Glasgow Coma Scale is based on the clinical components of 3 Neurological functions:
Best motor response
Best verbal response
Glasgow coma scale allows
clinicians to rate the severity of injury and to monitor recovery
Glasgow Coma scales score is a summation of all three responses
A score of 8 or less defines a coma
Three functions are rated as follows:
1)Eye opening from none to spontaneous and response to speech or pain from 4 to 1
2)Motor response from 6 to 1
3)Verbal response form 5 to 1
4)Pts who score less than 4 usually die
Glasgow Coma Scale allows us a standard reference for
monitoring or assessing a pt. w/ confirmed or suspected brain injury.
One is able to monitor three human responses to stimuli eye opening, motor and verbal response.
Rancho Los Amigos Cognitive Scale (LOCF) developed
to describe the types of behaviors head injured patients exhibit
Eight levels that describe patient behavior range from
no response to purposeful and appropriate
Phase I: No Response
Pt. appears to be in a deep sleep and is complettely unresponsive to any stimuli.
Phase II: Generalized Response
Pt. reacts inconsistently and non-purposefully to stimuli i a nonspecific manner. Responses are limited and often the same regardless of stimulus presented. Responses may be phsiolgoical changes, gross body movements, and/or vocalization.
Phase III: Localized Response
Pt. reacts specifically but inconsistently to stimuli. Responses are directly related to the type of stimulus presented. May follow simple commands such as closing eyes or squeeszing hand in an inconsistent, delayed manner.
Phase IV: Confused-Agitated
Pt. is in a heightened state of activity. Behavior is bizarre and non-purposeful relative to immediate environment. Does not discrimintate among persons or objects; is unable to cooperate directly with treatment efforts. Verbalizations frequently are incoherent and/or inappropriate to the environment; confabulation may be present. Gross attention to environment is very brief; selective attention is often nonexistent. Patient lacks short- an long-term recall.
Phase V: Confused-Inappropriate
Pt. is able to respond tosimple commands fairly consistently. However, w/i increased complexity of commands or lack of any external structure, responses are non-purposeful, random, or fragmented. Demonstrates gross attention to the environment bu is highly distractible and lacks ability to focus attention on a specific task. With structure, may be able to converse of a social automatic level for short periods of time. Verbalization is often inappropriate and confabulatory. Memory is severly impaired; often shows inappropriate use of objects; may perform previously learned tasks w/ structure but is unable to learn new information.
Phase VI: Cnfused Appropriate
Patient shows goal-directed behavior but is dependent on external input or direction. Follows simple directions consistently and shows crryover for relearned tasks such as self-care. Responses may be incorrect due to memor problems, but they are appropriate to the situation. Past memories show more depth and detail than recent memory.
Phase VII: Automatic-Appropriate
Pt appears appropriate and oriented w/i the hospital and home settings; goes thought daily routine automatically, but frequently robot like. Pt. shows minimal to no confusion and has shallow recall of activities. Shows carryover for new learning but at a decreased rate. With structure is able to initiate social or recr eational activities; judgement remains impaired.
Pt. is able to recall and integrate past and recent events and is aware of and responsive to environment. Shows carryover for new learning and needs no supervision once activities are learned. Pt. may continue to show a decreased ability relateive to pre-morbid abilities, learned. Pt. may continue to show a decreased ability relative to pre-morbid abilities, abstract reasonin, tolerance for stress, and judgment in evergencies or unusual circumstances.
Posturing is typical of a severally head injured patient and is an important part of the initial evaluation. Two types are part of the evaluation process:
is noted when inhibition of the reticular formation and vestibular nuclei is lost, increasing extensor tone (brainstem damage)
All four limbs show some degree of increased extensor tone.
Full Decerebrate Posture
Shoulder internal rotation, extension and adduction
Wrist Flexion, pronation
LE's same as above
indicates damage to the corticospinal tract (the pathway between the brain and spinal cord).
Although a serious sign, it is usually more favorable than decerbrate posture.
Increased flxor tone isnoted in the UE's and extensor tone in the LE's.
Studies have shown that abnormal arm flexion means
a less serious prognoses than arm extension
Comatose pts w/ flexor responses in their arms have a
37% recovery rate
Comatose pts. w/ extensor responses in their arms have