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Glasgow Coma Scale in Intubated Patients

Multiple Choice Questions in Neurology:

A 60 year old male patient, known case of Diabetes mellitus and chronic hypertension, presented with sudden onset of right sided hemiparesis and altered mental status. The patient was aspirated and gasping in the emergency room. He was immediately intubated and put on ventilatory support in an intensive care ward. While the patient was on ventilator, doctor examined the patient. He was able to localize painful stimulus from left side of hand. He was able to open eyes on painful stimulus, but unable to open eyes on voice command. What was the Glasgow Coma Scale (GCS) of that patient?
  1. 6
  2. 8
  3. 10
  4. 12

Recommendations:

Glasgow Coma Scale is very frequently asked topic in neurology entrance examination question paper. This topic should be included in your neurology question bank.

Glasgow Coma Scale (GCS) in Tracheostomized or Intubated Patients

Glasgow Coma Scale is a neurological scale to assess the level of consciousness of the patient. It is developed by Graham Teasdale & Bryan J. Jennett, in 1974. “Glasgow Coma Scale” named after University of Glasgow. It has minimum score: 3 and maximum score: 15.

Glasgow Coma Scale (GCS)

Eye Scale:
  • Score 4: Opens eyes spontaneously
  • Score 3: Opens eyes in response to voice
  • Score 2: Opens eyes in response to pain
  • Score 1: Does not open eyes
Verbal Scale:
  • Score 5: Oriented, converses normally
  • Score 4: Confused, disoriented
  • Score 3: Words
  • Score 2: Makes sounds
  • Score 1: Makes no sounds
Motor Scale:
  • Score 6: Obeys commands
  • Score 5: Localizes to painful stimuli
  • Score 4: Flexion / Withdrawal to painful stimuli
  • Score 3: Abnormal flexion to painful stimuli (decorticate response)
  • Score 2: Extension to painful stimuli (decerebrate response)
  • Score 1: Makes no movements
Severity of Brain Damage based on Glasgow Coma Scale (GCS):
  • Severe: GCS < 8–9
  • Moderate: GCS 9–12
  • Minor: GCS ≥ 13

Glasgow Coma Scale in Special Situation

Sometimes, we may have to clinically access the tracheostomized or intubated patients. In these situations, motor and eye score would be normal but score for verbal will be changed as follows:
  1. Post-fix (t) is used to denote “Tube”
  2. Score should be “1”
  3. In practice, we usually avoid “1” and write only post-fix like EV(t)M. Ideally it should be EV(1t)M.
  4. So, maximum score in tracheostomized or intubated patient is 11 [E4V(t)M6) or E4V(1t)M6)].

References:

  • Teasdale G, Jennett B. Assessment of coma and impaired consciousness: a practical scale. The Lancet. 1974 Jul 13;304(7872):81-4.
  • Teasdale G, Murray G, Parker L, Jennett B. Adding up the Glasgow coma score. InProceedings of the 6th European Congress of Neurosurgery 1979 (pp. 13-16). Springer, Vienna.
  • Meredith, Wayne, et al. "The conundrum of the Glasgow Coma Scale in intubated patients: a linear regression prediction of the Glasgow verbal score from the Glasgow eye and motor scores." Journal of Trauma and Acute Care Surgery 44.5 (1998): 839-845.

Analysis of the Above Multiple Choice Questions in Neurology

  • The patient was on ventilator => Patient should be intubated or tracheostomized.
  • So modified Glasgow Coma Scale should be applied. Verbal response should be V(1t) or simply V(t). Score is “1”.
  • The patient was able to localize painful stimulus from left side of hand => M5
  • The patient was able to open eyes on painful stimulus => E2
  • So, total GCS is “8”.
[Answer is 2. 8.]

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