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Eyes: There really are very few choice for getting someone to open their eyes when their eyes are closed, wouldn’t you agree? You can talk to them and you can physically stimulate them. That’s about it. There are a few subtleties however. Voice means loud voice. If someone is simply relaxing and you speak to them and they open their eyes, we score them as spontaneous (4). Likewise, pain means painful or noxious stimuli. If we give someone a gentle shake and they open their eyes we’re still going to score them as verbal (3).

Verbal Response: The patients verbal responses are somewhat more complex. The range of possible verbal responses are considerably more varied so we add an additional criteria. People who are oriented (5) speak in context and understand the classic who, where, what questions of orientation. People who are confused (4) still form sentences in context with the conversation. When they speak they reveal that they are misunderstanding their reality. They are at the bus stop but they think they are at home. They are unable to tell you who they are, etc. Inappropriate words (3) doesn’t imply that the patient is being profane. Patients can be socially inappropriate and still be completely oriented. Inappropriate implies that they speak completely out of context or they speak word salad. You ask, “Where are you?” and they reply, “Potato salad.” or, to quote Steve Martin, “Can I go mambo dog-face to the banana patch?” They speak real words, but those words are out of order or context. When the real words turn into sounds we transition to incomprehensible (2). If the patients response is comprised completely of vowels, or words that don’t belong to any language, they are incomprehensible.

Motor Response: This one can be challenging as well. The confusion with the lower motor scores often lies with recognizing the difference between localizing pain (5) and withdrawing from pain (4), and the difference between decorticate (flexion) (3) and decerebrate (extension) (2) posturing. Let’s look at both pairings.

Localizing pain (5) is not recognition of where the pain is located. That’s a common misconception. The patient who is able to localize pain can cross the midline and use resources on the other side of their body to remove that pain. Let’s take the example of starting an IV on a confused patient. If your patient simply pulls the hand that you are starting the IV in away from you, they have withdrawn from pain (4). If they use the opposite hand to cross the midline and try to push the stimulus away, they have localized the pain. In both cases they recognize where the pain is located but only in the second example did they recognize and use resources on the opposite side of their body to cross the midline and attempt to remove the stimulus.

If the painful or noxious stimulus is on the head (ie. insertion of a nasopharangeal airway) the clavicals are used as a marker. If the patients hand is able to rise above the level of the clavicle, the patient has localized the pain.

Decorticate Posturing By: Scleroplex

Flexion (3), also known as decorticate posturing and extension (2), also known as decerebrate posturing are both signs of increased intracranial pressure, or occasionally, brain hypoxia. They tend to be associated with poor outcomes in head injury patients. Flexion (3) involves the contraction of the muscle groups in the anterior arms and the relaxation of the muscle groups in the posterior arms. The arm curl inward toward the midline and the wrists flex. Extension (2) is the contraction of the posterior arm muscle groups and the relaxation of the anterior arm muscles. The arms straiten. The shoulder flexes inward and the hands drift away from the body. The wrists straiten as well. Posturing may also be seen in the legs.

The last thought I’ll leave you with on the Glasgow is one that I repeat frequently in my writings. If you want to be good at anything you need to practice. When you encounter disoriented, confused, combative or unconscious patients, practice factoring in the Glasgow. If you find that you’re not ready to do it on the fly yet, write it down and work through it on your trip report after the fact. The more you practice, the more at ease you’ll become, and perhaps you’ll be ready when you’re calling that trauma alert and the surgeon requests a quick Glasgow Score. (http://theemtspot.com/2009/02/05/remembering-the-glasgow-coma-score/)

Decerebrate posture is characterized by adduction (internal rotation) and extension of the arms, with the wrists pronated and the fingers flexed. The legs are stiffly extended, with forced plantar flexion of the feet. In severe cases, the back is acutely arched (opisthotonos). Decerebrate posture indicates upper brain stem damage, which may result from primary lesions, such as infarction, hemorrhage, or tumor. Other causes include metabolic encephalopathy, head injury, and brain stem compression associated with increased intracranial pressure (ICP).Decerebrate posture may be elicited by noxious stimuli or may occur spontaneously. It may be unilateral or bilateral. With concurrent brain stem and cerebral damage, decerebrate posture may affect only the arms, with the legs remaining flaccid. Decerebrate posture may also affect one side of the body and decorticate posture the other. The two postures may also alternate as the patient’s neurologic status fluctuates. Generally, the duration of each posturing episode correlates with the severity of brain stem damage. (See Comparing decerebrate and decorticate postures.) Act Now: Upon initial assessment of the decerebrate posture, your first priority is to ensure a patent airway. Insert an artificial airway and institute measures to prevent aspiration. (Don’t disrupt spinal alignment if you suspect spinal cord injury.) Suction the patient as necessary.

Next, examine spontaneous respirations. Give supplemental oxygen, and ventilate the patient with a handheld resuscitation bag, if necessary. Intubation and mechanical ventilation may be indicated. Keep emergency resuscitation equipment handy. Be sure to check the patient’s chart for a do-not-resuscitate order. ((http://www.wrongdiagnosis.com/symptoms/decerebrate_posturing/book-causes-13a.htm).)