EMS World Magazine is the most authoritative source in the world for clinical and educational material designed to improve the delivery of prehospital emergency medical care.
Issue link: https://emsworld.epubxp.com/i/852553
EMSWORLD.com | AUGUST 2017 33 When a disaster or terror attack occurs, do you have the skills and strategies to help you respond? The first few hours are critical in assessing and treating those impacted. All Disasters Are Local Learn how to respond when disaster strikes through Disaster and Counter-Terrorism Medicine; a series of presentations developed by Gregory Ciottone, M.D., FACEP, an international expert in the field of disaster and counter-terrorism medicine. 24-7.hsi.com/DisasterMedicine score to predict early mortality. I think FOUR Score is more reflective of modern medi - cine and critical care than the GCS, while remaining simpler to implement compared to other scores. Grayson: Honestly, I don't see FOUR Score changing the way I do things in the field, simply because coma scoring in gen- eral doesn't much dictate my treatment. However, since it is more accurate and reli- able than GCS, I'll use it. For one thing, as Jason pointed out, using a scale like FOUR Score may up a medic's street cred in the physician's eyes, and greater respect and trust from the ED physician is a benefit not lightly discounted. I foresee the most utility in critical care transports. A great many of those patients are intubated and/or sedat- ed, and the GCS is a pretty blunt instrument for monitoring them. Kodat: There's no reason to spend much time on these in the field, since they were never intended to be used in the field. There's even less reason when the scales have an accuracy that isn't particularly impressive. I'm going to pick on the GCS simply because it's older and has much more research behind it. In one study, emergency physicians assessing the same patients independently got the same GCS score only 38% of the time and were within one point of each other only two-thirds of the time—they got one-third of all scores at least two points different! 2 The very people who created it didn't intend the numbers to be added, either, but rather used as three separate scales. 3 They also once wrote: "We have never rec- ommended using the GCS alone, either as a means of monitoring coma or to assess the severity of brain damage or predict outcome." 4 Gandy: Looking back at the history of GCS, it's apparent it was never intended to be used in emergency medicine; rather it was a way to track the progress of neu- rologic patients in the ICU. How did we get this into EMS? Is there any science that validates its use in emergency medicine? Kodat: The GCS makes up one compo- nent of the Revised Trauma Score, which has been shown to be predictive of mortal- ity but isn't particularly useful on its own. This makes sense when you understand that a GCS of 4 can predict a fatality rate of 19%, 27% or 48%, based simply on which of the three scales was ranked a 2. 5 In fact, the motor component of the GCS actually outperforms the summed GCS in virtually every aspect that has been tested. A lot of the push to use it comes from researchers. Real patients and real charts are messy. Researchers want to study things that are easy to type into SPSS (the most common statistical analysis software): yes or no, present or absent, alive or dead, and numbers. Creating a numerical scale makes messy data look For More Information Circle 22 on Reader Service Card