ASSESSING THE MOTOR COMPONENT OF THE GCS SCORING SYSTEM AS A BETTER PREDICTOR OF OUTCOME

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1 ASSESSING THE MOTOR COMPONENT OF THE GCS SCORING SYSTEM AS A BETTER PREDICTOR OF OUTCOME Meyei S Appachi*1, Mahadevan D2, Eswaran VP3 ABSTRACT Background: Components of the Glasgow Coma Scale [GCS] alone are simpler and can predict outcome in TBI and acute stroke [AS]. Conclusions: The motor of GCS scoring system is a better predictor of 3 month outcome while the GCS in its summed form is a better indicator for requirement of endotracheal intubation in TBI and AS. Objectives: To assess whether motor of the GCS on initial presentation is enough as a better predictor of outcome and better indicator of endotracheal intubation [ETI] in patients with TBI and AS. Keywords: Acute Stroke, Endotracheal intubation, Glasgow coma scale, Outcome predictors, Traumatic brain injury. Methods: Patients aged above 14 years diagnosed of having TBI and AS presenting within 24 hours were included. Patient's arrival GCS in Emergency Room and GCS during ETI either on arrival or during course of hospital stay were recorded. The outcomes were determined in terms Glasgow Outcome Scale [GOS] at 3 months and requirement of ETI. The ability of total GCS and its Components to predict outcome using receiver operating characteristic [ROC] analysis was carried out. The Glasgow Coma Scale [GCS] also known as the Glasgow Coma Score is a neurological scale which aims to give a reliable, objective way of recording the conscious state of a person, for initial as well as continuing assessment (1). Teasdale and Jennett in 1974 wrote Impaired consciousness is an expression of dysfunction in the brain as a whole that may be due to agents acting diffusely... or to the combination of remote and local effects produced by brain damage which was initially focal (2). The GCS is typically praised for its ease of use and has been used to grade individual levels of consciousness, compare effectiveness of treatment, and as a prognostic indicator. Results: Of 375 patients, 68.8% were TBI and 31.2% were AS. 65.1% of all patients had a good outcome at 3 months and 45.1% was intubated. For outcome at 3 months, area under curve [AUC] was greatest for motor in all patients [0.937] as well as in TBI [0.959]. But in AS, AUC was greatest for total GCS [0.909] with similar magnitude for motor [0.908]. Among AS, AUC was greatest for motor in ischemic stroke [0.892] and greatest for total GCS [0.944] followed by motor [0.919] in haemorrhagic stroke. For requirement of ETI, AUC was greatest for total GCS in all patients [0.977], TBI [0.982] and AS [0.967]. Among AS, AUC was greatest for eye [0.969] in ischemic stroke and greatest for total GCS [0.981] in haemorrhagic stroke. INTRODUCTION GCS has enjoyed universal acceptance as an important standard tool for communication of mental status in both traumatized and non-traumatized patients, and in the care of trauma patients (3, 4). It is incorporated into many scoring systems due to the ease and appeal of the GCS. GCS is used as part of several intensive care unit [ICU] scoring systems, including Acute Physiology and Chronic Health Evaluation II [APACHE II], Simplified Acute Physiology Score II [SAPS II], and Sepsis-related Organ Failure Assessment [SOFA], to assess the status of the central nervous system and is a of the Trauma 1 Assistant Professor, Department of Accident, Emergency & Critical Care Medicine, Vinayaka Mission's Kirupananda Variyar Medical College & Hospitals, Vinayaka Mission University, Sankari Main Road [NH-47], Veerapondi-Post, Salem , Tamilnadu,India. docmeyei@gmail.com 2 Associate Professor, Department of Neurology, Vinayaka Mission's Kirupananda Variyar Medical College & Hospitals, Vinayaka Mission University, Sankari Main Road [NH-47], Veerapondi-Post, Salem , Tamilnadu,India. drdmahadevan@gmail.com 3 Prof of General Medicine, Academic Director Dept of Accident, Emergency & Critical Care Medicine, Vinayaka Mission's Kirupananda Variyar Medical College & Hospitals, Vinayaka Mission University, Sankari Main Road [NH-47], Veerapondi-Post, Salem , Tamilnadu,India. info@vinayakahospital.com mailto:drvpchandru@gmail.com 41

2 and Injury Severity Score [TRISS], the Circulation, Respiration, Abdomen,, Speech [CRAMS] Scale and the Revised Trauma Score (1, 4, 5, 6). Traumatic Brain Injuries [TBI] are a major public health problem in India, resulting in deaths, injuries and disabilities of young and productive people of our society. India has the rather unenviable distinction of having the highest rate of head injury in the world. In India, more than 100,000 lives are lost every year with over 1 million suffering from serious head injuries and 1 out of 6 trauma victims die. Most road traffic accident victims are in the 20- to 40-year age group, the main bread-earners of the family, putting the whole family below the poverty line, while depriving society of vital drivers of economy as in many cases these are entrepreneurs or professionals (7). The economic losses to India are phenomenal, though unmeasured. As India progresses to greater growth and development in terms of motorization, urbanization, TBIs would increase in India. By 2050, India would have the greatest number of automobiles on the planet, overtaking the United States (8). Stroke is defined as a sudden loss of brain function resulting from an interference with blood supply to the brain. It limits stroke to an acute vascular phenomenon that includes ischemic strokes and haemorrhagic strokes (9). Brain stroke is the third largest killer in India and the second largest in the world, and the incidence in India is around 130 per 100,000 population every year according to the World Health Organization (10). The last few decades have seen a rise in the incidence and prevalence of stroke in India, attributable to increasing life span, urbanization, and better survival, and the rates are now matching western figures (11). As a result of both TBI and Stroke, there is an increase in mortality and long-term or lifelong disability that will need for help in performing activities of daily living (12). A patient's condition during the first few weeks after a TBI is extremely unstable and life-threatening. During such critical periods, accurate neurological assessment is essential for predicting recovery (13). The GCS is a quick, simple, and objective tool widely used and accepted prognostic score for both traumatic and non-traumatic altered conscious level (14, 15, 16). The ability to predict the outcome in TBI and stroke can influence clinical 42 decisions and also helps in the efficient use of resources and communicating with the families of the victims (17, 18). As stroke may cause localized motor, speech or language deficits, the accuracy of GCS to measure the level of consciousness as well as its prognostic predictability may be affected (3). Similarly in head injury, there could be inaccuracy in GCS measurement due to un-testable s due to sedation paralysis, intubation, alcohol or illicit drug intoxication or in facial injury causing periorbital swelling (19, 20, 21, 22). Simplicity of the GCS was the principle concern with the goal to provide a method to quantify and communicate with other members of the health care system describing the degree of altered consciousness or coma (23, 24). The correct assessment of the GCS shows variability among health care providers and it is unnecessarily complex for the initial assessment in the out-of-hospital setting (3, 25). The GCS is most often reported as a single and overall score, although the scale authors did not recommend the summary score for use in clinical practice. The use of a global summary score may result in a loss of information that adversely affects the predictive accuracy of the GCS (26, 27, 28). Various simplified scoring systems have been formulated to predict the outcome in TBI and stroke (3, 29). As the motor response forms the major of the GCS scoring system and due to the complexity of GCS, the motor alone could replace The Glasgow Coma Scale in prediction of outcome in TBI and stroke. is a simpler, quicker and easier method of measurement. The aim of this study is to assess the s of the GCS on initial presentation and to see if motor score alone is enough as a better predictor of outcome and as a better indicator of endotracheal intubation [ETI] in patients with TBI and acute stroke [AS]. MATERIALS AND METHODOLOGY Study Design:The proposed study was submitted to the institutional review board of our hospital. Following approval we performed a prospective observational study from October 2009 to July 2011.

3 Study Setting and Population:Vinayaka Mission Hospitals is the one of the Level 1 trauma centers located in Salem, in the southern part of India. The hospital has got a well equipped and sophisticated thirty bedded emergency room with a good quantum of varied cases with agile emergency physicians, vigilant staff nurses and paramedics round the clock. The Emergency Department [ED] treats about 5000 patients per year from a population of approximately over thirty lakh inhabitants in an area of 5200 square kilometers, 50% of the population live in an urban environment. Our 450 bedded hospital treats more than 20,000 patients per year, with 3000 admissions to intensive care units. All the patients aged above 14 years diagnosed of having TBI and AS presenting within 24 hours were included. Patients who are intubated and/or sedated on presentation, patients with hypoxia [SpO2 < 92%], hypotension [Systolic Blood Pressure < 90 mm Hg], alcohol or illicit drug intoxication on presentation, patients with bilateral orbital edema, traumatic paralysis [high spinal cord injury], previous functional/cognitive disabilities, causes of mortality other than TBI and AS, and patients who are unable to be followed-up at 3 months were excluded from the study. Methods:All consecutive patients attending the ED of our Hospital with TBI or AS included in the study were treated according to Advanced Trauma Life Support [ATLS] and American Stroke Association [ASA] guidelines respectively. Data collected on all patients on admission included age, sex, GCS [eye, motor and verbal], vital signs, pupil size and response, time and cause of injury, and Computed Tomography [CT] brain result. The CT brain scanning in stroke was performed to exclude any nonvascular cause of neurological deficit (29). The GCS during ETI either on arrival or during course of hospital stay was also recorded. The Glasgow Coma Scale: GCS is the sum of three coded values that describe a patient's best motor [1 6], verbal [1 5] and eye [1 4] response to speech or pain [TABLE 1]. The patient is assessed against the criteria of the scale and the resulting points give a score between 3 being the lowest [worst] and 15 being the highest [best] score. The patient's best initial summed GCS score as well as the GCS score that is broken down in to s [eye, motor and verbal], after fluid resuscitation and stabilization of the patient, are recorded by experienced emergency physician at the time of arrival to the ED. The GCS score calculated by paramedics on the scene is not considered as it had no prognostic value (30). For AS patients presenting with aphasia, the GCS verbal score is arbitrarily assigned as 'one' (31). When assessing the motor sub-score, the best location for applying a painful stimulus is the nail bed and the best response is recorded from either arm. For those with more experience, supraorbital pressure was used as a painful stimulus (32). Outcome Measures:The main outcome considered in this study was measurement of functional disability by the five-point Glasgow Outcome Scale [GOS] score at 3 months (33) [TABLE 2]. For ease of analysis and reporting, the fivepoint GOS score was modified into broader outcome categories as good outcome [good recovery or moderate disability] and bad outcome [severe disability, persistent vegetative state or dead] (34, 35) [TABLE 3]. The follow up GOS was rated by an expert physician unaware of the study protocol, on the basis of the response to a structured telephone call or neurological examination at 3 months (36). Additionally, the requirement for ETI was also assessed. Data Analysis:All data were compiled into Microsoft Excel 2007 spread sheet and statistical analysis was accomplished using statistical method for calculations provided within Statistical package for social science software [version 11.5]. The logistic regression analysis was performed and classifications of observed and predicted outcomes were identified. The Receiver Operating Characteristic [ROC] analysis was carried out by Non-parametric Receiver Operating Characteristic Analysis Software [Version 2.5] for GCS and its s, and measured the areas under these curves [AUCs] to compare the predictive valve for outcome at 3 months in TBI and AS patients. The 43

4 same method was used for analysis of GCS and its s in predicting requirement for ETI in TBI and AS patients. p < 0.05 was considered statistically significant. RESULTS The study sample analyzed consisted of 375 cases, of which 81.33% were male and 18.67% were female. The median age was 40 years [IOR = 29 years]. Of 375 patients in the study, 68.8% were TBI and 31.2% were AS. Out of 258 cases of TBI, 36.4% were due to mild TBI, 17.4% were due to moderate TBI and 46.1% were due to severe TBI. Out of 117 cases of AS, 53.8% were due to ischemic stroke and 46.2% were due to haemorrhagic stroke. At admission, median of total GCS score was 10 [TBI - 9 and AS - 10]. Highest frequency of total GCS occurred for 15 in 81 [21.6%] patients followed by 7 in 43 [11.5%] patients. 45.1% of patients were intubated either on arrival or during the course of hospital stay [TABLE 4]. The median GCS for requirement of ETI was 6 [TBI - 7 and AS - 6]. 65.1% of patients had a good outcome as per GOS at 3 months [67.8% for TBI and 59% for AS]. From the classification of observed and predicted cases for overall patients, it is found that 80.9% correctly classified the bad outcome, 96.3% correctly classified the good outcome and 90.9% correctly classified overall outcome by the logistic regression. For TBI, it is found that 85.5% correctly classified the bad outcome, 96% correctly classified the good outcome and 92.6% correctly classified overall outcome by the logistic regression. For AS, it is found that 75% correctly classified the bad outcome, 94.2% correctly classified the good outcome and 86.3% correctly classified overall outcome by the logistic regression. The ROC curve analysis showed the AUC was greatest for motor in all patients [AUC = 0.937] {95% confidence interval [CI] = to 0.965} as well as in TBI [AUC = 0.959, 95% CI = to 0.982] with p < In AS, the AUC was greatest for total GCS [AUC = 0.909, 95% CI = to 0.964] with similar magnitude for motor [AUC = 0.908, 95% CI = to ], with p < [GRAPH 1, 2, 3, TABLE 5]. From the classification of observed and predicted cases for acute ischemic stroke, it is found that 72.2% correctly classified the bad outcome, 100% correctly classified the 44 good outcome and 92.1% correctly classified overall outcome by the logistic regression. For acute haemorrhagic stroke, it is found that 90% correctly classified the bad outcome, 83.3% correctly classified the good outcome and 87% correctly classified overall outcome by the logistic regression. The ROC curve analysis showed the AUC was greatest for motor in acute ischemic stroke [AUC = 0.892, 95% CI = to 1.001] with p < In acute haemorrhagic stroke, the AUC was greatest for total GCS [AUC = 0.944, 95% CI = to 1.001] followed by motor [AUC = 0.919, 95% CI = to 0.993] with p < [GRAPH 4, 5, TABLE 6]. From the classification of observed and predicted cases for overall patients, it is found that 91.1% correctly classified the non intubated cases, 96.7% correctly classified the intubated cases and 93.3% correctly classified the overall requirement of ETI by the logistic regression. For TBI, it is found that 92.7% correctly classified the non intubated cases, 94.1% correctly classified the intubated cases and 93.3% correctly classified the overall requirement of ETI by the logistic regression. For AS, it is found that 91.5% correctly classified the non intubated cases, 87% correctly classified the intubated cases and 89.7% correctly classified the overall requirement of ETI by the logistic regression. The ROC curve analysis showed the AUC was greatest for total GCS [AUC = 0.977, 95% CI = to 0.991] in all patients with p < In TBI and AS, the AUC was greatest for total GCS [AUC = 0.982, 95% CI = to and 0.967, 95% CI = to respectively] with p < [GRAPH 6, 7, 8, TABLE 7]. From the classification of observed and predicted cases for acute ischemic stroke, it is found that 93.2% correctly classified the non intubated cases, 84.2% correctly classified the intubated cases and 90.5% correctly classified the overall requirement of ETI by the logistic regression. For acute haemorrhagic stroke, it is found that 92.6% correctly classified the non intubated cases, 92.6% correctly classified the intubated cases and 92.6% correctly classified the overall requirement of ETI by the logistic regression. The ROC curve analysis showed the AUC was greatest for eye [AUC = 0.969, 95% CI = to 1.006] followed by total GCS [AUC = 0.944,

5 95% CI = 0.882to 1.006] in acute ischemic stroke with p < In acute haemorrhagic stroke, the AUC was greatest for total GCS [AUC = 0.981, 95% CI = to 1.009] with p < [GRAPH 9, 10, TABLE 8]. Parameter Response Score Spontaneous 4 To speech 3 To pain 2 None 1 Oriented 5 Confused conversation 4 Inappropriate words 3 Incomprehensible sounds 2 None 1 Obeys commands 6 opening Best verbal response Best motor response Good/Favourable Bad/Unfavourable Good recovery Moderate Disability Severe Disability Persistent Vegetative State Dead TABLE 3 : Broader outcome categories of GOS Variables Age Localizes pain 5 Sex Withdrawal (normal flexion) Abnormal flexion (decorticate) Extension (decerebrate) Diagnosis None 1 TABLE 1 : GLASGOW COMA SCALE Severity of TBI 1 Dead 2 Vegetative state Non-survival Minimal responsiveness Severe disability Conscious and able to follow commands Dependent on others for daily support Moderate disability Able to live independently Unable to return to work or school Can work in sheltered setting Nature of acute stroke Endotracheal intubation Details n [%] Mean Median - 40 IQR - 29 Male 305 [81.3%] Female 70 [18.7%] Traumatic Brain Injury 258 [68.8%] Acute Stroke 117 [31.2%] Mild Head Injury 94 [36.4%] Moderate Head Injury 45 [17.4%] Severe Head Injury 119 [46.1%] Ischemic Stroke 63 [53.8%] Haemorrhagic Stroke 54 [46.2%] Traumatic Brain Injury 115 [44.6%] Acute stroke 54 [46.2%] All Patients 169 [45.1%] TABLE 4: Demographic and injury characteristics Able to return to work or school Good recovery Resumption of normal life despite minor deficits TABLE 2 : The Five-Point GOS 45

6 Patient Groups Test Result Variable[s] Area Std. Error p All Patients [n=375] Ischemic stroke [n=63] Test Result Variable[s] Area Std. Error p Haemorrhagic stroke [n=54] Acute Stroke [n=117] Patient Groups Asymptotic 95% Confidence Interval Lower Upper Bound Bound TBI [n=258] Asymptotic 95% Confidence Interval Lower Upper Bound Bound TABLE 5 : AUCS FOR TOTAL AND INDIVIDUAL GCS COMPONENTS ROC CURVES FOR OUTCOME AT 3 MONTHS TABLE 6 : AUCS FOR TOTAL AND INDIVIDUAL GCS COMPONENTS ROC CURVES FOR OUTCOME AT 3 MONTHS ACCORDING TO NATURE OF ACUTE STROKE: [N=258] Patient Groups All Patients [n=375] TBI [n=258] Acute Stroke [n=117] Asymptotic 95% Confidence Interval Lower Upper Bound Bound Test Result Variable[s] Area Std. Error p TABLE 7 : AUCS FOR TOTAL AND INDIVIDUAL GCS COMPONENTS ROC CURVES FOR REQUIREMENT OF ENDOTRACHEAL INTUBATION 46

7 Patient Groups Ischemic stroke [n=63] Asymptotic 95% Confidence Interval Lower Upper Bound Bound Test Result Variable[s] Area Std. Error p Haemorrhagic stroke [n=54] GRAPH 2 : AUCS FOR TOTAL AND INDIVIDUAL GCS COMPONENTS ROC CURVES FOR OUTCOME AT 3 MONTHS IN TBI : [N=258] TABLE 8 : AUCS FOR TOTAL AND INDIVIDUAL GCS COMPONENTS ROC CURVES FOR REQUIREMENT OF ENDOTRACHEAL INTUBATION ACCORDING TO NATURE OF ACUTE STROKE: [N=258] GRAPH 3 : AUCS FOR TOTAL AND INDIVIDUAL GCS COMPONENTS ROC CURVES FOR OUTCOME AT 3 MONTHS IN ACUTE STROKE:[N=117] GRAPH 1 : AUCS FOR TOTAL AND INDIVIDUAL GCS COMPONENTS ROC CURVES FOR OUTCOME AT 3 MONTHS IN ALL PATIENTS: [N=375] GRAPH 4 : AUCS FOR TOTAL AND INDIVIDUAL GCS COMPONENTS ROC CURVES FOR OUTCOME AT 3 MONTHS IN ACUTE ISCHEMIC STROKE: [N=63] 47

8 GRAPH 5 : AUCS FOR TOTAL AND INDIVIDUAL GCS COMPONENTS ROC CURVES FOR OUTCOME AT 3 MONTHS IN ACUTE HEMORRHAGIC STROKE: [N=54] GRAPH 8 : AUCS FOR TOTAL AND INDIVIDUAL GCS COMPONENTS ROC CURVES FOR REQUIREMENT OF ENDOTRACHEAL INTUBATION IN ACUTE STROKE:[N=117] GRAPH 6 : AUCS FOR TOTAL AND INDIVIDUAL GCS COMPONENTS ROC CURVES FOR REQUIREMENT OF ENDOTRACHEAL INTUBATION IN ALL PATIENTS:[N=375] GRAPH 9 : AUCS FOR TOTAL AND INDIVIDUAL GCS COMPONENTS ROC CURVES FOR REQUIREMENT OF ENDOTRACHEAL INTUBATION IN ACUTE ISCHEMIC STROKE: [N=63] GRAPH 7 : AUCS FOR TOTAL AND INDIVIDUAL GCS COMPONENTS ROC CURVES FOR REQUIREMENT OF ENDOTRACHEAL INTUBATION IN TBI: [N=258] GRAPH 10 : AUCS FOR TOTAL AND INDIVIDUAL GCS COMPONENTS ROC CURVES FOR REQUIREMENT OF ENDOTRACHEAL INTUBATION IN ACUTE HAEMORRHAGIC STROKE:[N=54] 48

9 DISCUSSION The main issues ensuing from TBI are cognitive and personality problems, rather than physical disability (37). TBI and AS patients with poor prognosis receiving an effective treatment may benefit only by surviving and become completely dependent with poor quality of life resulting in a huge burden of care, largely borne by the immediate relatives (29). Continuous efforts are being made by researchers to identify the prognostic indicators in these patients that would help the family for an efficient planning of their income and funds. Unlike many other studies, we assessed the outcome predictive ability of GCS and its s in both TBI and AS patients. We also carried out a similar analysis in subgroup of AS patients according to the nature of stroke [hemorrhagic and ischemic stroke]. In this study, we found that the motor of the GCS scoring system performed better than the total GCS, eye and verbal s of GCS in predicting outcome in all patients [both TBI and AS together] as well as in TBI patients alone. In AS patients alone, the total GCS and the motor accurately predicted outcome in an equivalent manner. Our findings were similar to the results of previous studies by Healey et al, Kameshwar Prasad et al, Gill et al and Al-Salamah et al using ROC curves that reported the motor of the GCS occupied nearly the same area under an ROC curve as did the total GCS score in their ability to predict outcome (28, 38, 39, 40). Similarly, Diringer et al, Meredith et al and Ross et al also reported that the motor of the GCS score accurately predicted outcome which is also comparable to our result (41, 42, 43). It appears that the motor response being the largest of the GCS scoring system practically contains all the information of the GCS itself and thereby better outcome predictive value. In contrast, a study using ROC analysis by C J Weir et al in assessing AS patients and a study by Moore et al in TBI patients reported that the total GCS accurately predicts outcome than the individual GCS s (29, 44). Data analysis from our study showed that the eye was the weakest predictor for TBI similar to the results of studies by Michelle Gill et al and Al-Salamah et al (3, 40). In AS patients, the verbal was the weakest predictor which was a comparable with the results of Diringer et al and Kameshwar Prasad et al but is different to findings of C J Weir et al (29, 38, 41). The s of the GCS may be affected due to focal deficits in these patients misjudging the actual level of consciousness. Another explanation to the varied results may be the false recording of the best motor and verbal response due to paralysis and dysphasia respectively (29). Further in AS patients, the performance of the GCS and its s according to the nature of the stroke in predicting outcome were not studied earlier. The results of this subgroup analysis obtained in our study for hemorrhagic stroke showed that the total GCS yields equivalent prediction rates as the motor since they occupied similar magnitude of AUC when compared to the eye and verbal s. But in ischemic stroke patients, the motor performed greatest with a marginal difference from that of the total GCS. There was no evidence to support or refute this finding from the literature. Very few studies have used ETI as TBI outcome measure (3, 39, 40, 45). This outcome measure was not considered in any of the previous studies in AS patients. The requirement of ETI was analyzed to determine which s of the GCS will display similar, better, or worse associations. Our data analysis reveals that the total GCS scoring system performed better than the individual s of GCS in predicting ETI in all patients [both TBI and AS] as well as in patients with TBI and AS separately. In agreement with our finding, studies by Michelle Gill et al and Haukoos JS et al also found the total GCS was accurate in predicting the requirement of ETI in TBI patients (3, 45). However this finding differed from the end result of a study by Al-Salamah et al in which they reported eye was the best predictor of ETI followed by the total GCS (40). While studying the requirement of ETI according to the nature of the stroke, the greatest predictive ability was retained by the total GCS in hemorrhagic stroke patients. But observations in ischemic stroke patients showed that the ability to correctly predict ETI by the eye 49

10 was the best followed by the total GCS when compared to the motor and verbal s. This was similar to findings of Al-Salamah et al in their study which was described as an isolated finding requiring further validation (40). By evaluating the GCS and its individual s in both TBI and AS patients, we have shown that the motor response has a good or better predictive value in assessing GOS. Due to simplicity of measuring the motor response as well as its applicability in intubated patients, the variability of its assessment among healthcare workers would reduce (3, 25). Hence, we believe that the total GCS could simply be replaced by the motor in predicting outcome of TBI and AS patients while maintaining higher specificity. Since the predictability of ETI by the motor score is not greater than total GCS, we suggest the GCS in its summed form should not be replaced by the motor in both TBI and AS patients. The application of these findings could be extended to out-of-hospital environment as well (3). CONCLUSION In the assessment of TBI and AS patients, the motor of GCS scoring system is a better predictor of 3 month outcome while the GCS in its summed form is a better indicator for requirement of endotracheal intubation. design, purpose, goals, and results. J Neurosurg Aug;59(2): I n d i a n H e a d I n j u r y Fo u n d a t i o n PK Sethi. Stroke - Incidence in India and Management of Ischaemic stroke. Neurosciences Today. July -September 2002;6(3) Subhash Kaul. Stroke in India: Are we different from the world? Pak J Neurol Sci. 2007;2(3): National Center for Injury Prevention and Control. Epidemiology of traumatic brain injury in the United States. Updated March 19, Accessed May 12, HyunSoo Oh and WhaSook Seo. Functional and Cognitive Recovery of Patients with Traumatic Brain Injury. Crit Care Nurse. 2009;29: Teasdale G, Gentlemen D. The description of 'conscious level ': a case for the Glasgow Coma Scale. Scott Med j Jan;27(1): Jagger J, Jane JA, Rimel R. The Glasgow Coma Scale: To sum or not to sum? Lancet Jul 9;2(8341): Levy DE, Bates D, Caronna JJ, Cartlidge NE, Knill-Jones RP, Lapinski RH, et al. Prognosis in non traumatic coma. Ann Intern Med Mar;94(3): Ramesh VG, Thirumaran KP, Raja MC. A new scale for prognostication in head injury Oct;15(10):1110-3; discussion Epub 2008 Jul Kaufmann MA, Buchmann B, Scheidegger D, Gratzl O, Radü EW. Severe head injury: should expected outcome influence resuscitation and first-day decisions. Resuscitation JunJul;23(3): Schreiber MA, Aoki N, Scott BG, Beck JR. Determinants of mortality in patients with severe blunt head injury. Arch of Surgery Mar;137(3): Oppenheim JS, Camins MB. Predicting outcome in braininjured patients. Using the Glasgow Coma Scale in primary care practice. Postgrad Med Jun;91(8):261-4, Rutledge R, Lentz CW, Fakhry S, Hunt J. Appropriate use of the Glasgow Coma Scale in intubated patients: a linear regression prediction of the Glasgow verbal score from the Glasgow eye and motor scores. J. Trauma Sep;41(3): Demetriades D, Kuncir E, Murray J, Velmahos GC, Rhee P, Chan L. Mortality prediction of head Abbreviated Injury Score and Glasgow Coma Scale: analysis of 7,764 head injuries. J.Am.Coll.Surg Aug;199(2): Molly McNett. Predictive Ability of Glasgow Coma Scale Scores in Head-Injured Patients: GCS and Other Predictor Variables. J Neurosci Nurs Apr;39(2): REFERENCES 1. on Friday, December 18, Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet Jul 13;2(7872): Gill M, Steele R, Windemuth R, Green SM. A Comparison of Five Simplified Scales to the Out-of-hospital GCS for the prediction of traumatic Brain Injury Outcomes. Acad Emerg Med Sep;13(9): Epub 2006 Aug George L. Sternbach. The Glasgow Coma Scale. The Journal of Emergency Medicine. 2000;19(1): Champion HR, Sacco WJ, Carnazzo AJ, Copes W, Fouty WJ. Trauma score. Crit Care Med Sep;9(9): Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli TA, Flanagan ME. A revision of the Trauma Score. J Trauma May;29(5): Marshall LF, Becker DP, Bowers SA, Cayard C, Eisenberg H, Gross CR, et al. The National Traumatic Coma Data Bank. Part I: 50

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