Glasgow Coma Scale and Clinical Diagnosis of Death

Question 1

What is the GCS?

Answer 1

Developed in 1974 to describe general Level of Consciousness in Traumatic Brain Injury – TBI

Question 2

Interpretation of GCS scoring?

Classify according to mild, moderate and severe injury
Best and lowest

Answer 2

Best score 15/15
Lowest score 3/15 – no response to pain, no verbalization, no eye opening
<8 is severe injury
9 – 12 moderate injury
>13 minor injury

Question 3

Scoring of eyes?

Answer 3

1 - no eye opening
2 - eyes open to painful stimulus
3 - opens eyes to voice
4 - spontaneously opens eyes

Question 4

How to score eyes opening to voice when a person is sleeping?

Answer 4

not to be confused with the awakening of a sleeping person; such patients receive a score of 4, not 3

Question 5

Where to initiate painful stimulus for eye opening?

Answer 5

a peripheral pain stimulus, such as squeezing the lunula area of the patient’s fingernail
Note: is more effective than a central stimulus such as a trapezius squeeze, due to a grimacing effect

Question 6

Scoring for voice?

Answer 6

1 - no speech
2 - incoherent speech
3 - inappropriate words
4 - confused
5 - oriented to time, place and person

Question 7

How is a patient ‘oriented’ in terms of verbal response?

Answer 7

patient responds coherently and appropriately to questions such as the patient’s name and age, where they are and why, the year, month

Question 8

How is a patient ‘confused’ in terms of verbal response?

Answer 8

the patient responds to questions coherently but there is some disorientation and confusion

Question 9

How does the patient exhibit ‘inappropriate words’ in terms of verbal response?

Answer 9

random or exclamatory articulated speech, but no conversational exchange

Question 10

How does a patient exhibit ‘incomprehensible sounds’ in terms of verbal response?

Answer 10

moaning but no words

Question 11

Scoring for motor?

Answer 11

1 - no movement
2 - extending decerebrate
3 - flexing decorticate
4 - withdraws from painful stimulus
5 - localises to painful stimulus
6 - obeys commands

Question 12

How does the patient obey commands in motor response?

Answer 12

the patient does simple things as asked, e.g. stick out tongue or move toes

Question 13

How does a patient ‘localize to pain’ in terms of motor response?

Answer 13

Purposeful movements towards painful stimuli
e.g. hand crosses mid-line and gets above clavicle when supra-orbital pressure applied

Question 14

How does a patient ‘flex/withdraw from painful stimuli’ in terms of motor response?

Answer 14

1. flexion of elbow, supination of forearm, flexion of wrist when supra-orbital pressure applied
2. pulls part of body away when nailbed pinched

Question 15

How does a patient ‘flex abnormally to pain’ in terms of motor response?

Answer 15

flexor posturing:
adduction of arm, internal rotation of shoulder, pronation of forearm, flexion of wrist
- decorticate response

Question 16

How does a patient ‘extend abnormally to pain’ in terms of motor response?

Answer 16

extensor posturing
abduction of arm, external rotation of shoulder, supination of forearm, extension of wrist
- decerebrate response

Question 17

Strengths of GCS?

Answer 17

1. Simple and standardized to detect changes in level of consciousness
2. Quick, easy, objective and accurate
3. Numerical, easy to chart and analyze
4. Reduces observer variability
5. Reliable
6. Helps make management decisions
7. Predicts outcome

Question 18

Weaknesses of GCS?

Answer 18

1. Localized injury – limb, eye etc. would make it difficult to score some parameters
2. Numerically skewed to motor responses
3. Children below 36 months can not be assessed
4. Intubated patients - cant score verbal

Question 19

Clinical diagnosis of death?

Answer 19

1. Absent brain function – control centre of body system functions
2. Heartbeat may still continue
3. Absent Respiratory and circulatory system functions

Question 20

Organic causes responsible for absent brainstem functions?

Answer 20

coma and its causes:
1. sedation
2. hypothermia
3. drug intoxication
4. narcotic analgesics
5. neuromuscular blocking agents

Question 21

Signs of absent brainstem functions?

Answer 21

1. Mid position or fully dilated pupils
2. Absence of motor response to supraorbital pressure
3. 5 minutes apnoea test to demonstrate no spontaneous respiratory effort
4. Absent oculocephalic (“dolls eye”) movement
5. Absent caloric-induced eye (vestibulo-ocular) movement
6. Absent corneal, gag, suck, cough reflexes
7. Absent respiratory movement with apnea testing

Question 22

What is the 5 minute apnea test?

Answer 22

remove oxygen from the patient for 5 minutes
- CO2 accumulates and initiates breathing as a normal response

Question 23

What is the oculocephalic/dolls eye reflex?

Answer 23

a reflex eye movement that stabilizes images on the retina during head movement

Question 24

How to test the oculocephalic reflex?

Answer 24

1. ensure the C-spine is cleared
2. the patient’s eyes are held open
3. the head is briskly turned from side to side with the head held briefly at the end of each turn
4. the eyes move in the opposite direction of the head movement
5. the reflex is suppressed in conscious individuals with normal neurological function function
6. the reflex is active in comatose patients with gross brain function

Question 25

Interpretation of the oculocephalic reflex?

Answer 25

1. a positive response occurs when the eyes rotate to the opposite side to the direction of head rotation, thus indicating that the brainstem (CN3,6,8) is intact.
2. when the head is flexed and extended — a positive result is downward deviation of the eyes during extension, and upward deviation during flexion (the eyelids, if closed, may also open as part of the ‘doll’s head phenomenon’)
   - These vertical responses indicates that the brainstem (CN3,4,8) is intact.
3. The eyes should gradually return to the mid-position in a smooth, conjugate movement if the brainstem is intact.

Question 26

What is the oculovestibular reflex?

Answer 26

introduce iced water into the external ear canal and the eyes move towards that side

Question 27

Clinical signs of death?

Answer 27

1. Respiratory effort – no breathing
2. No Heart beat
3. Disability – no response to stimulus

Question 28

Stages of death?

Answer 28

1. Irreversible loss of respiratory function
2. Irreversible loss of circulatory function
3. Algor mortis (postmortem coldness)
4. Livor mortis (postmortem lividity)
5. Rigor mortis (postmortem rigidity)
6. Cadaveric spasm
7. Loss of muscle contraction
8. Putrefaction

Question 29

What is livor mortis?

Answer 29

the pooling of blood in the lower portion or dependent parts of the body after death
- this results in a dark purple discoloration of the skin
- begins 30 minutes after death

Question 30

What is rigor mortis?

Answer 30

stiffened muscles
- begins 2-4 hours after death

Question 31

What is cadaveric spasm?

Answer 31

instantaneous rigor - accelerated rigor mortis
- a rare condition in which extremely rapid muscle stiffening occurs after cardiac arrest in contrast to normal rigor that gradually occurs 3 - 6 hours after cardiac arrest

Question 32

What is putrefaction?

Answer 32

decay of organic matter by the action of microorganisms resulting in the production of a foul smell
- involves the decomposition of proteins, breakdown of tissues and liquefaction of the organs