwick. And I'm James Yates. And we're back with another roadside to Resus and this time it's on GCS. Well it certainly is. The Glasgow Coma scale and uh along with whiskey and chip building I guess uh you know the third thing that made Glasgow famous but slightly more medically orientated, so I suppose that that's probably why we're covering it. We're going whiskey next month. It's gonna be awesome. Stand by.

It's the middle of the day though, I didn't feel that was really appropriate right now. Indeed, yeah no I I get ya, it'll have to be spoke building. Yeah. I think this is a really super interesting topic and we have delved into this like many, many years ago, haven't we? And uh talked about the detail and the devil here in the devil in the detail even.

Uh, so I think this is a super interesting topic to cover again because it's just something that's ubiquitous, isn't it, in medical care-the old GCS. So, really delve into It means and the nuances of how we do that score is just incredibly important, I think. So, yeah, really looking forward again to this episode.

And also what it's evolved into, which certainly wasn't what it was designed for. But we don't want to have too many spoilers, do we? We um we probably need to cover that in the podcast. Corporation who collaborate with us on the podcast and make this all free, open access and available to you. Once you've listened to the episode, go over to the website and have a look at the CPD portal, which they also partner with us on.

and get your free certificate of listening. And if you fancy a course and a bit more resource room time, then take a look at the intubation and RSI course, the sedation course, the cardiac arrest masterclass, and also our critical appraisal course. So enough of that, let's crack in to GCS.

Okay, well we all use it every day, multiple times a day, generally when we're at work. The Glasgow Coma Scale. And it is scale, isn't it? It's not score.

As a bit of a background, it was first introduced over fifty years ago after a publication in the Lancer in nineteen seventy four by Sir Graham Teesdale and Brian Jennett. As a clinical Scale, which was evolved for assessing the depth and duration of impaired consciousness and coma for use on wards by staff, importantly to track clinical progress in patients.

Now prior to the GCS, there wasn't a standardized method of documenting a patient's level of consciousness in the context of traumatic brain injury. Five. Just imagine having a conversation with your local emergency department or neurosurgical center about a patient with a head injury or traumatic brain injury. How difficult would it be nowadays doing that without? Talking about GCS.

Now at the time it was described that the scale facilitates consultations Between general and specialized units in cases of recent brain damage and is also useful in defining duration of prolonged coma. Glasgow wasn't just a special area of interest for shipbuilding and whiskey that James has mentioned, but it was a centre of excellence for neurosurgical disorders around the nineteen seventies and when the GCS was developed.

And as we've mentioned, over the past fifty years not only become a common language for healthcare professionals to describe patients with, but it's also crept Into a number of different areas, not just traumatic brain injury, and we'll discuss that and the pros and the cons throughout this episode. All of us probably have a roughly similar idea of what GCS three means. And we probably all have an idea of what GCS fifteen looks like.

But to assess GCS in the best possible way, understand the implications for practice and help prognosticate our patients in an excellent manner, we need to know more. And that's what this episode is going to be all about. And I'm sure that you're all at a heightened state of consciousness. Probably a GCS of sixteen with heady anticipation of the episode. That old James and Robber got a GCS of three. So let's crack on with it.

And we need to start by talking about consciousness and what it actually is, because after all, that's what we're trying to quantify with the GCS. Well, I feel like we're about to delve into philosophy here rather than medicine assignment. Well, it was pretty difficult just delving into Google to try and find a good definition because as you'd expect, there are numerous and diverse definitions. But one definition of consciousness that seemed pretty reasonable to uh to quote.

Was it's the presence of a wakeful arousal state and the awareness and motivation to respond to self and or environmental events. So quite difficult really to contextualize, but I I think we've all got an idea of what we're talking about. And consciousness requires your brainstem, your basal forebrain, diencathalic areas to support generalized arousal in addition to to functioning phalamacortical networks to be aware and respond to environmental and internal stimuli. So really simple.

Just gloss over that. Yeah. I mean to be fair, when he started talking about definitions of consciousness, I wasn't really expecting something really slick and smooth to come out that was gonna be really easy to understand. Well, I'm glad I've obliged. I think as soon as in that definition you mentioned the awareness and motivation to respond, I'm downpaying my conscious level right now. Crack on boy.

Well, as you both know, there are a wide range of conditions that can affect consciousness or lead to impaired level of consciousness. So things like brain injuries, strokes global ischemia, seizures, metabolic derangements, and toxic agents. But we probably need to have a little bit more of a think about the Glasgow Coma scale, what it's made up of, and how you end up with a different scale or score at the end of it.

Yeah, so I was just gonna pull us back a little bit there, son, but you did it to yourself. You know, where on earth does the Glasgow Coma scale fit into all of this? Well, let's start by having a think about what's entailed in that scale. And remember Teesdale and Jennet described this.

as Simon has said, to track changes in that patient's clinical picture on the wards and to communicate patients with a recent brain injury. So that was what they designed it for. Not necessarily what we use it for nowadays. Now the scale is made up of three components of course, so there's the I response, the verbal response, and the motor response. Each of the three components contributes to its own score, so one being the lowest in each.

So eyes have got a maximum of four, verbal's got a maximum of five, and motors got a maximum of six. And the scale, as we've said here, is the individual aspects mapped out. Whereas the score, and this is what caused a bit of confusion, is the sum of all of these three parts. So for example, the scale is E one, M three, V two, whereas the score is six. Simple enough.

One of the best things about GCS I think is the opportunity to be unbelievably pedantic about people using the word score or scale which is probably the real reason that we thought we'd cover this topic. I feel like we've built this up massively. I'm really nervous for my section now. I'm gonna be just like watching myself and just checking. Is it score scale? Oh, I can't remember. No. A one of us is definitely slipping off here. Definitely, 100%. Wait for it.

What of course it doesn't include is all of the brainstem reflexes. So there is no assessment of gag, cough, pupils, or corneal reflexes, all of which are aspects that might be really relevant. to both prognosis and the immediate and ongoing treatment. Now for each component of the scale, when we test it, we need to give the patient the best chance of achieving the highest score possible. So we need to weight them up first and we have

not taking a cheeky eyes assessment before you've even said anything when you've crept into their room. Okay. And we addition just to just to ease that neurosurgical referral through a little bit quicker. No, no, no. We need to give them the best chance of waking up. And we additionally of course need to consider their injuries and really importantly their communication needs and only then we make the assessment.

So let's start off with eyes then. So eyes or the eye open response. So this is a score between one and of course a maximum of four. So describing those different things. So four, well this is where the patient opens their eyes spontaneously. But this is context dependent, okay. 'Cause it needs to not only be open spontaneously but also interact with you. So follow you around the room. Do what you'd expect someone to do with their eyes when you're talking to them. So this is an active process.

So think of a corpse lying in the morgue, well their eyes could absolutely be open, okay, but clearly they're not gonna have a GCS of six, so one for motor, one for voice and four for eyes, are they? No. So this is context dependent.

So it's about being open spontaneously and following round the room after you've given them a second to wake up, of course, if they're asleep. Now three So to get a score of three, this is where the patient would open their eyes to sound and again keep their eyes open for a period of time. Point number two is when they open their eyes to pain. And we're gonna delve into this a little bit more, but essentially it's more appropriately termed a physical pain.

stimulus. So we are going to talk more about this in a second, but just be aware of the different ways you could inflict some sort of physical stimulus. So poking around patients' eyes at this point isn't necessarily a great thing to do'cause you can get that grimacing effect and then cause the eyes to close even further. Now to get a one on the eye score, so this is where the Skull! Okay. There he is.

No, on the scale at this point, one on their on their scale, uh eyes scale doesn't open their eyes to a physical stimulus. So after you've inflicted some form of physical stimulus, the patient still doesn't open their eyes.

Oh man, I I know it's my go, but I'm just really nervous to say anything now. Um so uh Can we mute Simon's microphone? Is that possible? So nice overview of the eyes component there. So I know you said we're gonna talk about the sort of physical stimulus and stuff. We'll definitely do that. But first up

Let's have a little think about the verbal component because uh and I and I do see what's happened here to be honest. We've given Rob the easy bit, assessing eye opening and stuff I reckon is the simplest part. Um but actually both both the verbal and the motor scales really need a decent bit of thought, I think, to ensure that we're really assessing them correctly and allocating the correct number for the patient's best response.

So think about that verbal component then. Rob's already said we've got a score between one and five. One's the lowest. Five is the is the best that we can get on this verbal uh scale. Uh a scale, yes. Top right. So yeah.

Whew. Um so five. We're gonna allocate a scale number of five uh to the patient that has an orientated verbal response. So what does that mean? Well It means that the patient can be engaged in a conversation, they can answer questions appropriately, and often resources around GCS talk about the patient being orientated as in they know who they are, where they are, and what the date is.

So they may be some specific questions you want to integrate into that conversation you're having with them. I reckon a five is probably relatively easy to allocate. Four and three, I think, is where there's some confusion. Literally. Well, exactly. Thanks. You spotted that one, Simon. You got there. Um because four is confused conversation. So to score a four, the patient needs to still be able to communicate coherently.

But they show some level of confusion. So they might not know where they are, for example, or what the date is. I guess the easiest way to think about this is just think about one of Simon's sections. You know, he's he's communicating fairly coherently, but there is a level of confusion in it. Um so that so that's a four. The when you drop down to a score of three, this is when the patient is no longer coherent. They're not talking in full sentences.

They're only verbalizing single but importantly recognizable words that are generally unrelated to the question. Or some guidelines talk about just single kind of expletives coming out and they're totally kind of unrelated to to what is going on. I mean in terms of the podcast you could consider that the bits that are edited out, I guess.

Absolutely. That's the that's the threes coming from you two while I'm trying to uh maintain my flow. Um and then a two, I think things become a bit easier now, don't they? This is when the patient is making some Sounds, but they're not verbalizing any recognizable words. So here really we're thinking about moaning and groaning, but they're not saying any distinguishable words. And then finally you've got one which is no verbal response at all.

And I think the only final thing to say on the verbal system is that clearly there may be times when you cannot assess a verbal response. I'm thinking about patients who've got a tracheostomy, for example, uh or who are intubated. And so documenting not testable at that point is really important rather than just putting a one down. And we'll maybe talk about that a little bit later on.

These are really interesting points to sort of consider here about where you get the orientated verbal response and what means you're fully orientated. And I think if you go back to the original paper they talk about being alert and orientated times three. So essentially like in my mind, what you want to do is ask the patient three questions that are absolutely achievable to anyone. So where are you?

What's the month? What's the year? They're really easy questions that you can do. Now, if you'd expect every patient to be able to answer that pretty much. So if the patient drops one of those questions, the original paper talks about classing them as being confused. So if you say I'm in hospital, it's May and it's twenty twenty, then you're going to be classed as given a four or a confused as in not

fully alert and orientated times three. But essentially I I don't think it matters massively which way you use it as in, but I think you need to have a system, you need to maintain that system and you need to be all using that system wherever you work.

Because again, these little drops in points can often be quite significant when they start to add up. So I think if you know that every time you're assessing a patient's orientation, you're going to ask the same three questions which you're going to expect them to know. And if they don't know it, you're going to drop them a point down.

And then of course, you know, if they're not answering any of those questions appropriately, then they then get a three. So I think it's just important that you think of that, have a system and use it widely in wherever you're working.

Yeah, nice thanks Rob and I think that's exactly I hope kind of what this episode is about, and I'm really glad you brought that up because I think the the nuance and the real detail behind how you apply these GCS assessments can sometimes get a little bit lost, can't it? So um really glad you brought that up. Thanks.

So I guess now we're gonna talk about the the final aspect which is the response to pain and I think the idea of applying a painful stimulus to a patient is pretty uncomfortable in itself really and I I know for sure when I was a uh you know a student paramedic and I was kind of coming up um sort of through my years of experience, I I definitely don't think I

did this assessment well because I was always really nervous um about applying pain. I was thinking, right, this this is sort of is really incongruous. It doesn't really sit very well with me, um, because I don't really want to inflict any pain. The whole point is I'm supposed to be here to make things better.

So I think it's really important probably at this point to say that w we're not actually there to inflict an injury for sure, and whilst we used to talk about a painful stimulus There's now this kind of focus, uh, and it might just be semantics, but we're now more focused on the idea of this sort of temporary, uncomfortable pressure stimulus is kind of how it's described now.

But the other thing to think about is where and how we apply that pressure stimulus,'cause that's really, really crucial. And Rob's already mentioned about supraorbital pressure, but there's another couple of options as well, things like nail bed pressure and a trapezius muscle squeeze. And so with all those o sorts of options out there, which one do we choose and and how do we apply it?

I think first up a real crucial consideration is thinking about what injuries the patient might have. So primarily we've said we're not there to create an injury in itself, so don't squash an existing injury. But also beware of the spinal injury patient when you're applying a stimulus. So, you know, they could be desensate, you know, for example, applying a a stimulus to the fingertips.

uh if they've got a mid-cervical spine fracture with a cord injury, and then the patient's actually got no sensation uh to their fingers. And so applying a central stimulus like a trapezius squeeze or a superorbital notch pressure. seems to be pretty sensible when you're thinking about assessing a motor score. Although we might also need to consider which bit of the test of the overall GCS we're undertaking because as Rob has said, a finger squeeze might be the most appropriate to assess.

Eye opening. So loads of complexity in there. But back to the motor school.

Scale. Man, he got me. Got ya. You walked into it, it was a trap. I've caught myself a James Yates. Anyway, I'll let him loose so he can carry. Um right, that's it. You're only having one. So I I mean I think of all of the elements of the GCS, I think probably motor score is one of the hardest to accurately interpret'cause there's some real specific goals that the patient has to be able to achieve for you to allocate each other.

bit of the scale. So let's look at it in detail. So we've already said this is a rating between one and six, with six being the absolute best you can get with motor. So, motor of six, this is a patient who can obey your commands. So again, thinking about injury patterns, asking them to maybe squeeze your hand is a bit of a classic, but what about if they actually just can't?

So actually think about maybe a a higher or a more central uh kind of motor activity that they can do. For example, sticking their tongue out. It's a really easy thing for them to do, but they have to do that very deliberately. So I quite often use that as my uh obeying commands um command. Um Request. Requ request. That's it. It's not yeah, right. It's not come on, that sounds a bit commanding. Dick tutorial. Mm-hmm. Yeah, absolutely.

Um so on to the more challenging sections though, because I think again, six and one, they're generally the easy ones, aren't they? Five is the patient is localizing pain. So what does that mean and how do we assess it? So For this score to be given, the patient has got to move one of their hands above the level of the clavicle in an active and purposeful way to try and remove the pressure stimulus.

And I think that's really important. This can't be a non purposeful action. It can't just be a little sort of twitch of the hand towards the belly button when you're squeezing on their trapezius. It has to be a really purposeful action that comes above the level of the clavicles. That is a five. So what does a four mean then?'Cause again I think between the five and the four that's where the challenge comes.

Four is withdraws from a pressure stimulus. So the difference here is that the patient tries to move away from a physical stimulus rather than reaching up. to remove it. So they might pull their hand away from you if there's nail bed pressure. Or they might sort of rotate their head away if there's superorbital pressure being applied, but it's a it's a sort of a movement of the body rather than a a movement of the hand to take the pain away.

And then finally we've got the two bits of the scale that we really worry about, the sort of the abnormal flexion and then the abnormal extension. So abnormal flexion, this is the score of three. I think it's just worth saying that this is really pretty rare and it often indicates really significant brain damage. So you're not gonna come across this regularly. So if you do see it, maybe just kinda question yourself, is this definitely what I'm seeing?

But think about a bit of the detail again behind what this abnormal flexion looks like. Then we're gonna see adduction of the arm, so it's brought to the side of their torso. And as the title suggests, you're gonna get flexion at the elbow and flexion at the wrists. And the difference

with number two, which is the abnormal extension, there's no surprises there because you're gonna see the exact opposite. You're gonna see extension of the head, the arms and the legs. And there's also internal rotation of the arms, so the palms end up sort of facing outwards. Away from the body. I wonder how many other people out there are in some really weird positions right now. Yeah. Is no one else acting this out? Oh, yeah.

These are really tricky to remember, but I think the way that I I remember it is decorticate is where the patient will pull their arms to their core, so as in they'll bring them upwards and flex them. Decerebrate has got loads of ease in it, so they'll turn that externally, so outwards.

So uh yeah, those are the my two tricks. And the other thing to say on that is that like you said, James, you see them really infrequently, but um what it is important for those that haven't seen them before is these happen really slowly in terms of movements like that. that decorticate posture and happens over one or two seconds, maybe even three or four seconds.

And it doesn't happen like instantly like you'd get with a localizing pain. So it's a slower, more purposeful process, but either to the core or to the extremities decortic decerab. No, Rob, again, I think really, really valuable because sometimes there is confusion around, you know, is this a four, is this a three? How do we differentiate it? And so really looking at what you're seeing and the time scales that's happening over, I think's really, really valuable.

And you know, just for completeness, uh, I just want to say that uh clearly the last one of this scale is number one when you get no motor response from the patient at all, uh, regardless of your pressure stimulus. Awesome. Yeah, I think just if we can go back to a second for those options that we've got for painful stimuli. I think these are really interesting points and like all of the things that we've mentioned are definitely recognized techniques.

Now, personally, and I will explain for a second why, I only ever use a trapezius squeeze. And let me explain the rationale for that. Now, firstly, if you want a patient to localize the pain and if you do pressure on the nail bed for example, then they might just pull away quickly.

Now that can happen so quickly that you have no idea whether that's because they're localizing it and because it's just quick to pull it away, or if that patient's actually purposefully sort of withdrawing to pain. And this is an important differentiator. So to be classed as localising pain fully, as James has said, the patient should really be moving a limb above the clavicle and ideally across the midline of their body.

So that's of course absolutely perfect when you use a trapezius squeeze because they've got to go up high and they've got to move basically across their midline. And what about that old sternal rub? Well thankfully that is long out of favour, but I guarantee you will still see it out there in practice. Well The same issue for me here is that it's not an ideal test. So the patient can't move across their midline or above their clavicle, can they, if you do a sternal rub?

How on earth can you also withdraw to pain from a sternal robby? I mean you're gonna sink into the bed and you know, of course, you know, decorticate movements involve the arms moving towards the centre of the chest. So you could interpret decortica as localizing pain or localizing pain as decortica, both of which are less than ideal, but for different reasons. So painful stimuli for me, the trapezius squeeze rule.

But I will accept actually on occasions a superorbital notch is as good and as reasonable an answer as you'll get. But yeah, trapeze screws for me all the way.

Jeez, Rob, I feel like you're absolutely on fire today, mate, coming out with loads of gems. I love it. That is all I've got. I'm going home. Is that you finished? Nice one. Well thanks mate. Nice to catch up. Um so j uh just to round out this section before uh we uh hand the reins back to uh Dr. Lang.

Just worth recapping, I think, isn't it? That we're gonna take each aspect in turn. We've got the three different components of the scale and adding all of the three aspects together we've then got the score with the maximum of fifteen, demonstrating that fully conscious patient and the score of three being an unconscious patient.

But I think what's really interesting to think about is that if you haven't really thought about this before, the score itself, so the one to fifteen, is not a linear scale. Oh no, it's not linear scale, it's not a scale. It's not a linear scoring system. Um so the change of a GCS of an additional point, so eight to nine or thirteen to fourteen.

actually doesn't represent a sort of a clinically equal change in the patient. And actually it can be really very different indeed. And I think I know a man who can explain why. You might do, but they're not going to be plugged into this podcast, so I'll have a crack at it instead. Let Simon have a go instead. Yeah. Yeah, well there is clearly a huge amount of evidence out there in terms of GCS and really helping us to understand what it means to have

a certain scale or score, depending on how you're using it, in certain contexts. So I'm just gonna pick out a few key papers that it's worth understanding. One of the best and one of my real favourites Wow, I'm so cool. Is a great paper in the Journal of Trauma from 2003 by Healy and colleagues. And it's just got some great facts in there which can really help give context to this. So in that they mention that GCS is actually a collection of a hundred and twenty different combinations.

of its three predictors grouped into twelve different scores. So anything from three to fifteen, by simple addition of the motor, the verbal, and the eyes on the scale. Although That is really interesting, Simon. Thank you. Thanks for that. That's the that's the big picture he's got hung up in his living room, you know, of the paper, yeah, two thousand and three.

I'll feed your appreciation back to Helian colleagues, James. I'm sure they'll be delighted to hear your opinion. Hold on. It gets even more interesting that it gets even more interesting that because I'm sure the Shoot of you, not James and Rob, will have spotted that there's actually a few more options to the hundred and twenty. So on the poster.

You'll recognize the fact that those that are intubated or have a tracheostomy will have not tested by them. So there you go. That will be the poster version two. They brought real attention in this paper to the fact that the different combinations that add up to the same GCS score may actually have very different mortalities. And this is the example in the paper. So take an example of a GCS

Score of four in a head injury that can present with any of the three on the GCS scale. So I'm Verbal one, motor two, has a mortality of forty eight percent in the context of traumatic brain injury. Eyes 1, Verbal 2, Motor 1, has a mortality of 27%, and Eyes 2 Verbal one, motor one has got a mortality of nineteen percent. So hugely different from forty eight percent to nineteen percent. when you've actually got the scale used in the right way, but the score equaling four.

And they mentioned, as James has said, that the GCS score isn't linear, but that the M component of the G C S by contrast is not only linearly related to survival, but preserves almost all of the predictive power of the GCS. So that paper really sums up the complexity of the Glasgow Coma Scale and the importance real importance of getting each part of it interpreted correctly in the way that Rob and James have just been through it.

And highlighting the importance of that motor component. But we don't just use it in the context of traumatic head injury. It has crept, as we said, into thinking about loads of different areas of practice. And what about the saying of GCS eight intubate? Something that Rob's got written on the back of quite a few of his t shirts. I'm getting one now. Yeah. GC has like 8 inch of 8 plus... A higher level of consciousness than you've ever, ever had.

So this comes from some of the earlier thinking in ATLS, and let's be honest, it's pretty catchy, which is why it's on his t shirt, with a rhyming sentence that's easy to apply to patients, but as with all things simple, it's never that clear. So the thinking at the time was that as the G C S drops to eight or less

Then the patient's ability to protect their airway patency and protect against the risk of aspiration falls, to the point that popping a tube in would be the safest option. But again, there's some great literature that's come out since that catchy phrase was developed. There's a small E D study where Duncan described a prospective cohort of patients with a decreased GCS.

score ranging from three to fourteen from drug or alcohol intoxication, not traumatic brain injury. And in that group, only one patient was intubated and none of the patients with a GCS score of eight or less required intubation or aspirated. Rotherhay up next showed, as you might expect, that gag and cough reflexes do indeed decrease.

With a decreasing Glasgow coma score in patients requiring critical care, but they didn't show a sudden point at which those reflexes were lost when they hit a GCS of eight. Of the ones that had a GCS of nine to fourteen, they found absent reflexes in over a third of patients and in those with a GCS of eight or less, sixty three percent had an absent gag reflex.

Perhaps most surprisingly, in those with a full GCS score of fifteen, twenty two percent hadn't got a gag reflex, and I don't think we'll be coming up with a rhyme to intubate all of those patients. We've also covered on papers of the month that we month before the idea of intubating a patient with a low GCS score in the context of poisoning from a paper back in twenty twenty four. Here, Freund published an RCT from twenty EDs looking at the conservative airway strategy versus routine practice.

Which included the decision to intubate if they wished to, excluding those with an indication for immediate intubation. Fifty six of the patients in a routine practice group got intubated. 16 in the conservative group. And they found that the conservative approach was better in terms of composite outcome and in terms of pneumonia rate.

That's a lot of waffle. What I'm trying to say here is that whilst GCS has got a significant utility in the context of head injuries, And in terms of communication, we need to be really careful in its wider interpretation into practice. It's part of a picture. It clearly describes aspects of the patient's presentation, but it contributes to that description rather than defines it. And we need to understand what it's good for and what it isn't.

Yeah, nice one. But I think there's also one other thing that we probably haven't touched on there that we should mention, and that is actually how good we are at assessing this scale. We've said how important it is that we do it well because it impacts on patients' care, patient prognostication, and so on, but we don't know about how good we are at actually doing it.

Um and also how reliably we'll all get the same result with the same patient and the same presentation. And therefore we're talking about interrator reliability. So again, heaps of papers looking at this, but a a really neat one to mention from Fisher, and we're gonna obviously link to that in the show notes as we will with uh everything else we've talked about. And they found the interracial agreement within a range of plus or minus one for the score was ninety percent.

And the exact interrator agreement, so two assessors getting exactly the same score for the GCS, was seventy one percent. On the surface of it, that might not sound too bad, but when you think about those numbers that Simon's just given earlier for mortality rates uh in TBI with a GCS of four,

And that mortality rate was hugely dependent on each part of that score of four being correct. And the mortality rates within that score of four varied by about thirty percent. So The fact that we haven't got a hundred percent interrated reliability probably isn't a surprise, but it does demonstrate that getting the same score as each other can be really tricky in the real world. And it can have a huge impact on how patients

might be treated and be prognosticated. And so I think really this just serves to remind us that we need to do everything we possibly can in our head injury patients in particular to get the assessment of the scale and the score absolutely spot on. And hopefully, having listened to this episode and run through how we apply that scale in absolute detail with me and Rob, hopefully we're all on track to just get that little bit better at assessing the GCS.

Yes, well boys, we've spoken a fair bit about the benefits obviously of this common language and of the GCS score, GCS scale and you know, the way it's enabled us all to get a feel of the patient that we can't physically see when someone speaks to us on the phone or on the radio. You know, and we've just touched on the difficulty in being accurate and reproducible, along with how important it is to be so.

So what about the other scoring systems out there? Surely, I mean, you know, this was nineteen seventy four, this was originally printed. Surely there should be something else out there we could use. Well, actually, there are. So there are a few different ones out there. So first up there's the four score. Well that was uh developed to enable a more accurate assessment for patients that were intubated more accurately than the GCS I should say and it brings in things like brainstem reflexes.

There's the old Av Poo, which I'm sure we're all aware of, and then there's Troll or the Simplified Motor Scales, and this stands for test responses, obeys, localizes, or less. Or of course we could always just go with an unstructured clinical judgment, you know, using our guest stout. Well in fact the four score has Got some literature support it and being potentially more reliable and with greater validity than the GCS. So should we just actually crack on?

Be like absolutely on the forefront of practice here and go changing. Well the answer today the answer today is absolutely not. So Uh Start quoting the four score on your pre alert to the E D. Well you're probably gonna hear that person on the other end of the phone saying they didn't catch that. Could you possibly please repeat it in nice words? And if you're you know like Patients coming in who are expected to be G C S four.

Yes, indeed, yes. You you may get maybe all get a very quick response, which might be what you're asking as Rali. So there might be other other knock on effects which are beneficial. Um but equally if you're the E D referring on to the next specialty, they'll You know, if you start quoting the four score, you know, they're probably gonna ask to have a chat with your senior, especially if it's you Langers and uh, you know, give'em a call back later. So, you know

Will practice change in the future? Well, maybe, maybe not. And probably the best bet I think at the moment is to take a combination of that GCS, but also, you know, to actually to appreciate those other parts of the unstructured tests and the not named bits that you'll see in those other scores, like clinical assessment, and incorporate all those aspects into your impression, into your handover and into your documentation.

So GCS absolutely keep it there, but it is important to remember its limitations and to bring in some additional things that could offer some real importance in terms of onward care for that patient and documentation.

Yeah, I absolutely agree, Rob, and that's a really, really valuable point. And um I'm uh very aware that we managed to get this far though without talking about little people. Uh and I it would be very remiss of me not to uh to bring that point up. And so it's worth thinking about, isn't it? What are we gonna do with those patients who aren't old enough to follow commands or to give you the verbal response that you need to, uh, you know, put your tick in the right box?

And so for children who are less than two years old, some guidelines say less than four years old, but I think particularly in your mind you need to be thinking the pre verbal kids. We need to reach for the pediatric Glasgow coma scale.

There's a few adaptions here to to make it applicable to pediatric patients and uh in some aspects it's not very different at all. In fact the I scale is exactly the same. And actually the motor scale is pretty similar too, but Slightly more focused on how they respond to a touch or then subsequently a pressure stimulus.

But it is worth knowing, I think, that actually abnormal flexion and abnormal extension are the same in all ages. They still score you a three and a two. So I th definitely think that's worth remembering. But then finally the key difference, I guess as you might expect, is in the verbal section. And it's here that I think you're gonna wanna reach for your crib sheet. But essentially there is a cascade.

from making normal, happy noises, uh, you know, babbling and cooing and generally being a happy baby, through to sort of crying and then to whimpering and moaning and to no response. But I've deliberately, I guess, not gone into the specifics of each of those components because, you know, this is a tool that we are going to be implementing pretty infrequently, certainly compared to adults.

And we've already seen how inaccurate we are with adult assessments. And we've also discussed how important it is to accurately assess the GCS because of how it can alter treatment and prognostication. So I'd absolutely encourage you to get your aid memoir out. and assess the child, maybe along with a colleague if you can, to ensure that you are recording the best and the most accurate result that you can when it comes to our pediatric pace.

Yeah, I think that that's a great idea. Other than getting the pediatric GCS tattooed on your forearm, which we wouldn't highly recommend for everybody out there. That's um that's that's gotta be a good way to increase the interrator reliability. But James, I think it's probably worth this just mentioning a few gotchas Isn't it with the GCS before we finish up because

Certainly in practice there seem to be a few mistakes that we all make that we could avoid and help utilise the GCS in a greater way. And I think one of the first ones to mention, and you've alluded to this already, and so have I is that if one part of the scale is untestable, it's really important to note that. So we talked about the fact that if a patient was intubated or got a tracheostomy and then we weren't going to be able to assess the V aspect of it.

But also there are other reasons as well, aren't there? So that patient with a a mid face injury or huge periorbital edema, where the patient can't physically open their eyes It's not that they can't from a conscious level perspective. Again, we need to write that, don't we, that that was not testable and that's really important information to feed onto the next clinicians that are looking after them. Any gotchas from your perspective?

Yeah, no, it's really interesting actually sitting down and thinking about this'cause there's loads and loads of aspects of the GCS that I think can potentially be challenging, either, you know, from the patient perspective or the situation that you're in.

Uh and it was really interesting sort of reflecting on them because actually I think uh a bit of a theme emerges that uh actually, Simon, you've already mentioned, but we'll talk through them and then we'll maybe round out with uh the that little theme at the end. So

I think first up, what about the patient that you've pretty sure has got a higher level of consciousness than you are being allowed to allocate to them? But Uh you know, they've they've got this kind of GCS of let's say three, but you're pretty sure it's not a GCS of three. Um, you know, th this is not to say, you know, we've done a a an episode a while ago, didn't we, on seizures and we talked about the psychogenic non epileptic seizures. This could be a really genuine functional presentation.

But it still feels quite awkward, doesn't it? Handing over the care of a patient who you have scored as a GCS of three to an ED, or I guess subsequently for you guys, you know, uh referring up to a ward uh and not to ITU. That sounds pretty horrendous. And totally inappropriate. But actually I think this just

highlights the importance of us including other aspects in the assessment of the patient and the documentation and and as part of our handover that demonstrates that we've really thought about our assessment and particularly an assessment of the consciousness. So

You know, y you've already said, I think, way back at the beginning of this episode, you know, we'd we don't cover on the GCS things like corneal reflexes or comments on a swallow or a gag or pupillary responses. So It's undertaking that slightly more detailed GCS assessment so that you can then hand that over as your sort of package of patient assessment. Yeah, I think it just reflects a a really higher plane assessment, doesn't it, of that that patient's neurological unconscious state and and

makes it very clear then, doesn't it, to the receiving clinician the way that you've come to that risk assessment and to that management plan. I think it's a really great thing to do. And I guess the other thing that would be just good to pick your brain on is what about those patients that have got pre existing factors that influence the GCS assessment? What sort of things should we be looking for and how is it going to affect what we find?

Yeah, absolutely. I mean I guess here we're thinking about things like patients, particularly patients with like dementia or patients who've had a stroke. They might have aphasia, they might have hemoplegia. Sometimes you're gonna come across language barriers, aren't you? That totally nullifies our kind of verbal responsibility to assess that.

And then sometimes we've got those patients who have got a medical cause uh of their unconsciousness. So things like drug overdoses. You know, all of these situations, the GCS is challenged. And it's really hard to uh to apply it to those patients. And, you know, sometimes you can overcome those issues, but uh on other occasions the GCS system just isn't set up to deal with those cases.

And I think if we're faced with that, we can only report what we find with regard to a a score and the individual components on the scale, but alongside our other findings and and relevant history that allows interpretation of the score that we've given.

Absolutely. I completely agree with that. I think the thing about a GCS is you are taking a snapshot in time. That could be different in ten minutes time, fifteen minutes time, thirty minutes time, or slightly different as we talked about with different iterators. But for me it's it's playing it with a straight bat and you know, for example, a patient with dementia who's confused, well, you record them as being confused.

You know, you don't record them for me as a G C S of fifteen because it's their normal mental state. You're you're taking a snapshot in time and you're doing that for every patient that you use it on. So For me, absolutely. I think I completely what you've said. You you need to write the additional context within your clinical assessment note.

Absolutely. That's definitely the way I see it. And so I think that kind of brings us to that kind of final point. You know, this whole episode's focus in on GCS and that can give you that kind of availability bias, doesn't it, of thinking like, right, GCS is is everything. And it can be an excellent tool when it's used correctly and used it accurately.

But it is simply part of our assessment of a patient. It's not the be all and end all and it's got to be taken into account within the wider picture of that patient's presentation. We need to be thinking about the history, we need to be thinking about the clinical context in which the assessment has been undertaken. But we shouldn't just deliver the GCS and expect the subsequent management to be hung just on that. Excellent. Well, that is it for this roadside to recess on GCS. So just to recap.

It is hugely important to understand where GCS came from 50 years ago and what it is to be used for. And also appreciate that it has crept into other areas of practice. From the evidence to assess patients, to prognosticate, and to work out what treatment is appropriate or not. Using a GCS chart is not a sign of weakness, it's a way to ensure that we can be more accurate.

got consistency amongst us or interrated reliability is as high as it can be and that we get the motor score most importantly correct because the same score depending on how it's made up can indicate really different outcomes. And we can use the scale to communicate, but we need to do that in the very best way that we can by it being accurate. Clearly we've talked about some negative aspects of the Glasgow Coma scale here, but

We don't need to fight the system'cause it's a common language and is still incorporated into care in multiple different areas and bucking that system is just gonna create unhelpful chaos. So Use it but understand its importance and its flaws. So that is it for this episode. A huge thanks once again to Zol Medical Corporation for collaborating with us on the podcast and making this all free, open access, and available to you.

Make sure you go over to thresarroom.co.uk, get your certificate for listening to the episode, and take a look at our courses if you fancy doing that. We have got some significant. discounts when institutions are looking for multiple purchases. So get in touch with us on our email address on the website. So that is it. Until next month, take care of yourselves and we'll speak to you soon.