Tag Archives: GCS

Is Intubation For Low GCS Necessary? Dangerous?

More dogma? I was taught that as the Glasgow Coma Scale (GCS) score drops toward 8, the higher the consideration of intubating the patient. And that a GCS 8 was pretty much an absolute indication for inserting the endotracheal tube. The rationale was that the more obtunded the patient was, the less able they were to protect their airway.

Even ATLS, our trauma textbooks, and practice guidelines from the likes of EAST recommend intubation for GCS 8 and less.

Having said that, I know many of you have been in a situation where you have a patient with GCS 8 or so, and they are lying there breathing peacefully with good oxygenation and ventilation. Do you really need to put in that tube? And we also tend to be very forgiving with obtunded children, avoiding premature intubation there as well.

Intubation is not a benign procedure. There is the potential for mayhem during the process, ICU admission will be required, and a host of ventilator and sedation-related complications are possible once the patient arrives there.

The trauma group at LAC + USC decided to look into this. They performed a five-year retrospective study of data from the TQIP database. A subset of patients was selected with isolated blunt head injury and GCS 7-8 who did not require immediate operation upon arrival. They were divided into intubation and non-intubation groups, and these were further subdivided into intubation within an hour of arrival, intubation after an hour, and never intubated groups.

Here are the factoids:

  • A total of 2,727 patients were studied; about two thirds were intubated within an hour, a quarter were never intubated, and the remaining 9% were intubated after the first hour
  • Immediately intubated patients were significantly younger and had fewer comorbidities
  • Mortality was 19% in the immediate intubation group vs 27% in the delayed group vs 11% in the never intubated group
  • Complications were significantly higher after immediate intubation, particularly DVT and ventilator associated pneumonia (VAP)
  • Regression analysis indicated that immediate intubation was independently associated with mortality compared to late or never intubated patients
  • Using additional regression testing, the authors concluded that the following two subsets of patients would benefit most from early intubation:
    • Younger patients (age < 45) with head AIS 5
    • Patients age <65 with head AIS 5

The authors recommend that “future research focus on more adequate parameters to identify patients requiring immediate intubation and should avoid an isolated fixed GCS threshold.”

Bottom line: This is a difficult paper to understand (at least for me). It looks like the authors are saying we should avoid immediate intubation of severe TBI patients with depressed GCS to reduce mortality and complications.

But you need to read the whole paper closely to really get it. First, let’s look at those mortality figures. The mortality in the three groups was:

  • intubated < 1 hour after arrival – 18.7% (from n = 1,866)
  • intubated > 1 hour after arrival – 27.4% (from n = 223)
  • never intubated – 11.4% (from n = 638)
  • If you combine the last two lines you get the mortality in the non-immediate intubations = 15.5% (from n = 861)

The authors then claim that the mortality for immediate intubation is greater than non-immediate intubation (the other two groups). This may be somewhat misleading, because the delayed intubation group actually has a higher mortality than the immediate group (27%)! This fact is covered up by combining delayed intubation with the never intubated group, bringing the number down to 15.5%!! Why shouldn’t you say that intubating the patient at any time is bad, immediate or delayed??

They suggest some criteria to try to focus in on the patients who really need intubation: younger patients (age < 45 or < 65) with head AIS 5 and GCS 7. Unfortunately, you can’t determine which patients have an AIS 5 in their head without a head CT, which may push them into the higher mortality delayed intubation group.

Remember, this type of study can only show an association, not cause and effect. The authors suggest that early intubation results in more deaths and complications. My suspicion is that patients with severe TBI don’t do poorly because they were intubated. I believe that they were intubated because the clinicians feared that they would do poorly. Unfortunately, this is information that can only be gleaned from a prospective study, not a retrospective database review.  And no amount of statistical manipulation or regression analysis can make up for this shortcoming.

This is yet another one of those studies that ends by concluding that a better study should be done. That would be okay if this one actually provided a hint that the endeavor would be worthwhile. But it doesn’t. I didn’t really learn anything from it, unfortunately.

So I still heartily recommend using your existing training, guidelines, and judgement to intubate these patients early and safely!

Reference: Isolated traumatic brain injury: Routine intubation for GCS 7 or 8 may be harmful! J Trauma, publish ahead of print, DOI: 10.1097/TA.0000000000003123, Feb 16, 2021.

Glasgow Coma Scale For Trauma Activation: What’s The Optimal Score?

Last month, I posted a survey to  find out the Glasgow Coma Scale (GCS) values trauma centers were using to trigger their highest level trauma activation. Nearly 150 people responded, providing a nice snapshot of practices worldwide. Today, I’ll summarize the responses and provide a bit of commentary about them.

There were a total of 147 respondents from around the world. I tried to eliminate duplicates from the same center using a self-reported postal code. However, this was an optional field, so there is the possibility that a few crept in. Readers from at least six countries outside the US also responded.

The question  was: “What is the highest GCS score that triggers a top-level trauma activation at your trauma center?”

Here is a chart that shows the results. The proper way to read it is “a trauma activation is called if GCS < xx” where xx is the score under the bar in the chart.

The whole point to calling a trauma activation is to have the full trauma team and infrastructure (labs, imaging, blood, etc.) in place to rapidly assess a patient with life-threatening injuries. In theory this should afford them the best probability of survival.

So what is the optimal GCS score to activate your trauma team? Unfortunately, this remains difficult to answer exactly. From the chart, you can see that the most common scores were 8, 9, and 13. Why such a spread?

The GCS 8 and 9 levels are a no-brainer (ha!). These patients are comatose or nearly so, and obviously need prompt attention such as airway control, head CT, and neurosurgical consultation. But what about the patients with GCS 13? They have lost two points, typically for eye-opening and verbal response. This may indeed indicate  a significant head injury. But all too often we see this same score in patients who are intoxicated. Do we really need (or want) to activate the full team for each and every intoxicated patient? Can we screen them out in some way?

The answer to both questions is yes. The most important tip is to know your patient population. There is an association between GCS and need for operative intervention that was oft-quoted in the ATLS course. However, I have not been able to find a definitive paper on this topic.

I recommend that you tap into your trauma registry and create a chart that shows presenting GCS vs early neuro-intervention (ICP monitor or craniectomy within 24 hours). Find the GCS score where you see a “significant” bump in the number needing a procedure, and use this as your trauma activation threshold. This report will automatically take into account the number of intoxicated patients you treat.

I would also recommend you do a separate report on age vs need for neuro-intervention with GCS<15. The older population tends to require craniectomy for TBI more often and at higher GCS levels than younger people. You may factor this into your single GCS criterion, or add a separate one at a different level for patients over 55, or 60, or whatever reflects your patient age mix.

Bottom line: Make sure your GCS trauma activation criteria adequately identify your patients who truly have a need for speed in their trauma evaluation. A GCS of 8 or 9 may be too low, and a score in the teens is probably more appropriate for most centers. Use your trauma registry to determine the best score for you so you can capture the patients who have critical needs while trying to keep overtriage under control.

 

Glasgow Coma Scale And Trauma Activation

The American College of Surgeons has a list of seven required criteria that must trigger a top-level trauma activation at trauma centers verified by it. One of the seven involves the Glasgow Coma Scale (GCS) score, and the threshold is defined as GCS < 9.  However, the range of actual scores used by trauma programs varies widely from about 13 down to the minimum of 8.

So I’m curious: what does your trauma center use? Please help me out and answer the survey I’ve posted below. Remember, I am asking for the threshold you use for only your top-level trauma activation. I’ll post the range of answers next week. Thanks!

Sorry, the survey is closed

GCS At 40: The New GCS-40

As discussed in my first post in this series, the original Glasgow Coma Scale (GCS) was described in 1974. It was originally intended to be a chart of all three components, trended over time. Ultimately, the three values for eye opening, verbal, and motor responses were combined into a single score ranging from 3-15. This combined score has become the main focus of our attention, with less interest in the individual components.

Here is the original GCS:

Forty years later (2014), there was interest in tweaking it to overcome a few of the perceived shortcomings. Two relatively small changes were made. First, a few terminology changes were made in the eye opening and verbal response components. Eye opening was clarified to indicate opening to pressure, not pain, and speech, not sound. Verbal response was also clarified, changing “incomprehensible” to “sounds”, and “inappropriate” to “words.”

Additionally, when eye opening or verbal response could not be tested (swelling, intubation), the value was scored as a 1. This was changed in 2014, so that the non-testable components are now marked “NT” and the total score should not be calculated.  Here’s an example:

  • Original GCS: E1 V1T M3 = 5T
  • GCS-40: E1 V-NT M3   (no total)

Here’s the new GCS-40 description published in 2014:

Finally, this year Teasdale and associates added one final tweak. They incorporated an indicator of pupillary response. This table shows the levels of response:

This factor is subtracted from the GCS-40, now resulting in score that can range from 1-15. Addition of this component greatly improves our ability to predict outcome.

Why does all this matter? One important reason is that the American College of Surgeons Trauma Quality Improvement Program will begin accepting data in 2019 with GCS 40 data. The National Trauma Databank data definitions will also incorporate GCS 40 in next tear. It looks like there will be a phase-in period where either system can be used. I could not find any indication that the pupillary score would be included any time soon.

I’m sure research will continue on this staple of trauma evaluation. Expect more tweaks in the future as we try to improve our ability to follow our patients clinically and predict how well they will do.

GCS At 40: Pediatric Glasgow Coma Scale

I’ve been discussing the Glasgow Coma Scale (GCS), but only the adult version so far. The pediatric GCS was created about 10 years after the classic adult scale after it was recognized that several of the scores were not appropriate for younger non-verbal children, typically less than one year of age. It has been validated several times over the ensuing years and has been integrated into our trauma practices.

So what is different about the pediatric GCS scale? It has the same three main components, eye opening, best verbal response, and best motor response. The number of scores under each remains the same as well. The major changes occurred in the verbal response scores. Here’s the breakdown; I’ve highlighted the differences.

Eye Opening

  • All components are the same as for adults

Best Verbal Response

  1. No response to stimuli
  2. Inconsolable, agitated
  3. Inconsistently inconsolable, moaning
  4. Cries but consolable. Has appropriate interactions.
  5. The child smiles, orients to sounds, follows objects, and interacts with adults

Best Motor Response

  1. No response to stimuli
  2. Decerebrate posturing (extension to stimulation, see the adult post for details)
  3. Decorticate posturing (flexion to stimulation, see the adult post for details)
  4. Withdraws from pain
  5. Withdraws from touch
  6. Spontaneous, purposeful movement

In my next post in the series, I’ll review what’s new with the GCS-40 score.

Reference: Neurologic evaluation and support in the child with an acute brain insult. Pediatric Annals 15(1):16-22, 1986.