Adult Glasgow Coma Scale

The Glasgow Coma Scale (GCS) is used to describe the general level of consciousness
in patients with traumatic brain injury (TBI) and to define broad categories of head
injury. [1] The GCS is divided into 3 categories, eye opening (E), motor response (M), and
verbal response (V). The score is determined by the sum of the score in each of the 3
categories, with a maximum score of 15 and a minimum score of 3, as follows:
GCS score = E + M + V
Also see Medscape’s Glasgow Coma Scale Calculator.
Eye opening scores
See the list below:
 4: Spontaneously
 3: To verbal command
 2: To pain
 1: No response

Best motor response scores

See the list below:
 6: Obeys command
 5: Localizes pain
 4: Flexion withdrawal
 3: Flexion abnormal (decorticate)
 2: Extension (decerebrate)
 1: No response

Best verbal response scores

See the list below:
 5: Oriented and converses
 4: Disoriented and converses
 3: Inappropriate words; cries
 2: Incomprehensible sounds
 1: No response

Interpretation
Patients who are intubated are unable to speak, and their verbal score cannot be
assessed. They are evaluated only based on eye opening and motor scores, and the
suffix T is added to their score to indicate intubation. In intubated patients, the maximum
GCS score is 10T and the minimum score is 2T. The GCS is often used to help define
the severity of TBI. Mild head injuries are generally defined as those associated with a
GCS score of 13-15, and moderate head injuries are those associated with a GCS score
of 9-12. A GCS score of 8 or less defines a severe head injury. These definitions are not
rigid and should be considered as a general guide to the level of injury.
EAR BLEEDING
Overview
There are a few possible causes of bleeding from your ear. Some of these may be
concerning. Make an appointment to see your doctor if you experience bleeding from your
ear. They can help you figure out what’s happening and why.

When you meet with your doctor, they’ll try to identify what could have caused the
bleeding. They’ll also ask you about other symptoms and try to detect any other signs you
might have.

Keep reading to understand the most common causes of ear bleeding.

Causes of ear bleeding

Several conditions or injuries could lead to bleeding from your ear. Each of these has
unique symptoms, which can help your doctor diagnose the underlying cause.

Ruptured or torn eardrum

A tear or puncture in your eardrum can also cause symptoms like:

 pain or discomfort in the ear

 hearing loss
 ringing in the ear
 a spinning sensation, known as vertigo
 nausea or vomiting caused by the vertigo

Some people will puncture their eardrum and not know it until they experience additional
symptoms.

Ear infection

An infection in the middle ear can also lead to:

 pressure or pain in the ear

 fever
 balance problems
 difficulty sleeping

Barotrauma
Sudden abrupt changes in altitude can cause ear barotrauma. This can lead to ear
bleeding from rupture of the eardrum as well as:

 ear pain and pressure

 dizziness
 ringing in the ears

Flying in an airplane or SCUBA diving can both increase your risk for this cause of ear
bleeding.

Foreign object in the ear canal

Losing or pushing on object in your ear canal can puncture your eardrum. This can lead
to bleeding from the ear and other symptoms like:

 pain
 pressure
 fluid discharge from your ear
 hearing loss
 dizziness

Cancer of the ear canal

This rare cancer can cause other symptoms, including:

 pain or pressure in the ear

 headaches
 facial pain or numbness
 blurred or altered vision

Trauma to the head

A hit, fall, or accident can cause a head injury that can lead to bleeding from the ear. This
could be a sign of bleeding around the brain, so you should seek emergency medical
attention.
 RESTLESSNESS
It is the body’s innate response to something that could cause some form of stress –
physical or mental. When you are restless, your heart rate accelerates, your breathing
quickens and you are not able to concentrate on anything in particular. Eventually, the
restlessness and its resultant actions fade. Restlessness before big situations like job
interviews or big decisions is normal but constant restlessness is not. Constant
restlessness keeps your body in a perpetual state of ‘fight or flight’ mode. The night tends
to amplify everything and restlessness at night tends to be worse off for your mind and
body.
Causes
The main causes of restlessness are usually secondary conditions like a physical
condition or a psychological disorder. Main disorders can conditions includes:

 Anxiety and related disorders like panic attacks, obsessive compulsive disorder and
even post trauma stress disorder can all cause restlessness in varying degrees.
 Nervousness
 Insomnia and other sleep disorders like sleep apnea or restless legs syndrome
 Restless Leg Syndrome is one of the conditions you could suffer from if you are
constantly restless. This disorder causes you to constantly move your leg or legs.
Though this condition is mostly genetic, some diseases can cause this symptom;
including the irritable bowel syndrome or IBS. Patients could see extreme restlessness
with IBS. Typically, in restless leg syndrome, patients move their legs because they
feel a tingling or a cramping in the legs, which reduces when moved.
 Boredom
 Attention deficit disorder
 Drugs-related behaviour – drug abuse, lethal drug combinations or just medications
which have known side effects that cause restlessness
 Hyperthyroidism
While you may not suffer from any condition, some other factors could also result in
restlessness. Eating very heavily at night or just bingeing on sugar could result in an
adrenaline rush which could result in restlessness. If you know you are prone to
restlessness, keep your intake of refined foods to a minimum. Choose foods that are more
complex in nature and get digested slowly.

Stimulating yourself too close to bed time or getting stressed too close to your sleep time
can also make you restless. Avoid alcohol, caffeine or other artificial stimulants if you are
prone to restlessness.
Symptoms
Restlessness primarily involves not being able to be still. Your head or brain will be
constantly occupied with some thoughts leading to anxiety. The anxiety will increase
and create physical symptoms. Some of those physical symptoms are:
 Inability to Sleep – You will thrash around, turning in bed, tossing the covers and not
being able to sleep peacefully
 Eventually, long term restlessness can lead to fatigue, insomnia, nightmares, and even
interfere with your sexual ability.
Restlessness is a symptom for so many diseases that when coupled with some other
symptom, it almost always represents some other condition.

Try holistic methods like yoga, meditation, writing a journal or relaxation techniques to
deal with restlessness. Get a routine like getting to bed on time, exercising at a fixed time
during the day, eating at fixed times and keeping special time slots for unwinding before
bed. If such methods don’t help you then you might need to get a full check-up done to
determine what the cause is behind the restlessness is.

Intracranial Pressure

Normal intracranial pressure

ICP is generally measured in mm Hg to allow for comparison with MAP and to enable
quick calculation of CPP. It is normally 7-15 mm Hg in adults who are supine, with
pressures over 20 mm Hg considered pathological and pressures over 15 mm Hg
considered abnormal. [33]
Note that ICP is positional, with elevation of the head resulting in lower values. A standing
adult generally has an ICP of -10 mm Hg but never less than -15 mm Hg. [34] In supine
children, ICP is normally lower, in the range of 15 mm Hg, with infants having ICP from
5-10 mm Hg and newborns have subatmospheric pressures regardless of position. [35]
In adults, the choroid plexus and other locations in the CNS produce CSF at a rate of 20
mL/hour, for a total of 500 mL/day. It is reabsorbed by the arachnoid granulations into the
venous circulation. CSF volume is most commonly increased by a blockage of absorption
due to ventricular obstruction, occlusion of venous sinuses, or clogging of the arachnoid
granulations.

Causes of increased intracranial pressure

 Space-occupying lesions: Tumor, abscess, intracranial hemorrhage (epidural
hematoma,subdural hematoma, intraparenchymal hematoma)
 CSF flow obstruction (hydrocephalus): Space-occupying lesion that obstructs
normal CSF flow, aqueductal stenosis, Chiari malformation
 Cerebral edema: Due to head injury, ischemic stroke with vasogenic edema, hypoxic
or ischemic encephalopathy, postoperative edema
 Increase in venous pressure: Due to cerebral venous sinus thrombosis, heart failure,
superior vena cava or jugular vein thrombosis/obstruction
 Metabolic disorders: Hypo-osmolality, hyponatremia, uremic encephalopathy,
hepatic encephalopathy
 Increased CSF flow production: Choroid plexus tumors (papilloma or carcinoma)
 Idiopathic intracranial hypertension
 Pseudo tumor cerebri