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01-12-2014 | Review Article

Clinical Monitoring Scales in Acute Brain Injury: Assessment of Coma, Pain, Agitation, and Delirium

Authors: Richard R. Riker, Jennifer E. Fugate, And the Participants in the International Multi-disciplinary Consensus Conference on Multimodality Monitoring

Published in: Neurocritical Care | Special Issue 2/2014

Abstract

Serial clinical examination represents the most fundamental and basic form of neurological monitoring, and is often the first and only form of such monitoring in patients. Even in patients subjected to physiological monitoring using a range of technologies, the clinical examination remains an essential tool to follow neurological progress. Key aspects of the clinical examination have now been systematized into scoring schemes, and address consciousness, pain, agitation, and delirium (PAD). The Glasgow Coma Scale has been the traditional tool to measure consciousness, but the full outline of unresponsiveness (FOUR) score has recently been validated in a variety of settings, and at present, both represent clinically useful tools. Assessment of PAD in neurologically compromised patients present special challenges. For pain, the Numeric Rating Scale is the preferred initial approach, with either the Behavioral Pain Scale or the Critical Care Pain Observation Tool in subjects who are not able to respond. The Nociception Coma Scale-Revised may be useful in patients with severe disorders of consciousness. Conventional sedation scoring tools for critical care, such as the Richmond Area Sedation Scale (RASS) and Sedation–Agitation Scale (SAS) may provide reasonable tools in some neurocritical care patients. The use of sedative drugs and neuromuscular blockers may invalidate the use of some clinical examination tools in others. The use of sedation interruption to assess neurological status can result in physiological derangement in unstable patients (such as those with uncontrolled intracranial hypertension), and is not recommended.

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Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974;13:81–4.CrossRef

Juarez VJ, Lyons M. Interrater reliability of the Glasgow Coma Scale. J Neurosci Nurs. 1995;27:283–6.CrossRefPubMed

Heron R, Davie A, Gillies R, Courtney M. Interrater reliability of the Glasgow Coma Scale scoring among nurses in sub-specialities of critical care. Aust Crit Care. 2001;14:100–5.CrossRefPubMed

Menegazzi JJ, Davis EA, Sucov AN, Paris PM. Reliability of the Glasgow Coma Scale when used by emergency physicians and paramedics. J Trauma. 1993;34:46–8.CrossRefPubMed

Rowley G, Fielding K. Reliability and accuracy of the Glasgow Coma Scale with experienced and inexperienced users. Lancet. 1991;337:535–8.CrossRefPubMed

Gill M, Windemuth R, Steele R, Green SM. A comparison of the Glasgow Coma Scale score to simplified alternative scores for the prediction of traumatic brain injury outcomes. Ann Emerg Med. 2005;45:37–42.CrossRefPubMed

Chamoun RB, Robertson CS, Gopinath SP. Outcome in patients with blunt head trauma and a Glasgow Coma Scale score of 3 at presentation. J Neurosurg. 2009;111:683–7.CrossRefPubMedCentralPubMed

Demetriades D, Kuncir E, Velmahos GC, Rhee P, Alo K, Chan LS. Outcome and prognostic factors in head injuries with an admission Glasgow Coma Scale score of 3. Arch Surg. 2004;10:1066–8.CrossRef

Tien HC, Cunha JR, Wu SN, et al. Do trauma patients with a Glasgow Coma Scale score of 3 and bilateral fixed and dilated pupils have any chance of survival? J Trauma. 2006;60:274–8.CrossRefPubMed

10.

Tsau JW, Hemphill JC, Johnston SC, Smith WS, Bonovich DC. Initial Glasgow Coma Scale score predicts outcome following thrombolysis for posterior circulation stroke. Arch Neurol. 2005;62:1126–9.CrossRef

11.

Schwarz S, Egelhof T, Schwab S, Hacke W. Basilar artery embolism. Clinical syndrome and neuroradiologic patterns in patients without permanent occlusion of the basilar artery. Neurology. 1997;49:1346–52.CrossRefPubMed

12.

Chandra RV, Law CP, Yan B, Dowling RJ, Mitchell PJ. Glasgow coma scale does not predict outcome post-intra-arterial treatment for basilar artery thrombosis. AJNR Am J Neuroradiol. 2011;32:576–80.CrossRefPubMed

13.

Schefold JC, Storm C, Kruger A, Ploner CJ, Hasper D. The Glasgow Coma Score is a predictor of good outcome in cardiac arrest patients treated with therapeutic hypothermia. Resuscitation. 2009;80:658–61.CrossRefPubMed

14.

Starmark JE, Holmgren E, Stalhammar D. Current reporting of responsiveness in acute cerebral disorders. A survey of the neurosurgical literature. J Neurosurg. 1998;69:692–8.CrossRef

15.

Rutledge R, Lentz CW, Fakhry S, Hunt J. Appropriate use of the Glasgow Coma Scale in intubated patients: a linear regression prediction of the Glasgow verbal score from the Glasgow eye and motor scores. J Trauma. 1996;41:514–22.CrossRefPubMed

16.

Meredith W, Rutledge R, Fakhry SM, Emery S, Kromhout-Schiro S. The conundrum of the Glasgow Coma Scale in intubated patients: a linear regression prediction of the Glasgow verbal score from the Glasgow eye and motor scores. J Trauma. 1998;44:839–44.CrossRefPubMed

17.

Buechler CM, Blostein PA, Koestner A, Hurt K, Schaars M, McKernan J. Variation among trauma centers’ calculation of Glasgow Coma Scale score: results of a national survey. J Trauma. 1998;45:429–32.CrossRefPubMed

18.

Balestreri M, Czosynka M, Chatfield DA, et al. Predictive value of Glasgow Coma Scale after brain trauma: change in trend over the past ten years. J Neurol Neurosurg Psychiatry. 2004;75:161–2.PubMedCentralPubMed

19.

Wijdicks EF, Bamlet WR, Maramattom BV, Manno EM, McClelland RL. Validation of a new coma scale: the FOUR score. Ann Neurol. 2005;58:585–93.CrossRefPubMed

20.

Iver VN, Mandrekar JN, Danielson RD, Zubkov AY, Elmer JL, Wijdicks EF. Validity of the FOUR score coma scale in the medical intensive care unit. Mayo Clin Proc. 2009;84:694–701.CrossRef

21.

Stead LG, Wijdicks EF, Bhagra A, et al. Validation of a new coma scale, the FOUR score, in the emergency department. Neurocrit Care. 2009;10:50–4.CrossRefPubMed

22.

Wolf CA, Wijdicks EF, Bamlet WR, McClelland RL. Further validation of the FOUR score coma scale by intensive care nurses. Mayo Clin Proc. 2007;82:435–8.CrossRefPubMed

23.

Fischer M, Ruegg S, Czaplinski A, et al. Inter-rater reliability of the full outline of unresponsiveness score and the Glasgow Coma Scale in critically ill patients: a prospective observational study. Crit Care. 2010;14:R64.CrossRefPubMedCentralPubMed

24.

Kramer AA, Wijdicks EF, Snavely VL, et al. A multicenter prospective study of interobserver agreement using the full outline of unresponsiveness score coma scale in the intensive care unit. Crit Care Med. 2012;40:2671–6.CrossRefPubMed

25.

Wijdicks EF, Rabinstein AA, Bamlet WR, Mandrekar JN. FOUR score and Glasgow Coma Scale in predicting outcome of comatose patients: a pooled analysis. Neurology. 2011;77:84–5.CrossRefPubMed

26.

Fugate JE, Rabinstein AA, Claassen DO, White RD, Wijdicks EF. The FOUR score predicts outcome in patients after cardiac arrest. Neurocrit Care. 2010;13:205–10.CrossRefPubMed

27.

Akavipat P, Sookplung P, Kaewsingha P, Maunsaivat P. Prediction of discharge outcome with the full outline of unresponsiveness (FOUR) score in neurosurgical patients. Acta Med Okayama. 2011;65:205–10.PubMed

28.

Sadaka F, Patel D, Lakshmanan R. The FOUR score predicts outcome in patients after traumatic brain injury. Neurocrit Care. 2012;16:95–101.CrossRefPubMed

29.

Ropper AH, Cole D, Louis DN. Clinicopathologic correlation in a case of pupillary dilation from cerebral hemorrhage. Arch Neurol. 1991;48:1166–9.CrossRefPubMed

30.

Marmarou A, Lu J, Butcher I, et al. Prognostic value of the Glasgow Coma Scale and pupil reactivity in traumatic brain injury assessed pre-hospital and on enrollment: an IMPACT analysis. J Neurotrauma. 2007;24:270–80.CrossRefPubMed

31.

Hoffmann M, Lefering R, Rueger JM, et al. Pupil evaluation in addition to Glasgow Coma Scale components in prediction of traumatic brain injury and mortality. Br J Surg. 2012;99(Suppl 1):122–30.CrossRefPubMed

32.

Uzan M, Yentur E, Hanci M, et al. Is it possible to recover from uncal herniation? Analysis of 71 head injured cases. J Neurosurg Sci. 1998;42:89–94.PubMed

33.

Smrcka M, Maca K, Juran V, et al. Cerebral perfusion pressure and SPECT in patients after craniocerebral injury with transtentorial herniation. Acta Neurochir Suppl. 2002;81:73–5.PubMed

34.

Du R, Meeker M, Bacchetti P, Larson MD, Holland MC, Manley GT. Evaluation of the portable infrared pupillometer. Neurosurgery. 2005;57:198–203.CrossRefPubMed

35.

Hults KN, Knowlton SL, Oliver JW, Wolfson T, Gamst A. A study of pupillary assessment in outpatient neurosurgical clinics. J Neurosci Nurs. 2006;38:447–52.CrossRefPubMed

36.

Meeker M, Du R, Bacchetti P, et al. Pupil examination: validity and clinical utility of an automated pupillometer. J Neurosci Nurs. 2005;37:34–40.CrossRefPubMed

37.

Larson MD, Muhiudeen I. Pupillometric analysis of the ‘absent light reflex’. Arch Neurol. 1995;52:369–72.CrossRefPubMed

38.

Taylor WR, Chen JW, Meltzer H, et al. Quantitative pupillometry, a new technology: normative data and preliminary observations in patients with acute head injury. Technical note. J Neurosurg. 2003;98:205–13.CrossRefPubMed

39.

Manley GT, Larson MD. Infared pupillometry during uncal herniation. J Neurosurg Anesthesiol. 2002;14:223–8.CrossRefPubMed

40.

Chen JW, Gombart ZJ, Rogers S, Gardiner SK, Cecil S, Bullock RM. Pupillary reactivity as an early indicator of increased intracranial pressure: the introduction of the Neurological Pupil index. Surg Neurol Int. 2011;2:82.CrossRefPubMedCentralPubMed

41.

Gelinas C, Klein K, Naidech AM, Skrobik Y. Pain, sedation, and delirium management in the neurocritically ill: lessons learned from recent research. Semin Respir Crit Care Med. 2013;34:236–43.CrossRefPubMed

42.

Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41:263–306.CrossRefPubMed

43.

Payen JF, Bru O, Bosson JL, et al. Assessing pain in critically ill sedated patients by using a behavioral pain scale. Crit Care Med. 2001;29:2258–63.CrossRefPubMed

44.

Gelinas C, Fillion L, Puntillo KA, Viens C, Fortier M. Validation of the critical-care pain observation tool in adult patients. Am J Crit Care. 2006;15:420–7.PubMed

45.

Gottschalk A, Yaster M. The perioperative management of pain from intracranial surgery. Neurocrit Care. 2009;10:387–402.CrossRefPubMed

46.

Laureys S, Faymonville ME, Peigneux P, et al. Cortical processing of noxious somatosensory stimuli in the persistent vegetative state. Neuroimage. 2002;17:732–41.CrossRefPubMed

47.

Schnakers C, Chatelle C, Demertzi A, Majerus S, Laureys S. What about pain in disorders of consciousness? AAPS. 2012;14:437–44.CrossRef

48.

Yu A, Teitelbaum J, Scott J, et al. Evaluating pain, sedation, and delirium in the neurologically critically ill-feasibility and reliability of standardized tools: a multi-institutional study. Crit Care Med. 2013;41:2002–7.CrossRefPubMed

49.

Schnakers C, Chatelle C, Vanhaudenhuyse A, et al. The Nociception Coma Scale: a new tool to assess nociception in disorders of consciousness. Pain. 2010;148:215–9.CrossRefPubMed

50.

Chatelle C, Majerus S, Whyte J, Laureys S, Schnakers C. A sensitive scale to assess nociceptive pain in patients with disorders of consciousness. J Neurol Neurosurg Psychiatry. 2012;83:1233–7.CrossRefPubMed

51.

Seder DB, Riker RR, Jagoda A, Smith WS, Weingart SD. Emergency neurological life support: airway, ventilation, and sedation. Neurocrit Care. 2012;17(Suppl 1):S4–20.CrossRefPubMed

52.

Robinson BR, Berube M, Barr J, Riker R, Gélinas C. Psychometric analysis of subjective sedation scales in critically ill adults. Crit Care Med. 2013;41(9 Suppl 1):S16–29.CrossRefPubMed

53.

Deogaonkar A, Gupta R, DeGeorgia M, et al. Bispectral Index monitoring correlates with sedation scales in brain-injured patients. Crit Care Med. 2004;32:2403–6.CrossRefPubMed

54.

Olson DM, Thoyre SM, Peterson ED, Graffagnino C. A randomized evaluation of bispectral index-augmented sedation assessment in neurological patients. Neurocrit Care. 2009;11:20–7.CrossRefPubMedCentralPubMed

55.

Augustes R, Ho KM. Meta-analysis of randomized controlled trials on daily sedation interruption for critically ill adult patients. Anaesth Intensive Care. 2011;39:401–9.PubMed

56.

Mehta S, Burry L, Cook D, et al. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: a randomized controlled trial. JAMA. 2012;308:1985–92.CrossRefPubMed

57.

Skoglund K, Enblad P, Marklund N. Effects of the neurological wake-up test on intracranial pressure and cerebral perfusion pressure in brain-injured patients. Neurocrit Care. 2009;11:135–42.CrossRefPubMed

58.

Helbok R, Kurtz P, Schmidt MJ, et al. Effects of the neurological wake-up test on clinical examination, intracranial pressure, brain metabolism and brain tissue oxygenation in severely brain-injured patients. Crit Care. 2012;16:R226.CrossRefPubMedCentralPubMed

59.

Mitasova A, Kostalova M, Bednarik J, et al. Poststroke delirium incidence and outcomes: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med. 2012;40:484–90.CrossRefPubMed

60.

Naidech AM, Beaumont JL, Rosenberg NF, et al. Intracerebral hemorrhage and delirium symptoms. Length of stay, function, and quality of life in a 114-patient cohort. Am J Respir Crit Care Med. 2013;188:1331–7.CrossRefPubMedCentralPubMed

61.

Frontera JA. Delirium and sedation in the ICU. Neurocrit Care. 2011;14:463–74.CrossRefPubMed

62.

Ouimet S, Riker R, Bergeron N, Cossette M, Kavanagh B, Skrobik Y. Subsyndromal delirium in the ICU: evidence for a disease spectrum. Intensive Care Med. 2007;33:1007–13.CrossRefPubMed

63.

Haenggi M, Blum S, Brechbuehl R, Brunello A, Jakob SM, Takala J. Effect of sedation level on the prevalence of delirium when assessed with CAM-ICU and ICDSC. Intensive Care Med. 2013;39:2171–9.CrossRefPubMed

64.

Patel SB, Poston JT, Pohlman A, Hall JB, Kress JP. Rapidly reversible, sedation-related delirium versus persistent delirium in the ICU. Am J Respir Crit Care Med. 2014;189:658–65.CrossRefPubMed

65.

Kress JP, Pohlman AS, O’Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000;342:1471–7.CrossRefPubMed

Title: Clinical Monitoring Scales in Acute Brain Injury: Assessment of Coma, Pain, Agitation, and Delirium
Authors: Richard R. Riker
Jennifer E. Fugate
And the Participants in the International Multi-disciplinary Consensus Conference on Multimodality Monitoring
Publication date: 01-12-2014
Publisher: Springer US
Published in: Neurocritical Care / Issue Special Issue 2/2014
Print ISSN: 1541-6933
Electronic ISSN: 1556-0961
DOI: https://doi.org/10.1007/s12028-014-0025-5

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