Comparison of Neurological Assessment Tools Gcs Avpu and Four

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An assessment of the level of consciousness (LOC) should be carried out during the primary survey of all patients, using the ABCDE approach Cole (2009: 28). Any initial or subsequent reduction in the LOC of the patient may be caused by hypoxia; hypovolaemia; head injury; drug or medicine use; hypoglycaemia; hypothermia or alcohol ingestion (Cole, 2009:44).

An assessment of the LOC of the patient is vital for an accurate pain assessment and the administration of analgesia, and the subsequent assessment of its efficacy (Rose, et al. 2011). Regular evaluation of a patient’s LOC helps detect the onset of hypothermia and hypovolaemia. Muehlberger, et al. (2010) state that the development of pre-hospital hypothermia is a directly negative prognostic factor for burns patients.

The inclusion of LOC assessment for burns patients seems to be a recent development however, neither Allison & Porter (2004) nor Allison (2002) refer in any way to assessing a patient’s LOC in their work on standardising a pre-hospital approach to burns patient management.

A coma scale is a defined methodology by which neurological observations can be recorded in a standardised way by clinicians (Coyne, et al. 2010). Many different scales have been developed in an attempt to standardise the assessment of consciousness (Majerus, 2005).

In this essay I will discuss three main coma scales and examine their strengths and weaknesses. I will also briefly discuss a number of revisions to these scales.

Glasgow coma scale (GCS) and variations

The GCS is the most commonly used coma scale in the acute setting (Majerus, 2005) and its use is recommended by the National Institute for Health and Clinical Excellence (NICE, 2007). The scale was devised by Teasdale & Jennett based on their work in the neurosurgery department at the University of Glasgow. Their scale allows a clinician with minimal training to perform three basic assessments measuring the eye, verbal and motor



References: Allison, K. (2002) ‘The UK pre-hospital management of burns patients: current practice and the need for a standard approach’ Burns. 28 pp.135-142. Allison, K. & Porter, K. (2004) ‘Consensus on the pre-hospital approach to burns patient management’ Accident and Emergency Nursing. 12 pp.53-57. Gosseries, O. & Laureys, S. (2011) ‘Comparison of the Full Outline of Unresponsiveness and Glasgow Liege Scale/Glasgow Coma Scale in an Intensive Care Unit Population’ Neurocritical Care. 15 pp.447-453. Coyne, I., Neill, F. & Timmins, F. (2010) Clinical Skills in Children’s Nursing. Oxford: Oxford University Press. Iyer, V.N., Mandrekar, J.N., Danielson, R.D., Zubkov, A.Y., Elmer, J.L. & Wijdicks E.F.M. (2009) ‘Validity of the FOUR Score Coma Scale in the Medical Intensive Care Unit’ Mayo Clinical Proceedings. 84 (8) pp.694-701. Kelly, C.A., Upex, A. & Bateman, D.N. (2004) ‘Comparison of consciousness level assessment in the poisoned patient using the alert/verbal/painful/unresponsive scale and the Glasgow Coma Scale’ Annals of Emergency Medicine. 44 (2) pp.108-13. Kornbluth, J. & Bhardwaj, A. (2011) ‘Evaluation of Coma: A Critical Appraisal of Popular Scoring Systems’ Neurocritical Care. 14 pp.134-143. Laureys S., Piret S., Ledoux D. (2005) ‘Quantifying Consciousness’ The Lancet Neurology. 4 (12) pp.789-790. Majerus, S., Gill-Thwaites, H., Andrews, K., Laureys, S. (2005) ‘Behavioural evaluation of consciousness in severe brain damage’ In: Laureys, S Matis, G. & Birbilis, T. (2008) ‘The Glasgow Coma Scale – a brief review. Past, present, future’ Acta Neurologica Belgica. 108 (3) pp.75-89. McNarry, A.F. & Goldhill, D.R. (2004) ‘Bedside assessment of consciousness’ Anaesthesia. 59 pp.34-37. Morray, J.P., Tyler, D.C., Jones, T.K., Stuntz, J.T. & Lemire, R.J. (1984) ‘Coma scale for use in brain-injured children’ Critical Care Medicine. 12 (12) pp.1018-1022. Muehlberger, T., Ottomann, C., Toman, N., Daigeler, A. & Lehnhardt, M. (2010) ‘Emergency pre-hospital care of burns patients’ The Surgeon. 8 pp.101-104. National Institute for Health and Clinical Excellence (2007) Head Injury: Triage, assessment, investigation and early management of head injury in infants, children and adults. Clinical guideline 56. London: NICE. Palmer, R. & Knight, J. (2006) ‘Assessment of altered conscious level in clinical practice’ British Journal of Nursing. 15 (22) pp.1255-1259. Rawlins, J.M. (2011) ‘Management of burns’ Surgery. 29 (10) pp.523-528. Rowley, G. and Fielding, K. (1991) ‘Reliability and accuracy of the Glasgow Coma Scale with experienced and inexperienced users’ The Lancet. 337 pp.535–538. Teasdale, G. & Jennett, B. (1974) 'Assessment of coma and impaired consciousness: a practical scale ' The Lancet. 2 (7872) pp.81-84. Teasdale, G., Jennett, B., Murray, L. & Murray, G. (1983) ‘Glasgow Coma Scale: to sum or not to sum’ The Lancet. 2 (8341) p.678. Ward, J. D. (1996) ‘Paediatric Head Injury’ In: Narayan, R.K., Wilberger, J.E. Jr. & Povlishock, J. T. (eds.) Neurotrauma. New York: McGraw-Hill. pp.859-867. Wiejdicks, E. F., Bamlet, W. R., Maramatomm, B. V., Manno E. M. & McClelland R. L. (2005) ‘Validation of a new coma scale: the FOUR score’ Annals of Neurology. 58 pp.585-593. Wilson, E. & McCormack, J.G. (2012) ‘Trauma and burns in children’ Anaesthesia & Intensive Care Medicine. 13 (1) pp.31-36.

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