Glasgow Coma Scale

What is new?

Dr.Venugopalan P P
Director and Lead consultant in
Emergency Medicine
Aster DM Healthcare
What is GCS?

The Glasgow Coma Scale provides a practical

method for assessment of impairment of
conscious level in response to defined stimuli.
 “The Glasgow Coma Scale is an
integral part of clinical practice and
research across the World. The
experience gained since it was first
described in 1974 has advanced the
assessment of the Scale through the
development of a modern structured
approach with improved accuracy,
reliability, and communication in its
use.”
Sir Graham Teasdale
Emeritus Professor of Neurosurgery
University of Glasgow
When looking back...
● The Scale was described in 1974
● Graham Teasdale and Bryan Jennett
● Way to communicate about the level of consciousness of
patients with an acute brain injury.

Assessment of coma and impaired consciousness. A practical scale.

Lancet 1974; 2:81-4
 GCS Score
What was our Understanding ?
What is new ?
One
Two
Three
Where and how to stimulate ?
No Painful
stimuli
Only pressure stimuli
Four
4 systematic steps in GCS assessment
Rate

Check Observe Stimulate

● Spontaneous
● To Sound
● To pressure
● None
 E- Eye opening
Spontaneous
Mnemonic S- Sound
P- Pressure
N- None
Eye opening
● Oriented
● Confused
● Words
● Sounds
● None
Mnemonic

FI VE rbal
Verbal Response
● Obey commands
● Localizing
● Normal flexion
● Abnormal flexion
● Extension
● None
Best motor response
Charts
Confounding factors rendering one or more components
of the Glasgow Coma Scale untestable

○ Drugs (anaesthetics, sedatives, Use NT

neuromuscular blockade, etc) whenever
○ Cranial nerve injuries such
○ Intoxication (alcohol or drugs) factors are
○ Hearing impairment existing
○ Intubation or tracheostomy
Confounding factors rendering one or more components
of the Glasgow Coma Scale Untestable

○ Limb or spinal-cord injuries Use NT

○ Dysphasia whenever
○ Pre-existing disorders (dementia
or psychiatric disorders)
such
○ Ocular trauma factors are
○ Language and culture existing
○ Orbital swelling
Paediatric GCS
Few areas of
confusions….
GCS
Prevention and management of missing components
● Avoid missing values
❖ Temporary stop sedation (wake-up test)
● Simple imputation (same value for each patient)
❖ Record the verbal scale in patients intubated or with
tracheostomy as VT(ube)
❖ We advise against assigning a score of 1 to eye and
verbal components in sedated or untestable patients
Prevention and management of missing components

● Statistical imputation (single or multiple

imputation) based on data
❖ Imputation of verbal score from eye and motor
components
❖ Imputation based on other patient

characteristics
Strategies to improve GCS

● Describe the responses of each of the

components in individual patients
● Use the extended six-point motor subscale
and 15-point score
● Do not assign 1 for imputation of missing
values
● Chart and display changes over time
Strategies to improve GCS
● Limit the use of the score to classification and research
● Improve standardisation in assessment of patients
● Develop training instruments and implement quality
improvement programmes
● Use the scale for prognosis only in combination with other
prognostic factors (eg, Age, Pupil reactivity, and
Imaging)
 GCS -P
Pupil Reaction Scale
PRS
GCS P

The GCS 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
How do I score GCS-P

● GCS-P is calculated by subtracting the Pupil Reactivity

Score (PRS) from the Glasgow Coma Scale (GCS) total
score

GCS-P = GCS minus PRS

GCS-P is Ranging from 15 to 1
How do I assess PRS?
Advantage of GCS P
● GCS and the pupil response to light are both related to
outcome
● Combining the information together in the GCS-P extends
the information provided about outcome to an extent
comparable to more complex methods of combination of
the data
● Improve decision making about patient care, and assist in
stratification of patients into clinical trials.
Advantage of GCS P
● GCS-P Score may also be a useful platform onto which
information about other key prognostic features can be
added in a simple format likely to be useful in clinical
practice
Evidence based exercise
In the first paper, Brennan, Murray, and Teasdale describe the
development of the Glasgow Coma Scale-Pupils score
(GCS-P), a simple but elegant tool that extends the
information collected by the GCS score on the severity of
TBI.
Evidence based exercise
The authors examined

1. Relationships between GCS scores and pupils’ reaction to

light
2. Relationships between these factors and patient outcome
6 months after injury
Evidence based exercise
They examined data from

● CRASH[1] and IMPACT[2]

● The two largest databases containing information on
individual patients with TBI
GCS P Case study
Imagine that you are asked to assess a patient who has been
ejected from the passenger seat of a car at high velocity.

They make no eye, verbal or motor movements

spontaneously, or in response to your spoken requests.
GCS P Case study

● When stimulated their eyes do not open

● Make only incomprehensible sounds
● Flex arms abnormally
● Scored as E1V2M3 using the Glasgow Coma
Scale
● Sum score of 6.
GCS P Case study

● Now test their pupil reactivity to light

● Neither pupil is reactive to light.
● Pupil Reactivity Score (PRS) of 2.
● GCS-P can then be determined as
GCS-PRS
● In this case it 6-2 =4.
GCS P Case study

● GCS 6 there is a 29% chance of death at 6

months
● When the pupil reactivity and GCS are
combined to give a GCSP, the mortality
increases to 39%
GCS -P
and
Mortality
GCS -P

● Used as an index of ‘overall’ brain damage

● Distinguishing head injuries of differing
severities
● Monitoring their progress and prognosis
GCS -P
‘Brain stem’ features were not incorporated into the scale, but
were expected to be assessed separately

There have nevertheless been views that more complex

scores, with extra features would be useful.
GCS- P A
Age
GCS PA
● GCS Pupils Age prognostic charts
● Developed by Gordon Murray, Paul Brennan and Graham
Teasdale, and published by the Journal of Neurosurgery
in 2018
● The charts provide a simple graphical presentation of
the probabilities of outcome from traumatic brain
injury based on GCS, Pupil reactivity, Age and CT
scan findings.
 GCS Pupils Age prognostic charts

● Four prognostic factors contain much of the

information about prognosis of people with an
acute head injury
● GCS, pupil reactivity to light, age, and the
findings on
● Computer Tomography (CT) scan are the
most useful investigative index
 GCS Pupils Age prognostic charts

● Combining them to convey

1. GCS
information graphically 2. Pupil
about risks of mortality, or reactivity
the prospects for 3. Age
independent recovery, 4. CT Scan
after head injury. finding
GCS PA
● Observed the additive effect on outcome that occurs
when age is added to the patient’s admission GCS-P
● The risk of death after TBI increases as patient age
advances
● At all ages the risk of death increases as the GCS-P
decreases.
GCS - PA

● Probability of favourable outcome is greater in

younger patients and in patients with higher
GCS-P
GCS -PA Charts
● The authors created two prediction charts based on the
GCS-P and patient age stratified into 5-year increments
(GCS-PA charts)
● One chart clearly shows risks of death
● Other chart probabilities of favourable outcomes in
patients 6 months after TBI.
6 month
mortality
6 months
favorable
outcome
GCS
Pupil &
Age
These factors have been validated in earlier
studies to be the most important prognostic
characteristics in head-injured patients.
 CT
Abnormalities
GCS-P A
GCS P A plus CT findings
● CT findings are the other important predictor of patient
outcome
● CT scan findings showed the differences in outcome are
very similar between patients with or without either a
haematoma, or absent cisterns, or subarachnoid
haemorrhage
GCS P A plus CT findings
Taken in combination there is a gradation in risk with
increasing numbers of any of these abnormalities

A simple extension of the prognostic charts can then be made

by stratifying the original charts into three CT groupings:

● No
CT Abnormalities ● Only One
● Two or more
GCS-PA CT charts
● Simplify three different abnormal CT findings into scores
based solely on the number of abnormalities
● Created two sets of three predictive charts based on the
GCS-P plus patient age and number of CT abnormalities
(GCS-PA CT charts)
● Charts for No CT abnormalities ,Only one abnormalities &
Two or More abnormalities
GCS-PA CT charts
1. One chart follows probabilities of death 6 months after
injury
2. Other set follows probabilities of favourable outcome at
the same time point.
● Charts can be used by clinicians in decision making
● Communicating predictive information to other clinicians,
patients, and caregivers.
GCS PA CT
Prediction Charts
GCS PA
CT-
prediction
charts
6 months
Mortality
No CT
findings
GCS PA
CT
prediction
charts
6 months
mortality
Only
One CT
findings
GCS-PA
CT
prediction
charts
6 month
mortality
Two or
more
CT
findings
GCS PA CT
Prediction
chart
6 months
Favorable
outcome
No CT
Findings
GCS PA CT
Prediction
chart
6 months
Favorable
outcome
Only One
CT
Findings
GCS PA CT
Prediction
chart
6 months
Favorable
outcome
Two or
More CT
Findings
GCS-P- A - CT prognostic Tables
● Developed from data created by the IMPACT and
CRASH studies
● These studies include patients exhibiting a wide spectrum
of haematoma.
● The size of the haematoma or severity of subarachnoid
haemorrhage does not need to be separately considered
● Size and severity will influence the GCS and pupil
reactivity
Summary
Authors response on the studies

“Decisions about patient care in the immediate

aftermath of a head injury are influenced by
physician perceptions of the patient’s likely
outcome, so it’s important that assumptions that
underlie these decisions are correct.
Authors response on the studies

“Working together between Glasgow and

Edinburgh, we have developed the GCS-P and
associated prognostic charts. These simple and
easy to use tools provide reliable estimates of
outcomes at 6 months and will support clinician
decision making in neurotrauma.”
How to assess GCS ? Video
You can search here ….
http://www.glasgowcomascale.org/
Resources
Thanks a lot
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