Desiree Duncan

1103671

ASSESSMENT OF THE GLOSGOW COMMA SCALE

There are a few different systems that medical practioners use to diagnose the symptoms
of Traumatic Brain Injury. The Glasgow Coma Scale (GCS) is the most common scoring system
used to describe the level of consciousness in a person following a traumatic brain injury. It is
used to help determine the severity of an acute brain injury. The test is simple, reliable, and
correlates well with outcome following severe brain injury.
The Glasgow Coma Scale can be applied to describe impairment of consciousness from
any cause. It has found most used in head injuries, but reports of its application in impaired
consciousness from other etiologies include: Spontaneous intracerebral haemorrhage and general
trauma. In conditions where the damage is predominantly focal, as in a stroke, additional
information is important.
The Glasgow Coma Scale is based on a 15 point scale for estimating and categorizing the
outcomes of brain injury on the basis of overall social capability or dependence on others. The
test measures the motor response, verbal response and eye opening response
The GCS measures the following functions:
Eye Opening (E)
4 Spontaneous eye opening
3 Eyes open to speech

2 Eyes open to pain

1 No eye opening
Verbal Response (V)
5 = normal conversation
4 = disoriented conversation
3 = words, but not coherent
2 = no words, only sounds
1 = none
Motor Response (M)
6 = normal
5 = localized to pain
4 = withdraws to pain
3 = decorticate posture (an abnormal posture that can include rigidity, clenched fists, legs
held straight out, and arms bent inward toward the body with the wrists and fingers bend and
held on the chest
2 = decerebrate (an abnormal posture that can include rigidity, arms and legs held straight
out, toes pointed downward, head and neck arched backwards
1 = none

Clinicians use this scale to rate the best eye opening response, the best verbal response,
and the best motor response an individual makes The final score is determined by adding the
values of E+V+M.
This number helps medical practioners categorize the four possible levels for survival, with a
lower number indicating a more severe injury and a poorer prognosis.
E + M + V = 3 to 15

90% less than or equal to 8 are in coma

Greater than or equal to 9 not in coma
8 is the critical score
Less than or equal to 8 at 6 hours - 50% die
9-12 = moderate severity
Greater than or equal to 13 = minor injury
Coma is defined as: (1) not opening eyes, (2) not obeying commands, and (3) not
uttering understandable words
Using the Glasgow Coma Scale
Every brain injury is different, but generally, brain injury is classified as:

Mild (13-15):
Moderate Disability (9-12):

Loss of consciousness greater than 30 minutes

Physical or cognitive impairments which may or may resolve

Benefit from Rehabilitation

Severe Disability (3-8(You cannot score lower than a 3.)):
Coma: unconscious state. No meaningful response, no voluntary
movement.

Mild brain injuries can result in temporary or permanent neurological symptoms and
neuro-imaging tests such as CT scan or MRI may or may not show evidence of any damage.
Moderate and severe brain injuries often result in long-term impairments in cognition (thinking
skills), physical skills, and/or emotional/behavioral functioning.

Limitations of the Glasgow Coma Scale

Factors like drug use, alcohol intoxication, shock, or low blood oxygen can alter a
patients level of consciousness. These factors could lead to an inaccurate score on the GCS
activities.
There are three main sources of possible interference with assessment of one or more
component of the scale.
1.

Pre-existing factors

Language or cultural differences

Intellectual or neurological deficit

Hearing loss or speech impediment

2.

Effects of current treatment

Physical e.g. intubation or tracheostomy

Pharmacological e.g. sedation or paralysis

3.

Effects of other injuries or lesions

Orbital/Cranial fracture

Dysphasia or Hemiplegia

Spinal cord damage

What is the reliability of the Glasgow Coma Scale?

There is not a single, overall figure for the reliability of assessment using the Glasgow
Coma Scale. This is because there are wide variations in the findings in reported studies. In
research performed during development of the Glasgow Coma Scale its reliability was shown to
be better than for other systems in use at the time and approached that of examination of pupil
reaction1. Since then various different studies have reported the reliability as high2 and low3.
The reliability of a scaling method is usually expressed as its Kappa statistic, for which 1
= perfect agreement and 0 = agreement no better than expected by chance. A formal literature
review found values reported for the Glasgow Coma Scale to range from 0.85 to 0.32. A factor
often found to reduce reliability is variation in the way that missing information is dealt with.
Factors shown to enhance reliability include the extent of training and experience of the
examiner along with the availability of data.

When and how often should Observations be recorded?

The timing and frequency of assessment that are appropriate varies according to the stage
after onset of the impairment of consciousness and the pattern in any previous observations of a
patient. Observation should begin as soon as possible after onset of the impaired consciousness
in order to guide initial management and to establish a baseline against which to interpret later
findings. Observations initially should be repeated frequently to establish if the patient is stable

or to detect any trends of improvement, or of deterioration from developing complications. When

a stable pattern emerges as time passes, the frequency can be reduced.
Specific criteria for patients with an acute head injury have been suggested by National
Institute of Clinical Excellence Clinical Guideline:

Observations should be performed and recorded on a half

hourly basis until GCS equal to 15 has been achieved. If GCS=15
Frequency of

observe: half-hourly for 2 hours, then 1 hourly for 4 hours, then 2

observation

hourly thereafter; Should the patient with GCS equal to 15

deteriorate at any time after the initial 2-hour period,
observations should revert to half-hourly.
A sustained (that is, for at least 30 minutes) drop of one

Urgent
reappraisal by
the supervising
doctor

point in GCS level (greater weight should be given to a drop of

one point in the motor score of the GCS);
Any drop of 3 or more points in the eye-opening or verbal
response scores of the GCS or 2 or more points in the motor
response.

If responsiveness reduces, the features to take into account in deciding action include:
1.

The pattern of responsiveness before the change: the more stable the pattern, the

more a change may be important

2.

The level of responsiveness before the change: the lower the preceding

responsiveness the sooner action is appropriate.

3.

The aspect of the scale that has changed and the extent of the change: motor

changes usually call for a response sooner than changes to the eye or verbal components.
4.

If the change persists when assessment is repeated, including confirmation by a

colleague if doubt remains, then the change is more likely to be significant.

Children and the Glasgow Coma Scale

The GCS is usually not used with younger children, especially those too young to have
reliable language skills. The Pediatric Glasgow Coma Scale, or PGCS, a modification of the
scale used on adults, is used instead. The PGCS still uses the three tests eye, verbal, and
motor responses and the three values are considered separately as well as together.
Here is the slightly altered grading scale for the PGCS:
Eye Opening (E)
4 = spontaneous
3 = to voice
2 = to pain
1 = none
Verbal Response (V)
5 = smiles, oriented to sounds, follows objects, interacts
4 = cries but consolable, inappropriate interactions

3 = inconsistently inconsolable, moaning

2 = inconsolable, agitated
1 = none

Motor Response (M)

6 = moves spontaneously or purposefully
5 = withdraws from touch
4 = withdraws to pain
3 = decorticate posture (an abnormal posture that can include rigidity, clenched fists, legs
held straight out, and arms bent inward toward the body with the wrists and fingers bend and
held on the chest)
2 = decerebrate (an abnormal posture that can include rigidity, arms and legs held straight
out, toes pointed downward, head and neck arched backwards
1 = none
Pediatric brain injuries are classified by severity using the same scoring levels as adults,
i.e. 3-8 reflecting the most severe, 9-12 being a moderate injury and 13-15 indicating mild. As in
adults, moderate and severe injuries often result in significant long-term impairments

Reference

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; 37:962-8
Zuercher M, Ummenhofer W, Baltussen A, Walder B. The use of Glasgow Coma Scale in injury
assessment: a critical review. Brain Inj. 2009 May;23(5):371-84. doi:
10.1080/02699050902926267. Review. PubMed PMID: 19408162.