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Glasgow Coma ScaleGlasgow Coma ScalePresented by: Jay Wuerker, EMTPresented by: Jay Wuerker, EMT--PP

EMS Instructor IIEMS Instructor IIEMS Instructor IIEMS Instructor II

This presentation made possible by:This presentation made possible by:Suzanne Martens, M.D. and the Southeastern Suzanne Martens, M.D. and the Southeastern Regional Trauma Advisory Council (SERTAC)Regional Trauma Advisory Council (SERTAC)

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Trauma ReviewTrauma Review

GCSGCS

GCSGCS

Glasgow Coma Scale / ScoreGlasgow Coma Scale / ScorePredictive of head injury outcomesPredictive of head injury outcomes3 categories3 categories

––MotorMotor––VerbalVerbal

E e OpeningE e Opening––Eye OpeningEye OpeningScore 15[alert] Score 15[alert] -- 3[unresponsive]3[unresponsive]

“Even a tree gets a 3”“Even a tree gets a 3”

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GCSGCS

GCS range 15 GCS range 15 –– 3 3 Record BEST effortRecord BEST effortRepeat score prior to ED arrivalRepeat score prior to ED arrival

MotorMotor VerbalVerbal Eye OpeningEye OpeningObeysObeys 66LocalizesLocalizes 55 OrientedOriented 55LocalizesLocalizes 55 OrientedOriented 55WithdrawsWithdraws 44 ConfusedConfused 44 SpontaneousSpontaneous 44FlexionFlexion 33 InappropriateInappropriate 33 VerbalVerbal 33ExtensionExtension 22 IncoherentIncoherent 22 PhysicalPhysical 22NoneNone 11 NoneNone 11 NoneNone 11

Adult Score Pediatric

Eye Opening Spontaneous 4 Spontaneous

To voice 3 To voice

To pain 2 To pain

None 1 None

Verbal Response Oriented 5 Appropriate/babbles

Confused 4 Cries but consolable

Inappropriate words 3 Persistent crying/screaming

Incoherent words 2 Grunting/moaning with pain

None 1 None

Motor Response Follows commands 6 Follows/spontaneous

Localizes to pain 5 Localizes to pain

Withdraws to pain 4 Withdraws to pain

Flexion posturing 3 Flexion posturing

Extension posturing 2 Extension posturing

None 1 None

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GCSGCS

1515--13: Mild Traumatic Brain Injury13: Mild Traumatic Brain Injury1212--9: Moderate TBI9: Moderate TBI88--3: Severe TBI = Coma3: Severe TBI = Coma

GCS vs. OutcomesGCS vs. Outcomes

GCS TBI “Good”Outcome

AnyDisability

ModerateDisability

SevereDisability

Death

15-13 Mild 99%

12-9 Moderate

8-3 Severe 14%35%

75% 85% “Mostsurvivors”

41%60% adults

Various answers from various studiesVarious answers from various studies In one study In one study allall patients who presented to patients who presented to

the ED with a GCS of 3 and fixed and the ED with a GCS of 3 and fixed and dilated pupils died dilated pupils died

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GCS vs. Admission vs. DeathGCS vs. Admission vs. Death

Death

Neuro Exam ShortcutNeuro Exam Shortcut

“Stick out your finger “Stick out your finger and touch your nose”and touch your nose”

Transporting agencies still need to Transporting agencies still need to document GCS in their reportdocument GCS in their report

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GCS?GCS?

MotorMotor–– Purposeful: 6Purposeful: 6Purposeful: 6Purposeful: 6

VerbalVerbal–– Nml? 5Nml? 5–– Confused? 4Confused? 4–– Mumbling? 3Mumbling? 3

EyesEyesLikely open if Likely open if –– Likely open if Likely open if fighting: 4fighting: 4

1515--1313 Mild TBIMild TBI

GCS?GCS?

MotorMotor–– Pain? 4Pain? 4–– Posturing?Posturing?–– None? 1None? 1

VerbalVerbal–– Mumbling? 3Mumbling? 3–– Moaning? 2Moaning? 2–– None? 1None? 1

EyesEyesPain? 2Pain? 2–– Pain? 2Pain? 2

–– None? 1None? 1 99--33 TBI? TBI? Or drunk?Or drunk?

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GCS?GCS?

MotorMotor–– Posturing:Posturing:Posturing:Posturing:–– Decorticate 3Decorticate 3–– Decerebrate 2Decerebrate 2

VerbalVerbal–– Moaning 2Moaning 2–– None 1None 1

EyesEyes EyesEyes–– None 1None 1

55--44 Severe TBISevere TBI

GCSGCS

GCS range 15 GCS range 15 –– 3 3 Record BEST effortRecord BEST effortRepeat score prior to ED arrivalRepeat score prior to ED arrival

MotorMotor VerbalVerbal Eye OpeningEye OpeningObeysObeys 66LocalizesLocalizes 55 OrientedOriented 55LocalizesLocalizes 55 OrientedOriented 55WithdrawsWithdraws 44 ConfusedConfused 44 SpontaneousSpontaneous 44FlexionFlexion 33 InappropriateInappropriate 33 VerbalVerbal 33ExtensionExtension 22 IncoherentIncoherent 22 PhysicalPhysical 22NoneNone 11 NoneNone 11 NoneNone 11

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BANG YOUR HEADBANG YOUR HEAD

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JEMS QuizJEMS Quiz

CONCUSSION & CONCUSSION & SECOND IMPACTSECOND IMPACTSECOND IMPACT SECOND IMPACT SYNDROMESYNDROME

How EMS providers How EMS providers should treat & protect should treat & protect their patientstheir patients

Concussion and Concussion and Traumatic BrainTraumatic BrainTraumatic BrainTraumatic Brain

Injury (TBI)Injury (TBI)

What is it?What is it?

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A concussion is a traumatic brain injury A concussion is a traumatic brain injury that alters the way your brain functionsthat alters the way your brain functionsy yy y

Usually temporaryUsually temporary

Problems with headache, concentration, Problems with headache, concentration, memory, judgment, balance and coordinationmemory, judgment, balance and coordination

Concussion may also be caused by the head Concussion may also be caused by the head and upper body being violently shakenand upper body being violently shakenand upper body being violently shakenand upper body being violently shaken

Concussion may cause loss of consciousness, Concussion may cause loss of consciousness, but most do not; some people have a but most do not; some people have a concussion and don’t realize itconcussion and don’t realize it

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Leading Causes of TBI

Falls 40.5%Children age 0 to 14 55%Children age 0 to 14 55%

Adults over age 65 81%

Unknown/Other 19.0%

Struck by/against 15.5%

Motor vehicle traffic 14.3%

Assaults 10.7%

Common in contact sports:Common in contact sports: Every concussion injures your brain to some extent Every concussion injures your brain to some extent

( h ll l l l) d d i d h l( h ll l l l) d d i d h l(on the cellular level), and needs time to rest and heal(on the cellular level), and needs time to rest and heal

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Symptoms of a ConcussionSymptoms of a Concussion ––may be subtlemay be subtle

Headache or feeling of pressure in the headHeadache or feeling of pressure in the head

AmnesiaAmnesia doesn’t remember the event that caused thedoesn’t remember the event that caused the Amnesia Amnesia –– doesn t remember the event that caused the doesn t remember the event that caused the symptomssymptoms

Confusion Confusion –– “in a fog”“in a fog”

Temporary loss of consciousnessTemporary loss of consciousness

Dizzy Dizzy –– “seeing stars”“seeing stars”

Nausea or vomitingNausea or vomiting

Ringing in the earsRinging in the ears

Slurred speechSlurred speech

FatigueFatigue

Symptoms may last for days, weeks or longerSymptoms may last for days, weeks or longer

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Additional, Immediate or Additional, Immediate or Delayed SymptomsDelayed Symptoms

Concentration and memory problemsConcentration and memory problems Concentration and memory problemsConcentration and memory problems

Personality changes Personality changes –– irritabilityirritability

Sensitivity to light and noiseSensitivity to light and noise

Sleep disturbancesSleep disturbances

Problems with smell and tasteProblems with smell and taste

DepressionDepression

Medical Care for Concussions is Medical Care for Concussions is Needed if:Needed if:

Loss of consciousness for more than 1 minuteLoss of consciousness for more than 1 minute Loss of consciousness for more than 1 minuteLoss of consciousness for more than 1 minute

Repeated vomitingRepeated vomiting

SeizuresSeizures

Obvious problems with physical coordination Obvious problems with physical coordination and mental functionsand mental functions

S t th t tiS t th t ti Symptoms that worsen over timeSymptoms that worsen over time

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Athletes or Those in SportsAthletes or Those in Sports

Should not return to play while signs or Should not return to play while signs or symptoms are presentsymptoms are present

Should seek medical evaluation before returningShould seek medical evaluation before returning

Risk Factors for Concussion:Risk Factors for Concussion:

Participation in contact sports without proper Participation in contact sports without proper safety equipment and supervisionsafety equipment and supervisionsafety equipment and supervisionsafety equipment and supervision

MVAMVA

Soldier in combatSoldier in combat

Physical abusePhysical abuse

Falls Falls –– very young and older adultsvery young and older adults

Previous concussionPrevious concussion

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Complications of ConcussionsComplications of Concussions

Epilepsy:Epilepsy:Two times the risk of developing epilepsy within 5Two times the risk of developing epilepsy within 5 Two times the risk of developing epilepsy within 5 Two times the risk of developing epilepsy within 5 years of the injuryyears of the injury

Cumulative effects of multiple concussions leading to Cumulative effects of multiple concussions leading to lasting cognitive impairment (i.e., boxers, football lasting cognitive impairment (i.e., boxers, football players)players)

Second Impact SyndromeSecond Impact SyndromeSecond Impact SyndromeSecond Impact Syndrome

What is it?What is it?

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Second impact syndrome refers to:Second impact syndrome refers to:

A.A. The repeated brain impacts that occur when The repeated brain impacts that occur when the head forcefully strikes a stationary objectthe head forcefully strikes a stationary objectthe head forcefully strikes a stationary objectthe head forcefully strikes a stationary object

B.B. A second brain injury occurring before the A second brain injury occurring before the patient has recovered from a first injurypatient has recovered from a first injury

C.C. The coup and The coup and contrecoupcontrecoup injuries that occur injuries that occur during brain traumaduring brain trauma

D.D. A secondary injury to the brain from brainA secondary injury to the brain from brainD.D. A secondary injury to the brain from brain A secondary injury to the brain from brain swelling after traumaswelling after trauma

Which of the following is not a Which of the following is not a structure in the brainstem?structure in the brainstem?

a. medulla oblongataa. medulla oblongata

b. ponsb. pons

c. diencephalonc. diencephalon

d. midbraind. midbrain

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Which of the following structures Which of the following structures control heart rate and breathing?control heart rate and breathing?

a. medulla oblongataa. medulla oblongata

b. ponsb. pons

c. diencephalonc. diencephalon

d. midbraind. midbrain

The hypothalamus is responsible The hypothalamus is responsible for maintaining:for maintaining:a. body temperaturea. body temperature

b. reflexive eye movementb. reflexive eye movement

c. involuntary smooth muscle movementc. involuntary smooth muscle movement

d. respiratory rated. respiratory rate

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Damage to the frontal lobe could Damage to the frontal lobe could result in:result in:a. inability to concentrate a. inability to concentrate

b. double visionb. double vision

c. hearing problems c. hearing problems

d. disorientation of spaced. disorientation of space

A patient with expressive A patient with expressive aphasia most likely has damage aphasia most likely has damage to which lobe?to which lobe?

a. frontal a. frontal

b. parietalb. parietal

c. temporal c. temporal

d i i ld i i ld. occipitald. occipital

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What mechanism of injury causes What mechanism of injury causes most mild traumatic brain Injuries?most mild traumatic brain Injuries?

a. blunt traumaa. blunt trauma

b. whiplash injuriesb. whiplash injuries

c. penetrating traumac. penetrating trauma

d. gunshot woundsd. gunshot wounds

Which of the following GCS scores best Which of the following GCS scores best represents a patient with a mild traumatic represents a patient with a mild traumatic brain injury?brain injury?

44a. 4 a. 4

b. 6b. 6

c. 12 c. 12

d. 14d. 14

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Leakage of cerebrospinal fluid from Leakage of cerebrospinal fluid from the ears following head trauma may the ears following head trauma may indicate:indicate:

a. basilar skull fracture a. basilar skull fracture

b. severe brain injuryb. severe brain injury

c. concussion c. concussion

d d id d id. ruptured meningesd. ruptured meninges

Pupillary changes following brain Pupillary changes following brain trauma may indicate:trauma may indicate:

a. basilar skull fracture a. basilar skull fracture

b. mild brain injuryb. mild brain injury

c. ruptured meninges c. ruptured meninges

d. brain swellingd. brain swelling

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Following brain trauma your patient Following brain trauma your patient is agitated and has no emotional is agitated and has no emotional control. control. You suspect injury to the:You suspect injury to the:You suspect injury to the:You suspect injury to the:

a. limbic system a. limbic system

b. basal gangliab. basal ganglia

c. hypothalamus c. hypothalamus ypyp

d. ponsd. pons

Obvious injury above the level of the Obvious injury above the level of the clavicles should prompt you to clavicles should prompt you to consider:consider:

a. endotracheal intubation a. endotracheal intubation

b. spinal immobilizationb. spinal immobilization

c. emergent transport c. emergent transport

d. fluid bolusd. fluid bolus

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Which of the following is true of mild Which of the following is true of mild TBI?TBI?

a.a. Plain XPlain X--rays can rule out significant brain rays can rule out significant brain tttrauma.trauma.

b.b. Surgery will often correct mild traumatic Surgery will often correct mild traumatic brain injury.brain injury.

c.c. About 8% of mild TB1 patients will suffer About 8% of mild TB1 patients will suffer longlong--term consequencesterm consequenceslonglong--term consequences.term consequences.

d.d. Patients with a GCS score of 8Patients with a GCS score of 8--10 rarely 10 rarely have serious longhave serious long--term problems.term problems.

Questions on the Quiz?Questions on the Quiz?

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New Imaging Technique

High-definition fiber tracking – Uses hi ti t d t l ith tsophisticated computer algorithms to

produce yellow, green and purple images of fibers that show breaks or damage to the cells.

Normal MRI’s or CT don’t show theNormal MRI s or CT don t show the damage.

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Fiber Tracking Video

New Brain Imaging Technique Reveals D C d b TBIDamage Caused by TBI

http://youtu.be/AvyVRQcHoyQ

Hyperbaric Oxygen Therapy

Military TBI victims say HBOT helps them li b tt lilive better lives.

Same treatment that is used for Diving injuries, CO poisoning, burns and other soft tissue injuries.

Air Force and Army study underway Air Force and Army study underway.

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Other Treatment

Wounded-warrior programs at Camp L J NC d C P dl t CALeJeune NC and Camp Pendleton CA

Music

DoD $19.5 million contract to Abbott Labs on August 13, 2014 to develop a kit to test for two proteins found in the blood after afor two proteins found in the blood after a blow to the head.

2011 Wisconsin Act 172

Concussion and Head Injury in “Youth thl ti ti it ”athletic activity”

Coach, athletic official or health care provider must remove a person who exhibits signs of a head injury from a youth athletic activity.athletic activity.

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GCS ReviewGCS Review

GCSGCS

Glasgow Coma Scale / ScoreGlasgow Coma Scale / Score

Predictive of head injury outcomesPredictive of head injury outcomes

3 categories3 categories MotorMotor

VerbalVerbal

E e OpeningE e Opening Eye OpeningEye Opening

Score 15[alert] Score 15[alert] -- 3[unresponsive]3[unresponsive]“Even a tree gets a 3”“Even a tree gets a 3”

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GCSGCS

GCS range 15 GCS range 15 –– 3 3

Record BEST effortRecord BEST effort

Repeat score prior to ED arrivalRepeat score prior to ED arrivalMotorMotor VerbalVerbal Eye OpeningEye Opening

ObeysObeys 66

LocalizesLocalizes 55 OrientedOriented 55LocalizesLocalizes 55 OrientedOriented 55

WithdrawsWithdraws 44 ConfusedConfused 44 SpontaneousSpontaneous 44

FlexionFlexion 33 InappropriateInappropriate 33 VerbalVerbal 33

ExtensionExtension 22 IncoherentIncoherent 22 PhysicalPhysical 22

NoneNone 11 NoneNone 11 NoneNone 11

Adult Score Pediatric

Eye Opening Spontaneous 4 Spontaneous

To voice 3 To voice

To pain 2 To pain

None 1 None

Verbal Response Oriented 5 Appropriate/babbles

Confused 4 Cries but consolable

Inappropriate words 3 Persistent crying/screaming

Incoherent words 2 Grunting/moaning with pain

None 1 None

Motor Response Follows commands 6 Follows/spontaneous

Localizes to pain 5 Localizes to pain

Withdraws to pain 4 Withdraws to pain

Flexion posturing 3 Flexion posturing

Extension posturing 2 Extension posturing

None 1 None

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GCSGCS

1515--13: Mild Traumatic Brain Injury13: Mild Traumatic Brain Injury

1212--9: Moderate TBI9: Moderate TBI

88--3: Severe TBI = Coma3: Severe TBI = Coma

Helicopter criteria sustained GCS <14Helicopter criteria sustained GCS <14 Not a transient LOC from standing level fall or Not a transient LOC from standing level fall or

sports injury; that is a concussionsports injury; that is a concussion

GCS?GCS?

MotorMotor Posturing:Posturing: Posturing:Posturing:

Decorticate 3Decorticate 3

Decerebrate 2Decerebrate 2

VerbalVerbal Moaning 2Moaning 2

None 1None 1

EyesEyes EyesEyes None 1None 1

55--44

Severe TBI Severe TBI

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GCS?GCS?

MotorMotor Purposeful: 6Purposeful: 6 Purposeful: 6Purposeful: 6

VerbalVerbal Nml? 5Nml? 5

Confused? 4Confused? 4

Mumbling? 3Mumbling? 3

EyesEyesLikely open ifLikely open if Likely open if Likely open if fighting: 4fighting: 4

1515--1313

Mild TBIMild TBI

GCS?GCS?

MotorMotor Pain? 4Pain? 4 Posturing?Posturing? None? 1None? 1

VerbalVerbal Mumbling? 3Mumbling? 3 Moaning? 2Moaning? 2 None? 1None? 1

EyesEyesPain? 2Pain? 2 Pain? 2Pain? 2

None? 1None? 1

99--33 TBI? TBI? Or drunk?Or drunk?

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GCSGCS

GCS range 15 GCS range 15 –– 3 3

Record BEST effortRecord BEST effort

Repeat score prior to ED arrivalRepeat score prior to ED arrivalMotorMotor VerbalVerbal Eye OpeningEye Opening

ObeysObeys 66

LocalizesLocalizes 55 OrientedOriented 55LocalizesLocalizes 55 OrientedOriented 55

WithdrawsWithdraws 44 ConfusedConfused 44 SpontaneousSpontaneous 44

FlexionFlexion 33 InappropriateInappropriate 33 VerbalVerbal 33

ExtensionExtension 22 IncoherentIncoherent 22 PhysicalPhysical 22

NoneNone 11 NoneNone 11 NoneNone 11

Triaging a trauma patient?Triaging a trauma patient?

“Depressed or open skull fracture”“Depressed or open skull fracture”Depressed or open skull fractureDepressed or open skull fracture

An indication for trauma triage and An indication for trauma triage and helicopter transporthelicopter transport

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Open & Depressed Skull FractureOpen & Depressed Skull Fracture

Child struck Child struck b tb tby stone by stone thrown by thrown by lawnmowerlawnmower

Linear Skull FractureLinear Skull Fracture

BMX crash

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Fatal MCCFatal MCC

Open or Depressed Skull Open or Depressed Skull FractureFracture

Brain surface with skull removed

and dura mater reflected

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Scalp HematomaScalp Hematoma

S S ---- Skin Skin S S ---- Skin Skin

C C ---- dense Connective tissuedense Connective tissue

A A ---- Aponeurosis (Galea)Aponeurosis (Galea)

L L ---- Loose connective tissueLoose connective tissue

P P ---- PeriosteumPeriosteum

C C ---- dense Connective tissuedense Connective tissue

A A ---- Aponeurosis (Galea)Aponeurosis (Galea)

L L ---- Loose connective tissueLoose connective tissue

P P ---- PeriosteumPeriosteum

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Scalp HematomaScalp Hematoma

GCS Helicopter IndicationGCS Helicopter Indication•• GCS GCS less thanless than 1414

2 point deficit2 point deficit

NOT i LOCNOT i LOC•• NOT transient LOCNOT transient LOC•• NOT transient confusionNOT transient confusion

MotorMotor VerbalVerbal Eye OpeningEye Opening

ObeysObeys 66

LocalizesLocalizes 55 OrientedOriented 55

WithdrawsWithdraws 44 ConfusedConfused 44 SpontaneousSpontaneous 44

FlexionFlexion 33 InappropriateInappropriate 33 VerbalVerbal 33

ExtensionExtension 22 IncoherentIncoherent 22 PhysicalPhysical 22

NoneNone 11 NoneNone 11 NoneNone 11

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Adult Score Pediatric

Eye Opening Spontaneous 4 Spontaneous

To voice 3 To voice

To pain 2 To pain

None 1 None

Verbal Response Oriented 5 Appropriate/babbles

Confused 4 Cries but consolable

Inappropriate words 3 Persistent crying/screaming

Incoherent words 2 Grunting/moaning with pain

None 1 None

Motor Response Follows commands 6 Follows/spontaneous

Localizes to pain 5 Localizes to pain

Withdraws to pain 4 Withdraws to pain

Flexion posturing 3 Flexion posturing

Extension posturing 2 Extension posturing

None 1 None

Glasgow Coma Scale• GCS range 15 – 3

• Record BEST effort

• Repeat score prior to ED arrival

Motor Verbal Eye Opening

Obeys 6

Localizes 5 Oriented 5

Withdraws 4 Confused 4 Spontaneous 4

Flexion 3 Inappropriate 3 Verbal 3

Extension 2 Incoherent 2 Physical 2

None 1 None 1 None 1

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For more information

• www.cdc.gov/traumatic brain injury/

• Internet search engine: Concussion and Traumatic Brain Injury (TBI)

• Heads Up App. For the iPhone or Android App on Google play

Random Thoughts

• The early bird may get the worm,

BUT

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• The second mouse gets the cheese!