GCS scoring question

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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

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