Not to be confused with Glasgow Outcome Scale.

Glasgow Coma Scale

Diagnostics

MeSH D015600

Glasgow Coma Scale (GCS) is a neurological scale which aims to give a

reliable and objective way of recording the conscious state of a person
for initial as well as subsequent assessment. A patient is assessed
against the criteria of the scale, and the resulting points give a patient
score between 3 (indicating deep unconsciousness) and either 14
(original scale) or 15 (the more widely used modified or revised scale).

GCS was initially used to assess level of consciousness after head

injury, and the scale is now used by first responders, EMS, nurses and
doctors as being applicable to all acute medical and trauma patients. In
hospitals it is also used in monitoring chronic patients in intensive care.

The scale was published in 1974 by Graham Teasdale and Bryan J.

Jennett, professors of neurosurgery at the University of Glasgow's
Institute of Neurological Sciences at the city's Southern General
Hospital.

GCS is used as part of several ICU scoring systems, including APACHE

II, SAPS II, and SOFA, to assess the status of the central nervous system,
as it was designed for. The initial indication for use of the GCS was
serial assessments of patients with traumatic brain injury [1] and coma
for at least 6 hours in the neurosurgical ICU setting, though it is
commonly used throughout hospital departments. A similar scale, the
Rancho Los Amigos Scale is used to assess the recovery of traumatic
brain injury patients.

Elements of the scale

Glasgow Coma Scale
1 2 3 4

Opens eyes in Opens eyes

Does not Opens eyes
Eye response to in response
open eyes spontaneously
painful stimuli to voice

Utters Oriented,
Makes no Incomprehensible Confused,
Verbal inappropriate converses
sounds sounds disoriented
words normally

Abnormal
Extension to flexion to
Flexion / Localizes
Makes no painful stimuli painful
Motor Withdrawal to
movements (decerebrate stimuli
painful stimuli
response) (decorticate
response)

Note that a motor response in any limb is acceptable. [2] The scale is
composed of three tests: eye, verbal and motor responses. The three
values separately as well as their sum are considered. The lowest
possible GCS (the sum) is 3 (deep coma or death), while the highest is
15 (fully awake person).

Eye response (E)

There are four grades starting with the most severe:

1. No eye opening

2. Eye opening in response to pain stimulus. (a peripheral pain stimulus,

such as squeezing the lunula area of the patient's fingernail is more
effective than a central stimulus such as a trapezius squeeze, due to a
grimacing effect).[3]

3. Eye opening to speech. (Not to be confused with the awakening of a

sleeping person; such patients receive a score of 4, not 3.)

4. Eyes opening spontaneously

Verbal response (V)

There are five grades starting with the most severe:

1. No verbal response

2. Incomprehensible sounds. (Moaning but no words.)

3. Inappropriate words. (Random or exclamatory articulated speech, but

no conversational exchange. Speaks words but no sentences.)

4. Confused. (The patient responds to questions coherently but there is

some disorientation and confusion.)

5. Oriented. (Patient responds coherently and appropriately to questions

such as the patient’s name and age, where they are and why, the year,
month, etc.)

Motor response (M)

There are six grades:

1. No motor response

2. Decerebrate posturing accentuated by pain (extensor response:

adduction of arm, internal rotation of shoulder, pronation of forearm and
extension at elbow, flexion of wrist and fingers, leg extension,
plantarflexion of foot)

3. Decorticate posturing accentuated by pain (flexor response: internal

rotation of shoulder, flexion of forearm and wrist with clenched fist, leg
extension, plantarflexion of foot)

4. Withdrawal from pain (Absence of abnormal posturing; unable to lift

hand past chin with supraorbital pain but does pull away when nailbed is
pinched)

5. Localizes to pain (Purposeful movements towards painful stimuli;

e.g., brings hand up beyond chin when supraorbital pressure applied.)

6. Obeys commands (The patient does simple things as asked.)

Interpretation

Individual elements as well as the sum of the score are important.

Hence, the score is expressed in the form "GCS 9 = E2 V4 M3 at 07:35".
Generally, brain injury is classified as:

Severe, with GCS < 8–9

Moderate, GCS 8 or 9–12 (controversial)[4]

Minor, GCS ≥ 13.

Generally when a patient is in a decline of their GCS score, the nurse or

medical staff should assess the cranial nerves and determine which of
the twelve have been affected.

Tracheal intubation and severe facial/eye swelling or damage make it

impossible to test the verbal and eye responses. In these
circumstances, the score is given as 1 with a modifier attached e.g.
"E1c" where "c" = closed, or "V1t" where t = tube. A composite might be
"GCS 5tc". This would mean, for example, eyes closed because of
swelling = 1, intubated = 1, leaving a motor score of 3 for "abnormal
flexion". Often the 1 is left out, so the scale reads Ec or Vt.

The GCS has limited applicability to children, especially below the age of
36 months (where the verbal performance of even a healthy child would
be expected to be poor). Consequently, the Pediatric Glasgow Coma
Scale, a separate yet closely related scale, was developed for assessing
younger children.

Revisions

Glasgow Coma Scale: While the 15-point scale is the predominant one
in use, this is in fact a modification and is more correctly referred to as
the Modified Glasgow Coma Scale. The original scale was a 14-point
scale, omitting the category of "abnormal flexion". Some centres still
use this older scale, but most (including the Glasgow unit where the
original work was done) have adopted the modified one.

The Rappaport Coma/Near Coma Scale made other changes.

Meredith W., Rutledge R, Fakhry SM, EMery S, Kromhout-Schiro S have

proposed calculating the verbal score based on the measurable eye and
motor responses.
 The most widespread revision has been the Simplified Motor and
Verbal Scales which shorten the respective sections of the GCS without
loss of accuracy.[5]

The GCS for intubated patients is scored out of 10 as the verbal

component falls away

Controversy

The GCS has come under pressure from some researchers who take
issue with the scale's poor inter-rater reliability and lack of prognostic
utility.[6] Although there is no agreed-upon alternative, newer scores
such as the Simplified motor scale and FOUR score have also been
developed as improvements to the GCS.[7] Although the inter-rater
reliability of these newer scores has been slightly higher than that of the
GCS, they have not gained consensus as replacements. [8]

See also

AVPU scale

Blantyre Coma Scale

Early warning score

Paediatric Glasgow Coma Scale

Rancho Los Amigos Scale

Revised Trauma Score

Triage

References

1. ^ Teasdale G, Jennett B (1974). "Assessment of coma and impaired

consciousness. A practical scale.". Lancet. 2 (7872): 81–4.
doi:10.1016/S0140-6736(74)91639-0 . PMID 4136544 .

2. ^ Hutchinson’s clinical methods 22nd edition

3. ^ "The Glasgow Coma Scale: clinical application in Emergency

Departments". Emergency Nurse. 14 (8): 30–5. 2006.
doi:10.7748/en2006.12.14.8.30.c4221 .

4. ^ http://www.cdc.gov/masstrauma/resources/gcs.pdf

5. ^ Gill M, Windemuth R, Steele R, Green SM (2005). "A comparison of

the Glasgow Coma Scale score to simplified alternative scores for the
prediction of traumatic brain injury outcomes.". Ann Emerg Med. 45 (1):
37–42. doi:10.1016/j.annemergmed.2004.07.429 . PMID 15635308 .

6. ^ Green S. M. (2011). "Cheerio, Laddie! Bidding Farewell to the

Glasgow Coma Scale". Annals of Emergency Medicine. 58 (5): 427–430.
doi:10.1016/j.annemergmed.2011.06.009 . PMID 21803447 .

7. ^ Iver, VN; Mandrekar, JN; Danielson, RD; Zubkov, AY; Elmer, JL;
Wijdicks, EF (2009). "Validity of the FOUR score coma scale in the
medical intensive care unit." . Mayo Clinic Proceedings. 84 (8):
694–701. doi:10.4065/84.8.694 . PMC 2719522 . PMID 19648386 .

8. ^ Fischer, M; Rüegg, S; Czaplinski, A; Strohmeier, M; Lehmann, A;

Tschan, F; Hunziker, PR; Marschcorresponding, SC (2010). "Inter-rater
reliability of the Full Outline of UnResponsiveness score and the
Glasgow Coma Scale in critically ill patients: a prospective
observational study" . BioMed Central: Critical Care. 14 (2): R–64.
doi:10.1186/cc8963 . PMC 2887186 . PMID 20398274 .
Teasdale G, Murray G, Parker L, Jennett B (1979). "Adding up the
Glasgow Coma Score". Acta Neurochir Suppl (Wien). 28 (1): 13–6.
doi:10.1007/978-3-7091-4088-8_2 . PMID 290137 .

Meredith W, Rutledge R, Fakhry SM, Emery S, Kromhout-Schiro S

(1998). "The conundrum of the Glasgow Coma Scale in intubated
patients: a linear regression prediction of the Glasgow verbal score from
the Glasgow eye and motor scores". J Trauma. 44 (5): 839–44;
discussion 844–5. doi:10.1097/00005373-199805000-00016 .
PMID 9603086 .

External links

Website to calculate the Glasgow Coma Scale

Glasgow Coma Scale Calculator

 Glasgow Coma Scale at the US National Library of Medicine Medical
Subject Headings (MeSH)

Dr. Graham Teasdale speaks with The Lancet - podcast, August

2014

Glasgow Coma Scale at 40

Simplified Motor Score

Glasgow Coma Scale Calculator for OS Android

Last edited 1 month ago by Donner60