Tag Archives: history

GCS At 40: The Original GCS

The Glasgow Coma Score (GCS) has been in use for more than 40 years. Since that 40th anniversary a few years back, there has been talk of updating this tried and true system. But where did this scale come from? How was it devised? And why are we looking to update it now? I’ll dig into this topic over my next several posts.

The original paper describing the GCS was published in 1974 by Graham Teasdale and Bryan Jennett. They were neurosurgeons at the Institute of Neurologic Sciences in Glasgow, Scotland (of course) and were based in the Southern General Hospital. Until this paper was published, each report in the literature described its own assessment of level of consciousness. Most divided the spectrum into various steps noted between fully alert and comatose. Unfortunately, these systems were confusing, and they varied from 3-17 steps! There was just no consensus. Some relied on a comprehensive neurologic exam, including brainstem function tests. However, none of these were really designed for repeated bedside assessment.

Teasdale and Jennett settled on three simple areas to examine: eye-opening, motor response, and verbal response. They selected easily observable responses for each of these components. Here is a copy of the original scale:

Notice that this differs from the current-day score. The motor response did not have a “withdrawal” option, so the maximum score was only 14! But that didn’t matter much at the time; the individual components were graphed out over time for inspection. A total score was not generally calculated.

Teasdale and Jennett found that inter-rater reliability for this system was excellent, compared to a 25% discrepancy for other less objective systems in use at the time. This led to its rapid adoption over the coming years.

In my next post, I’ll describe how GCS came to be used over the ensuing years.

November Trauma MedEd Newsletter Released!

The November newsletter is now available! Click the link below to download. This month’s topic is “History”, and I look at the impact of articles written 20-25 years ago on your current practice.

In this issue you’ll find articles on:

  • Trauma and critical care
  • CT imaging of the aorta
  • ED intubation for head injury
  • Seatbelt injuries
  • CAVR for hypothermia
  • Early or delayed femur fracture fixation

Subscribers received the newsletter last Monday night. If you want to subscribe to get early delivery in the future (and download back issues), click here.

Click here to download newsletter.

The Robert Jones Dressing

The Robert Jones dressing is a thick, padded bandage classically applied to the thigh and leg. It is thought to reduce swelling by applying even pressure to the extremity, which in turn should promote healing. And since it is a soft dressing, as opposed to a cast, there is less chance of developing skin breakdown from direct pressure. Here’s a compression-type dressing described in 1937 using stockinette, cotton wool, and elastic cloth, although it was not attributed to Jones at that point.

Charnley provided a detailed description of the bandage in 1950, and was the first to refer to Jones.

Interestingly, Robert Jones never really referred to the dressing by name. There were references to a “pressure crepe bandage over copious wool dressing” in his operative logs, but it wasn’t until much later that his name became associated with it. Because of this, the composition of the bandage has varied greatly over time.

But who was Robert Jones? We in the States are fairly ignorant, but my UK readers are very familiar. Jones was a British surgeon who practiced through the late 1800s and past the end of World War I. He learned about fractures from his uncle, and became one of the few surgeons of the time to be interested in fracture care. Until then, orthopaedics was focused primarily on correcting deformities in children. He received his FRCS in 1889. After being appointed Surgeon-Superintendent of the Manchester Ship Canal, he established the first comprehensive accident service in the world to take care of injured workers. He founded the British Orthopaedic Society in 1894, and introduced the concept of military orthopaedic hospitals during World War I. His innovations led to significant decreases in morbidity and mortality from fractures in the war, particularly of the femur.

And does his eponymous dressing actually work? There has been little research in this area. There is one study that I have found that actually measured compartment pressures to see if the loss of edema from compression caused a noticeable pressure decrease. Here are the factoids:

  • This was a very small prospective study from 1986 of 9 patients (!) who had just undergone knee arthroplasty
  • Slit catheters were placed into the compartment 10 cm below the knee joint (but they didn’t say which compartment)
  • Thick cotton-wool from a roll was applied over the surgical dressings twice, each with a thickness of two inches. An elastic bandage was then applied snugly.
  • Much to the researchers’ surprise, compartment pressures did not fall as expected over time. They were basically constant until the dressing was removed. Then the pressures fell significantly.

Bottom line: Robert Jones’ fame is well deserved. However, his dressing (which he did not name, and may not even be what he used), did not have the pressure-reducing effect on an injured limb that surgeons thought. No studies on edema and healing have been done. It’s basically a fluffy dressing. However, that is a good thing. It keeps the leg padded, protecting the skin, and immobilized. It’s like a very well padded cast, without the risk of skin breakdown. And because of its simplicity, it will probably be used for quite some time to come.

Related posts:

References:

  • The Robert Jones bandage. JBJS 68B(5):776-779, 1986.
  • The treatment of fracture without plaster of Paris. Closed Treatment of Common Fractures, E&S Livingstone 1950, pg 28-29.
  • Handbook of Orthopaedic Surgery. CV Mosby 1937, pg 418.

Trauma 20 Years Ago: CAVR For Hypothermia

Hypothermia is the bane of major trauma resuscitation, causing mortality to skyrocket. A number of rewarming techniques have been developed over the years. These are classified as passive (the patient generates their own heat) or active (we deliver calories to them), and noninvasive vs invasive. Rewarming speed increases as we move from passive to active and from noninvasive to invasive.

Continuous arteriovenous rewarming (CAVR) is one of the invasive techniques used today. Its use in humans was first reported 20 years ago this month. Larry Gentilello at Harborview in Seattle had experimented with this technique in animals, and reported one case of use in a human who had crashed his car into icy water. After a 20 minute extrication, the patient was pulseless with fixed and dilated pupils, but he regained pulse and blood pressure at the hospital.

The initial core temperature was 31.5C. Peritoneal, bladder and gastric lavage were carried out for warming, as was delivery of warm inspired gas via the ventilator. However, after an hour the temperature had dropped to 29.5C. CAVR was initiated as a last-ditch effort using a jerry-rigged Rapid Fluid Warmer from Level 1 Technologies. The core temperature was raised to 35C after 85 minutes.

The patient did have typical complications (ARDS, acute renal failure), but survived with recovery of his renal and pulmonary function, and a normal neurologic exam. At the time, the authors were unsure whether the complications were due to the near-drowning or the rapid rewarming.

Reference: Continuous arteriovenous rewarming: report of a new technique for treating hypothermia. J Trauma 31(8):1151-1154, 1991.

Related posts:

Why Do They Call Them Rounds?

Face it. Everyone uses this term. But where did it come from? After a little digging, I think I’ve found the answer. I’m sure someone will step forward and offer another explanation, but the origins of some of our traditions grow foggy with time.

Supposedly, the term “rounds” was introduced by Sir William Osler, the famed physician, while he was at Johns Hopkins hospital in Baltimore. The original building was built in the 1880s and had a round dome. Osler and his trainees had to walk circular hallways to see their patients. I’ve not been there, but looking at the picture above, the corners of the building appear to be octagonal patient wards as well.

The term has stuck with us, and today just about every discipline from prehospital to rehab medicine use it! If anybody has another theory or correction, please let me know!

Reference: CIRCULAR HOSPITAL WARDS: PROFESSOR JOHN MARSHALL’S CONCEPT AND ITS EXPLORATION BY THE ARCHITECTURAL PROFESSION IN THE 1880s. Medical History 32:426-448, 1988.