Supplementary webappendix

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1 Supplementary webappendix This webappendix formed part of the original submission and has been peer reviewed. We post it as supplied by the authors. Supplement to: Teasdale G, Maas A, Lecky F, Manley G, Stocchetti N, Murray G. The Glasgow Coma Scale at 40 years: standing the test of time. Lancet Neurol 2014; 13:

2 WEB - EXTRA TABLES Table 1: Use of Glasgow Coma Scale in 85 Countries Represented by Member societies of the World Federation of Neurosurgical Societies (WFNS) Use of GCS Totals Yes n % Yes For head injuries in neurosurgery For other neurosurgical patients In General Wards In Intensive Care Units In Emergency Departments Pre-hospital In English Translated into the language(s) of the country A method in addition to the GCS is being used to score head injuries Data from online survey between November 2013 and February 2014 responded to by 85 National Member Societies of World Federation of Neurosurgery (WFNS): Societies Responding: Afganistan, Albania, Algeria, Argentina, Armenia, Australia &New Zealand, Austria, Bangladesh, Belgium, Brazil, Bulgaria, Canada, Chile, China, Colombia, Costa Rica, Croatia,Cuba,Cyprus, Czech Republic, Dominican Republic, Egypt, Ethiopia, Finland, France, Germany, Ghana, Great Britain &Ireland, Greece, Honduras, Hong Kong, Hungary, India, Israel, Iran Italy, Japan, Jordan, Kazakhstan, South Korea, Kuwait, Latvia, Lebanon, Lithuania,, Malaysia, Mexico, Morocco, Nepal, Netherlands, Nicaragua,Nigeria, Norway, Pakistan, Panama, Philippines, Poland, Paraguay, Peru, Portugal, Romania, Russia, Saudi Arabia, Serbia, Singapore, Slovakia, Slovenia, South Africa, Spain, Sudan, Sweden, Switzerland, Taiwan, Thailand, Tunisia, Turkey, Ukraine, United Arab Emirates, Uruguay, USA, Venezuela Vietnam, Zimbabwe 1

3 Table 2. Examples of recommendations in evidence based guidelines for employing the GCS Guideline Action Criterion based on GCS NICE Head Injury guideline 176, 2014 Refer patients with head GCS less than 15 on initial assessment injury to a hospital A&E department Initial assessment by GCS Base monitoring and exchange of information about individual patients on the three separate responses on the GCS; If total score is recorded, base it on a sum of 15 and specify this denominator; Describe the individual components in all communications and every note; Include a grimace alternative to the verbal score in pediatric GCS; Establish a pre-injury baseline GCS were possible and take into account during assessment An alerting call to the destination GCS < 15 A&E department Urge for a neck collar (cervical spine immobilization) GCS < 15 on initial assessment by health care professional Make standby calls to destination GCS<8 ED CT scan within 1 hour of the risk factor being identified Adults GCS < 13 on initial ED assessment; GCS of 15 at 2 hours after the injury on ED assessment; Imaging of cervical spine within 1 hour of the risk factor being identified Involving the Neurosurgeon Transfer to neuroscience unit Hospital admission following head injury Immediate intubation and ventilation Frequency of observation Children On initial ED assessment GCS< 14 or for children under 1 year pediatric GCS < 15; At 2 hours after injury, GCS<15; GCS<13 on initial assessment Persisting coma (GCS < 8) after initial resuscitation or deterioration of GCS after admission GCS<8 Patients who have not returned to GCS equal to 15 after imaging, regardless of the imaging results. GCS < 8 Observations should be performed and recorded on a half hourly basis until GCS equal to 15 has been achieved. If GCS=15 observe: half-hourly for 2 hours, then 1 hourly for 4 hours, then 2 hourly thereafter; Should the patient with GCS equal to 15 deteriorate at any time after the initial 2-hour period, 2

4 Evidence-based Guidelines for the Management of Severe TBI, Brain Trauma Foundation, 2007 Surgical management of TBI, Brain Trauma Foundation, 2006 Prehospital Severe TBI Guidelines Brain Trauma Foundation, 2007 observations should revert to half-hourly. Urgent reappraisal by the A sustained (that is, for at least 30 minutes) supervising doctor drop of one point in GCS level (greater weight should be given to a drop of one point in the motor score of the GCS); Any drop of 3 or more points in the eyeopening or verbal response scores of the GCS or 2 or more points in the motor response. Further imaging (CT/MRI) GCS equal to 15 not achieved within 24h Discharge to community If GCS equals 15 Intracranial pressure (ICP) monitoring Surgery for epidural hematoma ICP monitoring in patients with subdural hematoma (SDH) Surgical evacuation of subdural hematoma (SDH) Surgery for brain contusions Prehospital neurological assessment in adults Prehospital neurological assessment in pediatrics population Establish airway Treatment of hypotension Assessment of progressive neurological deterioration as a sign of cerebral herniation In all salvageable patients with severe TBI: a GCS score of 3-8 after resuscitation and a abnormal CT scan. In patients with severe TBI with a normal CT scan if > 2 of the following: age over 40 years, unilateral or bilateral motor posturing, or systolic blood pressure < 90 mmhg An EDH less than 30 cm3 and with less than a 15-mm thickness and with less than a 5-mm midline shift (MLS) in patients with a GCS score greater than 8 without focal deficit can be managed non-operatively All patients with acute SDH in coma (GCS score less than 9). GCS<9 with SDH less than 10-mm thick and a midline shift less than 5mm, if GCS decreased between the time of injury and hospital admission by 2 or more points on the GCS and/or the patient presents with asymmetric or fixed and dilated pupils and/or the ICP exceeds 20 mm Hg GCS 6-8 with frontal or temporal contusions greater than 20 cm3 in volume with midline shift of at least 5mm and/or cisternal compression on CT scan, and patients with any lesion greater than 50cm3 GCS should be repeatedly assessed to identify improvement or deterioration over time; GCS should be assessed after stabilization of ABC, and preferably prior to sedation or after sedative drugs have been metabolized; GCS should be assesses by trained personnel. P-GCS should be repeatedly assessed to identify improvement or deterioration over time; Use P-GCS in pre-verbal children. Use adult GCS in kids over 2 years old; GCS should be assessed after stabilization of ABC, and preferably prior to sedation or after sedative drugs have been metabolized; Severe TBI, ie GCS<9 TBI patients with GCS < 8: hypertonic resuscitation instead of isotonic fluids is a treatment option Decrease of more than 2 points in GCS from patients best prior score in patients with initial GCS < 9 Pediatric Severe TBI Guidelines, Brain Indications for ICP monitoring Severe TBI (i.e. GCS <9) 3

5 Trauma Foundation, 2012 Additional recommendations in severe TBI pediatric patients are not specifically based on GCS NICE head injury guidelines Brain trauma Foundation: Guidelines for the management of severe TBI, 3 rd edition. J. Neurotrauma 2007;24:S Bullock MR, Chesnut R, Ghajar J, et al. Guidelines for the surgical management of Traumatic Brain Injury. Neurosurgery. 2006; 58 (3 Suppl). Guidelines for Pre-hospital management of TBI, 2 nd edition, Prehospital Emergency Care 2007, 12; 1. Kochanek PM, Carney N, Adelson PD, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents--second edition. Pediatr Crit Care Med. 2012;13 Suppl 1:S

6 Table 3. Total Citations between January 1974 and January 2014 found in Web of Science to descriptions of 18 Coma Scales described from 1974 onwards Year Reference Origin Citations 1974 Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A Glasgow 5468 practical scale. Lancet. 2(7872):81-4, 1974 Jul Ohta T, Waga S, Handa W, et al. New grading of level of disordered Osaka / 0 consiousness (author s transl). No shinkei geka. Neurol Surg. 2:623 7, Bricolo A. Battistini N. Bergamini L. Columella F. Loeb C. Mingrino S. Rossi GF. Verona 0 Terzian H. A proposal for the clinical classification of acute coma due to organic cerebral lesions. Journal of Neurosurgical Sciences. 19(3):113-9, R Brinkmann, D Von Cramon, H Schulz. The Munich Coma Scale (MCS). Munich 23 J Neurol Neurosurg Psychiatry. 39: , Frowein RA. Classification of coma. Acta Neurochirurgica. Cologne 43 34(1-4):5-10, Bouzarth W, Flindermuth J R. Head injury watch sheet modified for a digital Philadelphia 10 scale. J of Trauma Infection and Critical Care. 18: ; J K Yen, R S Bourke, L R Nelson, A J Popp. Numerical grading of clinical Albany, New York 16 neurological status after serious head injury. J Neurol Neurosurg Psychiatry. 41: , Salcman M. Schepp RS. Ducker TB. Calculated recovery rates in severe head Maryland 1 trauma. Neurosurgery. 8(3):301-8, K Sugiura, K Muraoka, T Chishiki, M Baba. The Edinburgh-2 coma scale: a new Edinburgh / 22 scale for assessing impaired consciousness. Neurosurgery. 12: , 1983 Tokyo 1983 K Sano, S Manaka, K Kitamura, M Kagawa, Kazuo Takeuchi, Tokyo 8 Motohide Ogashiwa, Masakuni Kameyama, Hideo Tohgi, Hisashi Yamada. Statistical studies on evaluation of mild disturbance of consciousness: Study of a simpler scale for clinical use. Journal of Neurosurgery. 58(2): , February Daniel E. Stanczak, Ph.D., James G. White III, M.D., William Pittsburgh 54 D. Gouview, Ph.D., Kurt A. Moehle, Ph.D., Michael Daniel, M.S., Thomas Novack, M.A., and Charles J. Long, Ph.D. Assessment of level of consciousness following severe neurological insult. A comparison of the psychometric qualities of the Glasgow Coma Scale and the Comprehensive Level of Consciousness Scale. Journal of Neurosurgery. 60(5): ,. May Benzer A. Mitterschiffthaler, Marosi, et al. Prediction of non-survival Innsbruck 51 after trauma. Innsbruck Coma Scale. Lancet. 338: , Born JD. The Glasgow Liege Scale Prognostic value and evolution of motor Liege 40 response and brain stem reflexes after severe head injury, Acta Neurochir (Wein). 91: 9-11, Born JD, Albert A, Hans P, Bonnal J. Relative prognostic value of best motor response and brain stem reflexes in patients with severe head injury. Neurosurgery 1985;16: Liege Starmark JE. Stalhammar D. Holmgren E. The Reaction Level Scale (RLS85). Manual and guidelines. Acta Neurochirurgica. 91(1-2):12-20, 1988 Gotheborg Stålhammar D, Starmark JE, Holmgren E, et al. Assessment of responsiveness in acute cerebral disorders: a multicentre study on the reaction level scale (RLS 85). Acta Neurochir 1988;90: Gotheborg 31 5

7 2003 Ohta T. Transition of judgment on depth of consciousness disturbance and its perspectives from the Japan Coma Scale to the Emergency Coma Scale. J Jpn Congr Neurol Emerg. 2003;16: A. F. McNarry, D. R. Goldhill. Simple bedside assessment of level of consciousness: comparison of two simple assessment scales with the Glasgow Coma scale. Anaesthesia. 59:34 37, 2004 (ACDU) 2005 Gill M, Windemuth R, Steele R, et al. A comparison of the Glasgow coma score to simplified alternative scores for the prediction of traumatic brain injury outcomes. Ann Emerg Med. 45:37-42 Simplified Motor Score, E F. M. Wijdicks MD, William R. Bamlet MS, Boby V. Maramattom MD, Edward M. Manno MD, Robyn L. McClelland PhD. Validation of a new coma scale: The FOUR score. Annals of Neurology, 58(4): , October 2005 Osaka 0 London 29 Loma Linda, California Rochester, Minnesota Web of Science Search Conducted on 17 January 2014 by Mr A McAinsh, Information officer Royal College of Physicians and Surgeons of Glasgow using References in Table 3 6