Advanced Trauma Life Support ATLS Student Course Manual 2018

110
CHAPTER 6 n Head Trauma
table 6-2 glasgow coma scale (gcs)
ORIGINAL SCALE REVISED SCALE SCORE
Eye Opening (E)
Spontaneous
To speech
To pain
None
Eye Opening (E)
Spontaneous
To sound
To pressure
None
Non-testable
4
3
2
1
NT
Verbal Response (V)
Oriented
Confused conversation
Inappropriate words
Incomprehensible sounds
None
Verbal Response (V)
Oriented
Confused
Words
Sounds
None
Non-testable
5
4
3
2
1
NT
Best Motor Response (M)
Obeys commands
Localizes pain
Flexion withdrawal to pain
Abnormal flexion (decorticate)
Extension (decerebrate)
None (flaccid)
Best Motor Response (M)
Obeys commands
Localizing
Normal flexion
Abnormal flexion
Extension
None
Non-testable
6
5
4
3
2
1
NT
GCS Score = (E[4] + V[5] + M[6]) = Best possible score 15; worst possible score 3.
*If an area cannot be assessed, no numerical score is given for that region, and it is considered “non-testable.” Source: www.glasgowcomascale.org
thrombosis). In such cases, doctors should consider
performing a cerebral arteriography (CT angiography
[CT-A] or conventional angiogram).
Open or compound skull fractures provide direct
communication between the scalp laceration and
the cerebral surface when the dura is torn. Do not
underestimate the significance of a skull fracture,
because it takes considerable force to fracture the
skull. A linear vault fracture in conscious patients
increases the likelihood of an intracranial hematoma
by approximately 400 times.
Intracranial Lesions
Intracranial lesions are classified as diffuse or focal,
although these two forms frequently coexist.
Diffuse Brain Injuries
Diffuse brain injuries range from mild concussions, in
which the head CT is normal, to severe hypoxic, ischemic
injuries. With a concussion, the patient has a transient,
nonfocal neurological disturbance that often includes
loss of consciousness. Severe diffuse injuries often
result from a hypoxic, ischemic insult to the brain from
prolonged shock or apnea occurring immediately after
the trauma. In such cases, the CT may initially appear
normal, or the brain may appear diffusely swollen, and
the normal gray-white distinction is absent. Another
diffuse pattern, often seen in high-velocity impact or
deceleration injuries, may produce multiple punctate
hemorrhages throughout the cerebral hemispheres.
These “shearing injuries,” often seen in the border
between the gray matter and white matter, are referred
to as diffuse axonal injury (DAI) and define a clinical
syndrome of severe brain injury with variable but often
poor outcome.
Focal Brain Injuries
Focal lesions include epidural hematomas, subdural
hematomas, contusions, and intracerebral hematomas
(n FIGURE 6-7).
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