What is the management approach for patients with severe brain injuries using the Glasgow Outcome Scale?

Management Approach for Severe Brain Injuries Using the Glasgow Outcome Scale

The management of severe traumatic brain injury should focus on systematic assessment using the Glasgow Coma Scale (specifically the motor response component), pupillary size and reactivity, and aggressive correction of systemic factors that could cause secondary cerebral insults to improve outcomes on the Glasgow Outcome Scale. 1

Initial Assessment and Monitoring

• Assess severity of traumatic brain injury using the complete Glasgow Coma Scale, documenting each component (Eye-Verbal-Motor) separately, with particular attention to motor response which remains robust even in sedated patients 1
• Evaluate pupillary size and reactivity as these are key predictors of neurological outcome at 6 months 1
• Perform repeated neurological examinations to detect secondary deterioration, with frequency based on TBI severity: every 30 minutes for first 2 hours, then hourly for 4-12 hours for moderate TBI (GCS 9-13) 1, 2
• A decrease of at least two points in the GCS should prompt immediate imaging with a second CT scan 1
• Document baseline function to allow for accurate assessment of recovery using the Glasgow Outcome Scale (GOS) or extended version (GOSE) 3, 4

Prevention of Secondary Brain Injury

• Investigate and correct systemic factors that can cause secondary cerebral insults, which significantly impact mortality and functional outcomes 1, 2
• Maintain systolic blood pressure above 110 mmHg to ensure adequate cerebral perfusion, as hypotension is strongly associated with poor outcomes 1, 2
• Prevent and promptly correct hypoxemia (SaO₂ <90%), which significantly worsens neurological outcomes 2
• The combination of hypotension and hypoxemia is particularly dangerous, with mortality rates as high as 75% 2

Diagnostic Imaging

• Obtain immediate brain and cervical CT scan for severe TBI (GCS ≤8) and prompt imaging for moderate TBI (GCS 9-13) 2
• For mild TBI (GCS 14-15) with risk factors (loss of consciousness, post-traumatic amnesia, headache, vomiting, age >60), CT scan is indicated 2
• Consider CT-angiography if risk factors for vascular injury are present 5

Treatment Approach

• Transfer severe TBI patients to specialized centers with neurosurgical facilities, as management in a specialized neuro-intensive care unit improves outcomes 2
• Secure airway and provide supplemental oxygen to maintain SaO₂ >95% 5, 2
• Establish IV access and maintain systolic blood pressure >110 mmHg 5, 2
• Consider external ventricular drainage if intracranial hypertension develops despite medical management 5
• Maintain normocapnia if mechanical ventilation is required, as hypocapnia can cause cerebral vasoconstriction 5
• Avoid hypotensive agents if sedation is needed 5

Outcome Assessment Using Glasgow Outcome Scale

• The Glasgow Outcome Scale (GOS) is the most widely used method for analyzing outcomes in severe head injury patients 3, 6
• The extended GOS (GOSE) provides a more detailed 8-point scale that offers greater sensitivity in measuring outcomes 4, 6
• Assess outcomes at standardized intervals (typically 3,6, and 12 months post-injury) to track recovery progression 3, 4
• The GOS categorizes outcomes from death (score 1) to good recovery (score 5), focusing on social recovery and functional independence 1, 3
• Use structured interview formats for GOS/GOSE assessment to improve reliability and consistency, particularly in multi-center studies 4, 6

Prognostic Factors

• Age, initial GCS (particularly motor component), and pupillary reactivity are key predictors of outcome at 6 months 1
• Bilateral fixed, dilated pupils are associated with the highest mortality rates (approximately 80%), though aggressive treatment may still be warranted as good outcomes are possible in some cases 7
• Intracranial pressure on admission is a significant predictive factor of outcome 7
• Implementation of protocols focused on monitoring and prevention of secondary insults significantly reduces mortality 2

Special Considerations

• The GOS was designed to provide an overview of outcome with focus on social recovery, but modern approaches recognize the multidimensional nature of brain injury outcomes 3
• For more detailed assessment of deficits across multiple domains, supplementary measures like the Functional Status Examination (FSE) may be used alongside GOS/GOSE 8
• Careful attention to the timing of GOS assessment is important, as recovery may continue for months or years after severe TBI 6