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What does the Glasgow Coma Scale measure?
level of initial injury in relation to the neurological severity caused to the brain
What are the levels of the GCS?
What are the categories that determine GCS?
- best motor response
- best verbal response
- best eye opening response
What are the scores for best motor response?
- 6-Obeys commands
- 5-Localizes stimulus
- 4-w/draws from stimulus
- 3-flexes arm
- 2-extends arm
- 1-no response
What are the scores for best verbal response?
- 4-conversant, but confused
- 3-states recognizable words or phrases
- 2-makes unintelligible sounds
- 1-no response
What are the scores for best eye opening response?
- 4-eyes open spontaneously
- 3-eyes open to voice
- 2-eyes open to painful stimulus
- 1-remain closed
What GCS levels result in mild brain injury?
Mild Brain Injury:
- loss of consciousness if very brief, usually a few seconds or minutes or does not occur at all
- dazed and confused
- testing or scans of the brain may appear normal
- diagnosed only when there is a change in the mental status at the time of injury -- person is dazed, confused, or loses consciousness
Mild brain injury symptoms:
- headache, fatigue, sleep disturbance
- irritability, sensitivity to noise/light, balance problems
- decreased concentration and attention span
- decreased speed of thinking and memory
- nausea, depression, and anxiety
- emotional mood swings
- can be debilitating, confusing to family as they are thinking, brain injury is mild
Which GCS are considered moderate brain injury?
Moderate brain injury:
- loss of consciousness lasts from a few minutes to a few hours
- confusion lasts from days to weeks
- 60% make good recovery
- 25% left w/ moderate degree of disability
- physical, cognitive, and/or behavioral impairments last for months or are permanent
Which GCS levels are considered severe brain injury?
8 or less
Severe brain injury:
- occurs when prolonged unconscious state or coma lasts days, weeks, or months
- further categorized into subgroups w/ separate features
What are the subgroups of severe brain injury?
- vegetative state
- persistent vegetative state (PVS)
- minimally responsive state
- akinetic mutism
- locked-in syndrome
- brain death
- state of unconsciousness from which the individual can't be awakened, in which the individual responds minimally or not at all to stimuli, and initiates no voluntary activites
- persons appear to be asleep, but can't be awakened
- there is no meaningful response to stimulation
arousal is present, but the ability to interact w/ the environment is not
What is eye opening like in vegetative state?
can be spontaneous or in response to stimuli
What is response to pain in vegetative state?
general responses to pain exist, such as increased HR, increased respiration, posturing, or sweating
What functions return in vegetative state?
- sleep-wake cycles
- respiratory functions
- digestive functions
What test diagnoses vegetative state?
there is no test, the diagnosis is made only by repetitive neurobehavioral assessments
Persistent vegetative state (PVS)
- vegetative state that has lasted for more than a month
- criteria same as vegetative state
Minimally responsive state:
- no longer in a coma or vegetative state
- demonstrates primitive reflexes; inconsistent ability to follow simple commands; awareness of environmental stimulation
- brief head turn to noise/voices; notices lights, TV on/off
- neurobehavioral condition that results when the dopaminergic pathways in the brain are damaged resulting in
- -minimal amount of body movement
- -little or no spontaneous speech
- -speech which can be elicited
- -eye opening and visual tracking
- -infrequent and incomplete ability to follow commands
How is akinetic mutism different from minimal responsive state?
b/c the lack of movement and speech w/ akinetic mutism is not b/c of neuromuscular disturbance
- brain shows no sign of functioning
- physician performs specific formula brain death exam
- families must be asked for organ donation at this stage; high grief while making this decision
- pre-injury characteristics (past med history, psychological conditions, social status, economic status)
- age (plasticity is improved in younger clients)
- severity of brain injury (site of lesion, mechanism of injury, secondary damage)
- severity of other injuries
- medical complications
- length of time b/w injury and initiation of rehab
- duration of coma
At how many days of coma does it predict poor functional outcome?
more than 20 days
Models of Care:
- acute medical rehab
- community integrated rehab
- adapted lifestyle sustaining services