EMS World

AUG 2017

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34 AUGUST 2017 | EMSWORLD.com very clean, regardless of whether it is and regardless of whether the scale is actually useful to the clinician at the bedside. Grayson: In EMS we often fall victim to a cognitive bias whereby we believe that if something can be measured, it should be measured. In my estimation, the greatest use of numerical rating systems like GCS and FOUR Score is in research. The more precisely and reliably we can quantify data points, the more assured we are that we're comparing apples to apples in medical research. They won't much alter my clini- cal practice at the point of care, but I can certainly see their utility for data mining. Cole: The GCS was not the first attempt to use a numerical scale in emergency medicine, but it has been perhaps the most widely accepted. I think the wide- spread use of the GCS was reflective of the growth of emergency medicine and trauma care in the '70s and the increase in the need/desire for data. When the GCS was introduced in 1974, physicians were tr ying to improve communication on a patient's condition between facilities and newly developed specialty centers. In that regard, the GCS did its job. It was simple, practical and (relatively) easy to perform and reproduce among multiple providers. Even as early as 1976, though, difficul- ties surfaced in interrater reliability. A 1991 study reaffirmed these difficulties. In some cases scoring a patient at all may have been impossible. A 1993 European study showed that in severe injuries, up to 61% of patients were "unscorable," meaning that other factors (such as intubation, chronic medical conditions or sedation) prevented accurate scoring, something not account- ed for in the original GCS. Finally, a 1998 study showed that incorrect assessment by "eyeballing" the patent was common (51%). Despite this, almost ever y EMS ePCR requires a GCS to be entered. As medicine and trauma care evolved, the GCS did not. The FOUR Score's value is that it reflects current practices and assessments more than the GCS while keeping the practicality of a simple tool any paramedic can use. The real question is, should we use coma scales at all? I think Jason touched on this well. After all, the impact of these scales at the point of care is negligible. The only reason to continue this practice is in docu- mentation, where EMS can participate in the overall research effort in emergency medicine. Otherwise, perhaps coma scales have outlived their usefulness altogether. Gandy: To sum up, GCS was never designed for use on the street but has been adapted, somewhat clumsily, to street use. It is useful for data miners but of little use to prehospital caregivers and emergency physicians. It may be more useful to the hospitalist who takes care of the patient in the ICU if she or he can compare the patient's current GCS to their score on arrival in the ER. In my mind reliance on a numerical score minimizes the ability to actually learn the fine art of patient assessment. FOUR Score uses more components than GCS, and in order to learn how to use it, one must become adept at using more assessment parameters. This is a good thing. Neither GCS nor FOUR Score will tell you much about a suspected CVA patient, but a one-minute survey of the cranial nerves surely will. As EMS rumbles along the rocky road toward "professionalism," it is incumbent upon all medics, of whatever level of train- ing, to continue to learn, improve skills and stay up with changes in concepts. While announcing a FOUR Score to your ED doc may not tell her or him all that much about the patient, it may say a lot about you and enhance the trust you are extended. Conclusion And with that, we return to our opening scenario. Just as you've almost decided your patient must be intubated, the charge nurse finally arrives with the patient's chart, which reveals that she is 10 years post-CVA with residual neurological deficits. She has essentially been in this same condition for the last 10 years but is usually more responsive. Read- ing her medication list, you see she received her nightly dose of alprazolam (Xanax) at 0430 instead of 2100, as prescribed. There is no explanation for this, but you decide intubation is not appropriate and decide to transport to rule out sepsis. Follow-up with the ED staff reveals that she was observed for four hours and then released back to the nursing facility. There was no sign of sep- sis, and her level of consciousness improved with time. You are left to ponder her GCS and how it helped you. You talk it over with several colleagues, but they each arrive at different scores. You are puzzled. We leave you with this scenario and ask you to decide for yourself what this patient's GCS should have been and how spending time figuring it on scene was of any benefit to either you or the receiving nurses and physicians. We welcome your feedback. REFERENCES 1. Weise MF. British hospitals and different versions of the Glasgow coma scale: telephone survey. BMJ, 2003; 327: 782. 2. Gill MR, Reiley DG, Green SM. Interrater reliability of Glasgow Coma Scale scores in the emergency department. Ann Emerg Med, 2004 Feb; 43(2): 215–23. 3. Teasdale G, Jennett B, Murray L, Murray G. Glasgow coma scale: to sum or not to sum. Lancet, 1983 Sep 17; 2(8,351): 678. 4. Teasdale G, Jennett B. Assessment of coma and severity of brain damage. Anesthesiology, 1978 Sep; 49(3): 225–6. 5. Healey C, Osler TM, Rogers FB, et al. Improving the Glasgow Coma Scale score: motor score alone is a better predictor. J Trauma, 2003 Apr; 54(4): 671–8. Additional Resources • Bruno MA, Ledoux D, Lambermont B, et al. Comparison of the Full Outline of UnResponsiveness and Glasgow Liege Scale/ Glasgow Coma Scale in an intensive care unit population. Neurocrit Care, 2011 Dec; 15(3): 447–53. • Cohen J. Interrater reliability and predictive validity of the FOUR score coma scale in a pediatric population. J Neurosci Nurs, 2009 Oct; 41(5): 261–7. • Gill M, Steele R, Windemuth R, Green SM. A comparison of five simplified scales to the out-of-hospital Glasgow Coma Scale for the prediction of traumatic brain injury outcomes. Acad Emerg Med, 2006 Sep; 13(9): 968–73. • Hosseini SH, Ayyasi M, Akbari H, Heidari Gorji MA. Comparison of Glasgow Coma Scale, Full Outline of Unresponsiveness and Acute Physiology and Chronic Health Evaluation in prediction of mortality rate among patients with traumatic brain injury admitted to intensive care unit. Anesth Pain Med, 2016 April; 6(2): e33653. • Jalali R, Rezaei M. A comparison of the Glasgow Coma Scale score with Full Outline of Unresponsiveness scale to predict patients' traumatic brain injury outcomes in intensive care units. Crit Care Research Practice, 2014; 289803. • Schnakers C, Giacino J, Kalmar K, et al. Does the FOUR Score correctly diagnose the vegetative and minimally conscious states? Ann Neurol, 2006; 60(6): 744–5. • Settervall C, de Sousa R. Glasgow Coma Scale and quality of life after traumatic brain injury. Acta paul enferm, 2012; 25(3), 364–70. • Stambrook M, Moore AD, Lubusko A A, Peters LC, Blumenschein S. Alternatives to the Glasgow Coma Scale as a quality of life predictor following traumatic brain injury. Arch Clin Neuropsychol, 1993 Mar; 8(2): 95–103. • Wijdicks EF, Bamlet WR, Maramattom BV, Manno EM, McClelland RL. Validation of a new coma scale: the FOUR score. Ann Neurol, 2005 Oct; 58(4): 585–93.

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