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GALVESTON ORI ENTATI ON AND AMNESI A TEST: APPLI CABI LI TY AND RELATI ON W I TH

TH E GLASGOW COM A SCALE

Silv ia Cr ist ina Für br inger e Silv a1 Regina Mar cia Car doso de Sousa2

Silv a SCF, Sou sa RMC. Galv est on or ien t at ion an d am n esia t est : applicabilit y an d r elat ion w it h t h e Glasgow

Com a Scale. Rev Lat ino- am Enfer m agem 2 0 0 7 j ulho- agost o; 1 5 ( 4 ) : 6 5 1 - 7 .

Rest rict ions in t he applicat ion of t he Galvest on Orient at ion and Am nesia Test and quest ionings about t he relat ionship bet ween conscience and post - t raum at ic am nesia m ot ivat ed t his st udy, which aim s t o ident ify, t hrough t he Glasgow Com a Scale scores, when t o init iat e t he applicat ion of t his am nesia t est , as well t o verify t he relat ionship bet ween t he result s of t hese t wo indicat ors. The longit udinal prospect ive st udy was carried at a referral cent er for t raum a care in São Paulo - Brazil. The sam ple consist ed of 73 vict im s of blunt t raum at ic brain inj ury, adm it t ed at t his inst it ut ion bet ween January 03rd and May 03rd 2001. Regarding t he applicabilit y, t he t est could be applied in pat ient s wit h a Glasgow Com a Scale score > 12; however, t he end of post t raum at ic am nesia was verified in pat ient s who scored > 14 on t he scale. A significant relat ionship ( rs = 0.65) w as verified bet w een t hese m easures, alt hough different kinds of relat ionship bet ween t he end of t he am nesia and changes in consciousness were observed.

DESCRI PTORS: am n esia; cr an iocer ebr al t r au m a; Glasgow com a scale

GALVESTON ORI ENTATI ON AND AMNESI A TEST: APLI CABI LI DAD Y RELACI ÓN CON LA

ESCALA DE COM A DE GLASGOW

Rest r iccion es en la ap licación d el Galv est on Or ien t at ion an d Am n esia Test y los cu est ion am ien t os sobr e la r elación en t r e con cien cia y am n esia post - t r au m át ica m ot iv ar on est e est u dio qu e v isa iden t if icar , a t r av és de la punt uación de la Escala de Com a de Glasgow , el per iodo m ás adecuado par a la aplicación de la pr ueba de am nesia, y obser var la r elación ent r e los r esult ados de esos dos indicador es. El est udio pr ospect ivo y longit udinal fue r ealizado en un cent r o de r efer encia par a t r aum as en São Paulo - Br asil. El núm er o fue de 73 v ict im as de t r aum a cr aneoencefálico cont uso, int er nadas en est a inst it ución en el per iodo de 03/ 01 a 03/ 05/ 2001. Con r elación a la aplicabilidad, la pr ueba puede ser aplicada en los pacient es con la Escala de Com a de Glasgow > 12, per o el t ér m ino de la am nesia post - t r aum át ica fue obser v ado en los pacient es con punt uación > 14 en la escala. Cor r elación significat iv a ( r s = 0, 65) fue obser v ada ent r e esas m edidas, aunque difer ent es for m as de r elación ent r e el t ér m ino de la am nesia y alt er ación de conciencia fuer on obser v adas.

DESCRI PTORES: am n esia; t r au m a cr an iocer ebr al; Escala de Com a de Glasgow

GALVESTON ORI ENTATI ON AND AMNESI A TEST: APLI CABI LI DADE E RELAÇÃO COM A

ESCALA DE COM A DE GLASGOW

Rest r ições na aplicação do Galvest on Or ient at ion and Am nesia Test e quest ionam ent os sobr e a r elação ent re consciência e am nésia pós- t raum át ica m ot ivaram est e est udo que visa ident ificar, pelos escores da Escala de Com a de Glasgow , quando iniciar a aplicação desse t est e de am nésia, bem com o v er ificar a r elação ent r e os result ados desses dois indicadores. O est udo prospect ivo longit udinal foi realizado em cent ro de referência para at endim ent o de t r aum a em São Paulo - Br asil. A am ost r a foi de 73 vít im as de t r aum a cr aniencefálico cont uso, int ernadas nessa inst it uição, no período de 3/ 1 a 3/ 5/ 2001. Com relação à aplicabilidade, o t est e pôde ser aplicado nas vít im as com Escala de Com a de Glasgow ³ 12, por ém , o t érm ino da am nésia pós- t raum át ica foi verificado nos pacient es com pont uação ³ 14 nessa escala. Correlação significat iva ( rs= 0,65) foi verificada ent re os indicadores, no ent ant o, diferent es form as de relação ent re t érm ino de am nésia e alt eração da consciência foram observadas.

DESCRI TORES: am n ésia; t r au m a cr an iocer ebr al; escala de com a de glasgow

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I NTRODUCTI ON

I

n r ecent y ear s, consciousness changes and p o s t - t r a u m a t i c a m n e s i a h a v e b e e n i m p o r t a n t

indicat or s of t he gr avit y of blunt t r aum at ic br ain inj ur y

( TBI )( 1 ), an d also t h e saf est par am et er s t o f or ecast fu n ct ion al capacit y aft er t h is k in d of t r au m a, in t h e

m edium and long t er m s( 2- 9).

Post - t r au m at ic am n esia is a v er y f r eq u en t

disor der in pat ient s w it h TBI and has been st udied for

m or e t han 50 year s. I n 1932, for t he fir st t im e, Rit chie

Ru sse l p r e se n t e d t h e d u r a t i o n o f p o st - t r a u m a t i c

am nesia as a sev er it y indicat or of t he cr anial inj ur y

and of t he dur at ion of t he subsequent disabilit y( 10). Unt il t he 1980’s, t he dur at ion and end of post

-t r au m a-t ic am n esia w er e es-t ablish ed r e-t r ospec-t iv ely,

q u e st i o n i n g t h e p a t i e n t a f t e r h i s/ h e r co n t i n u o u s

m em or y h ad b een r est or ed( 1 1 ). Cr it icism r elat ed t o t he accur acy of t he r et r ospect iv e m easur e appoint ed

t h e su bj ect iv it y of t h e m et h od an d con sider ed t h at

t he dur at ion and end of post - t r aum at ic am nesia could

t h u s on ly be est im at ed af t er t h e pat ien t ’s r ecov er y

fr om t he m ent al confusion( 5,11- 12).

I n 1 9 7 9 , t h e Ga l v e s t o n Or i e n t a t i o n a n d

Am nesia Test ( GOAT)( 12) was published. This w as one o f t h e f i r st i n a se r i e s o f i n st r u m e n t s a i m e d a t

p r osp ect iv ely est ab lish in g t h e d u r at ion of am n esia

af t er TBI .

Si n ce i t s p u b l i ca t i o n , t h e GOAT h a s b een

w idely used. St udies apply ing t he t est dem onst r at ed

t h at it is an im p or t an t in st r u m en t t o d et ect p ost

-t r aum a-t ic am nesia and de-t er m ine i-t s dur a-t ion( 5). How ev er, in v iew of t he obser ved r est r ict ive

c o n d i t i o n s , a c l e a r g u i d e l i n e i s m i s s i n g f o r i t s

applicat ion. To det erm ine t he GOAT score, a t en- it em

quest ionnaire is applied. I n clinical pract ice, t here are

var ious sit uat ions im peding it s use, m ainly r elat ed t o

t h e v i c t i m s ’ i n a b i l i t y t o m a i n t a i n v e r b a l

com m u n icat ion .

I n t he lit erat ure review , t he crit erion t o apply

t h e s c a l e h a s b e e n d e s c r i b e d a s “ i n d i v i d u a l s

consist ent ly out of com a”( 3), a descript ion t hat rem ains indefinit e on how t o apply t he inst r um ent .

Thus, indicat or s ar e needed on w hen t o apply

t he GOAT. The Glasgow Com a Scale ( GCS) is a globally

r en ow n ed scale an d w id ely u sed t o assess v ict im s

a f t e r TBI( 1 3 ). Th e r e f o r e , i t c a n b e a n i m p o r t a n t i n d i c a t o r o f t h e a p p r o p r i a t e t i m e t o a p p l y t h i s

in st r u m en t .

Th e GCS is t h e m ost w id ely u sed scale t o

gr aduat e changes in consciousness( 13- 15). I t w as fir st pu blish ed in 1 9 7 4 an d w as elabor at ed t o pr opose a

con sist en t clin ical assessm en t of t h e con sciou sn ess

lev el of pat ient s w it h br ain dam age( 16).

I n post - t r aum at ic am nesia r esear ch, st udies

at t em pt ing t o r eveal t he r elat ion bet w een t he change

in t he consciousness lev el and am nesia aft er TBI ar e

i m p o r t a n t t o cl a r i f y t h e p h y si o p a t h o l o g y o f t h ese

phenom ena( 5, 17).

I n i t i a l l y, p o s t - t r a u m a t i c a m n e s i a w a s

con sid er ed t h e in it ial p h ase of r eco v er y, af t er t h e

low er consciousness level int erval t hat occurs in sever

b l u n t TBI( 3 ). Ho w e v e r, i n p r a ct i ce , so m e p a t i e n t s ex p er ien ce a lon g er p ost - t r au m at ic am n esia p er iod

t h a n t h e ch a n g e d co n sci o u sn e ss l e v e l p e r i o d , a s

m easur ed by t he GCS. I n ot her w or ds, pat ient s w it h

a n or m al or close t o n or m al GCS scor e w h o, w h en

ask ed ab ou t ear lier at t it u d es or b eh av ior s, can n ot

r em em b er.

Th e lack of defin it ion s abou t w h en t o apply

t h e GO AT a n d a b o u t t h e a s s o c i a t i o n b e t w e e n

con sciou sn ess ch an g e an d p ost - t r au m at ic am n esia,

led t o t he realizat ion of t his st udy, w it h t he follow ing

ob j ect iv es: id en t if y, t h r ou g h t ot al an d p ar t ial GCS

scor es, t he m ost appr opr iat e t im e t o apply t he GOAT

a n d t o v e r i f y t h e r e l a t i o n s b e t w e e n t h e r e s u l t s

obt ained on t he GOAT and t he GCS, w it h a v iew t o

cont r ibut ing t o know ledge about t he r elat ions bet w een

t h e v i c t i m s ’ p o s t - t r a u m a t i c a m n e s i a a n d

con sciou sn ess alt er at ion .

CASES AN D METHOD

We carried out a prospect ive longit udinal field

st u dy w it h a qu an t it at iv e an d cor r elat ion appr oach ,

at a public hospit al t hat is a referral cent er for care t o

t r au m a v i ct i m s i n t h e West o f g r eat er São Pau l o.

Vi ct i m s o f TBI h o sp i t a l i zed a t t h i s i n st i t u t i o n a r e

adm it t ed at t he em er gency car e unit .

St udy par t icipant s w er e vict im s of blunt TBI ,

b et w een 1 2 an d 6 0 y ear s ol d , w i t h ou t a p r ev i ou s

d iag n osis of TBI or m em or y ch an g e, w h o r eceiv ed

car e at t he place of st udy aft er t he t r aum a and w er e

h ospit alized f or t r eat m en t bet w een Jan u ar y 3r d an d May 3rd 2001.

To co l l e ct i n f o r m a t i o n f o r t h i s st u d y, a n

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p e r m i t t e d t h e v i c t i m s ’ i d e n t i f i c a t i o n a n d

ch ar act er izat ion , besides daily n ot es on par t ial an d

t ot al GCS and GOAT scor es.

Ev er y day du r in g t h e dat a collect ion per iod,

v ict im s of blu n t TBI w er e t r ack ed w h o r eceiv ed car e

a t t h e e m e r g e n c y c a r e u n i t a n d h a d b e e n

h ospit alized at t h e st u dy in st it u t ion du r in g t h e last

2 4 h ou r s. To id en t if y an d locat e t h ese v ict im s, w e

co n su l t ed t h e f i l es o f p at i en t s h o sp i t al i zed i n t h i s

h ospit al ar ea an d also ask ed n u r ses f r om t h e sect or

f or in f or m at ion .

O n c e t h e v i c t i m s w h o a t t e n d e d t o t h e

inclusion cr it er ia had been locat ed, assessm ent s w it h

t he GCS and t he GOAT st ar t ed and w er e car r ied out

ev er y d ay, p r ef er ab l y at t h e sam e t i m e, u n t i l t h e

end of t he am nesia w as det ect ed ( m inim um scor e of

7 5 on t h e GOAT f or t w o con secu t iv e d ay s) . Deat h ,

dischar ge, hospit al t r ansfer and ot her cir cum st ances

descr ibed in t he r esult s, w hich m ade it im possible t o

con t in u e daily assessm en t s, t er m in at ed t h e v ict im ’s

f o l l o w - u p b e f o r e t h e e n d o f t h e a m n e si a p e r i o d .

Sit u at ion s of su r ger y, t est s ou t side t h e u n it , or any

ot h er sit u at ion t h at im p ed ed t h e ap p licat ion of t h e

t w o s c a l e s , w e r e b r i e f l y d e s c r i b e d i n t h e d a t a

collect ion inst r um ent , but did not det er m ine t he end

of t h e pat ien t ’s follow - u p.

Th e t o t a l GO AT s c o r e w a s o b t a i n e d i n

a cco r d a n ce w i t h g u i d e l i n e s b y t h e sca l e a u t h o r s,

subt ract ing t he t ot al er r or point s fr om 100 ( Tot al scor e

= 100 - t ot al er r or point s) . I n t he applicat ion of t his

inst r um ent , scor es under 75 indicat e t hat t he v ict im

is st ill in t he am nesia per iod. As indicat ed by ear lier

r e se a r ch , t h e e n d o f t h e p o st - t r a u m a t i c a m n e si a

per iod w as consider ed t o be t he fir st t im e w hen t he

v ict im r eached, for t w o consecut iv e day s, a scor e of

75 or higher on t he GOAT( 3,11).

Af t er t h e in f or m at ion h ad b een in ser t ed in

a d a t a b a s e , a n a l y s e s w e r e p e r f o r m e d t o

ch ar act er ize t h e cases u n d er st u d y an d r each t h e

pr oposed obj ect iv es. To v er ify t h e r elat ion bet w een

sequ en t ial GCS an d GOAT scor es, Spear m an ’s Ran k

Cor r elat ion Coefficien t w as applied. I n t h is an aly sis,

a p - v a l u e u n d er 0 . 0 5 w as co n si d er ed st at i st i cal l y

si g n i f i can t .

Th e st u d y r e ce i v e d w a s a p p r o v e d b y t h e

I nst it ut ional Rev iew Boar d of t he st udy hospit al and

t he v ict im s w er e included in t he r esear ch aft er t heir

or t heir r elat iv es’ consent .

RESULTS

Dur ing t he dat a collect ion per iod, 73 v ict im s

of TBI at t en ded t o t h e st u dy in clu sion cr it er ia, w it h

7 2 . 6 % m ale pat ien t s an d a lar ge m aj or it y ( 7 9 . 5 % )

bet w een 12 and 36 y ear s old; as t o ex t er nal cause,

t he m ost fr equent ev ent s t hat pr ov ok ed blunt TBI in

t h e st u d y g r o u p w e r e t r a f f i c a cci d e n t s ( 7 5 . 3 % ) ,

follow ed by falls ( 21.9% ) ; w it h r espect t o t he sever it y

of t he TBI , t he ext r em e cat egor ies included t he lar gest

num ber of v ict im s ( 35. 6% sev er e and 48. 0% light ) .

The m ean follow - up t im e of v ict im s w as 8.7 day s ( +

8 . 9 day s) . This t im e r anged fr om 1 t o 3 9 day s and

m o st o f t h e v i ct i m s ( 6 9 . 9 % ) w e r e f o l l o w e d a n d

assessed for up t o 10 day s.

Du r in g t h e f ollow - u p , t h e 7 3 v ict im s w er e

subm it t ed t o 419 assessm ent s. The GOAT could not be

applied in 188 of t hese ( 44.9% ) , due t o sit uat ions t hat

im peded t he pat ient ’s collabor at ion in t he applicat ion

of t he t est , such as or ot r acheal int ubat ion, agit at ion

an d ot h er accen t u at ed b eh av ior al or con sciou sn ess

changes. I n t hese cases, only t he GCS w as applied.

Table 1 show s t hat , in all assessm ent s in w hich

t he GCS w as low er t han 12, t he GOAT could not be

applied. The t est could only be applied once in a pat ient

w it h a GCS score of 12, alt hough it result ed in a score

under 75.

Table 1 - GCS and GOAT scor es in t he assessm ent s

( n= 419) . São Paulo, 2001

S C

G <12 12 13 14 15

T A O

G % % % % %

5 7

< - - 1 11.11 18 81.8 89 78.1 29 28.4

> 57 - - - 22 19.3 72 70.6

* A

N 172 100 8 88.9 4 18.2 3 2.6 1 1.0

l a t o

T 172 100 9 100 22 100 114 100 102 100

( * ) Not applicable

Th e GOAT cou ld be applied r elat ively easily

in pat ient s w it h a GCS score of 13, alt hough scores in

all ap p licat ion s d id n ot r each 7 5 . I n t h e 1 1 4 GCS

ap p licat ion s t h at r esu lt ed in scor e 1 4 , t h e v ict im s

r eached scor es ³ 75 in only 22 of GOAT assessm ent s

( 1 9 . 3 % ) . On t h e ot h er h an d , m ost ( 7 0 . 6 % ) of t h e

t est ap p licat ion s r each ed t h is scor e w h en p at ien t s

scor ed 15 on t he GCS.

I n Table 2, it is obser ved t hat t he t est could

be applied in v ict im s w h o scor ed 2 or m or e on t h e

Eye Opening param et er of t he GCS, alt hough t he GOAT

indicat ed t he end of post - t r aum at ic am nesia only w hen

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Table 2 - GOAT and GCS Eye Opening ( EO) param et er

scor es on t he assessm ent s ( n= 419) . São Paulo, 2001

st at ist ically significant posit iv e or dinal cor r elat ion ( rs = 0.65; p< 0.001) .

For t h e sak e of a bet t er ch ar act er izat ion of

t he relat ion bet ween consciousness alt erat ion and post

-t r aum a-t ic am nesia, r esul-t s for -t he v ic-t im s for w hom

t h e en d of post - t r au m at ic am n esia w as det er m in ed

during t he follow - up period are present ed in Table 5.

Of t he 73 v ict im s included in t his st udy, t he

du r at ion of post - t r au m at ic am n esia w as det er m in ed

in on ly 4 0 ( 5 4 . 8 % ) . I n v ar iou s sit u at ion s, t h e daily

assessm en t of t h e st u d y p ar t icip an t s cou ld n ot b e

con t in u ed u n t il t h e en d of t h e am n esia p er iod : 1 4

( 19.2% ) w er e dischar ged and w ent hom e; 9 ( 12.3% )

died; 5 ( 6.8% ) w er e t r ansfer r ed t o ot her hospit als; 2

( 2 . 8 % ) e sca p e d f r o m t h e h o sp i t a l a n d 3 ( 4 . 1 % )

ev olv ed w it h disabilit ies t h at m ade it im possible t o

assess t heir m em or y ( aphasia, behav ior al disor der ) .

These 40 v ict im s w er e dist r ibut ed accor ding

t o t h e r elat ion ob ser v ed b et w een t h e en d of t h eir

m em or y and consciousness changes. I n t his analysis,

w e c o n s i d e r e d t h a t s c o r e 1 5 o n t h e GCS i s a n

im port ant indicat or of a norm al physiological condit ion

on t h e con sciou sn ess par am et er.

Table 5 - Vict im s w hose post- t r aum at ic am nesia t im e

w as d et er m in ed ( n = 4 0 ) , accor d i n g t o t h e r el at i on

obser ved bet w een t he end of post - t r aum at ic am nesia

and t he end of t he consciousness change per iod. São

Paulo, 2 0 0 1

O

E 1 2 3 4

T A O

G % % % %

5 7

< - - 1 6,7 23 28,7 113 46,9

> 57 - - - - 12 15,0 82 34,0

* A

N 83 100 14 93,3 45 56,3 46 19,1

l a t o

T 83 100 15 100 80 100 241 100

( * ) Not applicable

Table 3 show s t hat t he t est was applied w hen

t he scor e on t he Best Ver bal Response par am et er of

t h e GCS w as 4 or 5 , w h en r esu lt s > 7 5 w er e also

obser ved on t he GOAT. Out of t hr ee GCS it em s, t his

w as t h e on e t h at m ost f r equ en t ly r each ed scor e 1 .

Sit uat ions t hat im peded t he assessm ent of t he Best

Ver b al Resp o n se w er e f r eq u en t i n t h i s p ar am et er,

a l m o s t a l w a y s d u e t o t h e p a t i e n t s ’ o r o t r a c h e a l

in t u bat ion .

Table 3 - GOAT and GCS Best Ver bal Response ( BVR)

scor es on t he assessm ent s ( n= 419) . São Paulo, 2001

R V

B <4 4 5

T A O

G % % %

5 7

< - - 102 87,2 35 28,7

> 57 - - 9 7,7 85 69,7

* A

N 180 100 6 5,1 2 1,6

l a t o

T 180 100 117 100 122 100

( * ) Not applicable

Table 4 r elat es t he scor e on t he Best Mot or

Response par am et er w it h t he t ot al GOAT scor e. The

vict im ’s collaborat ion in t he applicat ion of t he t est w as

only achieved in individuals w ho scor ed 6 on t he Best

Mot or Response it em of t he GCS, t hat is, w ho w er e

capable of obey ing sim ple com m ands. Sim ilar ly, w it h

t his GCS scor e, t he vict im s r eached ³ 75 on t he GOAT.

Table 4 - GOAT and GCS Best Mot or Response ( BMR)

scor es on t he assessm ent s ( n= 419) . São Paulo, 2001

R M

B <6 6

T A O

G % %

5 7

< - - 137 45,4

> 57 - - 94 31,1

* A

N 117 100 71 23,5

l a t o

T 117 100 302 100

( * ) Not applicable

To analy ze t he r elat ions bet w een GOAT and

GCS r esu lt s, t h e d aily scor es on b ot h in st r u m en t s

w e r e p a i r e d a n d su b m i t t e d t o Sp e a r m a n ’ s Ra n k

Co r r e l a t i o n Co e f f i c i e n t . Th e a n a l y s i s s h o w e d a

a i s e n m a c i t a m u a r t -t s o p f o d n

E No %

5 1 = S C G h t i w y l t n a t i m o c n o

C 21 52.5

5 1 = S C G e r o f e

B 10 25.0

5 1 = S C G r e t f

A 09 22.5

l a t o

T 40 100

I t is observed in Table 5 t hat , in m ost of t he

vict im s, 21 pat ient s ( 52.5% ) , signs of norm al m em ory

and consciousness appeared at t he sam e t im e, t hat is,

t hey present ed t he end of t he post - t raum at ic am nesia

p er iod at t h e sam e t im e as scor e 1 5 on t h e GCS.

How ever, 10 pat ient s pr esent ed t he end of t he post

-t raum a-t ic am nesia period before reaching score 15 on

t he GCS and, in 9 pat ient s, t he end of t he post - t raum at ic

am nesia period was only det erm ined som e days aft er

t hey had reached t he m axim um score on t he GCS.

DI SCUSSI ON

I n t his research, in order t o ident ify t he m ost

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GCS scores, obt ained during t he follow- up of blunt TBI

vict im s were analyzed in view of t he GOAT, considering

t he obt ained result s and t he possibilit y of it s applicat ion.

I n t hese analy ses, it w as obser v ed t hat t he

m i n i m u m GCS s c o r e t o o b t a i n t h e v i c t i m ’ s

collabor at ion t o apply t he GOAT was 12, w it h par t ial

scor es of 2 on t he Eye Opening param et er, 4 on Best

Ver bal Response and 6 Best Mot or Response.

I n p r esen t in g an ex p an d ed p r op osal of t h e

GCS, w hich includes t he assessm ent of post - t r aum at ic

am nesia, t hat aut hors affir m t hat , w it h r espect t o t his

param et er, pat ient s w it h a scor e of £ 12 on t he GCS

can r ar ely be assessed( 15).

Scor e 6 for Best Mot or Response has alr eady

b e e n a p p o i n t e d b y o t h e r a u t h o r s( 3 ) a s t h e m o st im por t ant indicat or in t he GCS t hat t he v ict im is out

of com a and has, t her efor e, t he m inim um per cept ivit y

needed t o collaborat e w it h t he applicat ion of t he GOAT.

The vict im ’s collaborat ion is essent ial t o apply

t h e GOAT or an y ot h er m em or y t est . Th is r eq u ir es

t he pr esence of answ er s t hat cov er per cept iv it y and

v er b al ex p r ession cap acit y.

When t he end of post - t r aum at ic am nesia w as

consider ed in t he analy ses on t he applicabilit y of t he

GOAT, t he r esult s indicat ed a t ot al GCS scor e of 14,

w i t h a m i n i m u m sco r e o f 3 o n t h e Ey e Op e n i n g

param et er, 4 on Best Ver bal Response and 6 on Best

Mot or Respon se.

Th i s o b se r v a t i o n m u st b e co n si d e r e d a n

im por t ant indicat or of w hen t o apply t he GOAT. To t he

ex t en t t h at n ew st u dies con fir m t h at scor es 1 2 an d

1 3 on t h e GCS p r eced e t h e en d of p ost - t r au m at ic

a m n e si a , t h e st a r t o f GOAT a sse ssm e n t s ca n b e

sy st em ized aft er r eaching scor e 14 on t he GCS. This

av oid s t h e v ict im ’s an d t h e ev alu at or ’s ex h au st ion

during a period in w hich t he GOAT scor e pr obably w ill

not r each 75 point s.

I n t h i s st u d y, w e o b se r v e d a st a t i st i ca l l y

significant correlat ion bet w een GOAT and GCS result s.

We did n ot locat e an y st u dies in scien t ific lit erat u r e

w h ich an aly zed t h e cor r elat ion b et w een t h e scor es

on t h ese t w o i n d i cat or s, al t h ou g h sev er al au t h or s

looked at t he r elat ion bet w een t he dur at ion of am nesia

and com a. Like in our st udy, t hese analyses aim ed t o

s t u d y t h e r e l a t i o n b e t w e e n p o s t - t r a u m a t i c

consciousness and m em or y changes. Result s cer t ified

a significant correlat ion bet w een t he indicat ors of t hese

t w o par am et er s( 3, 6, 18).

Th e am n esic d ef icit af t er TBI is f r eq u en t ly

accom panied by disor ient at ion in t er m s of t im e, place

an d per son , besides agit at ion , disin h ibit ed beh av ior,

deficient at t ent ion and ot her m em or y changes, such

as con f ab u lat ion an d r et r og r ad e am n esia. Ph y sical

or v er bal agit at ion and aggr ession ar e com m on, and

hallucinat ions can also occur( 12).

I n st u d y i n g co g n i t i v e ch a n g e s d u r i n g t h e

a c u t e r e c o v e r y p e r i o d o f TB I , r e s e a r c h e r s f r o m

To r o n t o , Ca n a d a , co n cl u d e d t h a t p o st - t r a u m a t i c

am n esia is essen t ially a p ost - t r au m at ic con f u sion al

st at e, defined as a t r ansit or y or ganic m ent al syndr om e

t h a t s t a r t s a c u t e l y, c h a r a c t e r i z e d b y a g l o b a l

im p air m en t of cog n it iv e f u n ct ion s, w it h con cu r r en t

consciousness disor der, at t ent ion abnor m alit y, r educed

or incr eased psy chom ot or act iv it y and dy sfunct ion in

t he sleep/ w ak e cy cle( 16).

For t h ese r esear ch er s, t h e clin ical sit u at ion

t h at h as b een d en o m i n at ed am n esi a seem s t o b e

secondar y t o t he inabilit y t o pay at t ent ion w hile coding

or r ecov er in g in for m at ion , su ggest in g t h at at t en t ion

pr oblem s ar e pr om inent or ev en t he m ost im por t ant

in t he r ecov er y phase aft er TBI .

Accor ding t o t hese asser t ions, post - t r aum at ic

am n esia sh ou ld b e con cu r r en t w it h t h e con f u sion al

st at e( 12,16) and, t her efor e, t he end of am nesia should occur at t he sam e t im e as a GCS scor e of 15. I n t his

st u d y, in 2 5 % of cases, t h e en d of p ost - t r au m at ic

am n esia p r eced ed scor e 1 5 on t h e GCS. Th is en d

occur r ed w hen scor e 14 w as r eached. Most of t hese

p at ien t s ob t ain ed t h e f ollow in g p ar t ial GCS scor es:

Eye Opening = 4, Best Ver bal Response = 4 and Best

Mot or Response = 6. This show ed confused pat ient s

w h ose GOAT scor es in d icat ed t h e en d of t h e p ost

-t r aum a-t ic am nesia. I n 22. 5% of cases, on -t he o-t her

hand, pat ient s had obt ained scor e 15 on t he GCS for

at least one day w hen t he end of t he post - t r aum at ic

am n esia occu r r ed .

This last gr oup of vict im s, w ho scor ed 15 on

t h e GCS b ef o r e t h ey r eco v er ed f r o m t h e m em o r y

ch an ge, does n ot su ppor t t h e h y pot h esis t h at post

-t r aum a-t ic am nesia is essen-t ially a confusional s-t a-t e.

On t he ot her hand, pat ient s w ho w er e confused but

pr esent ed signs of t he end of am nesia, ar e not dir ect ly

opposed t o t his hy pot hesis as, in t hese cases, it can

b e co n si d e r e d t h a t t h e a m n e si a e n d s b e f o r e t h e

con f u sion al st at e.

Post - t raum at ic am nesia w as longer in r elat ion

t o com a in a su b g r ou p of TBI v ict im s an aly zed b y

r esear cher s fr om t he Unit ed Kingdom . These aut hor s

o b se r v e d t h a t 1 7 o u t o f 3 8 p a t i e n t s, w h o w e r e

(6)

-t r au m a-t ic am n esia f or -t w o d ay s or m or e, al-t h ou g h

t hey pr esent ed com a per iods for less t han six hour s.

Am ong t hese 17 vict im s, eight st ood out because t heir

am nesia last ed for m or e t han seven days. For pat ient s

w ho rem ained in a com a for six hour s or m or e, r esult s

w er e m or e coher ent and, in m ost cases, t he am nesia

cont inued for m or e t han sev en day s( 6).

I n t his st udy, t he eight pat ient s wit h an ext ended

am nesia t im e and short com a period, when com paring

m agn et ic r eson an ce r esu lt s w it h t h ose of t h e ot h er

pat ient s, pr esent ed m or e ex t ensiv e br ain hem ispher e

d am ag e. I n t h e g r ou p as a w h ole, b ot h com a an d

am nesia were relat ed t o t he num ber of lesions det ect ed

in cent ral brain st ruct ures, but only t he durat ion of t he

post - t r aum at ic am nesia w as significant ly r elat ed w it h

t h e n u m b er o f h em i sp h er i c l esi o n s. Th ese r esu l t s

perm it t ed t he conclusion t hat bot h com a and am nesia

are relat ed wit h t he brain dam age, alt hough t hey reflect

different inj ury pat t erns( 6).

I n v i e w o f t h e se o b se r v a t i o n s, i t ca n b e

su ggest ed t h at dif f er en t in j u r y pat t er n s cau sed t h e

d i f f e r e n t r e l a t i o n s b e t w e e n t h e m e m o r y a n d

co n sci o u sn e ss p a r a m e t e r s, o b se r v e d i n Ta b l e 5 .

H o w e v e r, t h e i m p o r t a n c e o f a t t e n t i o n i n t h e

m em o r i zat i o n p r o cess an d t h e d i f f i cu l t y t o cl ear l y

dist inguish bet w een confusion and t he post - t r aum at ic

am nesia sy ndr om e cannot be ignor ed. Hence, in t he

gr ou p in w h ich t h e en d of am n esia occu r r ed at t h e

sam e t im e as or b ef or e scor e 1 5 on t h e GCS, t h e

possibilit y t hat t he change in t he consciousness lev el

influenced m em or y r esult s cannot be put aside( 6). Mo r e o v e r, t h e u se o f t h e GOAT sco r e t o

d et er m i n e t h e en d o f t h e p o st - t r au m at i c am n esi a

id en t if ies a r ecov er y st ag e t h at seem s t o b e m or e

concurrent w it h t he ret urn of orient at ion capacit y t han

w it h t he r ecov er y of spont aneous m em or y. Accor ding

t o s o m e a u t h o r s , i n m o r e s e v e r e l y t r a u m a t i z e d

pat ient s, t he am nesia act ually cont r ibut es t o t he GOAT

score but , in light er t raum as, at t ent ion and confusion

ar e t he pr im ar y fact or s cont r ibut ing t o t he scor e.

Th e u se of t h e GOAT as an in st r u m en t t o

est ablish t he end of am nesia lim it s t he r esear cher ’s

capacit y t o dist in gu ish bet w een con fu sion an d post

-t r au m a-t ic m em or y ch an ges. I n -t h e GOAT s-t r u c-t u r e,

t he pr edom inance of or ient at ion m easur es is ev ident

and in accor dance w it h t he pr em ise t hat t he am nesia

period is t he init ial phase of recovery, aft er an int erval

w it h a low er consciousness lev el.

Th e st u dy of post - t r au m at ic am n esia is st ill

p er m eat ed b y m an y g ap s, as w ell as t h e r elat ion s

bet w een t he cognit iv e funct ions. New st udies, w it h a

clear er d ist in ct ion b et w een t h e assessed cog n it iv e

pr ocesses and w it h a concom it ant analysis of t he im age

diagnosis of t he inj ury, can result in clearer inform at ion

of t he physiopat hology involved in t he post - t r aum at ic

cognit iv e r ecov er y pr ocess, especially of m em or y. I n

t his st udy, t he pot ent ial adv er se effect s of t he dr ugs

u se d i n t h e a cu t e t r a u m a p h a se sh o u l d a l so b e

consider ed, w hich can affect m em or y per for m ance( 3).

CONCLUSI ONS

As t o t he best m om ent t o apply t he GOAT, it

can be affir m ed t hat :

- Th is in st r u m en t can b e ap p lied w h en scor e 1 2 is

r eached on t he GCS, w it h par t ial scor es higher t han

2 f o r Ey e Op en i n g , h i g h er t h an 4 f o r Best Ver b al

Response and 6 for Best Mot or Response.

- Vict im s w it h scor es 1 4 an d 1 5 on t h e GCS, w it h

par t ial scor es of 3 or 4 on t he it em Eye Opening, 4 or

5 on Ver bal Response and 6 on Mot or Response r each

scor es ³ 75 on t he GOAT. These r esult s indicat e t he

applicat ion of t his inst r um ent aft er t he v ict im s r each

t hese scor es on t he GCS.

As t o t he r elat ions bet w een GOAT and GCS r esult s, it

can be concluded t hat :

- Sp ear m an ’s Ran k Cor r elat ion Coef f icien t b et w een

seq u en t i al GCS an d GOAT sco r es cor r esp on d ed t o

0.65, p < 0.001, indicat ing a r elat ively st r ong r elat ion

b et w een t h ese m easu r es; h ow ev er, t h e an aly sis of

t h e e n d o f p o s t - t r a u m a t i c a m n e s i a a n d o f t h e

c o n s c i o u s n e s s c h a n g e s a p p o i n t e d b y t h e s e

inst r um ent s show ed t hat , in 47.2% of t he cases, t he

end of post - t r aum at ic am nesia occur r ed befor e or aft er

scor e 15 w as r eached on t he GCS.

REFERÊNCI AS BI BLI OGRÁFI CAS

1 . Al v es D, Mu ssi FC, Jeu k en s MMF, Si l v a SCF, Si l v a EB, Koizum i MS. O que lem br a o pacient e com TCE sobr e o per íodo de h ospit alização?. Rev Lat in o- am En f er m agem 2 0 0 0 abr il; 8 ( 2 ) : 9 1 - 8 .

2 . Cifu DX, Key ser - Mar cus L, Lopez E, Wehm an P, Kr eut zer JS, Englander J, et al Acut e pr edict or s of successful r et ur n t o w or k 1 year aft er t r aum at ic br ain inj ur y: a m ult icent er analysis. Ar ch Ph y s Med Reh ab il 1 9 7 7 ; 7 8 : 1 2 5 - 3 1 .

(7)

4 . Jen n et t B, Teasd ale G. Pr ed ict in g ou t com e in in d iv id u al p at ien t s af t er sev er e h ead in j u r y. Lan cet 1 9 7 6 ; 1 ( 7 9 6 8 ) : 1 0 3 1 - 4 .

5 . McMillan TM, Jon gen ELMM, Gr een w ood RJ. Assessm en t of post - t r au m at ic am n esia af t er sev er e closed h ead in j u r y : r et r ospect iv e or pr ospect iv e? J Neur ol Neur osur g Psy chiat r y 1 9 9 6 ; 6 0 : 4 2 2 - 7 .

6. Wilson JTL, Teasdale GM, Hadley DM, Wiedm ann KD, Lang, D L. Po st - t r a u m a t i c a m n esi a : st i l l a v a l u a b l e y a r d st i ck . J Neu r ol Neu r osu r g Psy ch iat r y 1 9 9 3 ; 5 7 : 1 9 8 - 2 0 1 .

7. Past or ek NJ, Hannay HJ, Cont ant CS. Pr edict ion of global o u t co m e w i t h a cu t e n eu r o p sy ch o l o g i ca l t est i n g f o l l o w i n g closed head inj ur y. J I nt Neur opsychol Soc 2004; 10( 6) : 807-1 7 .

8 . Or ien t - Lóp ez F, Sev illa- Her n án d ez E, Gu ev ar a- Esp in osa D, Ter r é- Bo l i ar t R, Ram ó n - Ro n a S, Ber n ab eu - Gu i t ar t M. Re s u l t a d o f u n c i o n a l a l a l t a d e l o s t r a u m a t i s m o s cr aneoencefálicos gr av es ingr esados en una unidad de daño cer eb r al. Rev Neu r ol 2 0 0 4 ; 3 9 ( 1 0 ) : 9 0 1 - 6 .

9 . De Gu ise E, Leb lan c J, Fey s M, Th om as H, Gosselin N. Effect of an int egr at ed r ealit y or ient at ion pr ogr am m e in acut e car eon p ost - t r au m at ic am n esia in p at ien t s w it h t r au m at ic br ain inj ur y. Br ain I nj 2 0 0 5 ; 1 9 ( 4 ) : 2 6 3 - 9 .

1 0 . Sh or es EA, Maeosszek y JE, San d an am J, Bat ch elor J. Pr elim in ar y v alidat ion of a clin ical scale f or m easu r in g t h e d u r a t i o n o f p o st - t r a u m a t i c a m n e si a . Me d J Au st 1 9 8 6 ; 1 4 4 ( 2 6 ) : 5 6 9 - 7 2 .

1 1 . Lev in HS, O’Don n ell VM, Gr ossm an RG. Th e Galv est on Or ien t at ion an d Am n esia Test : a pr act ical scale t o assess c o g n i t i o n a f t e r h e a d i n j u r y. J N e r v M e n t D i s 1 9 7 9 ; 1 6 7 ( 1 1 ) : 6 7 5 - 8 4 .

1 2 . Lader a- Fer nandez V. Síndr om e am nésico post r aum át ico. Rev Neu r ol 2 0 0 1 ; 3 2 ( 5 ) : 4 6 7 - 7 2 .

13. Alves D, Koizum i MS. Escala de Com a de Glasgow : t em po de r eav aliar seu u so em ser v iço de em er gên cia. Act a Pau l En f er m a g em 1 9 9 9 ; 1 2 ( 3 ) : 9 2 - 1 0 0 .

1 4 . Br ook s DN, Hosie J, Bon d MR, Jen n et t B, Au g h t on M. Cogn it iv e sequ elae of sev er e h ead in j u r y in r elat ion t o t h e Gl a sg o w Ou t co m e Sca l e . J Ne u r o l Ne u r o su r g Psy ch i a t r y 1 9 8 6 ; 4 9 : 5 4 9 - 5 3 .

15. Nell V, Yat es DW, Kr uger J. An ex t ended Glasgow Com a Scale ( GCS- E) w it h enhanced sensit iv it y t o m ild brain inj ur y. Ar ch Ph y s Med Reh ab il 2 0 0 0 ; 8 1 ( 5 ) : 6 1 4 - 7 .

1 6 . Mar ion D W, Car lier PM. Pr ob lem s w it h in it ial Glasg ow Com a Scale assessm ent caused by pr ehospit al t r eat m ent of pat ient s w it h head inj ur y : r esult s of a nat ional sur v ey. J Traum a 1 9 9 4 ; 3 6 ( 1 ) : 8 9 - 9 5 .

17. St uss DT, Binns MA, Car r ut h FG, Lev ine B, Br andy s CE, Moult on RJ, et al. The acut e per iod of r ecover y fr om t r aum at ic b r a i n i n j u r y : p o s t t r a u m a t i c a m n e s i a o r p o s t - t r a u m a t i c con f u sion al st at e? J Neu r osu r g 1 9 9 9 ; 9 0 : 6 3 5 - 4 3 .

18. Kat z DI , Alex ander MP. Traum at ic brain inj ur y : pr edict ing cou r se of r ecov er y an d ou t com e f or p at ien t s ad m it t ed t o r eh ab ilit at ion . Ar ch Neu r ol 1 9 9 4 ; 5 1 : 6 6 1 - 7 0 .

Imagem

Table 1 show s t hat , in all assessm ent s in w hich t he GCS w as low er  t han 12,  t he GOAT could not  be applied
Table 5 -  Vict im s w hose post- t r aum at ic am nesia t im e w as  d et er m in ed   ( n = 4 0 ) ,   accor d i n g   t o  t h e  r el at i on obser ved bet w een t he end of post - t r aum at ic am nesia and t he end of t he consciousness change per iod

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