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The 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, 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 Taesdale 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 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.
|Eye||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 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).
There are four grades starting with the most severe:
There are five grades starting with the most severe:
There are six grades:
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:
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.
The GCS has come under pressure from some researchers that take issue with the scale's issues, such as poor inter-rater reliability and lack of prognostic utility. Although there is not an agreed upon alternative, newer scores such as the Simplified motor scale and FOUR score have also been developed as improvements to the GCS. While inter-rater reliability of these newer scores have been slightly higher than the GCS, they were not significant enough to gain consensus as a replacement.