Glasgow Coma Scale

Glasgow Coma Scale 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 15 on the widely used GCS 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. 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. The scale was first 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. Elements of the scale Glasgow Coma Scale 1 2 3 4 5 6 Opens eyes in Does not Opens eyes in Opens eyes Eyes response to painful N/A N/A open eyes response to voice spontaneously stimuli Utters Oriented, Makes no Incomprehensible Confused, Verbal inappropriate converses N/A sounds sounds disoriented words normally Abnormal flexion Extension to painful Flexion / Localizes Makes no to painful stimuli Obeys Motor stimuli (decerebrate Withdrawal to painful movements (decorticate commands response) painful stimuli stimuli response)

Decerebrate rigidity or abnormal extensor posturing describes the involuntary extension of the upper extremities in response to external stimuli. In decerebrate posturing, the head is arched back, the arms are extended by the sides, and the legs are extended. A hallmark of decerebrate posturing is extended elbows. The arms and legs are extended and rotated internally. The patient is rigid, with the teeth clenched. The signs can be on just one or the other side of the body or on both sides, and it may be just in the arms and may be intermittent. A person displaying decerebrate rigidity in response to pain gets a score of two in the motor section of the Glasgow Coma Scale. Decorticate posturing (also called decorticate response, decorticate rigidity, flexor posturing, or, colloquially, mummy baby.) Patients with decorticate posturing presents with the arms flexed, or bent inward on the chest, the hands are clenched into fists, and the legs extended and feet turned inward. A person displaying decorticate posturing in response to pain gets a score of three in the motor section of the Glasgow Coma Scale. Decorticate posturing indicates that there may be damage to areas including the cerebral hemispheres, the internal capsule, and the thalamus. It may also indicate damage to the midbrain. While decorticate posturing is still an ominous sign of severe brain damage, decerebrate posturing is usually indicative of more severe damage as the rubrospinal tract and hence, the red nucleus, is also involved indicating lesion lower in the brainstem. www.physiosrilanka.com The scale: 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 supraorbital 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.

Keep in mind that, although the descriptions of what a "point" entails may be straightforward, it's not always easy for medical professionals to assess in which category patients fall. For example, swollen eyes due to head trauma may prevent doctors from evaluating visual responsiveness. Consequently, both doctors and nurses regularly use the Glasgow Coma Scale multiple times on individual patients to determine their evolving needs and changing conditions. 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. www.physiosrilanka.com For children: 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. For children under 5, the verbal response criteria are adjusted as follow SCORE 2 to 5 YRS 0 TO 23 Mos.

5 Appropriate words or phrases Smiles or coos appropriately

4 Inappropriate words Cries and consolable

3 Persistent cries and/or screams Persistent inappropriate crying &/or screaming

2 Grunts Grunts or is agitated or restless

1 No response No response

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.

Modified and adapted from: http://en.wikipedia.org/wiki/Glasgow_Coma_Scale http://www.unc.edu/~rowlett/units/scales/glasgow.htm http://www.brainandspinalcord.org/recovery-traumatic-brain-injury/glasgow-coma-scale.html%20 http://en.wikipedia.org/wiki/Abnormal_posturing#Decorticate