# Alert and Oriented in relationship to GCS Scoring



## MedicMcGoo (Feb 20, 2019)

Seeking opinion on how to chart a particular situation. The patient is alert to person, place, event, but not time. Charting as alert but not answering all questions appropriately. Would this result in a GCS of 14 due to a loss of a point in the verbal category because the patient is not fully oriented.


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## akflightmedic (Feb 20, 2019)

A normal finding would be A/O x 4

Your finding would be A/O x 3 (time)

Yes, they would be a 14 technically on the GCS scale. 

Is this patient a trauma patient?


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## Peak (Feb 20, 2019)

GCS, like APGAR, has essentially no predictive value and doesn't really have a good place in modern medicine. It is far more valuable to simply describe what is abnormal than to chart a score.

Even in trauma GCS is pretty useless. There are plenty of severe traumas who we don't save and rapidly decline from an essentially normal GCS. If homeboy has a few too many, has a failure to fly over the balcony at the bar, has a brief LOC but now has a GCS of 15 is he still low risk/acuity? Are there patients who lose their ability to guard their airway with a GCS greater than 7, and the converse as well? Are there drunk people who would score quite low with minor falls who can be sobered and discharged in a few hours?


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## akflightmedic (Feb 20, 2019)

I agree Peak, however it is still being taught for now, so I was trying to keep it simple for the student. Funny thing you mention APGAR, I was just reading a journal last week that actually shows data demonstrating that children who have APGAR of 7 or less at the 5 min mark are underperformers/slow learner in the education system. If I find it again I will post a link. Full disclosure I did not read all the data and analyze it, just sharing its main gist.


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## MedicMcGoo (Feb 20, 2019)

Thanks guys. I was giving report enroute to the receiving facility and after providing the full report including the AxO3 he asked why the patient was a GCS of 14. Just wanted some feedback. Thank you.


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## Peak (Feb 20, 2019)

akflightmedic said:


> I agree Peak, however it is still being taught for now, so I was trying to keep it simple for the student. Funny thing you mention APGAR, I was just reading a journal last week that actually shows data demonstrating that children who have APGAR of 7 or less at the 5 min mark are underperformers/slow learner in the education system. If I find it again I will post a link. Full disclosure I did not read all the data and analyze it, just sharing its main gist.



I'd be interested to see it. I'm a bit skeptical but that doesn't mean it can be valid. I'd be curious as to what they think the correlation is caused by.

Our NICU and L&D still love APGARS, but our ED refuses to score kids. It isn't the only neonatal thing that our ED and PICU disagree with the NICU about.


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## DrParasite (Feb 20, 2019)

MedicMcGoo said:


> Thanks guys. I was giving report enroute to the receiving facility and after providing the full report including the AxO3 he asked why the patient was a GCS of 14. Just wanted some feedback. Thank you.


I'll be honest, I have never used AOx4; I have always used AOx3, so if you use 4, and take one off, it looks normal to me.  I'd have asked the same question.

I am not saying the 4th (event) isn't important or shouldn't be done, but if a 5th qualifier is added, if the patient misses 2, they will still be AOx3.


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## akflightmedic (Feb 20, 2019)

Apgar scores at 5 minutes after birth in relation to school performance at 16 years of age - PubMed
					

II.




					www.ncbi.nlm.nih.gov
				












						Five-minute Apgar score as a marker for developmental vulnerability at 5 years of age
					

To assess the relationship between the 5 min Apgar score and developmental vulnerability at 5 years of age.Population-based retrospective cohort study.Manitoba, Canada.All children born between 1999 and 2006 at term gestation, with a documented ...




					www.ncbi.nlm.nih.gov
				












						Newborn Apgar score related to teen school performance
					

(Medical Xpress) -- According to a new study published in Obstetrics and Gynecology, the Apgar test which is given to newborns one minute and five minutes after birth to evaluate their health is also an indicator of how they may perform in school when they are teenagers.




					medicalxpress.com
				




"The researchers discovered that infants with an Apgar score of seven or below had twice the risk of special educationrequirements due to cognitive deficits. They noted that one in 44 of the infants with low Apgar scores were enrolled in special education of some kind but that the others were able to perform just fine. These chances of special education, the researchers stress, are not high enough for parents to be concerned if their child has a low Apgar score.
The researchers stress that while this study shows that a low Apgar score, or the medical conditions that may have caused the low Apgar score, may be related to later performance in school, the Apgar score should not be looked to as a prediction of a learning disability. They believe the real connection is in which conditions, such as preterm delivery or infections, caused the low Apgar score and which ones may be affect brain function later in life."

So something is there but not enough to be conclusive it seems...


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## EpiEMS (Feb 21, 2019)

Consensus guidelines seem to suggest AVPU is useful for AMS.

Anecdotally, I prefer AVPU to GCS - I think inter-rater reliability is higher and I'm not convinced that there is a better NPV.

As far as research goes, there's not anything great on outcome predictiveness for GCS vs AVPU in the prehospital setting (my guess is that GCS is better, but less consistent). Though I will note that AVPU is more consistently measured across providers than GCS is.

I'd love to see a study like this comparing outcomes & presenting them in the context of initial presenting GCS and AVPU.


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## cprted (Feb 22, 2019)

GCS was developed to be used to score TBI patients in a clinical setting ... somehow it has become a ubiquitous vital sign to be applied to all patients. Is the ++++ ETOH patient really a GCS (3/2/5) 9? That makes them sound critically ill when really they need a safe place to be monitored while they sleep it off.


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## Aprz (Feb 25, 2019)

You are correct, they are a GCS of 14. I usually say their score and then describe how came to that score (eg, he was alert, disoriented to time, and obeyed commands). Something like that. Like @Gurby, I don't usually use AOx4 or use events. I think "events" vary more than GCS itself, lol, with people ask how many dimes are in a dollar, who is our current president, or considering a syncope patient who didn't remember losing consciousness as disoriented to event. Because there are too many variations in what people consider events, I just avoid it.

That nurse may have just been trying to clarify/understand where the patient was deficient at. "He's a GCS of 14 because he was confused and disoriented to time" and leave it at that.

I think that a lot of us worry about a low GCS being interpreted as critical or abnormal. I consider it just like any other tool where it can be meaningful in the right context. Like being a GCS of 9 is abnormal when you are normally a GCS of 15, right? Being a GCS of 9, but you're always a GCS of 9 because of a stroke 10 years ago, that's no big deal. Also just because you're GCS of 9 compared to you normally being 15 doesn't mean that you are critically ill; It just means your mentation is down for whatever reason, and if that's alcohol, no harm, no foul. If it's a 9 because you got hit by a car, that's obviously not good. I personally overall don't consider GCS to be super useful; It's similar to shock index. An abnormal shock index for someone experiencing tachycardia because they are in SVT/AVNRT is very different from someone who has an abnormal shock index because they are in sepsis or have been bleeding out. Context is important. A lot of these tools are mostly useless and meaningless by themselves.

I don't find GCS hard to calculate, but I do find that there are variations in how people interpret just like "event" in AO questions. I do wish it was a bit more universal. The only time we seem to come up with the same GCS is if they are a GCS 3/dead or GCS of 15, lol. GCS 14 (confused verbally) seem to be somewhat consistent, but not always.


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## akflightmedic (Feb 25, 2019)

I find it interesting that you interpret it as "event" since I do not. Which further illustrates the point you went on to make.

I was taught and always used it as "situation", so in that context someone can and should understand their situation. The person may not remember the event of losing consciousness, but now that they are conscious, do they understand the situation. Event and Situation are two different things. May be semantics...this is simply how I understand it to be.


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## Aprz (Feb 26, 2019)

akflightmedic said:


> I find it interesting that you interpret it as "event" since I do not. Which further illustrates the point you went on to make.
> 
> I was taught and always used it as "situation", so in that context someone can and should understand their situation. The person may not remember the event of losing consciousness, but now that they are conscious, do they understand the situation. Event and Situation are two different things. May be semantics...this is simply how I understand it to be.


If you're talking to me, I completely avoid event and make no interpretation of it at all, but I think you see my point based on how much others people interpretation of it varies. I think it's stupid to consider a patient confused just because they don't remember passing out or having a seizure. I think it's firefighters ways to try to convince patients to go to the hospital with us or feel like they have the power to force the patient to go with us. Ugh.


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## medic2EMSdoc (May 20, 2019)

MedicMcGoo said:


> Seeking opinion on how to chart a particular situation. The patient is alert to person, place, event, but not time. Charting as alert but not answering all questions appropriately. Would this result in a GCS of 14 due to a loss of a point in the verbal category because the patient is not fully oriented.




The original paper and score was developed back in 1994. The scoring of orientation was based upon an orientedconversation which implies awareness of the self (e.g., the patient can answer the question: “What is your name?”) and environment (e.g., the patient correctly answers the questions: “Where are we?” and “What year/month is it?”) which would be recorded as A&O x3 (times three has always meant person, place, and time) x 4 - would include situational awareness but per the original scoring and even the changes that came out in 2014 orientation to situation is not a requirement to score the gcs lower. 
Consistency of applying scoring scales, whether is is GCS or the varied stroke scales helps maintain inter-provider reliability. So always score what you test - but it is helpful if you provide baseline gcs compnents if known (i.e. dementia pt who fell who is oriented x1 at baseline, or paralyzed limbs).

Of note in 2014-the GCS changes changed response to pain - to pressure, recommends providing individial scoring and marking NT = not testable items i.e. no more "3T". A newer less validated gcs-p scale that subtracts points for non-reactive pupils is showing some interesting prognostic data. 

Take a look at www.glasgowcomascale.org for some additional tools and info.


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## Akulahawk (May 23, 2019)

TernionEMSdoc said:


> The original paper and score was developed back in 1994. The scoring of orientation was based upon an orientedconversation which implies awareness of the self (e.g., the patient can answer the question: “What is your name?”) and environment (e.g., the patient correctly answers the questions: “Where are we?” and “What year/month is it?”) which would be recorded as A&O x3 (times three has always meant person, place, and time) x 4 - would include situational awareness but per the original scoring and even the changes that came out in 2014 orientation to situation is not a requirement to score the gcs lower.
> Consistency of applying scoring scales, whether is is GCS or the varied stroke scales helps maintain inter-provider reliability. So always score what you test - but it is helpful if you provide baseline gcs compnents if known (i.e. dementia pt who fell who is oriented x1 at baseline, or paralyzed limbs).
> 
> Of note in 2014-the GCS changes changed response to pain - to pressure, recommends providing individial scoring and marking NT = not testable items i.e. no more "3T". A newer less validated gcs-p scale that subtracts points for non-reactive pupils is showing some interesting prognostic data.
> ...


Actually the original paper was published in 1974. Otherwise I couldn't have learned about it in 1988, if it had been initially published in 1994.


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## medic2EMSdoc (May 23, 2019)

Yep, that was a typo - saw it after I posted it and your can not edit posts. Thought it was such a small part of my post that the correction was not really that important but thanks for clarifying it for the forum. 

Clarification: Original paper for the glasgow coma scale was in 1974. 

Take a look at www.glasgowcomascale.org for some additional tools and info.


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## Eli (May 29, 2019)

Peak said:


> GCS, like APGAR, has essentially no predictive value and doesn't really have a good place in modern medicine. It is far more valuable to simply describe what is abnormal than to chart a score.



I don't agree. The GCS is good for what it is intended. It quantifies in a narrow scope the results of a very superficial neuro exam in a manner that be easily communicated in a rapid manner to illustrate the result of the exam. Team members not with a patient can spend 5,6, 10 sentences explaining a patient's general neuro state or they could shoot of the GCS and accomplish the exact same thing with no loss of clarity in 1 second. In the realm of triaging and preparing to care for trauma patients, stroke patients, and so forth, this enhances the efficiency of the care delivered. Not can enhance.... does enhance. All this is how I've come to look at it over that years at least.

Cheers.


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## mgr22 (May 29, 2019)

Eli, can you cite any research that confirms GCS accuracy? Are you claiming its principal benefit is shorter hospital reports?

Here's one study that raises questions about use of GCS:









						Glasgow Coma Scale Scoring is Often Inaccurate.
					






					read.qxmd.com


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## Eli (Jun 3, 2019)

Thanks mgr. But I don't need research data to supplement my years of experience with the strengths and weakness of the GCS. It is a tool that has value, but it doesn't tell anything other than a quick story. That all it was ever intended for and it works well in that regard. If a medic is the type that thinks he must intubate someone with a GCS of 8 and can't intubate someone with a GCS of 9, well that medic needs some training and experience. Thanks for the link though. Cheers.


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## akflightmedic (Jun 3, 2019)

https://en.wikipedia.org/wiki/Dunning–Kruger_effect


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