SECONDs Administration Guidelines: A Fast Tool to Assess Consciousness in Brain-injured Patients

The accurate diagnosis of patients with disorders of consciousness is essential to their management, but can be time consuming. The SECONDs is a validated diagnostic scale designed for time constraint clinical settings. The SECONDs provides a reliable diagnosis of consciousness within 10 minutes whereas the current gold standard scale takes nearly three times longer, limiting its use in clinical practice.

When learning the SECONDs, it's essential to follow the administration guidelines closely to obtain reproducible results. For example, by respecting the prescribed time between trials and using the suggested wording. Before starting a behavioral examination, adjust the lighting of the room to a level that is adequate for performing the exam and ensure that the patient is positioned comfortably with the forelimbs exposed and the head oriented as straight as possible.

Turn off any TV, radio, or other potentially distracting stimuli. Note any recent changes in medication in the patient's current treatment regimen with particular attention to sedative and psychoactive drugs. Then select a mirror of a minimum recommended 10 by 10 centimeter size for a square shaped mirror or a 10 centimeter diameter for a round shaped one.

To assess spontaneous movement, observe the patient for one minute, recording any spontaneous behaviors. At any time during the assessment, if no sustained eyeopening is observed, or if the patient stops following commands for at least one minute, administer auditory, tactile or noxious stimulation to arouse the patient and observe the patient again, recording any spontaneous behaviors. To assess command following, test three simple movements three times with a 10 second interval between trials that are within the physical capabilities of the patient and that were not observed as spontaneously repetitive during the observation period.

In cases of suspected locked-in syndrome, relate at least one command to eye movements. In cases of known or suspected deafness, administer written commands. If the patient does not react to any of the oral commands, test at least one written command.

Report the commands used on the scoring sheet, along with the number of successful trials. If at least two distinct responses to a command have been successfully performed, or if the patient can express a yes and no, clearly explain the communication code to the patient and ask the five binary autobiographical questions. If the patient fails to correctly answer the autobiographical questions, the situational question set should be asked.

Report the nature of the yes/no code, the modality and the type of the questions used, the number of responses and the number of correct responses. To assess visual pursuit, move silently around the bed while observing whether the patient's gaze spontaneously and clearly follows this movement during at least two SECONDs in two different directions. If a clear pursuit is not spontaneously observed, position the mirror about 30 centimeters in front of the patient's face.

After confirming that the patient can see their reflection, move the mirror slowly from left to right, right to left, top to bottom, and bottom to top for at least four seconds per movement. Report the number of observed pursuits on each axis, the type of stimulus used, and whether manual eyeopening was employed. To score visual fixation, enter the patient's field of view and observe whether the patient's gaze spontaneously fixates on the examiner for at least two seconds in two different visual quadrants by turning towards the examiner.

If no clear and spontaneous visual fixations are observed, present the mirror about 30 centimeters away from the patient's face in all four quadrants of the patient's visual field outside of the access of their gaze for at least four seconds per quadrant. Report the quadrants in which the patient showed the fixations as well as the type of the stimulus used and whether manual eyeopening was employed. If the patient did not demonstrate command following, place a pen or pencil on the patient's fingernail bed for five seconds without applying pressure and instruct the patient to remove their hand to avoid the pain.

If the patient removed their hand after the warning, proceed to the other hand and repeat the warning. If the patient does not remove the hand within five seconds, administer pressure to the nail bed for five seconds, repeating the warning. Record the anticipation and localization responses and the side on which they were observed.

To assess oriented behaviors, perform continuous observation throughout the examination and score any patient motor behavior clearly oriented toward themselves, another person or an object such as scratching their nose, holding the bed, pulling on a feeding tube, grabbing the bedsheets or smiling to a joke or nodding. Report the type and the number of times each behavior is observed. To assess arousal, perform continuous observation throughout the examination and score zero for no arousal if during the entire evaluation the patient never opened their eyes with or without stimulation.

Score one for arousal, if the patient opened their eyes at least once during the assessment, either spontaneously or following stimulation. Report the approximate percentage of time that the patient's eyes were opened throughout the examination and specify if the eyeopening happened spontaneously or following a noxious, tactile or auditory stimulation. Select the correct clinical diagnosis corresponding to the highest items scored by the patient and calculate the additional index using the dedicated table.

Pitfalls may be encountered while administering this scale. For example, in patients demonstrating spontaneous vertical eye movements, administering the lookup command could result in a score of six and a consequent erroneous diagnosis of MCS+as spontaneous repeated movements must not be used to test command following. As another example, in a patient with Korsakoff syndrome, testing communication using only autobiographical questions could result in a score of seven and a diagnosis of MCS+due to memory deficits and not altered consciousness.

Correct administration of the SECONDs, testing communication with both autobiographical and situational question sets would result in a correct score of eight and a diagnosis of emergence from the minimally conscious state. The importance of manual eyeopening is especially important in patients suffering from motor impairments preventing eyeopening, such as neurotoxic ptosis as the administration of the SECONDs without manual eyeopening would result in a score of zero, corresponding to a diagnosis of coma. A correct administration in which manual eyeopening is employed would result in a score of eight and a diagnosis of emergence from the minimally conscious state.

In a French validation study performed on 57 patients with disorders of consciousness, three SECONDs and one CRSR assessments were performed on two consecutive days by three different examiners blinded for diagnosis. The administration duration of the SECONDs was significantly shorter compared to the CRSR duration. The concurrent validity was excellent between the CRSR and the best SECONDs diagnosis.

The intra and inter rater reliability were also excellent. The CRSR total score strongly correlated with the score of the best SECONDs. For reliable results, the SECONDs must be performed under the best possible conditions.

The examiner should promote arousal and motivation, but only clear and non-ambiguous responses must be scored. The SECONDs a fast diagnostic test designed for clinical settings with limited time. Complimentary assessments, such as the Coma Recovery Scale-Revised, the Nociception Coma Scale-Revised, the Glasgow Liege, the Disability Rating Scale, as well as the FOUR, the BARA or the SWADOC scales can provide useful information on targeted deficits in patients with disorders of consciousness.