Dr. Paul Auerbach is the world's leading outdoor health expert. His blog offers tips on outdoor safety and advice on how to handle wilderness emergencies.See all posts »
Hoofbeats Chasing the Glasgow Coma Scale
I posted recently about using a higher (minimally abnormal) Glasgow Coma Scale (GCS) score to determine triage of an elder patient to a facility that specializes in trauma care when an injured brain is suspected. In fact, the GCS is coming under scrutiny now for its complexity and the fact that different individuals often rate the same patient differently when using this metric. In an article entitled “Validation of the simplified motor score in the out-of-hospital setting for the prediction of outcomes after traumatic brain injury” authored by David Thompson, MD et al in the Annals of Emergency Medicine (2011;58:417-425), the authors concluded that after their analysis of an urban Level I trauma registry that included 19,408 patients, a 3-point Simplified Motor Score (SMS) was similar to the GCS score for predicting outcomes in traumatic brain injury in the out-of-hospital setting.
The SMS is defined as a score of 2 for the patient obeying verbal commands, a score of 1 for the patient being able to localize a painful stimulus, and a score of 0 for the patient only being able to withdraw from pain or having even worse mental status. Its direct application for use by laypersons—e.g., what score to use and how—remains to be determined. The presumption would be that if one scores less than 2, trouble may loom on the horizon.
In an accompanying editorial by Steven Green, MD, the assertion was made that “it is time to abandon the Glasgow Coma Scale.” For the reasoning behind this recommendation, Dr. Green stated that the GCS was confusing, often not remembered by the clinicians using it, unreliable, unnecessarily complex, and as used, statistically flawed. Very importantly, he noted that it was not designed as a measure of acute mental status or for its applicability to acute brain injury, but as a tool to be used in a neurosurgical unit to measure the duration of coma.
Time will tell which score, if any, correlates consistently with a brain injury sufficient to warrant transport to a trauma center. Will it be the Simplified Motor Scale (obeys commands, localizes pain, withdrawal to pain or less response) [alternatively known as TROLL: test responsiveness: obeys, localizes, or less], AVPU (alert, responds to verbal stimuli, responds to painful stimuli, unresponsive to all stimuli), ACDU (alert, confused, drowsy, unresponsive), or something else?
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