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Chapter 36: Intracranial and Spinal Trauma

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A 23-year-old man presents to the emergency department after being involved in a motor vehicle crash. On physical examination, he opens his eyes to painful stimulation, he occasionally mumbles incomprehensible sounds, he localizes to painful stimulation with his right upper extremity, and he withdraws his left upper extremity to pain. His pupils are 4 mm bilaterally and reactive. What is this patient’s Glasgow Coma Scale (GCS) score?

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(A) 7

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(B) 9

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(C) 8

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(D) 10

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(B) The GCS is the most widely used scale for predicting outcome following head trauma. It was developed by Teasdale and Jennett as a practical means of assessing and categorizing a patient’s level of arousal and neurologic function. The scale is divided into three categories: eye opening, best verbal response, and best motor response. Eye opening is rated on a scale of 1–4, verbal response is rated on a scale of 1–5, and motor response is rated on a scale of 1–6 (Table 36-1). Therefore, the lowest possible score is 3, and the highest possible score is 15. The patient in this question receives 2 points for opening his eyes to painful stimulation, 2 points for verbalizing incomprehensible sounds, and 5 points for localizing to stimulation since this represents his best motor response. Pupillary size and reactivity do not factor into the GCS score. Therefore, the patient’s total score in this question is 9. A major disadvantage of using the GCS is that endotracheal intubation prevents the use of the best verbal response category. In such cases, the letter “T” follows the combined score of the remaining two categories. For example, if the patient in this case had been intubated, then his score would have been 7T. When using the GCS, one must keep in mind that although it is an effective tool for rapidly assessing neurologic function and assisting with outcome predictions, it only shows general trends in the patient’s status over time. It is not an accurate or valuable means of following a patient’s specific clinical status, and it should not replace a thorough neurologic examination.

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Table 36-1 Glasgow Coma Scale
Measure No. of Points
Eye opening
Spontaneous 4
To speech 3
To pain 2
No eye opening 1
Best verbal response
Oriented and appropriate 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
No verbal response 1
Best motor response
Obeys commands 6
Localizes to pain 5
Withdraws to pain 4
Flexor (decorticate) posturing 3
Extensor (decerebrate) posturing 2
No motor response 1

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Cerebral perfusion pressure (CPP) is equal to

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