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Glasgow Coma Scale or GCS is a neurological scale that aims to give a reliable, 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 aid, EMS, 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.

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. A similar scale, the Rancho Los Amigos Scale is used to assess the recovery of traumatic brain injury patients.

Contents

Elements of the scale

Glasgow Coma Scale
1 2 3 4 5 6
Eyes Does not open eyes Opens eyes in response to painful stimuli Opens eyes in response to voice Opens eyes spontaneously N/A N/A
Verbal Makes no sounds Incomprehensible sounds Utters inappropriate words Confused, disoriented Oriented, converses normally N/A
Motor Makes no movements Extension to painful stimuli (decerebrate response) Abnormal flexion to painful stimuli (decorticate response) Flexion / Withdrawal to painful stimuli Localizes painful stimuli Obeys commands

The scale comprises 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).

Best eye response (E)

There are 4 grades starting with the most severe:

  1. No eye opening
  2. Eye opening in response to pain. (Patient responds to pressure on the patient’s fingernail bed; if this does not elicit a response, supraorbital and sternal pressure or rub may be used.)
  3. Eye opening to speech. (Not to be confused with an awaking of a sleeping person; such patients receive a score of 4, not 3.)
  4. Eyes opening spontaneously

Best verbal response (V)

There are 5 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)
  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.)

Best motor response (M)

There are 6 grades starting with the most severe:

  1. No motor response
  2. Extension to pain (abduction of arm, internal rotation of shoulder, pronation of forearm, extension of wrist, decerebrate response)
  3. Abnormal flexion to pain (adduction of arm, internal rotation of shoulder, pronation of forearm, flexion of wrist, decorticate response)
  4. Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist when supra-orbital pressure applied ; pulls part of body away when nailbed pinched)
  5. Localizes to pain. (Purposeful movements towards painful stimuli; e.g., hand crosses mid-line and gets above clavicle when supra-orbital 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
  • Moderate, GCS 9 - 12
  • Minor, GCS ≥ 13.

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.

See also

References

  • Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974,2:81-84. PMID 4136544.

External links

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Simple English

Glasgow Coma Scale or GCS is a scale that is used to measure the consciousness of a person. It was invented in 1974 by Graham Teasdale and Bryan J. Jennett, professors of neurosurgery at the University of Glasgow.

GCS is used in evaluation of patients, especially in ICUs. This scale consists of three tests, which are described below. A score is given for each test, and the GCS score is calculated by adding the scores given to each test. The maximum score is 15, which means the patient is fully conscious. The minimum score is 3, and is usually seen in patients with brain death or those in deep coma.

Contents

Elements of the scale

Glasgow Coma Scale
6 5 4 3 2 1
Eyes N/A N/A Opens eyes by himself Opens eyes in response to voice Opens eyes in response to pain Does not open eyes
Verbal N/A Oriented (normal) Confused (disoriented) Says inappropriate words Makes meaningless sounds Makes no sounds
Motor Obeys commands Localizes pain Withdraws from painful stimulus Decorticate posturing with painful stimulus Decerebrate posturing with painful stimulus Makes no movements

The scale comprises three tests: eye, verbal (talking) and motor (movement) responses.

Best eye response (E)

There are 4 grades for this test:

  1. No eye opening
  2. Eye opening in response to pain (for example when his sternum is pressed firmly).
  3. Eye opening to speech (that is, when he is called).
  4. Eyes opening by himself (normally).

Best verbal response (V)

There are 5 grades for this test:

  1. No verbal response (not talking at all).
  2. Meaking meaningless sounds (that is, moaning but no words).
  3. Inappropriate words (like random speech, without being able to communicate correctly).
  4. Confused. (The patient responds to questions but there is some confusion).
  5. Oriented. (Patient responds appropriately to questions such as the patient’s name and age, where they are and why, the year, month, etc).

Best motor response (M)

There are 6 grades for this test:

  1. No motor response (no movement at all).
  2. Extension in response to pain (decerebrate response: adduction, internal rotation of shoulder, pronation of forearm).
  3. Flexion in response to pain (decorticate response).
  4. Withdrawing from pain (pulling part of body away when pinched).
  5. Localizing to pain. (Purposeful movements towards the painful location).
  6. Obeys commands. (The patient does simple things he is asked to do).

References

  • Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974,2:81-84. PMID 4136544.

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