Goodbye GCS!

Summary by: Mark Wilson

Consciousness comprises “wakefulness” (that’s the brain stem, opening your eyes component) and “content” (that’s the supratentorial, thinking, “someone’s home” component). You can have wakefulness without content (e.g. persistent vegetative state) but not content without wakefulness.

Describing a “level” of consciousness, converting this multifaceted human brain ability into a linear scale was possibly the biggest neuroscience break through of the 20th Century. The 1974 Lancet paper in which Brian Jennet and Sir Graham Teasdale proposed the Glasgow Coma Scale (GCS) is certainly the most cited neuroscience paper. We had even put a man on the moon before this had been created. It’s relative simplicity and repeatability meant GCS was rapidly taken up across the world. Now 40 years on, is it out of date?

There are problems with the GCS – it doesn’t include pupil response, it doesn’t look at ventilation or other autonomic functions hence other systems such as the 4 score system have been proposed. But these take longer, and are poorly known so cannot be used like GCS to rapidly convey in a meaningful way the level of consciousness of a patient between clinicians.

In this talk Mark Wilson goes through the history of the GCS and other conscious measures… is it time to say Goodbye to GCS?


Direct download: Day_3_C23_Mark_Wilson.mp3
Category:general -- posted at: 6:00am AEST

One of the many things that we, as intensivists or emergency physicians, do better than anyone in the business is obtain the emergent airway. We are usually introduced to our patients on the worst days of their lives and even though we may sometimes wish for it, we do not have the option to reschedule our intubations. Smashed, bloody, distorted, edematous airways secondary to trauma, anaphylaxis, and GI bleeds are the commonality not the exception. We manage those airways routinely with nary a complaint or even a hither for a better look at the glottis than what we can obtain. We often feel lucky to even get a glimpse of the arytenoids much less something that actually resembles normal laryngeal anatomy.

Personally, if I knew that I would need to be intubated today, that my airway would be a bloody, edematous, traumatic mess and there was only chance for one person to take a shot at placing the tube, then I would pray to God that the last face I saw before the Roc and Ketamine pushed me asunder was the familiar grill of one of my EM/critical care colleagues. Who better to bet all my chips on then someone who deals with the most difficult airways on the face of the planet as part of their daily routine?

The EM doc or critical care provider can not only get that airway, but is so relaxed about it that they will often casually check on the patient in the next bed before and after the intubation. That’s the confidence I’m looking for when it comes to the fast-paced life and death world of emergency airway. Now put a child’s life on the line. Are you ready to intubate what was a perfectly healthy three year old two hours before trauma threatened their life and placed their airway in your hands? You will be...

Andrew Sloas DO, RDMS, FACEP, FAAEM, FAAP Editor-in-Chief: The PEM ED Podcast

Direct download: Are_we_Masters_of_the_Paediatric_Airway-_Andy_Sloas.mp3
Category:general -- posted at: 1:30pm AEST