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The '''Glasgow Coma Scale''' (GCS) is a neurological assessment scale which aims to give a reliable, objective way of quantifying level of consciouness following a traumtic brain injury. [http://en.wikipedia.org/wiki/Glasgow_Coma_Scale]
<onlyinclude>The '''Glasgow Coma Scale''' (GCS) ([http://www.brainline.org/content/2010/10/what-is-the-glasgow-coma-scale.html], [https://en.wikipedia.org/wiki/Glasgow_Coma_Scale]) is a commmon neurological assessment scale used to quantify the level of consciousness in a person following a '''traumatic brain injury'''. </onlyinclude> Basically, it is used to help gauge the severity of an acute brain injury.  
The Glasgow Coma Score is also used as part of the [[:Category:APACHE II|APACHE II]] assessment score for Critical Care Program and the [[MOST]] assessment score for Medicine Program.


== Instructions ==
* The '''Glasgow Coma Score''' is also used as part of the [[:Category:APACHE II|APACHE II]] assessment score for Critical Care Program and the [[ALERT Scale]] for Medicine Program.
Select the '''best''' Eye, Motor or Verbal response in the '''first 24''' hours after admission to '''ICU''' from the dropdown lists on your PDA and in Access.
* The '''bedside nurses''' doing the GCS evaluation on the patient will record the best response.
* The '''data collector''' will enter the GCS as per [[Selection and timing of APACHE components]]
For reference only:
{| class="wikitable" border=1 <hiddentext> set to 0 for no borders</hiddentext>


|-  align="center" valign="top"
== Special Cases ==
|style="background-color:#CCCCE6" width="125" height="27" | '''Score'''
The below are only meant to help you '''use your judgement''' keeping in mind that the purpose of the GCS is to assess the severity of a '''brain injury''', within the first 24hrs of admission.
| width="64" | '''6'''
| width="58" |''' 5'''
| width="48" | '''4'''
| width="48" |''' 3'''
| width="48" | '''2'''
| width="48" | '''1'''
 
|-  align="center" valign="top"
|style="background-color:#CCCCE6" width="125" height="27" | '''EYE''' Response
| width="64" | &nbsp;
| width="58" | &nbsp;
| width="48" | Spontaneous
| width="48" | To
 
Speech
| width="48" | To
 
Pain
| width="48" | None
 
|-  align="center" valign="top"
|style="background-color:#CCCCE6" height="39" | '''MOTOR''' Response
| Obeys
 
Command
| Localizes
 
Pain
| Withdraws
 
to Pain
| Abnormal
 
Flexion
| Abnormal
 
Extension
| None
 
|-  align="center" valign="top"
|style="background-color:#CCCCE6" height="38" | '''VERBAL''' Response
| &nbsp;
| Oriented
| Confused
| Inappropriate
 
words
| Incomprehensible
 
sounds
| None
 
|- align="center"  valign="top"
|style="background-color:#CCCCE6" height="38" | '''VERBAL''' Response -'''Ventilated'''
| width="48" | &nbsp;
| width="48" | Appears Oriented
| width="48" | &nbsp;
| width="48" | ? Oriented
| width="48" | &nbsp;
| width="48" | No response


|}
===Sedated patients ===
 
<!-- These instructions were given by Dr Garland utilizing the APACHE manual created by APACHE Medical Systems. --[[User:LKolesar|LKolesar]] 09:02, 2013 January 16 (EST) -->
== Special Cases ==
# If a pt is an overdose, use the worst score because the sedative effect and the potential injury to the brain due to the drug overdose is part of the acuity score.
# If a pt is heavily sedated, a GCS is not considered accurate, therefore, if possible, use the worst GCS done when the pt. is '''not''' on sedation in the first 24 hours.
# If a non-sedated GCS is unavailable in the first 24 hours, use the previous un-sedated GCS if possible. 
# If there is absolutely no un-sedated GCS available (e.g. [[Lost/missing chart]]), default to a '''normal GCS'''.


=== Patients with normally limited communication ability===
=== Patients with normally limited communication ability===
For patients whose ability to communicate are reduced due to '''pre-existing conditions''', score as fully functioning if they are able to function at the level that is '''normal for this patient'''. (e.g. Down's syndrome)
For patients whose ability to communicate are reduced due to '''pre-existing conditions''', score as fully functioning if they are able to function at the level that is '''normal for this patient'''. (e.g. Down's syndrome)


=== Patients who cannot '''speak''' but are communicating ===
=== Patients who fail assessments for reasons other than consciousness ===
Patients who are '''aphasic''' or '''intubated''' but clearly can communicate in '''writing''' should be coded as functioning normally for Verbal assessment.  
Patients who are '''aphasic''' or '''intubated''' but clearly can communicate in '''writing''' should be coded as functioning normally.
Same is true for patients whose eyes are swollen shut etc. [http://en.wikipedia.org/wiki/Glasgow_Coma_Scale#Interpretation]


=== Sedated or Paralyzed Patients ===
==GSC dropdown list and scores ==
*FOR non-neuro or post op patients:  Being sedated or paralyzed may not allow us to accurately assess neurological status. For '''sedated''' or '''paralyzed''' patients consider their likely neurological status prior to sedation or paralysis or status when sedation wears off.
=== Best Eye ===
* when using information that was '''documented prior to sedation/paralysis''' or POST OP use "best guess" based on chart notes.
* stored in the [[AP_Eye field]]:
*trauma or neuro patient:  use "Best score" in first 24 hours of admission to ICU.
{| class="wikitable" border=1
|-  
|| ''Value'' || ''Points''
|-
|| 1 none || 1
|-
|| 2 to pain || 2
|-
|| 3 to speech || 3
|-
|| 4 spontaneous || 4
|}


====Discussion====
=== Best Motor ===
* stored in the [[AP_Motor field]]
{| class="wikitable" border=1
|-
|| ''Value'' || ''Points''
|- 
|| 1 None
|| 1
|-
|| 2 abn. extension
|| 2
|-
|| 3 abn. flexion
|| 3
|-
|| 4 withdraws to pain
|| 4
|-
|| 5 localizes pain
|| 5
|-
|| 6 obeys commands
|| 6
|}


* The important thing to keep in mind when doing apache GCS is that it focuses on the first 24 hours.  If a patient comes in sedated,and remains sedated for the first 24 hours and there is clear documentation about GCS just prior to sedation (for example in ER), then you can use this information.  If the patient is sedated and there is no documented GCS prior to sedation, you can use once the sedation is reduced '''if''' it is close to the 24 hour mark.  Otherwise, if it is days later, there is no guarantee that this was correct during the first 24 hours. The guidelines say to put the value as normal if unable to obtain this information close to the 24 hour timeframe.--[[User:LKolesar|LKolesar]] 12:09, 17 October 2008 (CDT)
=== Best Verbal ===
 
* stored in the [[AP_Verbal field]]
* In terms of patients where brain injury is in question and the pt. remains sedated for several days, therefore making an accurate determination of GCS impossible, we are still debating as to whether a normal GCS should be used.  This is being worked on by the Task Group.  Right now, according to Trish, until we have a decision to change the guideline, we should be using our own judgement as far as assessment once the sedation is worn off.  --[[User:LKolesar|LKolesar]] 13:02, 17 October 2008 (CDT)
{| class="wikitable" border=1
** For purposes of calculating scores off the GCS, would leaving it blank result in a score as if coded as "normal"?[[User:Ttenbergen|Ttenbergen]] 13:28, 17 October 2008 (CDT)
|-
** We're not sure if we will leave it blank but this would not result in a normal score, it would just mean there was insufficient data to have an accurate GCS.  This is still under review and data collectors should still use the guideline of using our own judgement to score the patient in the case of lack of information.  --[[User:LKolesar|LKolesar]] 11:47, 21 October 2008 (CDT)
|| ''Value'' || ''Points''
 
|-
=== Patients following drug overdose where outcome uncertain ===
|| 1 oriented + conv.|| 5
====Discussion====
|-  
What should be coded for patients who had a drug overdose where the outcome is not clear during the GCS time frame? [[User:Ttenbergen|Ttenbergen]] 14:10, 16 October 2008 (CDT)
|| 2 disoriented + conv. || 4
|-  
|| 3 inappropriate words || 3
|-
|| 4 incomp. Sounds || 2
|-
|| 5 no response || 1
|-  
|| 6 ''ventilated''-appear oriented || 5
|-
|| 7 ''ventilated''-?questionably oriented || 3
|-
|| 8 ''ventilated''-no response || 1
|}


==From general guide needs reviewing==
== Implementation ==
For Head traumas select the '''worst''' score in the first 24 hours in ICU.  If sedated or paralyzed select the '''best''' score in the first 24 hours in ICU prior to sedation.
In CCMDB:
For non neuro & post operative patients who are sedated or paralyzed, please record a '''normal''' neuro score, unless there is a neurological problem.  If this is the case, you must select the select the '''worst''' values prior to sedation or “best guess” based on history prior to sedation. 
* L_Log populated by lookup from [[s_GCS table]]:
Sedation does not allow us to accurately assess Neuro status, therefore we use alternative information that was documented prior to OR or sedation or we use our “best guess” base on chart notes.
**ap_eye text(13) lookup "1 None;2 To Pain;3 To Speech;4 Spontaneous"
==== to do before de-stubbing ====
**ap_motor text(19) lookup "1 None;2 Abn. Extension;3 Abn Flexion;4 Withdraws to Pain;5 Localizes Pain;6 Obeys Commands"
* what does "best score" mean in this context? Best to make the patient score a high APACHE, or best to let him live?
**ap_verbal text(26) lookup "1 Oriented+Conv;2 Disoriented+Conv;3 Inappropriate Words;4 Incomp. Sound;5 No response;6 vented-appears oriented;7 vented-? oriented;8 vented-no response"
* in case of sedation or OR, what is the precedence of "alternative" information vs. chart? Are the two not the same?
*** '''The list sorting numbers for this one are opposite to scoring'''
{{Discussion}}


== Discussion ==  
== Background ==
* see entries above.[[User:Ttenbergen|Ttenbergen]] 14:09, 16 October 2008 (CDT)
It is the most common scoring system used to describe the level of consciousness in a person following a '''traumatic brain injury'''. Basically, it is used to help gauge the severity of an acute brain injury.
* Could we improve the definition to reduce the special cases. [[User:Ttenbergen|Ttenbergen]] 14:13, 16 October 2008 (CDT)
*http://www.brainline.org/content/2010/10/what-is-the-glasgow-coma-scale.html
*From the other articles referenced,primarily [http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2874%2991639-0/abstract]  
*http://simple.wikipedia.org/wiki/Glasgow_Coma_Scale] OR [http://en.wikipedia.org/wiki/Glasgow_Coma_Scale regular wikepedia which is needlessly verbose]
*http://reference.medscape.com/calculator/glasgow-coma-scale


{{stub}}
== Related articles ==
{{Related Articles}}


[[Category:APACHE II Physiological Variables]]
[[Category:APACHE II Physiological Variables]]
[[Category: MOST]]
[[Category:ALERT Scale Elements]]
[[Category:Critical Care Review Group]]
[[Category:Glasgow Coma Scale | *]]
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