Glasgow Coma and Glasgow Outcome Scales for Brain Injury

Glasgow Coma and Glasgow Outcome Scales for Brain InjuryABSTRACTTraumatic understanding spot (TBI) is a leading ca delectation of death in adults down the stairs the age of 45 and an estimated 7.7 million people in the European Union are living with a dis office ca apply by TBI. The severities of these injuries are differentiated by the use of the Glasgow Coma Scale (GCS), and the upshot is assessed by the Glasgow Outcome Scale (GOS). These scales drop be used to develop a prognosis for individuals with TBIs in various ways. Primarily, the lower the GCS bring in the more than severe the intelligence tarnish and therefore the worse the outcome for the persevering. The GOS is applied 6 months after injury and provides a print of 1-5 with a lower score indicating the worse outcome, death. To conclude GCS by itself cannot be used to provide a long term prognosis for brain injuries. GCS can be used in addition to other factors such(prenominal) as presence of a midline shift on Computer mental imagery and fixed pupil dilations are significant in determining prognosis. The presence of lesions on the brainstem correlates with the GCS and GOS scores allowing reliable and valid prognosis to be made. knowledgeabilityTraumatic brain injury (TBI) affects an estimated 1.4 million people every year in the United Kingdom (UK)1, and is a leading cause of death in adults under the age of 45. 2 It is currently estimated that at least 7.7 million people in the European Union are living with disabilities caused by TBIs. 3 TBIs notice for 6.6% of the Accident Emergency (AE) attendees. 4 95% of all TBIs presented at AE are mild, 5% severe and moderate injuries. 5 It is extremely important to determine the severity of the TBI as it has implications on the treatment and afterwards reclamation of the tolerant. TBI can be open or closed injuries, with open TBI injuries being linked to worse useful outcomes and increase mortality.The most common method of assessing TBI is the Glasgow Coma Scale (GCS) and a common method for addressing the outcome of a diligent is the Glasgow Outcome Scale (GOS).WHAT IS THE GLASGOW COMA overcome?The GCS is a test to ascertain the consciousness of a patient after being subject to a TBI. The maximum score with this scale is 15 and the minimal 3, this is comprised of three separates spirit opening, verbal reaction and motor response. (Table 1). GCS is included in subject Institute for Health and Clinical Excellence (NICE) guideline on maneuver up injury3 to provide information on survival rates for patients suffering different severities of TBI. The guideline also indicates that GCS is a measurement that should be taken at the injection of the injury by paramedics. If this is not possible it should be taken at admission to AE as early indication of TBI severity is imperative in the later treatment.The GCS differentiates between the severities of toss injury by score ranges. A GCS of 13-15 indicates a mild c hief injury, 9-12 moderate and 3-8 severe. The GCS score can be affected by the time it is applied after injury, therefore in order to universalise this, GCS is often used once the patient has been stabilised.4The GCS can be difficult to use in scathe cases, as localised trauma, swelling, sedation and intubation can affect testing the eye and verbal responses. 6 7 In a survey performed by The European Brain Injury Consortium yet 49% of patients could be tested fully against the scale after being stabilised in resuscitation.8 propertyResponseScoreTotalEye OpeningSpontaneously4To speech3To pain2No response1E /4Verbal ResponseOrientated5Confused4Inappropriate words3Incomprehensible words2No response1V /5 force ResponseObeys commands6Localises pain5Withdraws from pain4Flexion to pain3Extension t pain2No response1M/6Total ScoreGCS/15Table 1- Glasgow Coma Scale Components of the GCS and how each section is scored individually Adapted from Bethel J. 2012, Emergency care of children and a dults with head injury, Nursing Standard, 26(43), 49-56The GCS is con inclinered by some to have acceptable inter-rater reliability9 when used by experienced practitioners. However mistakes are made consistently by inexperienced users of up to 1 mark per section. Inter-rater reliability was shown to improve after exposure to a training video.10 Reliability with score is imperative in making accurate TBI severity diagnosis, and indeed the relevant treatment associated with them.In severe TBIs the motor component of the GCS is the best power of prognosis, this is due to verbal and eye scores not being able to be performed. 11 This has led to an adaption of the motor score of the GCS, called the simplified motor score (SMS). The SMS has 3 scores 2 obey commands, 1 localises pain and 0 withdrawal to pain.12 It was found that the SMS and GCS were useful in indicating whether neurosurgery was needed and also intubation. Overall GCS was better in predicting contingency of death, however SMS was able to be used to assess patient involved in trauma more effectively as intubation and eye swelling would not be detrimental.12 This indicates that SMS may be better used in conjunction with GCS with patients who present to AE with severe head trauma.HOW CAN THE GLASGOW COMA overcome BE USED IN BRAIN INJURY PROGNOSIS?A more severe TBI will lead to a worse 6-month functional outcome for the patient. 30% of patients with initial GCS 13 and 50% of patients with GCS 8 after being stabilized in resuscitation will die.6 Patients who have a GCS score of 3-5 have a 5% chance of survival 6 months after injury.14There is no direct correlation between GCS score and the patients ability to function in daily life afterwards. This is due to varied functional outcomes being linked to different scores on the GCS.15Patients with GCS 8 had 85% chance of favourable prognosis, if this score was obtained 24 hours post-admission.16 The predictive value of GCS scores alter according to the time at which the score was obtained. GCS scores obtained at least 24 hours after trauma were linked to the set the TBI was classified by MRI data. These grades are associated with brain stem lesions, grade 4 being the worst and grade 1 the best.The higher(prenominal) the GCS score the lower the grade of brainstem lesion and therefore the better prognosis in terms of functional outcome for the patient. 14 In a look at performed by Utomo et al there were no patients with GCS 3-8 that were living independently 6 months after injury. In addition patients with this GCS score were 24 time more in all probability to die when compared to patients with GCS score 13-15.17GCS alone cannot accurately predict the brain injury prognosis for a patient. However, if GCS is applied with computer tomography (CT) evidence and pupil dilations, thusly a prognosis of possible functional outcome can be made for an individual patient.18WHAT IS THE GLASGOW OUTCOME SCALE?The GOS was developed to assess func tional convalescence of patients with brain injuries.19 The GOS is based on a structured interview that assesses 7 areas consciousness, independence at home, independence in the community, work, leisure and social events, relationship with family and friends and last return to normal life.20 The area in which the patient is living is not taken into account with the GOS but is taken note of separately.GOS is often split into ii broad outcomes favourable and unfavourable. Favourable outcome encompasses beloved recovery and moderately handicapped. Unfavourable outcome includes death, persistent vegetative state and severely disabled.9The standard GOS has a 5 point scale (Table 2) but was extended after concerns were raised that it was not sensitive enough in detecting minor disabilities that may oblige the patient in returning to work. This led to the GOS extended (GOSE) being devised.Guidance has been published to increase the universal reliability of the GOSE21, but there are n oneffervescent issues with its application. This is mainly due to the time period between the TBI and the GOSE being applied, this is normally taken at 6-12 months post injury. A GOS assessment at 12 months was more reliable than at 6 months22, but it may increase the number of patients lost in follow up. 10% of patients who were moderately or severely disabled at the 6 month GOS test improved by one category.GOSGOS(extended)1Death1Death2Persistent Vegetative affirm2Persistent Vegetative State3Severely incapacitate3Lower Severely Disabled4Upper Severely Disabled4Moderately Disabled5Lower Moderately Disabled6Upper Moderately Disabled5Good recovery7Lower Good Recovery8Upper Good RecoveryTable 2 Glasgow Outcome Scale Shows on the left hand side the original GOS (5 point scale) and on the right the extended GOS (8 point scale) Adapted from Nichol A, Higgins A, Gabbe B, Murray L, Cooper D, Cameron P. 2011, Measuring functional and quality of life outcomes following study head injury Coma scales and checklists, Injury, 42(3), 281-287The 5 sections of the GOS refer to the functional ability that will ultimately be achieved by the patient. Vegetative state refers to the patient being otiose to respond severely disabled patients cannot live on their own moderately disabled patients can live by their selves but have reduced ability to work good recovery infers that the patient returns to work fully.23It is also possible that the patient when interviewed presents a more positive outlook of their situation leading to the GOS score being faulty. In addition to this a patient may be given a GOS score of 5 indicating a good recovery, but this only refers to the patient being able to return to work. With a good recovery prognosis may still have changes in personality and an inability to write out in social situations.20 This leads to the GOS not fully indicating a good recovery, again highlighting the reason why the GOSE was devised. Under these circumstances a patient can be given a GOSE score of 7 indicating a lower good recovery.The GOS and the GOSE scores can be obtained via phone call increasing their realisticity as a scale. This scale is reliable when performed over the phone due to the standardized interview which informs the score that the patient will receive.19HOW CAN THE GLASGOW OUTCOME SCALE BE USED IN BRAIN INJURY PROGNOSIS?When applied to the GOS a patient with a severe TBI had 40% likelihood of death 4% chance of being in a vegetative state 16% severe disability 19% moderate disability and 21% chance of a good recovery.6 This was a 40% likelihood of a favourable functional outcome at the 6-month GOS test.This is compared to mild brain injury that had 9% chance of dying 0% of being in a vegetative state 14% of severe disability 24% of moderate disability and 53% of having a good recovery.6 This has a 77% overall prognosis of a favourable outcome for individuals with a mild brain injury. This shows that the GOS will make a different iation in functional outcome for different severity of brain injury.This score is unlikely to change from an unfavourable to favourable outcome after this time period although some modest improvements may be seen.18 Any further improvement is probably linked to rehabilitative treatment, and not the improvement of the patients TBI.There is a 94% chance of a good recovery with GCS 8.5 (9 +) and age 49.5 years. This is compared to an 81% chance of good recovery with GCS 8.5 (9 +) and age 49.5 years. This highlights how age can affect the probability of a patient achieving a good recovery from their brain injury.24Patients aged 75 years with a moderate or severe TBI were three times more likely to die from their TBI than patients aged 65-74 years. It was also less common for patients aged 75 years to be living independently 6 months post-injury than patients that were younger.15The age of the patient and the severity of their TBI need to be taken into account when deciding on treatment . The prognoses for individuals in the 75+ age range are unfavourable according to the GOS. 15 Due to this treatment should be decided based on this factor.There is a correlation between the GOC score a patient is given and the grade of their brainstem lesion that is provided by MRI data. A higher grade of brainstem lesion correlates to a more unfavourable outcome for the patient.14CONCLUSIONSOverall the GCS cannot by itself provide every long or short term brain injury prognosis. This is because there are too many variables that affect each GCS score, including the fluctuation of the GOS associated with these scores and the difference in reliability depending on who has applied the scale. The GCS is used to assess the severity of a brain injury and to allow medical professionals to constantly monitor the patients progress.GOS can be used to give prognosis 6 to 12 months after injury if the scale is used before this time then the score will not indicate the full functional outcome of the patient. This time period of scoring is not beneficial for prognosis at such a time that it will be used to inform treatment of the patient. The GOS does not provide a long term prognosis for brain injury as over time and with rehabilitation improvements can be made past what is predicted. Due to the time period necessary for GOS to be more accurately applied, the GCS can be used for the interim on a general scale in order to infer the likely GOC score a patient may receive. This score will be linked to other factors such as age, pupil dilation and presence of a midline shift on computer tomography, in addition to initial GCS score.18To conclude the GCS and GOS are vital in identifying the severity of brain injury and are still the most used scales for their purpose due to their simplicity and acceptable reliability. The use of these scales in brain injury prognosis helps direct treatment for individual patients, and allows realistic individual rehabilitation goals to be made for that individual.References1Hodgkinson D, Berry E, Yates D. 1994, Mild head injury a positive approach to management, European diary of Emergency Medicine, 1(1), 9-122 Moppett I. 2007, Traumatic brain injury assessment, resuscitation and early management, British Journal of Anaesthesia, 99(1), 18-313 Roozenbeek B, Maas A, Menon D. 2013, Changing patterns in the epidemiology of traumatic brain injury, Nature Reviews Neurology, 9(4), 231-2364 Swann I, Walker A. 2001, Who cares for the patient with head injury now?, Emergency Medicine, 18(5), 352-3575 National Institute for Health and Clinical Excellence (NICE) 2014 Head Injury Triage, assessment, investigation and early management of head injury in children, young people and adults operational at http//www.nice.org.uk/guidance/cg176/resources/guidance-head-injury-pdf (Accessed 18/03/2015)6 Chieregato A, Martino C, Pransani V, Nori G, Russo E, Simini B et al. 2010, Classification of traumatic brain injury the Glasgow Coma Scale is not enough, Acta Anaesthesiologica Scandanavica,54(6), 696-7027 Kushner D, Johnson-Greene D. 2014, Changes in cognition and continence as predictors of rehabilitation outcomes in individuals with severe traumatic brain injury, Journal of replacement Research Development, 57(7), 1057-10688 Murray G, Teasdale G, Braakman R et al. 1999, The European Brain Injury Consortium survey of head injuries, Acta neurochirurgica, 141(3), 223-2369 Rowley G, Fielding K. 1991, Reliability and accuracy of the Glasgow Coma Scale with experienced and inexperienced users, Lancet, 337(8740), 535-53810 McLernon S. 2014, The Glasgow Coma Scale 40 years on A review of its practical use, British Journal od Neuroscience Nursing, 10(4), 179-18411Lingsma H, Roozenbeek B, Steyerberg E, Murray G, Maas A. 2010, Early prognosis in traumatic brain injury from prophecies to predictions, Lancet Neurology 9(5), 543-55412 Singh B, Murad H, Prokop L, Erwin P, Wang Z, Parsaik A, et al. 2013, Meta-analysis of Glasgow Coma Score and Simplified Motor Score in predicting traumatic brain injury outcomes, Brain Injury, 27(3), 293-30013 Thornhill S, Teasdale G, Murray G, McEwan J, Roy C, Penny K. 2000, Disability in young people and adults one year after head injury prospective age bracket study, British Medical Journal 320(7250), 1631-163514 Maas A, Stocchetti N, Bullock R. 2008, Moderate and severe traumatic brain injury in adults, the Lancet Neurology, 7(8), 728-74115Udekwu P, Kromhout-Schiro S, Vaslef S, baker C, Oller D. 2004, Glasgow coma scales score, mortality, and functional outcome in head-injured patients, Journal of Trauma and Acute Care Surgey, 56(5), 1084-108916 Woischneck D, Firsching R, Schmitz B, Kapapa T. 2013, The prognostic reliability of the Glasgow Coma Scale in traumatic brain injuries evaluation of MRI data, European Journal of Trauma and Emergency Surgery, 39(1), 79-8617 Utomo W, Gabbe B, Simpson P, Cameron P. 2009, Predictors of in-hospital mortality and 6-moth functional ou tcomes in older adults after moderate to severe brain injury, Injury, 40(9), 973-97718Husson E, Ribbers G, Willemse-van countersign A, Stam H. 2010, Prognosis of six-month functioning after moderate to severe traumatic brain injury A systematic review of prospective cohort studies, Journal of Rehabilitation Medicine, 42(1), 425-43619Brooks D, Hosie J, Bond M, Jennett B, Aughton M. 1986, Cognitive sequelae of severe head injury I relation to the Glasgow Outcome Scale, Journal of Neurological and Neurosurgical Psychiatry, 49(5), 549-55320 Jourdan c, Bosserelle V, Azerad S, Ghout I, Bayen E, Aegerter P, Weiss J, Mateo J, Lescot T, Vigue B, Razarourte K, Pradat-Diehl P, Azouvi P. 2013, Predictive factors for 1-year outcome of a cohort of patients with severe traumatic brain injury results from PariS-TBI study, Brain Injury, 27(9), 1000-100721 Wilson J, Pettigrew L, Teasdale G. 1998, Structured interviews for the Glasgow Outcome Scale and the extended Glasgow Outcome Scale Guidelines fo r their use, Journal of Neuro-trauma, 15(8), 573-58722 Nalt J. 2001, Prediction of outcome in mild to moderate head injury A review, Journal of Clinical and Experimental Neuropsychology, 23(6), 837-85123 Nichol A, Higgins A, Gabbe B, Murray L, Cooper D, Cameron P. 2011, Measuring functional and quality of life outcomes following major head injury Coma scales and checklists, Injury, 42(3), 281-28724 Oh H, Seo W. 2013, Development of a decision tree analysis model that predicts recovery from acute brain injury , Japan Journal of Nursing Science, 10(1), 89-97