Glasgow Coma Scale or GCS is a neurological scale that aims to give a reliable, objective way of recording the conscious

state of a person for initial as well as subsequent assessment. A patient is assessed against the criteria of the scale, and the resulting points give a patient score between 3 (indicating deep unconsciousness) and either 14 (original scale) or 15 (the more widely used modified or revised scale).

Best eye response (E) y There are 4 grades starting with the most severe: y No eye opening y Eye opening in response to pain. (Patient responds to pressure on the patients fingernail bed; if this does not elicit a response, supraorbital and sternal pressure or rub may be used.) y Eye opening to speech. (Not to be confused with an awaking of a sleeping person; such patients receive a score of 4, not 3.) y Eyes opening spontaneously Best verbal response (V) y There are 5 grades starting with the most severe: y No verbal response y Incomprehensible sounds. (Moaning but no words.) y Inappropriate words. (Random or exclamatory articulated speech, but no conversational exchange) y Confused. (The patient responds to questions coherently but there is some disorientation and confusion.) y Oriented. (Patient responds coherently and appropriately to questions such as the patients name and age, where they are and why, the year, month, etc.) Best motor response (M) y There are 6 grades starting with the most severe: y No motor response y Extension to pain (abduction of arm, internal rotation of shoulder, pronation of forearm, extension of wrist, decerebrate response) y Abnormal flexion to pain (adduction of arm, internal rotation of shoulder, pronation of forearm, flexion of wrist, decorticate response) y Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist when supra-orbital pressure applied ; pulls part of body away when nailbed pinched)

y y

Localizes to pain. (Purposeful movements towards painful stimuli; e.g., hand crosses mid-line and gets above clavicle when supra-orbital pressure applied.) Obeys commands. (The patient does simple things as asked.)

INTERPRETATION Individual elements as well as the sum of the score are important. Hence, the score is expressed in the form "GCS 9 = E2 V4 M3 at 07:35". Generally, brain injury is classified as: Severe, with GCS 8 Moderate, GCS 9 - 12 Minor, GCS 13.

NASOGASTRIC INTUBATION is a medical process involving the insertion of a plastic tube (nasogastric tube or NG tube) through the nose, past the throat, and down into the stomach.
USES- A nasogastric tube is used for feeding and administering drugs and other oral agents such as activated charcoal. For drugs and for minimal quantities of liquid, a syringe is used for injection into the tube. For continuous feeding, a gravity based system is employed, with the solution placed higher than the patient's stomach. If accrued supervision is required for the feeding, the tube is often connected to an electronic pump which can control and measure the patient's intake and signal any interruption in the feeding. Nasogastric aspiration (suction) is the process of draining the stomach's contents via the tube. Nasogastric aspiration is mainly used to remove gastric secretions and swallowed air in patients with gastrointestinal obstructions. Nasogastric aspiration can also be used in poisoning situations when a potentially toxic liquid has been ingested, for preparation before surgery under anesthesia, and to extract samples of gastric liquid for analysis. If the tube is to be used for continuous drainage, it is usually appended to a collector bag placed below the level of the patient's stomach; gravity empties the stomach's contents. It can also be appended to a suction system, however this method is often restricted to emergency situations, as the constant suction can easily damage the stomach's lining. In non-emergent situations, intermittent suction may be applied giving the benefits of suction without the untoward effects of damage to the stomach lining. Suction drainage is used for patients who have undergone a pneumonectomy in order to prevent anesthesia-related vomiting and possible aspiration of any stomach contents. Such aspiration would represent a serious risk of complications to patients recovering from this surgery. Contraindications The use of nasogastric intubation is contraindicated in patients with base of skull fractures, severe facial fractures especially to the nose and obstructed esophagus, esophageal varices, and/or obstructed airway. The use of an NG tube is also contraindicated in patients who have had gastric bypass surgery. Complications Minor complications include nose bleeds, sinusitis, and a sore throat. Sometimes more significant complications occur including erosion of the nose where the tube is anchored, esophageal perforation, pulmonary aspiration, a collapsed lung, or intracranial placement of the tube.