Problems With Initial Glasgow Coma Scale Assessment Caused by Prehospital Treatment of Patients With Head Injuries

The rapid treatment of patients with a severe head injury often includes prehospital intubation and sedation, but such measures compromise the ability to obtain an accurate Glasgow Coma Scale (GCS) score in the emergency department (ED). Major head injury centers in the United States were surveyed to determine how they currently obtain initial GCS scores when these or other complicating circumstances exist. A two-page questionnaire was distributed to seven members of the trauma team at 17 major neurotrauma centers in which they were asked who usually determines the initial GCS scores, where they are assessed, and when. Respondents were also asked how they assign scores for patients who received medications or were intubated before arrival at their hospital and how they score patients who are hypotensive, hypoxic, or have severe periorbital swelling. Most centers assess the initial GCS scores in their ED within 1 hour after the discovery of the patient by prehospital personnel. Most neurosurgeons said that hypotension and hypoxia are stabilized before the initial GCS scores are assessed and that intubated patients receive a non-numerical designation. But the majority of non-neurosurgical ED personnel said that they determine the initial GCS scores immediately after arrival of the patients in their department, regardless of hypoxia or hypotension. There also were significant discrepancies between attending neurosurgeons and their residents with regard to who actually assesses the GCS scores and how the scores are determined for patients who have received neuromuscular paralysis or sedation or who have severe periorbital swelling. In addition, 20% of attending neurosurgeons and 24% of non-neurosurgical ED personnel reported using the worst, rather than the best, GCS sum score when motor or eye-opening abilities are asymmetrical. This survey revealed important inter-center and intra-center differences of opinion regarding how the initial GCS scores are obtained. Such differences make it difficult to interpret the results of head injury studies that use the initial GCS scores to describe injury severity. The results of this survey emphasize the need for nationally recognized policies for determining the initial GCS scores that account for contemporary prehospital management of patients with severe head injuries.