GLASGOW COMA SCALE

 

< 2 YEARS OLD

ADULT & PEDIATRIC > 2 YEARS OLD

EYES

SPONTANEOUSLY

4

TO VOICE

3

TO PAIN

2

NO RESPONSE

1

SPONTANEOUSLY

4

TO VOICE

3

TO PAIN

2

NO RESPONSE

1

VERBAL

COOS, BABBLES

5

IRRITABLE CRY, CONSOLABLE

4

CRIES TO PAIN

3

MOANS TO PAIN

2

NO RESPONSE

1

ORIENTED

5

CONFUSED

4

INAPPROPRIATE WORDS

3

GRUNTS, GARBLED SPEECH

2

NO RESPONSE

1

MOTOR

NORMAL MOVEMENTS

6

WITHDRAWS TO TOUCH

5

WITHDRAWS TO PAIN

4

FLEXION (DECORTICATE)

3

EXTENSION (DECEREBRATE)

2

NO RESPONSE

1

OBEYS COMMANDS

6

LOCALIZES P AIN

5

WITHDRAWS TO PAIN

4

FLEXION (DECORTICATE)

3

EXTENSION (DECEREBRATE)

2

NO RESPONSE

1

 

  • Signs of cerebral herniation:
    • Dilated and unresponsive pupils, bradycardia,
      A  Ventilate at 20 breaths per minute when signs
    • {Ventilate to maintain EtCO2 readings of 30 mmHg (30 torr)}.
      P  Ventilate at a rate of ten faster than normal respiratory rate when the signs of cerebral herniation are present.

Maintain good ventilation at rate of about one breath every 5-6 seconds (10-12 per minute), with high flow oxygen. Prophylactic hyperventilation for head injury is not recommended. Cerebral herniation syndrome is the only situation in which hyperventilation (rate of 20 per minute; pediatric rate of 10 faster than the normal rate) is indicated.

Hypoventilation increases the level of CO2 in the brain, causing cerebral vasodilatation and increased swelling. Hyperventilation decreases the level of CO2 and causes cerebral vasoconstriction, hypoxia and ischemia. Both hyperventilation and hypoventilation could cause cerebral hypoxia and increased mortality.

In cerebral herniation, there is a sudden rise in intracranial pressure. Portions of the brain may be forced downward, applying great pressure on the brainstem. This is a life-threatening situation characterized by a decreased LOC that rapidly progresses to coma, dilation of the pupil, an outward- downward deviation of the eye on the side of the injury, paralysis of the arm and leg on the side opposite the injury, or decerebrate posturing. When this occurs, the vital signs frequently reveal increased blood pressure and bradycardia. The patient may soon cease all movement, stop breathing, and die. If these signs are developing in a head injury patient, cerebral herniation is imminent and aggressive therapy is needed. Hyperventilation will decrease intracranial pressure (ICP). In this situation, the danger of immediate herniation outweighs the risk of ischemia.

 

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