First of all, it is clear that the current system of assigning levels of severity to traumatic brain injury (TBI) is both ineffective and harmful. This is because it has been inappropriately tied to what is known as the Glasgow Coma Scale (GCS).
GLASGOW COMA SCALE
| Response | Scale | Score |
|---|---|---|
| Eye Opening Response | ||
| Eyes open spontaneously | 4 Points | |
| Eyes open to verbal command, speech, or shout | 3 Points | |
| Eyes open to pain (not applied to face) | 2 Points | |
| No eye opening | 1 Points | |
| Verbal Response | ||
| Oriented | 5 Points | |
| Confused conversation | 4 Points | |
| Inappropriate responses, words discernible | 3 Points | |
| Incomprehensible sounds or speech | 2 Points | |
| No verbal response | 1 points | |
| Motor Response | ||
| Obeys commands from movement | 6 Points | |
| Purposeful movement to painless stimulus | 5 Points | |
| Withdraws from pain | 4 Points | |
| Abnormal (spastic) flexion, decorticate posture | 3 Points | |
| Extensor (rigid) response, decerebrate posture | 2 Points | |
| No motor response | 1 Points | |
| Minor Brain Injury = 13-15 Points; Moderate Brain Injury = 9-12 points; Severe Brain Injury = 3-8 Points |
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The GCS was adopted in order to give EMTs and emergency room treaters a way to easily determine if someone is in cognitive and system decline. It certainly was not meant to give insurance companies a defense to brain injury claims, but that is what happens in practice. Generally, a person who was "unresponsive" or unconscious will receive a much lower score than someone who is conscious. (The lowest score is 3, which you can get even with death, while the highest normal functioning score is 15). Imagine the difference in proving your case between the EMT's arriving within two minutes of your car accident and finding you unconscious behind the wheel, facts which would give you a GCS of 6 to 10, versus the EMT's arriving 25 minutes after the accident and finding you awake, alert and, even if confused, fairly normal. In most of those instances you would receive a score of 15 instead of a 6 to 10. A 14 is a score which shows confusion on the part of the individual, but EMT's are mostly unwilling to parse out confusion in a person who has just been in a serious accident because the EMT assumed they are going to be confused, which they are.
Another way that traumatic brain injuries (TBIs) are described is as either mild, mild complicated, moderate or severe.
| Mild | Moderate | Severe | |
|---|---|---|---|
| Primary Damage/Injury mechanism: | predominately blast, non-penetrating | frequently mixed, blast+ acceleration/deceleration, typically non-penetrating | complex, blast+ acceleration/deceleration + penetration |
| Loss/alteration of consciousness: |
< 30 minutes | > 30 minutes, < 24 hours | > 24 hours |
| Amnesia: | <24 hours | > 24 hours, < 7 days | > 7 days |
| GCS | 13-15 | 9-12 | < 9 |
| Imaging | negative | transient changes | positive, lasting abnormalities |
| Comorbidity: | Post Traumatic Stress Disorder, overlapping symptoms | PTSD, other injuries | Polytrauma, such as multiple organ injuries |
| Outcome: | Transient neuropsychiatric deficits, mostly full-recovery, longterm neuropsychiatric especially after repeated injuries are frequent | mild-to-moderate, typically chronic, neurological and neuropsychiatric abnormalities | death, significant neurological and neuropsychiatric deficits, severe, chronic physical and neuropsychiatric disabilities |
The first issue is with the word "mild." Having a concussion or a mild brain injury (mild TBI) can lead to a lifetime of serious and life altering symptoms. There is nothing "mild" about it.
A "mild complicated" injury is one in which there was little or short loss of consciousness, but abnormalities are seen immediately on a CT or MRI of the brain. These types of injuries are more respected by all involved and, of course, these injuries can lead to significant lifetime impairment.
"Moderate" traumatic brain injury can be life changing or can have a relatively good outcome for the patient, depending on many variables. For the moderate TBI, one would expect to be held overnight or longer in the hospital. There would be an expectation of abnormalities on MRI or CT scans as well as immediate and ongoing cognitive difficulties with amnesia, short term memory, confusion, speech as well as possible motor deficits with walking, talking or feeding oneself. Moderate TBI will require follow-up rehabilitation and staging to get out of the hospital.
"Severe" traumatic brain injury will always be life changing in a negative way. Many of these individuals will be in a coma, will be looked at for possible brain death, and "pulling the plug" and will require ongoing serious rehabilitation. These individuals will have blood in the brain, which is an irritant, and are at a greater risk for post traumatic seizures and slow recovery.
Once hospitalized, doctors and nurses will commonly change from the Glasgow Coma Scale to another scale known as the "Ranchos" or Ranchos Los Amigos Scale.
Ranchos Los Amigos Scale
| Rancho Level | Clinical Correlate |
|---|---|
| I | No Response |
| II | Generalized response |
| III | Localized response |
| IV | Confused, agitated |
| V | Confused, inappropriate, non-agitated response |
| VI | Confused, appropriate |
| VII | Automatic, inappropriate |
| VIII | Purposeful, appropriate |
As can be seen, the most severe level is Level I where there is no responsiveness at all. As the person is able to track with their eyes or even nod in response, on occasion, they might be seen at a Level II or III. This scale is important because it is used to identify patients who are well enough to be transferred to sub-acute care. Rehabilitation facilities often will not take patients until they reach Level IV and are disconnected from a feeding tube. From Level IV and higher there is both responsiveness and speech, however, they may be confused.