Glascow Coma Score

The Glasgow Coma Scale (GCS) is used to objectively describe the extent of impaired consciousness in all types of acute medical and trauma patients. The scale assesses patients according to three aspects of responsiveness: eye-opening, motor, and verbal responses. Reporting each of these separately provides a clear, communicable picture of a patient. The findings in each component of the scale can aggregate into a total Glasgow Coma Score which gives a less detailed description but can provide a useful summary of the overall severity. The Glasgow Coma Scale and its total score have since been incorporated in numerous clinical guidelines and scoring systems for victims of trauma or critical illness. This activity describes the use of the Glasgow Coma Scale and reviews the role of using the scale for the interprofessional team to successfully communicate a patients condition.

The use of the Glasgow Coma Scale became widespread in the 1980s when the first edition of the Advanced Trauma and Life Support recommended its use in all trauma patients. Additionally, the World Federation of Neurosurgical Societies (WFNS) used it in its scale for grading patients with subarachnoid hemorrhage in 1988,[3] The Glasgow Coma Scale and its total score have since been incorporated in numerous clinical guidelines and scoring systems for victims of trauma or critical illness.[4] These cover patients of all ages, including preverbal children. The Glasgow Coma Scale is a required component of the NIH Common Data Elements for studies of head injury and the ICD 11 revision and is used in more than 75 countries.[5][4][6]

Glascow Coma Score

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There are instances when the Glasgow Coma Scale is unobtainable despite efforts to overcome the issues listed above. It is essential that the total score is not reported without testing and including all of the components because the score will be low and could cause confusion.

The information gained from the three components of the Scale varies across the spectrum of responsiveness [9]. ( Figure 1 ) Changes in motor response are the predominant factor in more severely impaired patients, whereas eye and verbal are more useful in lesser degrees. In individual patients, the clinical findings in three components should, therefore, be reported separately. The total score communicates a useful summary overall index but with some loss of information.

The Glasgow Coma Scale has been taken into numerous guidelines and assessment scores. These include trauma guidelines (such as Advanced Trauma Life Support), Brain Trauma Foundation (severe TBI guidelines), intensive care scoring systems (APACHE II, SOFA) and Advanced Cardiac Life Support.

A relationship between assessments of the GCS (typically reported as the total GCS Score) and the outcome was shown clearly by Gennarelli et al.,[10] who demonstrated the existence of a continuous, progressive association between increasing mortality after a head injury and decreases in GCS Score from 15 to 3( Figure2). This association has been seen in many other subsequent studies. The findings for the eye, verbal and motor responses also relate to the outcome but in distinctive ways so that assessment of each separately yields more information than the aggregate total score.[9]

Alternatives to the GCS Scale have been described. These typically have been derived either by shortening components of the scale or by adding extra features. The Simplified Motor Scale recognizes only three levels of motor response; this may be sufficient to support binary decisions, for example about intubation, in prehospital care and emergency room but it has no advantage over the GCS Score in identifying early mortality.[15][16] Such contracted scales inevitably convey less information and cannot match the discrimination provided by the GCS or GCS-P score in stratifying patients across the full spectrum of early severity, in monitoring changes during care in the individual or in relating to the prognosis for different late outcomes.

A systematic review has not been reported on comparisons between the reliability and prognostic yield of the Four Score and the GCS Score. Nevertheless, most studies have not shown a significant difference,[18] and the addition to the GCS of information about pupil response will increase its performance relative to the FOUR score.[16]

The GCS assesses a person based on their ability to perform eye movements, speak, and move their body. These three behaviours make up the three elements of the scale: eye, verbal, and motor. A person's GCS score can range from 3 (completely unresponsive) to 15 (responsive). This score is used to guide immediate medical care after a brain injury (such as a car accident) and also to monitor hospitalised patients and track their level of consciousness.

The Glasgow Coma Scale is reported as the combined score (which ranges from 3 to 15) and the score of each test (E for eye, V for Verbal, and M for Motor). For each test, the value should be based on the best response that the person being examined can provide.[6]

For example, if a person obeys commands only on their right side, they get a 6 for motor. The scale also accounts for situations that prevent appropriate testing (Not Testable). When specific tests cannot be performed, they must be reported as "NT" and the total score is not reported.

The results are reported as the Glasgow Coma Score (the total points from the three tests) and the individual components. As an example, a person's score might be: GCS 12, E3 V4 M5. Alternatively, if a patient was intubated, their score could be GCS E2 V NT M3.

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".Patients with scores of 3 to 8 are usually considered to be in a coma.[8]Generally, brain injury is classified as:

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). Often the 1 is left out, so the scale reads Ec or Vt. 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".

A number of assessments for head injury ("coma scales") were developed, though none were widely adopted. Of 13 scales that had been published by 1974, all involved linear scales that defined levels of consciousness.[11][12][13][14][15][16][17][18][19] These scales posed two problems. First, levels of consciousness in these scales were often poorly defined. This made it difficult for doctors and nurses to evaluate head injury patients. Second, different scales used overlapping and obscure terms that made communication difficult.[20]

Their work resulted in the 1974 publication of the first iteration of the GCS.[1] The original scale involved three exam components (eye movement, motor control, and verbal control). These components were scored based on clearly defined behavioural responses. Clear instructions for administering the scale and interpreting results were also included. The original scale is identical to the current scale except for the motor assessment. The original motor assessment included only five levels, combining "flexion" and "abnormal flexion". This was done because Jennett and Teasdale found that many people struggled in distinguishing these two states.[1]

Teasdale did not originally intend to use the sum score of the GCS components.[20] However, later work demonstrated that the sum of the GCS components, or the Glasgow Coma Score, had clinical significance. Specifically, the sum score was correlated with outcome (including death and disability).[21] As a result, the Glasgow Coma Score is used in research to define patient groups. It is also used in clinical practice as shorthand for the full scale.

The Glasgow Coma Scale was initially adopted by nursing staff in the Glasgow neurosurgical unit.[20] Especially following a 1975 nursing publication, it was adopted by other medical centres.[22] True widespread adoption of the GCS was attributed to two events in 1978.[20] First, Tom Langfitt, a leading figure in neurological trauma, wrote an editorial in Journal of Neurosurgery strongly encouraging neurosurgical units to adopt the GCS score.[23] Second, the GCS was included in the first version of Advanced Trauma Life Support (ATLS), which expanded the number of centres where staff were trained in performing the GCS.[24]

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.[25] 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.[26] Although the inter-rater reliability of these newer scores has been slightly higher than that of the GCS, they have not yet gained consensus as replacements.[27]

It is often used to gauge the severity of an acute brain injury due to trauma or medical cause. The test is simple, reliable, and correlates well with outcomes following brain injury. It is composed of 3 domains which are assessed separately and given numerical scores. The sum of these scores is the Glasgow Coma Score.

Instead of writing GCS score to begin with, just start PRACTICING with using E4, S5, M6. Get in the habit of looking at a patient and judging his response. If he's totally responsive, he's E4, S5, M6. If he's a little confused, like after a concussion, but his eyes open and he has purposeful movements, then you only have to take 1 from speech. So the confused guy is E4, S4, M6.

Use it like a checklist. Do his eyes open? If yes, then score a 4. If no, then score a 1. If "kinda," then look at the criteria. Same with the other 2. Check yes or no or kinda. If "kinda" then check out that specific list and proceed. e24fc04721