Glasgow Coma Scale (GCS)

3 response scores

- Motor response

- Verbal response

- Eye opening

Cut off scores

- 8 or less = severe

- 9-12 = moderate

- 13-15 = mild

Eye opening scores

Spontaneous = 4

To speech = 3

To pain = 2

No response = 1

Motor response scores

Follows motor commands = 6

Localizes = 5

Withdraws = 4

Abnormal flexion = 3

Extensor response = 2

No response = 1

Verbal response

Oriented = 5

Confused conversation = 4

Inappropriate words = 3

Incomprehensible sounds = 2

No response = 1

Predictor of poor recovery in patients with mod to severe TBI

Low initial score on GCS

Other factors associated with poor outcomes

- Age

- Race

- Lower education level

Found on initial CT:

- Petechial hemorrhages

- Subarachnoid bleed

- Obliteration of third ventricle

- Basal cisterns

- Midline shift

- Subdural hematoma

In addition to examining arousal, attention, and cognition, other areas to examine include:

- Integument integrity

- Sensory integrity

- Motor function

- ROM

- Reflex integrity

- Ventilation and respiration/gas exchange

Decorticate rigidity/posturing

Arms adducted and flexed, wrists and fingers flexed; legs extended, internal rotated, plantar-flexed

(DeCORticate = limbs towards your core)

Indicates a lesion at or above brain stem

Decerebrate rigidity/posturing

UE and LE extended

More severe

Lesion in lower brain stem

Outcome measures

- Coma recovery scale- revised (CRS-R)

- Disorders of consciousness scale (DOCS)

- Rancho Los Amigos levels of cognitive functioning (LOCF)

Coma recovery scale- revised (CRS-R)

- 23 items

- Measures: auditory, visual, motor, promoter, communication, arousal

- Useful in distinguishing between different states of consciousness, determining the prognosis, and informing treatment planning

Disorders of consciousness scale (DOCS)

- 23 items

- Assesses: social knowledge, taste/swallowing, olfactory function, proprioception, tactile sensation, auditory function, visual function

- Differentiates states of consciousness

Rancho Los Amigos levels of cognitive functioning (LOCF)

- Used to examine cognitive and behavioral recovery in individuals with TBI as they emerge from a coma

- 8 categories

Contraindications to early mobilization

- Unstable spine

- Increased intracranial pressure (ICP)

Precautions for early mobilization

- WB'ing restrictions

- Skin and joint integrity

- Autonomic integrity

- Cardiovascular status

Interventions to promote early mobilization

- Cervical collar to support the head

- Tilt table or specialized tilt table to assist pt into standing position

- Body weight support system (overground or on treadmill)

Rancho Los Amigos levels of cognitive functioning (LOCF): level 1

- No response

- Patient appears to be in a deep sleep and is completely unresponsive to any stimuli

Rancho Los Amigos levels of cognitive functioning (LOCF): level 2

- Generalized response

- Patient reacts inconsistently and non purposefully to stimuli in a nonspecific manner

- Responses are limited and often the same regardless of stimulus present

- Responses may be physiological changes, gross body movements, and/or vocalization

Rancho Los Amigos levels of cognitive functioning (LOCF): level 3

- Localized response

- Patient reacts specifically but inconsistently to stimuli

- Responses are directly related to the type of stimulus present

- May follow simple commands such as closing eyes or squeezing hand in an inconsistent, delayed manner

Rancho Los Amigos levels of cognitive functioning (LOCF): level 4

- Confused agitated

- Patient in heightened state of activity

- Behavior is bizarre and non purposeful relative to immediate environment

- Does not discriminate among persons or objects; is unable to corporate directly with treatment efforts

- Verbalization frequently incoherent and/or inappropriate

- Gross attention is brief, selective attention nonexistent

- Patient lacks short term and long term recall

Rancho Los Amigos levels of cognitive functioning (LOCF): level 5

- Confused inappropriate

- Able to respond to simple commands fairly consistently

- With increased complexity of commands or lack of external structure, responses are non purposeful, random, or fragmented

- Highly distractible and lacks ability to focus attention on a specific task

- With structure, may be able to converse for short periods of time

- Verbalization is often inappropriate and confabulatory

- Memory severely impaired

- Unable to learn new information

Rancho Los Amigos levels of cognitive functioning (LOCF): level 6

- Confused appropriate

- Shows goal-directed behavior but is dependent on external input or direction

- Follows simple directions consistently and shows carryover for relearned tasks

- Responses may be incorrect due to memory problems, but they are appropriate to the situation

- Past memories show more depth and detail than recent memory

Rancho Los Amigos levels of cognitive functioning (LOCF): level 7

- Automatic appropriate

- Goes through routine automatically but frequently robot-like

- Minimal to no confusion and has short recall of activities

- Judgement remains impaired

Rancho Los Amigos levels of cognitive functioning (LOCF): level 8

- Purposeful appropriate

- Patient able to recall and integrate past and recent events and is aware and responsive to environment

- Shows carryover for new learning and needs no supervision once activities are learned

- May continue to show a decreased ability relative to premorbid activities, abstract reasoning, tolerance for stress, and judgement in emergencies/unsual situations

Preventing secondary impairments

- Proper positioning in bed and WC

- Bed = head in neutral, hips and knees slightly flexed, but monitor ROM to prevent contractures

- Splints and special boots to help with positioning and prevent skin breakdown

- Serial casting (often used for PF and biceps contractures)

Special considerations for confused and agitated patients

- Consistency

- Expect no carryover

- Model calm behavior

- Expect egocentricity

- Flexibility/ options

- Safety

- Environment

Special considerations for confused and agitated patients: consistency

- Team and family members should address inappropriate behaviors in a consistent manner

- To decrease confusion, patient should be seen by same person, same time, same location everyday

- Establish a daily routine

- Provide orientation frequently (person, place, time)

Special considerations for confused and agitated patients: expect no carryover

- Teaching new skills is unrealistic

- Use of charts/graphs may be useful to help patient progress each day

Special considerations for confused and agitated patients: model calm behavior

- Patient may perceive or reflect the demeanor of the caregiver

- Important to remain calm and focused

- Patient may not be able to control his or her behavior and may not feel safe

Special considerations for confused and agitated patients: expect egocentricity

- Patient cannot see another's point of view

- Tend to think only of him or herself

Special considerations for confused and agitated patients: flexibility/options

- Patient has short attention span --be prepared with numerous activities

- Treat the patient at an appropriate age level

- Give control to the patient when it is safe and appropriate

- Provide safe choices for the patient

Special considerations for confused and agitated patients: safety

- Patients may be kept in a locked unit of the hospital

- May require one-to-one supervision and assistance throughout the day

Special considerations for confused and agitated patients: environment

- Initially interventions should be performed in a closed environment with limited distractions

- Progress to more open environment to challenge patient as he/she improves