Glasgow Coma Scale.pdf

Glasgow Coma Scale
https://www.ncbi.nlm.nih.gov/books/NBK513298/
Last Update: June 12, 2023.
Authors
Shobhit Jain1
; Lindsay M. Iverson2
.
Affiliations
1
Childrens Mercy Hospital
2
Creighton University
Continuing Education Activity
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 patient’s condition.
Objectives:
• Explain the value of the Glasgow Coma Scale for patient care.
• Outline the three areas the Glasgow Coma Scales assesses.
• Summarize the severity findings for each range of the Glashow Coma Scale.
• Review how the interprofessional team can use the Glasgow Coma Scale to
communicate regarding a patient’s condition.
Access free multiple choice questions on this topic
Introduction
The Glasgow Coma Scale was first published in 1974 at the University of Glasgow
by neurosurgery professors Graham Teasdale and Bryan Jennett.[1] 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’s state.
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 ‘shorthand’
summary of the overall severity.[2] The score expression is the sum of the scores as well
as the individual elements. For example, a score of 10 might be expressed as GCS10 =
E3V4M3.

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]
Function
Scoring and Parameters
The Glasgow Coma Scale divides into three parameters: best eye response (E), best
verbal response (V) and best motor response (M). The levels of response in the
components of the Glasgow Coma Scale are ‘scored’ from 1, for no response, up to
normal values of 4 (Eye-opening response) 5 (Verbal response) and 6 (Motor response)
The total Coma Score thus has values between three and 15, three being the worst and
15 being the highest.
The score is the sum of the scores as well as the individual elements. For example, a
score of 10 might be expressed as GCS10 = E3V4M3.
• Best eye response (4)
1. No eye opening
2. Eye opening to pain
3. Eye opening to sound
4. Eyes open spontaneously
• Best verbal response (5)
1. No verbal response
2. Incomprehensible sounds
3. Inappropriate words
4. Confused
5. Orientated
• Best motor response (6)
1. No motor response.
2. Abnormal extension to pain
3. Abnormal flexion to pain
4. Withdrawal from pain
5. Localizing pain
6. Obeys commands

Application of the Glasgow Coma Scale in Pediatrics
The Glasgow Coma Scale can be used in children older than 5 years with no modification.
Younger children and infants are not able to provide the necessary verbal responses for
the practitioner to use the scale to assess their orientation or obey the commands to
evaluate their motor response. Since a Pediatric Glasgow Coma Scale was initially
described in Adelaide, there have been several modifications without any particular one
becoming universally accepted.[7] The versions below derive from those of James and
the Pediatric Emergency Care Applied Research Network[8][6]
Children less than 2 years old (pre-verbal) / Children greater than 2 years old
(verbal)
• Best eye response
1. No eye opening
2. Eye opening to pain
3. Eye opening to sound
4. Eyes open spontaneously
• Best verbal response
1. None
2. Moans in response to pain / Incomprehensible sounds
3. Cries in response to pain / Incomprehensible words
4. Irritable/cries / Confused
5. Coos and babbles / Orientated - appropriate
• Best motor response
1. No motor response
2. Abnormal extension to pain
3. Abnormal flexion to pain
4. Withdrawal to pain
5. Withdraws to touch / Localises to pain
6. Moves spontaneously and purposefully / Obeys commands
Issues of Concern
The following factors may interfere with the Glasgow Coma Scale assessment:
1. Pre-existing factors
§ Language barriers
§ Intellectual or neurological deficit
§ Hearing loss or speech impediment
2. Effects of current treatment
§ Physical (e.g., intubation): If a patient is intubated and unable to speak, they are
evaluated only on the motor and eye-opening response and the suffix T is added
to their score to indicate intubation.
§ Pharmacological (e.g., sedation) or paralysis: If possible, the clinician should
obtain the score before sedating the patient.

3. Effects of other injuries or lesions
§ Orbital/cranial fracture
§ Spinal cord damage
§ Hypoxic-ischemic encephalopathy after cold exposure
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.
Clinical Significance
Assessment of responsiveness with the Glasgow Coma Scale is widely used to guide early
management of patients with a head injury or other kind of acute brain injury. Decisions
in more severely impaired patients include emergent management such as securing the
airway and triage to determine patient transfer. Decisions in less severely impaired
patients include the need for neuroimaging, admission for observation or discharge.
Serial Glasgow Coma Scale assessments are also critical in monitoring the clinical course
of a patient and guiding changes in management.
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.
In both preverbal and verbal pediatric patients, the Glasgow Coma Scale is an accurate
marker for clinically important traumatic brain injury (i.e., injury requiring neurosurgical
intervention, intubation for over 24 hours, hospitalization for more than two nights, or
causing death.[6]
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.
Relation to Outcome
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]
However, although it is one of the most powerful clinical prognostic features, neither
the GCS score nor any single feature alone should be used to predict an individual

patient’s outcome. This is because the prognostic implications of the score are
influenced by several factors. These include the diagnosis, and in trauma the cause and
if there are extracranial injuries,[11] patient-related factors such as age and other
clinical indices (such as pupillary dysfunction and imaging findings), the GCS score is a
key component of multifactorial models for prediction of outcomes such as in the
IMPACT and CRASH trials.[11][12]
Glasgow Coma Scale Pupils Score
The Glasgow Coma Scale Pupils Score (GCS-P) was described by Paul Brennan, Gordon
Murray, and Graham Teasdale in 2018 as a strategy to combine the two key indicators
of the severity of traumatic brain injury into a single simple index.[13][14]
Calculation of the GCS-P is by subtracting the Pupil Reactivity Score (PRS) from the
Glasgow Coma Scale (GCS) total score:
• GCS-P = GCS – PRS
The Pupil Reactivity Score is calculated as follows.
Pupils unreactive to light - Pupil Reactivity Score
• Both pupils - 2
• One pupil - 1
• Neither pupil - 0
The GCS-P score can range from 1 and 15 and extends the range over which early
severity can be shown to relate to outcomes of either mortality or independent recovery.
Classification of Severity of TBI
The relationship between the GCS Score and outcome l is the basis for a common
classification of acute traumatic brain injury:
• Severe, GCS 3 to 8
• Moderate, GCS 9 to 12
• Mild, GCS 13 to 15
With the GCS-P score values between one and 8 denote a severe injury.
Other Issues
The reliability of the GCS Scale has undergone extensive study. Although its
reproducibility has been questioned in a small number of reports, these have proved to
be exceptions. Thus, a systematic review of all 53 published reports in 2016 concluded
that 85% of the findings in higher quality studies showed substantial reliability as judged
by the standard criterion of a kappa statistic (k) above 0.6 [15]. The reproducibility of
the total GCS Score was also high with kappa greater than 0.6 in 77 % of observations. A
clear beneficial effect on reliability resulted from education and training. To promote
this initiative, a standardized structured approach to assessment has been set out
(Teasdale GM et al. Nursing Times. 2014. 110: 12-16.).

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.
More complex scales include the "Full Outline Of Unresponsiveness" or FOUR developed
in neurological intensive care.[17] In addition to eye and motor responses derived from
GCS, FOUR incorporates two additional, brain stem and respiratory, components. These
additional features have been found to have lesser relations to with outcome than the
eye and motor scales. The ‘brain stem’ feature has as its basis the observations of pupils,
corneal, and cough responses. The value of assessing pupil reactivity is well established,
but the additional contribution of the other features is not clear. The basis of the
respiratory subscale is the rhythm of breathing, but the reliability of the feature is
unclear; the pattern of breathing can be variable, is influenced by extracranial factors,
by sedation and by the technique of ventilation.
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 Glasgow Coma Scale - PA charts combine the prognostic information from the GCS,
the pupil response, imaging findings and the patient’s age in a simple visual way that is
easy to understand.[17] They provide a user-friendly predictive tool that balances
between the simplicity but limited information in a ‘score’ and the more precise but
more complex calculations of multivariate models.
Enhancing Healthcare Team Outcomes
All healthcare workers should know about the GCS and what the numbers mean.
Anytime the GCS is initially performed, the numbers should be recorded in the medical
chart so that the patient can undergo serial monitoring.
Review Questions
• Access free multiple choice questions on this topic.
• Comment on this article.
References
1. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical
scale. Lancet. 1974 Jul 13;2(7872):81-4. [PubMed: 4136544]
2. Teasdale G, Murray G, Parker L, Jennett B. Adding up the Glasgow Coma Score. Acta
Neurochir Suppl (Wien). 1979;28(1):13-6. [PubMed: 290137]

3. Teasdale GM, Drake CG, Hunt W, Kassell N, Sano K, Pertuiset B, De Villiers JC. A
universal subarachnoid hemorrhage scale: report of a committee of the World
Federation of Neurosurgical Societies. J Neurol Neurosurg Psychiatry. 1988
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4. Teasdale G, Maas A, Lecky F, Manley G, Stocchetti N, Murray G. The Glasgow Coma
Scale at 40 years: standing the test of time. Lancet Neurol. 2014 Aug;13(8):844-
54. [PubMed: 25030516]
5. Grinnon ST, Miller K, Marler JR, Lu Y, Stout A, Odenkirchen J, Kunitz S. National
Institute of Neurological Disorders and Stroke Common Data Element Project -
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PMC3513359] [PubMed: 22371630]
6. Borgialli DA, Mahajan P, Hoyle JD, Powell EC, Nadel FM, Tunik MG, Foerster A, Dong
L, Miskin M, Dayan PS, Holmes JF, Kuppermann N., Pediatric Emergency Care Applied
Research Network (PECARN). Performance of the Pediatric Glasgow Coma Scale
Score in the Evaluation of Children With Blunt Head Trauma. Acad Emerg Med. 2016
Aug;23(8):878-84. [PubMed: 27197686]
7. Reilly PL, Simpson DA, Sprod R, Thomas L. Assessing the conscious level in infants
and young children: a paediatric version of the Glasgow Coma Scale. Childs Nerv
Syst. 1988 Feb;4(1):30-3. [PubMed: 3135935]
8. James HE. Neurologic evaluation and support in the child with an acute brain
insult. Pediatr Ann. 1986 Jan;15(1):16-22. [PubMed: 3951884]
9. Reith FCM, Lingsma HF, Gabbe BJ, Lecky FE, Roberts I, Maas AIR. Differential effects
of the Glasgow Coma Scale Score and its Components: An analysis of 54,069 patients
with traumatic brain injury. Injury. 2017 Sep;48(9):1932-1943. [PubMed: 28602178]
10. Gennarelli TA, Champion HR, Copes WS, Sacco WJ. Comparison of mortality,
morbidity, and severity of 59,713 head injured patients with 114,447 patients with
extracranial injuries. J Trauma. 1994 Dec;37(6):962-8. [PubMed: 7996612]
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Marmarou A, Roberts I, Habbema JD, Maas AI. Predicting outcome after traumatic
brain injury: development and international validation of prognostic scores based on
admission characteristics. PLoS Med. 2008 Aug 05;5(8):e165; discussion e165. [PMC
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E, Poccock S, Roberts I, Shakur H, Steyerberg E, Yutthakasemsunt S. Predicting
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13. Brennan PM, Murray GD, Teasdale GM. Simplifying the use of prognostic
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29631516]
14. Reith FC, Van den Brande R, Synnot A, Gruen R, Maas AI. The reliability of the
Glasgow Coma Scale: a systematic review. Intensive Care Med. 2016 Jan;42(1):3-
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15. Haukoos JS, Gill MR, Rabon RE, Gravitz CS, Green SM. Validation of the Simplified
Motor Score for the prediction of brain injury outcomes after trauma. Ann Emerg
Med. 2007 Jul;50(1):18-24. [PubMed: 17113193]
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Patients. Crit Care Med. 2015 Oct;43(10):e471-2. [PubMed: 26376275]

17. Murray GD, Brennan PM, Teasdale GM. Simplifying the use of prognostic
information in traumatic brain injury. Part 2: Graphical presentation of
probabilities. J Neurosurg. 2018 Jun;128(6):1621-1634.[PubMed: 29631517]
18. Ghelichkhani P, Esmaeili M, Hosseini M, Seylani K. Glasgow Coma Scale and FOUR
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