GCS scoring question

[Ian Civil]

Dear Falco,
   
  Not sure I can help you with this.
   
  We use estimated GCS 15 when there is no brain injury, if not recorded but use 2T (and therefore unable to TRISS) when intubated. Large database groups (like those in Quebec province) use imputated data from 10 other variables but I am not expert in this.
   
  I can't quote the evidence
   
  Ian C

Falco Hietbrink <falcohietbrink at hotmail.com> wrote:
  Dear dr. Civil,

I am interested in the discussion of this subject. In our clinic the individual components of the GCS are always reported.

However, the implementation of the GCS in other scores, such as the APACHE II Score and the SOFA score causes problems. I like the concept of giving a maximum GCS in expected normal brain function patients and giving a minimal score for sedated patients with severe brain injury. Unfortunately, I can not find any good literature backing up this way of filling in these score (APACHE II and/or SOFA). Especially in the SOFA score the GCS causes a problem as it remains constant in sedated patients. How do you deal with this problem and can you back it up with literature?

Kind regards,

Falco Hietbrink





> Date: Mon, 10 Sep 2007 12:38:55 +1000> From: SeppelI at wahs.nsw.gov.au> To: karim at trauma.org; trauma-list at trauma.org> CC: > Subject: RE: GCS scoring question> > I disagree, Karim - it's the 'T' that is bogus. (and 'S' and 'P' that> are doubly bogus, for those that use them)> > This is crucial when you extrapolate GCS outside neurotrauma. It is a> component of APACHE and is used for example in calculating SMRs for> comparison between ICUs. A well known way of 'fudging' APACHE and> getting artifically good SMRs is to give sedated ventilated patients a> GCS of 3. By definition, your sedated ventilated patient (who is> expected to wake up with a normal brain) is scored GCS 15. [the> neurological APACHE points come from '15 - GCS' so by default these> patients score no points, but do score points if you mususe the GCS]> > To score anything else in a sedated patient is meaningless as it is> impossible to actually do any sensible neurological examination in> someone who is
 significantly sedated (or especially paralysed!!!!! -- I> have seen exam candidates try to apply painful stimuli to paralysed ICU> patients. They score badly in the exam.)> > In trauma, again by definition, the one GCS you are interested in is> the post resuscitation unsedated GCS, predominantly so you can get the M> componenet (the only thing which has any prognostic value from GCS). A> 'next best' is the preintubation GCS, especially if there is no such> thing as a 'post resuscitation unsedated' phase for this patient.> > Ron Simon's patient in question, assuming he has sustained a severe> brain injury, and assuming the information we have been given was prior> to sedation, has a GCS of 3.> > Incidentally, I do not allow trainees to just give me a global GCS but> insist on knowing the components. It quickly tells me if the trainee has> actually examined the patient!!!> > Cheers, Ian> > Ian Seppelt FANZCA FJFICM> Senior Staff Specialist> Dept of Intensive Care Medicine>
 The Nepean Hospital, PO Box 63 Penrith NSW 2751> Director of Clinical Research, Sydney West AHS> Clinical Lecturer, University of Sydney> > >>> karim at trauma.org 6/09/2007 7:19am >>>> 3...> Or 2T> The purpose of the T is to declare that you cannot score the V> component due> to intubation.> Therefore GCS is E1VTM1 and so 2T.> 3T is bogus and scores the V component twice.> Trying to do a GCS on a paralyzed patient is more bogus.> > But then again, Applying the GCS system to anything beyond the initial> evaluation is stretching the scale beyond its validation and is used as> an> excuse for failing to describe the complete neurology.> > Screwing with the GCS because a stupid registry doesn't accept> non-numbers> or a blank is double bogus!!> > :-)> > Karim> > -----Original Message-----> From: trauma-list-bounces at trauma.org> [mailto:trauma-list-bounces at trauma.org] > On Behalf Of Ronald Simon> Sent: 05 September 2007 19:37> To: Trauma & Critical Care mailing list> Subject: GCS
 scoring question> > Just a quick question for the group.> What is the GCS of this patient:> No spont eye opening> No movt to deep pain> Intubated> Is it 3, 3T or 2T?> Thanks> ron simon> > --> trauma-list : TRAUMA.ORG> To change your settings or unsubscribe visit:> http://www.trauma.org/index.php?/community/> --> trauma-list : TRAUMA.ORG> To change your settings or unsubscribe visit:> http://www.trauma.org/index.php?/community/
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