Neuromuscular System: Glasgow Coma Scale and Concussion

Which of the following Glasgow Coma Scale scores indicates severe brain injury? 7 9 11 14

A Scores less than or equal to 8 on the Glasgow Coma Scale indicate severe brain injury. Options 2 and 3 represent moderate injury and Option 4 represents mild injury.

concussion grade 2

- moderate head injury - transient confusion that lasts longer than 15 minutes - pt may exhibit poor concentration, retrograde and anterograde amnesia - requires CT scan to check for further damage - athlete removed from play immediately for medical eval - pt should be asymptomatic for 2 weeks at rest and with exertion

concussion grade 1

- no loss of consciousness, but transient confusion by the pt - sx will typically resolve wi/n 15 min of event - pt may exhibit full moemory of event - athlete should be reomoved from the competition and only return if sx free after 1 week of rest

concussion grade 3

- head injury with any form of loss of consciousness - requires emergency response and if severe enough can result in coma - full neuro exam - no return to play until pt is sx free for at least 1 mo - secondary to diffuse axonal injury

what are the levels of Ranchos Los Amigos Levels of Consciousness?

1. No Response 2. Generalized Response 3. Localized Response 4. Confused Agitated 5. Confused Inappropriate 6. Confused Approrpriate 7. Automatic Appropriate 8. Purposeful Appropriate

A score of 5 on the Glasgow Coma Scale indicates: severe head injury severe spasticity moderate head injury moderate spasticity

A The Glasgow Coma Scale is a reliable, objective assessment of the conscious state of a person. The scale is graded from 3-15 with 3 being the lowest possible score and 15 being the highest possible score. A score of 8 or less is indicative of a severe head injury.

Which level of the Rancho Los Amigos Levels of Cognitive Functioning Scale would be characterized by non-purposeful reactions to stimuli? Level I - No Response Level II - Generalized Response Level III - Localized Response Level IV - Confused-Agitated

B Level II - Generalized Response is characterized by the patient reacting inconsistently and non-purposefully to stimuli in a nonspecific manner. Responses are limited and often the same regardless of the stimulus presented.

Which level on the Rancho Los Amigos Levels of Cognitive Functioning Scale would be most appropriate for a patient who responds specifically, but inconsistently to stimuli? Level II Level III Level V Level VII

B Patients who respond specifically but inconsistently to stimuli would be considered Level III - Localized Response on the Rancho Los Amigos Scale. These patients are able to respond directly to the type of stimulus and may follow simple commands inconsistently.

Which patient response in the motor component of the Glasgow Coma Scale would receive the largest score? extensor response follows motor commands localizes withdraws

B Scoring in the motor component of the Glasgow Coma Scale: follows motor commands = 6, localizes = 5, withdraws = 4, abnormal flexion = 3, extensor response = 2, no response = 1.

Which of the following scores on a Glasgow Coma Scale is indicative of a moderate brain injury? 6 8 10 13

C The Glasgow Coma scale is utilized to measure brain injury severity. According to the scale, a moderate brain injury is associated with a score between 9-12. The minimum score on the scale is 3 and the maximum score is 15.

Which level of the Rancho Los Amigos Levels of Cognitive Functioning Scale is characterized by appropriate orientation to situations within the home and hospital settings, but continues to demonstrate impaired judgment? Level VI - Confused-Appropriate Level V - Confused-Inappropriate Level VII - Automatic-Appropriate Level VIII - Purposeful-Appropriate

C Level VII - Automatic-Appropriate is characterized by the patient appearing appropriate and oriented within the hospital and home settings. The patient shows little to no confusion and has some recall of activities. Judgment remains impaired, but the patient is able to initiate social or recreational activities with structure.

Which level of the Rancho Los Amigos Levels of Cognitive Functioning Scale is characterized by the patient no longer requiring supervision once tasks have been learned? Level V - Confused-Inappropriate Level VI - Confused-Appropriate Level VII - Automatic-Appropriate Level VIII - Purposeful-Appropriate

C Level VIII - Purposeful-Appropriate is characterized by the patient's ability to recall past and recent events and responsiveness to the environment. The patient no longer requires supervision once a task is learned. The patient may continue to have impairments with abstract reasoning, tolerance for stress, and judgment in emergencies or unusual circumstances.

What is the highest attainable score on the Glasgow Coma Scale? 6 12 15 18

C The Glasgow Coma Scale is a neurological assessment tool used initially after injury to determine arousal and cerebral cortex function. The assessment tool utilizes an ordinal scale ranging from 3-15 with a higher score representing a greater level of consciousness.

What is the most appropriate approach to use when treating a patient who is at the Confused-Agitated level on the Rancho Los Amigos Levels of Cognitive Functioning Scale? verbally quiz the patient on the previous treatment force the patient to adhere to the therapy plan administer random practice activities provide the patient with choices of treatments

D During the Confused-Agitated level, the patient will likely have a limited attention span and may not be able to concentrate on an activity for a long time. At this level, it is important to provide some control to the patient while maintaining safety. This can be done by giving the patient treatment options.

Which stage of the Rancho Los Amigos Levels of Cognitive Functioning Scale is characterized by the patient showing goal-directed behavior dependent on external cues and the ability to relearn simple tasks? Level III - Localized Response Level IV - Confused-Agitated Level V - Confused-Inappropriate Level VI - Confused-Appropriate

D Level VI - Confused-Appropriate is characterized by goal directed behavior that is dependent on external input or direction. The patient follows simple commands consistently and demonstrates the ability to relearn simple tasks. Past memories show more depth and detail than recent memories.

Which description is most consistent with a patient that is classified as Level I - No Response on the Rancho Los Amigos Levels of Cognitive Functioning Scale? unresponsive to auditory stimuli unresponsive to visual stimuli unresponsive to pain stimuli unresponsive to any stimuli

D Rancho Los Amigos Levels of Cognitive Functioning Scale will also assist to classify the level of injury based on where the patient best meets the criteria of each level. Level I - No Response is described as the patient appearing to be in a deep sleep and completely unresponsive to any stimuli.

T/F: lowest score on the GCS is a 0/15

FALSE. 3/15

T/F: coma is uncommon in patients with a GCS of 3-8.

FALSE. 90% are in a coma

T/F: A characteristic of confused inappropriate is carryover of relearned tasks

FALSE. confused appropriate

No Response

Level 1 RLA: - coma - appears to be sleeping - NO response to ANY stim

Purposeful Appropriate - Modified Independent

Level 10 RLA: - independent with everythingwithin their functional abilities - return to work, school etc.

Generalized Response

Level 2 RLA: - vegetative state - inconsistent and NON-purposeful response to stim - responses can be physiological, movement and/or vocal

Localized Response

Level 3 RLA: - minimally conscious state - inconsistent and specific response - specific = response is directly related to the stimulus presented - may follow command like closing eyes or squeezing hands - not purposeful - that would indicate a higher level of awareness

Confused Agitated

Level 4 RLA: - heightened state - non-purposeful behavior/response: usually incoherent and inappropriate - gross attention to environment is brief; NO selective attention - unable to cooperate directly with PT; min response to commands - no short or long term recall

Confused Inappropriate

Level 5 RLA: - less heightened state - can demonstrate simple conversing for short periods BUT still usually inappropriate - gross attention to enviroment intact, but very distractable; NO selective attention - fairly consistent response to simple commands, but fragmented/non-purposeful response to more complex commands - memory still impaired

Confused Appropriate

Level 6 RLA: - goal directed behavior BUT depends on external stim or direction - consistent response to simple tasks, with carryover for relearned tasks like self-care - appropriate response, possibly confused d/t memory - memory returns: better older mems than recent

Automatic Appropriate

Level 7 RLA: - judgement is still impaired - min to no confusion; completes daily routine automatically ONLY(robot) - can initiate social or recreational activities - carryover for new learning but at decreased rate - appropriate and oriented in hospital and home setting - memory: shallow recall for activities

Purposeful Appropriate

Level 8 RLA: - improved judgement but still may have decreased ability for pre-accident activities, tolerance for stress, judgement in emergencies or atypical situations - appropriate awareness to environment - carryover for new learning, no supervision once activities are learned - memory: can recall and integrate events

Purposeful Appropriate - Stand by Assist on Request

Level 9 RLA: - gradual increase in independence - can think about the consequences of their actions - awareness of fatigue - needs reminders to adapt to task, feels frustrated with limits

T/F: carry over new tasks is a characteristic of automatic appropriate

TRUE

T/F: patients in the generalized response stage may respond to stimuli with vocalizations

TRUE

Using the Rancho Los Amigos Levels of Cognitive Functioning Scale, a patient with a heightened state of activity, confusion, disorientation, aggressive behavior, inability to perform self-care, and lack of awareness of present events would be classified as: Level III Level IV Level V Level VI

Rancho Los Amigos Levels of Cognitive Functioning Scale will also assist to classify the level of injury based on where the patient best meets the criteria of each level. Level IV - Confused-Agitated is defined as: Patient is in a heightened state of activity. Behavior is bizarre and non-purposeful relative to the immediate environment. Does not discriminate among persons or objects; is unable to cooperate directly with treatment efforts. Verbalizations frequently are incoherent and/or inappropriate to the environment; confabulation may be present. Gross attention to environment is very brief; selective attention is often nonexistent. Patient lacks short and long-term recall.

Spontaneous eye opening on the Glasgow Coma Scale would receive a score of: 1 2 3 4

Scoring in the eye opening component of the Glasgow Coma Scale: spontaneous = 4, to speech = 3, to pain = 2, no response = 1.

What three categories does the Glasgow Coma Scale evaluate? a) tone, breathing, reflexes b) motor response, verbal response, respiratory function c) eye opening, motor response, verbal response d) eye opening, verbal response, tone

The Glasgow Coma Scale is a neurological assessment tool used initially after injury to determine arousal and cerebral cortex function. A total score of eight or less correlates to severe brain injury and coma in 90% of patients.

Which parameter is not assessed as part of the Glasgow Coma Scale? eye opening motor response reflex response verbal response

The Glasgow Coma Scale is a neurological assessment tool used initially after injury to determine arousal and cerebral cortex function. The assessment tool examines eye opening, motor response, and verbal response.

What is the minimum score obtainable on the Glasgow Coma Scale? 0 1 2 3

The Glasgow Coma Scale is a neurological assessment tool used initially after injury to determine arousal and cerebral cortex function. The minimum score on the Glasgow Coma Scale is 3 and the maximum score is 15.

Which level of the Rancho Los Amigos Levels of Cognitive Functioning Scale is characterized by the ability to respond purposefully to simple commands, but verbalization is often inappropriate with confabulation? Level III - Localized Response Level IV - Confused-Agitated Level V - Confused-Inappropriate Level VI - Confused-Appropriate

evel V - Confused-Inappropriate is characterized by the ability to respond to simple commands rather consistently. Responses to more complex commands become non-purposeful, random or fragmented. Verbalization is often inappropriate and confabulatory. The patient is still unable to learn new information at this stage.

match: eye opening motor response verbal response 1-5 1-6 1-4

eye opening: 1-4 motor response: 1-6 verbal response: 1-5

What is the Glasgow Coma Scale score of a patient who withdraws from pain, converses but is confused, and opens his eyes spontaneously? 6 9 12 15

Verbal: 4 Eye Response: 4 Motor: A patient who withdraws from pain scores 4 out of 6 points on the motor response scale. A patient who is able to carry on a conversation but is confused scores 4 out of 5 on the verbal response scale. Spontaneous eye-opening earns 4 out of 4 points on the eye-opening scale. Added together, this patient scores 12 out of 15. The patient is probably not in acute danger, but should be monitored.

Glasgow Coma Scale

eyes, verbal, motor Max- 15 pts, below 8= coma

stupor

general unresponsiveness with arousal from repeated stim

obtundity

state of consciousness that is characterized by a state of sleep, reduced alertness to arousal, and delayed responses to stimuli

Clouding of consciousness

state of consciousness that is characterized by quiet behavior, confusion, poor attention, and delayed responses