Glasgow Coma Scale (GCS)

id

64

full_title

Glasgow Coma Scale (GCS)

short_title

Glasgow Coma Scale (GCS)

med_description

Coma severity based on Eye (4), Verbal (5), and Motor (6) criteria.

description

The Glasgow Coma Scale (GCS) estimates impaired consciousness and coma severity based on response to defined stimuli including Eye, Verbal, and Motor criteria.

keywords

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complaint

[ "AMS", "Head Injury", "Injury/Trauma" ]

formula

The Glasgow ComaScoreis calculated by addition of the total points selected under each component (eye, verbal, motor) below, e.g. "15 points". The Glasgow ComaScaleis comprised of the individual components, e.g. "E(4) V(5) M (6)".

evidence

• The Modified Glasgow Coma Scale (the 15-point scale that has been widely adopted, including by the original unit in Glasgow, as opposed to the 14 point original GCS Scale) was developed to be used in a repeated manner in the inpatient setting to assess and communicate changes in mental status and to measure the duration of coma (Teasdale 1974).
• The evidence in 53 published reports on the reproducibility of the scale was synthesised in a systematic review by Reith et al. 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. Reproducibility of the total GCS Score was also high, with kappa greater than 0.6 in 77% of observations. Education and training on usage of the scale resulted in A clear beneficial effect on reliability (Reith 2016).
• In its most common usage, the three sections of the scale are often summed to provide a summary of severity. The authors themselves have explicitly objected to the score being used in this way, and analysis has shown that patients with the same total score can have huge variations in outcomes, specifically mortality (GCS score of 4 predicts a mortality rate of 48% if calculated 1+1+2 for eye, verbal, and motor, a mortality of 27% if calculated 1+2+1, but a mortality of only 19% if calculated 2+1+1 (Healey 2014).

In summary, the Modified Glasgow Coma Scale provides a nearly universally accepted method of assessing patients with acute brain damage. Summation of its components into a single overall score loses information and provides only a rough guide to severity. In some circumstances, such as early triage of severe injuries, assessment of only a contracted version of the motor component of the scale, as in the Simplified Motor Scale (SMS) can perform as well the GCS and is significantly less complicated. However, the SMS may be less informative in patients with lesser injuries.

measurements

[]

information

refrences

{ "Clinical Practice Guidelines": [], "Manufacturer Website": [], "Original/Primary Reference": [ { "href": "https://www.ncbi.nlm.nih.gov/pubmed/4136544", "text": "Teasdale G, Jennett B.Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974 Jul 13;2(7872):81-4." } ], "Other References": [ { "href": "https://www.ncbi.nlm.nih.gov/pubmed/686455", "text": "Teasdale G, Jennett B. Assessment of coma and severity of brain damage. Anesthesiology. 1978;49:225-226." }, { "href": "https://www.ncbi.nlm.nih.gov/pubmed/6136811", "text": "Teasdale G, Jennett B, Murray L, Murray G. Glasgow coma scale: to sum or not to sum. Lancet. 1983 Sep 17;2(8351):678." }, { "href": "https://www.ncbi.nlm.nih.gov/pubmed/12707528", "text": "Healey C, Osler TM, Rogers FB, Healey MA, Glance LG, Kilgo PD, Shackford SR, Meredith JW. Improving the Glasgow Coma Scale score: motor score alone is a better predictor. J Trauma. 2003 Apr;54(4):671-8; discussion 678-80." }, { "href": "https://www.ncbi.nlm.nih.gov/pubmed/21803447", "text": "Green SM. Cheerio, laddie! Bidding farewell to the Glasgow Coma Scale. Ann Emerg Med. 2011 Nov;58(5):427-30. doi: 10.1016/j.annemergmed.2011.06.009. Epub 2011 Jul 30." }, { "href": "https://www.ncbi.nlm.nih.gov/pubmed/22947690", "text": "Middleton PM. Practical use of the Glasgow Coma Scale; a comprehensive narrative review of GCS methodology. Australas Emerg Nurs J. 2012 Aug;15(3):170-83. doi: 10.1016/j.aenj.2012.06.002. Epub 2012 Aug 3. Review." }, { "href": "https://www.ncbi.nlm.nih.gov/pubmed/24899079", "text": "Yeh DD. Glasgow Coma Scale 40 years later: in need of recalibration? JAMA Surg. 2014 Jul;149(7):734. doi: 10.1001/jamasurg.2014.47. No abstract available." }, { "href": "https://www.nursingtimes.net/Journals/2014/10/10/n/p/l/141015Forty-years-on-updating-the-Glasgow-coma-scale.pdf", "text": "Teasdale G. Forty Years on: Updating the Glasgow Coma Scale. Nursing Times. 2014; 110(42)." }, { "href": "https://www.ncbi.nlm.nih.gov/pubmed/15635308", "text": "Gill M, Windemuth R, Steele R, Green SM. A comparison of the Glasgow Coma Scale score to simplified alternative scores for the prediction of traumatic brain injury outcomes. Ann Emerg Med. 2005 Jan;45(1):37-42." }, { "href": "https://www.ncbi.nlm.nih.gov/pubmed/17113193", "text": "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. Epub 2006 Nov 16." }, { "href": "https://www.ncbi.nlm.nih.gov/pubmed/21803448", "text": "Thompson DO, Hurtado TR, Liao MM, Byyny RL, Gravitz C, Haukoos JS. Validation of the Simplified Motor Score in the out-of-hospital setting for the prediction of outcomes after traumatic brain injury. Ann Emerg Med. 2011 Nov;58(5):417-25. doi: 10.1016/j.annemergmed.2011.05.033. Epub 2011 Jul 30." }, { "href": "https://www.ncbi.nlm.nih.gov/pubmed/25030516", "text": "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;13(8):844-54." } ], "Outcomes": [], "Validation": [ { "href": "https://www.ncbi.nlm.nih.gov/pubmed/16766966", "text": "Moore L, Lavoie A, Camden S, Le Sage N, Sampalis JS, Bergeron E, Abdous B. Statistical validation of the Glasgow Coma Score.J Trauma. 2006 Jun;60(6):1238-43; discussion 1243-4." }, { "href": "https://www.ncbi.nlm.nih.gov/pubmed/26564211", "text": "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;42(1):3-15." } ], "Validations": [] }

pearls

• The GCS allows providers in multiple settings and with varied levels of training to communicate succinctly about a patient’s mental status.
• The GCS has been shown to have statistical correlation with a broad array of adverse neurologic outcomes, including brain injury, need for neurosurgery, and mortality.
• The GCS has been incorporated into numerous guidelines and assessment scores (e.g. ACLS, ATLS, APACHE I-III, TRISS, and WNS SAH Grading Scale).
• In some patients, it may be impossible to assess one or more of the three components of the coma scale. The reasons include, but are not limited to:
  • Eye: local injury and/or edema.
  • Verbal: intubation.
  • All (eye, verbal, motor): sedation, paralysis, and ventilation eliminating all responses. 
• If a component is untestable, a score of 1 should not be assigned (Teasdale 2014). In this circumstance, summation of the findings into a total Glasgow Coma Score is invalid.
• The 3 parts of the Glasgow Coma Scale are charted independently, and the position can be recorded as NT (not testable), with an option of indicating the reason, e.g. C for eye closure and T for intubation.

Points to keep in mind:

• Correlation with outcome and severity is most accurate when applied to an individual patient over time; the patient’s trend is important.
• A GCS of 8 should not be used in isolation to make a determination of whether to intubate a patient, but does suggest a level of obtundation that should be evaluated carefully.
• Reproducibility is usually good (Reith 2016). If individual institutions have concerns about agreement among providers, training and education are available from the GCS creators at glasgowcomascale.org.
• Simpler scores have been shown to perform as well as the GCS in the prehospital and emergency department setting (for initial evaluation). These are often contracted versions of the GCS itself (the Simplified Motor Score (SMS) uses the motor portion of the GCS only) and are less well studied than the GCS for outcomes like long-term mortality, and the GCS has been studied trended over time, while the SMS has not.

usecase

• Designed for use in serial assessments of patients with coma from either medical or surgical causes to be widely applicable.
• The GCS is commonly used in the pre-hospital and acute care setting as well as over a patient’s hospital course to evaluate for mental status assessment in both traumatic and non-traumatic presentations.
• In the care of an individual patient, the ratings of the three criteria in the Scale should be assessed, monitored, reported, and communicated separately.
• The combined Score is an index of the net severity of impairment and is useful as a summary of a patients condition, in classifying groups of different severity, for triage, and in research. The Score cannot be calculated if one or other of the component criteria is not testable.

reasons

The Glasgow Coma Scale is an adopted standard for assessment of impaired consciousness and coma in the acutely ill trauma and non-trauma patient and assists with predictions of neurological outcomes (complications, impaired recovery) and mortality.

next_advice

The GCS score can be indicative of how critically ill a patient is.

• Trauma patients presenting with GCS <15 warrant close attention and reassessment.
• A declining GCS is concerning in any setting and should prompt assessment of the airway and possible intervention.

Conversely, a GCS of 15 should not be taken as an indication that a patient (trauma or medical) is not critically ill. Decisions about the aggressiveness of the management and treatment plans should be made based on clinical presentation and context and not in any way overridden by the GCS score.

next_actions

• Although it has been adopted widely and in a variety of settings, the GCS score is not intended for quantitative use.
• Clinical management decisions should not be based solely on the GCS score in the acute setting.

From the creators of the GCS:

“We have never recommended using the GCS alone, either as a means of monitoring coma, or to assess the severity of brain damage or predict outcome.” (Teasdale 2014)

next_management

• Clinical management decisions should not be based solely on the GCS score in the acute setting.
• If a trauma patient has a GCS ≤8 and there is clinical concern that they are unable to protect their airway or that they have an expected worsening clinical course based on exam or imaging findings, then intubation can be considered.
• In any patient, a rapidly declining or waxing and waning GCS is concerning and intubation should be considered in the context of the patient's overall clinical picture.

diseases

[ "Coronavirus", "COVID-19", "Delirium", "Dementia", "Ingestion/Overdose", "Meningitis", "Trauma" ]

instructions

• Note that this calculator has been updated as of May 2019 in order to add more supporting references and to distinguish between the Glasgow Coma Score (total score, only applicable when all three components are testable) and the Glasgow Coma Scale (component scores, applicable if any of three components is not testable).
• For preverbal children (≤2 years of age), consider using the Pediatric Glasgow Coma Scale.

published

2022-04-21T20:29:44.739Z

purpose

[ "Diagnosis" ]

search_terms

[ "ams", "trauma", "gcs", "covid", "covid19", "covid-19", "covid 19", "coronavirus", "brain injuries", "coma scale", "level of consciousness", "motor response", "glasgow coma scale", "gcs score" ]

seo

{ "keywords_en": "glasgow coma scale, glasgow head injury, glasgow scale, loss of consciousness GCS, GCS LOC, GCS eye ,GCS verbal, GCS motor, glasgow coma calc, gcs calc, coma rule, glasgow coma severity, estimate coma severity, glasgow head trauma, neuro function GCS, GCS coma severity, motor response GCS, verbal response GCS, eye response GCS, GCS calc, GCS calculator, glasgow coma score, s/p head trauma, coma calc, coma score, coma scale, coma severity scale, glasgow coma severity calc, glasgow coma severity rule, glasgow coma severity estimate, serial neuro exams, GCS neuro, coma glasgow, coma assessment, coma calc, coma score, coma scale, trauma scale, head trauma score, trauma neuro, trauma neuro scale, trauma neuro score, trauma pt gcs, trauma pt neuro assessment, serial neuro, glasgow coma scale gcs, brain injuries, coma scale, level of consciousness, motor response, glasgow coma scale, gcs score", "meta_description_en": "The Glasgow Coma Scale (GCS) estimates impaired consciousness and coma severity based on response to defined stimuli including Eye, Verbal, and Motor criteria." }

specialty

[ "Critical Care", "Emergency Medicine", "Geriatrics", "Hospitalist Medicine", "Internal Medicine", "Neurology", "Neurosurgery", "Surgery (Trauma)", "Toxicology" ]

departments

[ "Neurologic" ]

tags

[]

version_number

1

versions

[]

related

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ismed

true

section

[ "whenToUseViewed", "pearlsPitfallsViewed", "whyUseViewed", "nextStepsViewed", "evidenceViewed" ]

cleaned_departments

[ "neurology" ]

cleaned_use

[ "Designed for use in serial assessments of patients with coma from either medical or surgical causes to be widely applicable.", "The GCS is commonly used in the pre-hospital and acute care setting as well as over a patient’s hospital course to evaluate for mental status assessment in both traumatic and non-traumatic presentations.", "In the care of an individual patient, the ratings of the three criteria in theScaleshould be assessed, monitored, reported, and communicated separately.", "The combinedScoreis an index of the net severity of impairment and is useful as a summary of a patients condition, in classifying groups of different severity, for triage, and in research. TheScorecannot be calculated if one or other of the component criteria is not testable." ]

pub

true