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Classification of Coma, Concussion and Traumatic Brain Injury
Concussion, Head Injury, Traumatic Brain Injury and Coma Classification Systems
Clinical Psychology Associates of North Central Florida, P.A. All rights reserved CPANCF.COM
Gainesville - Ocala (352) 336-2888
Various organizations and researhers have proposed classification systems of concussion, brain injury and coma. While the Glasgow Coma Scale is in wide use in EMT and ER settings, examination and classification of concussion has been less uniform across medical, research and even sports settings. Most include considerations of alteration or loss of consciousness, coma level and duration, amnesia, complications such as fracture or intracranial findings.
CLASSIFICATIONS OF CONCUSSION
Diagnosotic and Statistical Manual - IV - DSM-IV
The current version of the Diagnosotic and Statistical Manual - IV has a limited classification system with respect to concussion, including Post-Concussional Disorder in a section of diagnoses requiring further study. No specific definition of mild, moderate, or severe Traumatic Brain Injury (TBI) is included though individuals who have suffered significant cognitive, memory and other higher cognitive deficits as a consequence of a brain injury would be diagnosed as Dementia due to Traumatic Brain Injury. Less severely impacted TBI's would be classified as Cognitive Disorder.
The DSM-IV definition of concussion deemed to require more study is much more conservative than other syndromes which offer a grading of concussions. Suggested critera include:
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unconsciousness lasting more than 5 minutes, and
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post-traumatic amnesia lasting more than 12 hours subsequent to the closed head injury, and
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new onset of seizures or marked worsening of pre-existing seizure disorder that occurs within the first six months.
DSM-IV criteria explicitly refer to necessary findings on neuropsychological testing. Memory and attention difficulties must be present difficulties in attention and memory must be demonstrated. The definition also includes that three or more of the following symptoms must be present for three months or more:
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becoming easily fatigued,
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disordered sleep,
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headache,
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vertigo or dizziness,
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irritability or aggression on little or no provocation,
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anxiety,
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depression or affective lability,
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changes in personality (e.g., social or sexual inappropriateness),
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apathy or lack of spontaneity.
American Academy of Neurology Concussion Severity- March 1997 Practice Parameter:
This system was used by our own Dr. Phalin in his doctoral study of different models for detecting recovery in sports concussions.
Grade 1: __ Transient Confusion
__ No Loss of Consciousness
__ Concussion Symptoms < 15 Minutes
Grade 2: __ Transient Confusion
__ No Loss of Consciousness
__ Concussion Symptoms > 15 Minutes
Grade 3: __ Any Loss of Consciousness, Brief or Prolonged
Concussion Severity: R.C. Cantu, 1991 Cantu's system is often used in reasearch involving sports concussions.
Cantu Concussion Severity Grades
Grade 1: No Loss of Consciousness AND Post Traumatic Amnesia < 30 Minutes
Grade 2: Loss of Consciousness < 5 Minutes OR Post Traumatic Amnesia of 30 Minutes to 24 Hours
Grade 3: Loss of Consciousness > 5 Minutes OR Post Traumatic Amnesia > 24 Hours
Ruff Concussion Grades:
Type I :
__ altered mental state or transient loss of consciousness (LOC)
__ 1-60 seconds of post-traumatic amnesia (PTA)
__ one or more neurological symptoms
Type II:
__ definite LOC with time unknown or < 5 minutes
__ 60 seconds to 12 hours of post-traumatic amnesia (PTA)
__ one or more neurological symptoms
Type III:
__ 5 - 30 minutes of LOC
__ more than 12 hours of PTA
__ one or more neurological symptoms
Head Injury or Traumatic Brain Injury Classifications
Severity of Injury Based on Post-Traumatic Amnesia (PTA) Duration (Bigler, as cited in Lezak, 1995).
Post-traumatic amnesia, or the period of time until continuous memory is established is another simple method of classifying severity of head injury.
PTA Duration............Severity of Injury
- < 5 minutes..............Very mild
- 5 - 60 minutes...........Mild
- 1 - 24 hours.............Moderate
- 1 - 7 days...............Severe
- 1 - 4 weeks..............Very severe
- > 4 weeks................Extremely severe
Traumatic Brain Injury (TBI) as defined by the 1993 Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine:
Mild head injury is defined as "a traumatically induced physiologic disruption of brain function, as manifested by one of the following:
- Any period of loss of consciousness (LOC)
- Any loss of memory for events immediately before or after the accident
- Any alteration in mental state at the time of the accident
- Focal neurologic deficits, which may or may not be transient.
The other criteria for defining mild traumatic brain injury (TBI) include the following:
- Glasgow Coma Scale (GCS) score greater than 12
- No abnormalities on CT scan
- No operative lesions
- Length of hospital stay less than 48 hours
The following criteria define moderate traumatic brain injury (TBI):
- Length of stay of at least 48 hours
- GCS score of 9-12 or higher
- Operative intracranial lesion
- CT abnormality
National Institute of Health (NIH) sponsored Traumatic Coma Data Bank (TCDB).
- Definition of severe Traumatic Brain (TBI) involves a GCS score below 9 within 48 hours of the injury.
GLASGOW COMA SCALE
The Glasgow Coma scale is frequently employed at time of injury by Emergency Medical Technicians and during acute admission for brain injury. It consists of a 1-5 rating of three areas: best occular response, speech, and movement/response to pain resulting in a best possible score of 15.
Glasgow Coma Scale: 13-15 mild; 8-12 moderate; < 7 = severe head trauma, poor prognosis
Eye opening Spontaneous = 4 ; To speech = 3; To painful stimulation = 2; No response = 1
Motor response Follows commands = 6; Makes localizing movements to pain = 5; Makes withdrawal movements to pain = 4;
Flexor (decorticate) posturing to pain = 3; Extensor (decerebrate) posturing to pain = 2; No response = 1
Verbal response Oriented to person, place, and date = 5; Converses but is disoriented = 4; Says inappropriate words = 3
Says incomprehensible sounds = 2; No response = 1
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