GCS Scoring System

Question 1

Motor?

Answer 1

Motor Response (M) 6—obeys commands 5—localizes painful stimulus 4—withdraws from pain 3—decorticate posture 2—decerebrate posture 1—no movement (Think: 6-cylinder motor)

Question 2

Verbal?

Answer 2

Verbal Response (V) 5—appropriate and oriented 4—confused 3—inappropriate words 2—incomprehensible sounds 1—no sounds (Think: Jackson 5 = verbal 5)

Question 3

What indicates coma by GCS score?

Answer 3

<8 (Think: “less than eight—it may be too late”)

Question 4

What does unilateral, dilated, nonreactive pupil suggest?

Answer 4

Focal mass lesion with ipsilateral herniation and compression of CN III

Question 5

What do bilateral fixed and dilated pupils suggest?

Answer 5

Diffusely increased ICP

Question 6

What are the four signs of basilar skull fracture?

Answer 6

1. Raccoon eyes—periorbital ecchymoses 2. Battle’s sign—postauricular ecchymoses 3. Hemotympanum 4. CSF rhinorrhea/otorrhea

Question 7

What is the initial radiographic neuroimaging in trauma?

Answer 7

1. Head CT scan (if LOC or GCS 15) 2. C-spine CT 3. T/L spine AP and lateral

Question 8

Should the trauma head CT scan be with or without IV contrast?

Answer 8

Without!

Question 9

What is normal ICP?

Answer 9

5 to 15 mm H2O

Question 10

What is the worrisome ICP?

Answer 10

>20 mm H2O

Question 11

What determines ICP (Monroe-Kelly hypothesis)?

Answer 11

1. Volume of brain 2. Volume of blood 3. Volume of CSF

Question 12

What is the CPP?

Answer 12

Cerebral Perfusion Pressure mean arterial pressure—ICP (normal CPP is >70)

Question 13

What is Cushing’s reflex?

Answer 13

Physiologic response to increased ICP: 1. Hypertension 2. Bradycardia 3. Decreased RR

Question 14

What are the three general indications to monitor ICP after trauma?

Answer 14

1. GCS <9 2. Altered level of consciousness or unconsciousness with multiple system trauma 3. Decreased consciousness with focal neurologic examination abnormality

Question 15

What is Kocher’s point?

Answer 15

Landmark for placement of ICP monitor bolt:

Question 16

What nonoperative techniques are used to decrease ICP?

Answer 16

1. Elevate head of bed (HOB) 30 (if spine cleared) 2. Diuresis-mannitol (osmotic diuretic), Lasix®, limit fluids 3. Intubation (PCO2 control) 4. Sedation 5. Pharmacologic paralysis 6. Ventriculostomy (CSF drainage)

Question 17

What is the acronym for the treatment of elevated ICP?

Answer 17

“ICP HEAD”:

INTUBATE

CALM (sedate)

PLACE DRAIN (ventriculostomy)/ PARALYSIS

HYPERVENTILATE TO PCO2 35

ELEVATE head

ADEQUATE BLOOD PRESSURE (CPP >70)

DIURETIC (e.g., mannitol)

Question 18

Can a tight c-collar increase the ICP?

Answer 18

Yes (it blocks venous drainage from brain!)

Question 19

Why is prolonged hyperventilation dangerous?

Answer 19

It may result in severe vasoconstriction and ischemic brain necrosis! Use only for very brief periods

Question 20

What is a Kjellberg? (pronounced “shellberg”)

Answer 20

Decompressive bifrontal craniectomy with removal of frontal bone frozen for possible later replacement

Question 21

How does cranial nerve examination localize the injury in a comatose patient?

Answer 21

CNs proceed caudally in the brain stem as numbered: Presence of corneal reflex (CN 5 + 7) indicates intact pons; intact gag reflex (CN 9 + 10) shows functioning upper medulla (Note: CN 6 palsy is often a false localizing sign)

Question 22

What is acute treatment of seizures after head trauma?

Answer 22

Benzodiazepines (Ativan®)

Question 23

What is seizure prophylaxis after severe head injury?

Answer 23

Give phenytoin for 7 days

Question 24

What is the significance of hyponatremia (low sodium level) after head injury?

Answer 24

SIADH must be ruled out; remember, SIADH = Sodium Is Always Down Here