GCS: Saying What We Mean

The Gist:  The Glasgow Coma Scale (GCS) is widely used, yet complicated by clunkiness and poor inter-rater reliability (explanation of kappa).  The Simplified Motor Score (SMS) is easier to use and equivalent, although this is prone to similar limitations.  Until a better means of communicating mental status comes, it may be best to communicate what the patient is doing (opening eyes to voice, moaning incomprehensibly, localizing pain). See this ScanCrit post.

The Case: A 29 year old male involved in a MVC with multiple traumatic injuries resulting in a prolonged ICU course at Janus General had a tracheostomy placed for respiratory failure.  The patient was responding appropriately to questions, following commands, opening his eyes spontaneous and lacked any signs of confusion or delirium, mouthing words, but was awaiting tracheostomy exchange for a fenestrated trach with a Passy-Muir valve.  What's the patient's GCS? Does this patient's GCS reflect their mental status?
  • Documented at as 10NT, 11T, and 15 by various providers.  The arguments behind each: 10NT - cannot test verbal, 11T -one point for showing up, 15 -patient oriented, and saying appropriate words, just without phonation.
In medicine, we communicate through abbreviations, codes, and numbers. When we see heart rate or blood pressure values we can place these numbers in the context of our knowledge of the patient’s peers. These numbers become actionable.  

Other critical components to the physical exam and evaluation are less easily quantified.  The mental status, for example, is a key component to evaluating a patient.  The GCS was developed to communicate the mental status of a head injured individual among providers during continuing care in a neurosurgical unit [1].  It is often used to track neurologic status when transferring care or over time.  A particular GCS in the prehospital setting may also qualify a patient for a trauma activation in some settings. 

Limitations: Unfortunately, unlike other vital signs, scores don't have explicit meaning.  The total GCS is often reported, yet this 13 point scale (3-15) actually has 120 different possible combinations.  A patient with a GCS of 10 may be completely oriented but totally paralyzed or be moaning incomprehensibly with their eyes own and a withdrawal reflex present.  Further, the sum of the GCS does not equal the parts, with regard to mortality. Healey et al used the National Trauma Database to model mortality predictions based on GCS and found that the same total sum score could be associated with double the mortality (ex: from 27% to 52%) depending on the individual components. Further, the mortality associated with scores is not linear [3].  So a GCS of 11, for instance may mean very different things for two different patients.

Yet, even if the numbers did mean something, the GCS has been found to have abysmal inter-rater reliability.  In one study, 19 emergency physicians rated 131 patients within five minutes of each other found a concordant GCS 32% of the time (Spearson's rho 75, weighted kappa 0.40) [4].   Even in the rather protected setting of case based written scenarios, emergency providers the overall GCS accuracy was 33.1% (95% CI, 30.2-36.0) [5].  In a written mock scenario, EMS personnel (n=178) generated an accurate GCS one-quarter of time without a scoring aid and a shocking 57% with the use of a scoring aid [7].

Alternatives: Given the inaccuracy of the GCS, Thompson et al set out to determine whether the performance of the SMS, a truncated version of the GCS was equivalent to the GCS in a retrospective cohort of out of hospital head injured patients. In the SMS, points are awarded for obeying commands (2), localizing pain (1), and withdrawing to pain or worse (0). They found that the predictive nature of the SMS paralleled that of the GCS, although the GCS seemed to predict mortality slightly better,  0.90 using GCS (0.88-0.01) vs 0.87 using SMS (0.86-0.88) [7].

So, what do we do?
Trashing the GCS is simply not an option for most of us; yet, score cards don't seem to do us any favors.  For example, during a trauma activation, the expectation (at least at Janus General) is to communicate to the room the patient’s GCS.  This may seem to convey more neurologic information than the actual exam discriminates. Recognizing the limitations to the GCS is important in discerning both what we do with this information and how we communicate what we mean, whether it's in documentation, to other providers, or family members.

  • Describe the exam.  With the knowledge of the subjectivity and poor reliability of the GCS, one may give the breakdown of points rather than a simple total GCS and describe the neurologic examination.  Documenting descriptors in medical records this may aid other teams in tracking the patient's exam.  
  • We may also engage in interdisciplinary discussions about use of simplified scoring systems such as the SMS or about the ways we communicate and document neurologic exams. 
1. Green SM. Cheerio, laddie! Bidding farewell to the Glasgow Coma Scale. Ann Emerg Med. 2011;58(5):427–30. doi:10.1016/j.annemergmed.2011.06.009.
2. Singh B, Murad MH, Prokop LJ, et al. Meta-analysis of Glasgow Coma Scale and Simplified Motor Score in predicting traumatic brain injury outcomes. 2013;27(March):293–300. 
3. Healey C, Osler TM, Rogers FB, et al. Improving the Glasgow Coma Scale score: motor score alone is a better predictor. J Trauma. 2003;54(4):671–678; discussion 678–680. 
4. Beveridge R, Ducharme J, Janes L, Beaulieu S, Walter S. Interrater reliability of Glasgow Coma Scale scores in the emergency department. Ann Emerg Med. 2004;43(February):215–223. 
5. Bledsoe BE, Casey MJ, Feldman J, et al. Glasgow Coma Scale Scoring is Often Inaccurate. Prehosp Disaster Med. 2014. doi:10.1017/S1049023X14001289.
6. Feldman A, Hart KW, Lindsell CJ et al. Randomized controlled trial of a scoring aid to improve glascow coma scale scoring by emergency medical services providers. Ann Emerg Med. 2015 Mar;65(3):325-329.e2.
7. Thompson DO, Hurtado TR, Liao MM, Byyny RL, Gravitz C, Haukoos JS. Validation of the Simplified Motor Score in the out-of-hospital setting for the prediction of outcomes after traumatic brain injury. Ann Emerg Med. 2011;58(5):417–25. 

FOAM on the Spot – A Needle in a Haystack?

At the SAEM conference, I had the privilege of partaking in a didactic with Dr. Anand Swaminathan, Dr. Ryan Radecki, and Dr. Matt Astin entitled, "FOAM on the Spot - Integration of Online Resources into Real-Time Education and Patient Care."

The cornucopia of free open access medical education (FOAM) resources may be overwhelming and I get frequent requests for guidance sorting through the cornucopia of FOAM.  People often have the question, "I remember hearing about this technique but I can't recall which site and want to review it..."  As such, I've posted a recording of my portion of the didactic here.

The Gist:
  • Filter FOAM by searching relevant information - FOAMsearch [1].
    • Customized Google search engine of 300+ blogs related to EM/critical care plus journal articles.
  • Engage in the community of personal librarians - Twitter (a few pearls on Twitter)
    • Tag others when you have a question
    • Participate in discussions and "be the librarian" for others.
  • Use a system to stay organized and collate resources - AgileMD.
    • Pro - Can collate several FOAM blogs, PV cards from Academic Life in Emergency Medicine, WikEM, and podcast notes all in one application on a smart phone/tablet.
    • Con - Presently can only build a "library" from a limited number of resources.
As a rather junior individual, selfishly, always welcome constructive feedback on my talks. This is my experiment in crowdsourcing feedback from the FOAM community to become a better presenter.

1. Raine T, Thoma B, Chan TM, Lin M. FOAMSearch.net: A custom search engine for emergency medicine and critical care. Emerg Med Australas. 2015;(March):n/a–n/a. doi:10.1111/1742-6723.12404.

Medicine’s Third: Polypharmacy

The Gist: Polypharmacy, the concurrent use of multiple medications (5+) or use of unnecessary medications, is problematic in medicine.  Consider “medication related problem” on the differential diagnosis and review the patient’s medications.  When prescribing a medication, consider the unwanted reactions and tailor therapy, recalling that medications frequently have subtle or additive effects that may be especially problematic in the elderly. When in doubt, send a communication to a patient's PCP.

The Case: A 58 y/o with a history of hypertension and diabetes presented with weakness, vomiting, and fatigue.  A basic chemistry panel returned with a creatinine of 3.8 mg/dL (last value, 0.9 mg/dL).  While initially it seemed as though the gentleman had prerenal acute kidney injury from vomiting, the patient revealed he had been taking both ibuprofen and naproxen for worsening arthritis, in addition to his prescribed ace-inhibitor and thiazide diuretic.  See another case in this post on medication reconciliation.

Newton's Third Law states:
"For every action there is an equal and opposite reaction.” 

We ponder this frequently looking at collisions or calculating billiard shots but I think this principle can be translated to medicine. In the medical realm we prescribe therapies for the primary action of that medication/intervention.  Yet, unintended consequences abound.  Despite the comically long “disclaimers” of side effects on advertisements, the additive effects, unintended as they may be, are often disguised in a patient’s presenting complaint.  Further, patients are often prescribed medication to mask the side effects of another medication. Struck by this during medical school, I created my own version:
Westafer’s Third Law of Medicine:
 “For every medication action there is an unequal and unintended reaction.” 

This came up recently in a discussion on Twitter regarding a new medication for hyperkalemia, targeted to combat the side effect of elevated potassium in patients on ACE-inhibitors, ZS-9. A medication for a medication side effect (with likely more broad application in reality).

Although prescriptions from the emergency department (ED) are likely a minority of offenders with regard to the volume of inappropriate medications, awareness of the role that medications may play in the patient’s complaint. Studies show that adverse drug events (ADEs) may be responsible for 10-12% of ED visits among patients > 65 years old, although the definition of adverse drug event and determination of causality vary based on the study [1-3].   A more recent Canadian database review demonstrated a lower prevalence of ADEs generating ED visits, 0.8%, but the methods leave something to be desired [4].

A small study by Chin and colleagues identified ED prescriptions for analgesia, notably NSAIDs, muscle relaxants, and narcotics, as an area for future intervention [5].  Interestingly, this paper was published prior to the massive spike in opioid prescriptions; thus, this area may be even more crucial presently [6].  

Polypharmacy, particularly in the elderly, is associated with an increase in the prevalence of falls, mortality, hospital admission, and hospital length of stay.  The elderly are more susceptible to many of these effects as clearance and metabolism change with age, and elderly patients tend to be on more medications. 

Drug-drug interaction - A medication alters the activity of another.  Example: warfarin + ciprofloxacin -> supratherapeutic INR and may lead to increased bleeding.
Drug-disease interaction - Medications that should be avoided in patients with specific medical conditions.  
  • Example: Use of aspirin 325 mg or non-steroid anti-inflammatories in patients with peptic ulcer disease.
Adverse effects - Many medications have more pronounced adverse effects in elderly patients, often because the pharmacokinetics, such as renal excretion, are altered and may predispose patients to acute kidney injury, delirium, or orthostatic hypotension.  Check out this podcast for more.
  • Example: Anticholinergic properties are abundant in medications, including antidepressants, antihistamines, and antipsychotics.  In the elderly these effects are more pronounced and are associated with hallucinations, impaired memory, tachycardia, falls, constipation, etc.
Unnecessary - Medications are frequently initiated and then continued without re-examination for appropriateness. A study of Veterans Association hospital discharges of patients age >65 y/o classified as "frail" found that 44% had at least one unnecessary medication at discharge [8]. These medications contribute to increase cost and may play a role in further drug interactions or adverse effects. 
  • Example: A H2 blocker such as ranitidine may be prescribed for prophylaxis but the anticholinergic effects can contribute to diminished cognition, constipation, etc (see above).
Under-recognized  A prospective observational study by Hohl and colleagues of ED patients > 65 y/o in Canada found ADEs in 8.3%-12.3%, depending on the breadth of the definition of ADEs.  A prospective study by Hohl et al found that many ADEs in the ED were not attributed as medication related, particularly in the older population [9]. 

ED Interventions
  • Consider the Third Law of Medication when pondering the differential diagnosis.  For example, geriatric fall patients should probably be screened for polypharmacy (What medications is the patient on?  Can the problem be explained by a medication?) and while prescribing medications (Is the medication truly necessary? Will it interact with any of their medications?  Does the patient need a bowel regimen or other precautions?)
  • Medication review in the ED.  The ED encounter can serve as an opportunity for an outsider to glance at the patients medications to gain a sense as to whether something may be dangerous or warrant further discussion with their primary physician.
  • Judicious prescription of medications.  In the ED, we often write for short courses of medication and may be lulled into the sense that these prescriptions don't matter, yet they may carry an unintended reaction.  Be familiar with medications that are common offenders.
    • The Beers' List has a long list of medications to avoid in the elderly, but often these aren't the biggest offenders (also note the STOPP criteria). The most common medications associated with ADEs, implicated in 67% of hospital admissions according to a national survey database, were: 
      • warfarin (33.3%)
      • insulins(13.9%)
      • oral antiplatelet agents (13.3%)
      • oral hypoglycemic agents (10.7) [1,4]
  • Targeted feedback to general practitioners regarding potentially problematic medications.  Many health systems and electronic medical records have easy ways to send messages to primary care physicians.  In the ED haste, these communications frequently take a back seat but may be important.  Yet, the ACEP Geriatric ED guidelines recommend referral to PCP for any concern for polypharmacy (>5 medications) or presence of any high risk medication [10].
  • ED pharmacists. Many study authors have called for increasing the role of ED pharmacists in identifying ADE related to medications [2].
1.Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011;365:(21)2002-12. 
2. Banerjee A, Mbamalu D, Ebrahimi S, Khan AA, Chan TF. The prevalence of polypharmacy in elderly attenders to an emergency department - a problem with a need for an effective solution. Int J Emerg Med. 2011;4(1):22.
3. Budnitz DS, Shehab N, Kegler SR, Richards CL. Medication use leading to emergency department visits for adverse drug events in older adults. Ann Intern Med. 2007;147:(11)755-65.
4.Bayoumi I, Dolovich L, Hutchison B, Holbrook A. Medication-related emergency department visits and hospitalizations among older adults. Can Fam Physician. 2014;60:(4)e217-22. 
5. Chin MH, Wang LC, Jin L, et al. Appropriateness of Medication Selection for Older Persons in an Urban Academic Emergency Department. Acad Emerg Med. 2007;6(12):1232–1242.
6. Ruscitto A, Smith BH, Guthrie B. Changes in opioid and other analgesic use 1995-2010: Repeated cross-sectional analysis of dispensed prescribing for a large geographical population in Scotland.Eur J Pain. 2015 Jan;19(1):59-66. 
7. Robitaille C, Lord V, Dankoff J, et al. Emergency Physician Recognition of Adverse Drug-related Events in Elder Patients Presenting to an Emergency Department. 2005;12(3). 
8.Hajjar ER, Hanlon JT, Sloane RJ, et al. Unnecessary drug use in frail older people at hospital discharge. J Am Geriatr Soc. 2005;53:(9)1518-23. 
9. Hohl CM, Zed PJ, Brubacher JR, Loewen PS, Purssell RA. Do Emergency Physicians Attribute Drug-Related Emergency Department Visits to Medication-Related Problems? YMEM. 2009;55(6):493–502.e4. 
10.American College of Emergency Physicians. Geriatric emergency department guidelines 2013