Glasgow coma scale

Dr. S. Parthasarathy MD., DA., DNB, MD (Acu),

Dip. Diab.DCA, Dip. Software statistics PhD (physio)

Mahatma gandhi medical college and research institute, puducherry, India

Some history

• Teasdale and Jennett in 1974

• 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.

First use !!

• as a method of describing states of impairment within the consciousness continuum

• a quick, practical standardized system for assessing

the degree of consciousness in the critically ill and

for predicting the duration and ultimate outcome

of coma, primarily in patients with head injuries

Original authors

• Changing level of consciousness – development of complications

• Depth of coma ---for ultimate recovery which can be expected

• Assessment at 6 h following head trauma.- influence of alcohol, drugs, hypoxia gone

• The scale involves • eye opening, • verbal response, • and motor response, all of which are

evaluated independently according to a rank order that indicates the level of consciousness and degree of dysfunction

Electronic Voting Machine

• E – 4 • V – 5 • M- 6

• The sum of the numeric values for each parameter can also be used as an overall objective measurement.

• E + V + M 15 indicative of no impairment, • 3 compatible with brain death, and • 7 usually accepted as a state of coma.

EVM – separate analyses

Localize

Withdrawal

Flexor

Extensor

Clinical uses

. The test score can also function as an indicator for certain diagnostic tests or treatments, such as the need for a computed tomography scan, intracranial pressure monitoring, and intubation.

The scale has a high degree of consistency even when used by staff with varied experience.

Clinical uses

• The results may be plotted on a graph to provide a visual representation of the improvement, stability, or deterioration of a patient's level of consciousness, which is crucial to predicting the eventual outcome of coma.

• various medical conditions including drug overdose, infection, spontaneous intracranial

bleeding, seizures and hepatic encephalopathy

v

Time

Head Injury Classification

• Severe Head Injury----GCS score of 8 or less Moderate Head Injury----GCS score of 9 to 12 Mild Head Injury----GCS score of 13 to 15

Clinical uses

• To facilitate understanding, clear description and communication between clinicians

• For research purposes

Prognosis

• The GCS motor score 2 weeks after injury was statistically significantly associated with the 12-month functional outcome in TBI survivors.

• Motor response was the most useful predictor among the GCS components with respect to the long-term functional outcome in patients with severe TBI. -- Controversial !!

In stroke !!

• The GCS verbal component may be misleading in acute stroke:

• a focal neurological deficit leading to dysphasia could affect the score, independently of level of consciousness.

Which will confuse GCS ??Ocular trauma , Cranial nerve injuries , edema of

tongue Facial trauma Injuries (spinal cord, peripheral nerves, extremities)Pain , Intoxication (alcohol, drugs)Medications (anaesthetics, sedatives)Dementia , Psychiatric diseasesDevelopmental impairmentsIntubation, tracheostomy, LaryngectomyMutism Hearing impairments

Detailed breakdown of GCS components

• Eyes

• GCS 0f 3- 4 – brain stem may be ok

• but 2 or less ??

• Vegetative state can have rarely spontaneous reflexive eye opening !!!

Verbal

• Presence of speech implies a high level of integration in the nervous system

• Motor scores of 6, 5 and 4 imply the presence of cerebral function and the ability to react appropriately to a noxious stimulus.

• 2 or 3 – may be brainstem ??

Children – verbal response

Compare with other scores

FOUR score

• The FOUR (Full Outline of UnResponsiveness)

score, not surprisingly, has four components,

each of which has 4 as the maximal grade.

• Eye, motor, brainstem reflexes, respiration

AVPU score • The GCS was compared to the AVPU• Alert, responds to Verbal stimuli, responds to

Painful stimuli, Unresponsive score and median GCS scores of 15, 13, 8 and 3 corresponded to AVP and U respectively

• A, V, P, U 15, 13, 8, 3

WFNS GCS motor deficit

• I 15 absent • II 14- 13 absent• III 14 – 13 present • IV 12 -7 present or absent• V 6 -3 present or absent

Conclusions

• All the advantages • But

• Concerns have been raised about the potential for misleading levels of precision engendered by the use of the GCS,

• and the use of simpler scales suggested.

• Thank you all