Glasgow Coma Scale: Difference between revisions

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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], [http://simple.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 notes regarding sedated patients: ==
|style="background-color:#CCCCE6" width="125" height="27" | '''Score'''
<!-- 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) -->
| width="64" | '''6'''
# 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.
| width="58" |''' 5'''
# 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.
| width="48" | '''4'''
# If a non-sedated GCS is unavailable in the first 24 hours, use the previous un-sedated GCS if possible.  
| width="48" |''' 3'''
# If there is absolutely no un-sedated GCS available (e.g. [[Lost/missing chart]]), default to a '''normal GCS'''.
| 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
 
|}


== Special Cases ==
== Special Cases ==
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.


=== 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 ===
*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.
* when using information that was '''documented prior to sedation/paralysis''' or POST OP use "best guess" based on chart notes.
*trauma or neuro patient:  use "Best score" in first 24 hours of admission to ICU.
 
====Discussion====
 
* 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)
 
* 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)
** 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)
 
=== Patients following drug overdose where outcome uncertain ===
====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)
 
==From general guide needs reviewing==
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.
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. 
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.
==== to do before de-stubbing ====
* what does "best score" mean in this context? Best to make the patient score a high APACHE, or best to let him live?
* in case of sedation or OR, what is the precedence of "alternative" information vs. chart? Are the two not the same?
{{Discussion}}
 
== Discussion ==
{{discussion}}
* Could we improve the definition to reduce the special cases. [[User:Ttenbergen|Ttenbergen]] 14:13, 16 October 2008 (CDT)
 
 
== Backward score for Verbal ==
{{discussion}}
* I have a data processing question. In [[CCMDB.mdb]] the options are numbered with verbal '''worsening''' from 1 to 5, whereas Motor and Verbal '''improve''' from 1 upwards. The data is also stored and output that way. I seem to remember having brought this up in the past, and I think by the time it hits Julie all is compensated for, but this should probably be confirmed and then documented.  [[User:Ttenbergen|Ttenbergen]] 15:27, 18 June 2009 (CDT)
** Julie/Pagasa/Trish, could you please address the above question? Debbie asked me about this again yesterday, and it is an irregularity that should really be documented. Thanks! [[User:Ttenbergen|Ttenbergen]] 11:28, 27 July 2010 (CDT)
***The numbers prior to the verbal items do not correspond to the score.  If you will notice, the downlist for VERBAL in the CCMDB.mdb  have 8 items - 5 items for Non-ventilated and 3 items for Ventilated. The corresponding score for the 8 items are tabulated in the above table. The total GCS is computed based on the scoring table above and not based on the order it was listed in the CCMDB.mdb. The score 5 is assigned to 'Oriented or Appears oriented' while score 1 is for 'No response'.  Just like you, I noticed the inconsistencies in the order and score of VERBAL as compared to the EYE and MOTOR.  I think the reason VERBAL is handled differently is because it has 8 items which the master database program assigns into 5 scores. If CCMDB.mdb will change the format  of the 8 items, then the master database program needs to be changed too (which we don't want to do anymore) and I supposed that was the reason why Tina still used the same format  even if they looked confusing and inconsistent with the EYE and MOTOR.  [[User:JMojica|JMojica]] 12:26, 27 July 2010 (CDT)
****GCS-verbal - was set up like this so that there was only one drop down list for non vent & ventilated patients.  Three of the items on the verbal list have the same points associated. When the data is "uploaded" to the "master" database, the upload program takes care of uploading the correct "points" that correspond with the item number selected. --[[User:TOstryzniuk|TOstryzniuk]] 17:21, 23 August 2010 (CDT)
**** I can change this dropdown to make it consistent with the others while keeping it to just one list for vents and non-vents, and without changing how the data output works, so no changes would be required for Ed's program. Do you think we should, or would this confuse collectors more than it would help them? [[User:Ttenbergen|Ttenbergen]] 12:49, 2 May 2011 (CDT)
******RESOLVED.[[User:TOstryzniuk|Trish Ostryzniuk]] 15:50, 2012 April 16 (CDT)
 
{| class="wikitable" border=1 <hiddentext> set to 0 for no borders</hiddentext>
|- style="font-weight:bold"
|style="font-size:12pt" width="26" height="23"  valign="bottom" | GCS Drop down list on laptops
| width="168"  valign="bottom" | &nbsp;
| width="40" align="center" valign="bottom" | &nbsp;
 
|- style="font-size:11pt;font-weight:bold"
| height="20" valign="bottom" | Eye
| valign="bottom" | &nbsp;
|style="font-style:Italic" align="center" valign="bottom" | Points


==GSC dropdown list and scores ==
=== Best Eye ===
{| class="wikitable" border=1
|-
|| ''Value'' || ''Points''
|-  
|-  
| height="14" valign="bottom" | 1
|| 1 none || 1
| valign="bottom" | none
|style="font-style:Italic" align="center" valign="bottom" | 1
 
|-  
|-  
| height="14" valign="bottom" | 2
|| 2 to pain || 2
| valign="bottom" | to pain
|style="font-style:Italic" align="center" valign="bottom" | 2
 
|-  
|-  
| height="14" valign="bottom" | 3
|| 3 to speech || 3
| valign="bottom" | to speech
|style="font-style:Italic" align="center" valign="bottom" | 3
 
|-  
|-  
| height="14" valign="bottom" | 4
|| 4 spontaneous || 4
| valign="bottom" | spontaneous
|}
|style="font-style:Italic" align="center" valign="bottom" | 4


=== Best Motor ===
{| class="wikitable" border=1
|-  
|-  
| height="14" valign="bottom" | &nbsp;
|| ''Value'' || ''Points''
| valign="bottom" | &nbsp;
|-
|style="font-style:Italic" align="center" valign="bottom" | &nbsp;
|| 1 None
 
|| 1
|- style="font-size:11pt;font-weight:bold"
| height="19" valign="bottom" | Motor
| valign="bottom" |
|style="font-style:Italic" align="center" valign="bottom" | Points
 
|-  
|-  
| height="14" valign="bottom" | 1
|| 2 abn. extension
| valign="bottom" | None
|| 2
|style="font-style:Italic" align="center" valign="bottom" | 1
 
|-  
|-  
| height="14" valign="bottom" | 2
|| 3 abn. flexion
| valign="bottom" | abn. extension
|| 3
|style="font-style:Italic" align="center" valign="bottom" | 2
 
|-  
|-  
| height="14" valign="bottom" | 3
|| 4 withdraws to pain
| valign="bottom" | abn. flexion
|| 4
|style="font-style:Italic" align="center" valign="bottom" | 3
 
|-  
|-  
| height="14" valign="bottom" | 4
|| 5 localizes pain
| valign="bottom" | withdraws to pain
|| 5
|style="font-style:Italic" align="center" valign="bottom" | 4
 
|-  
|-  
| height="14" valign="bottom" | 5
|| 6 obeys commands
| valign="bottom" | localizes pain
|| 6
|style="font-style:Italic" align="center" valign="bottom" | 5
|}


=== Best Verbal ===
{| class="wikitable" border=1
|-  
|-  
| height="14" valign="bottom" | 6
|| ''Value'' || ''Points''
| valign="bottom" | obeys commands
|style="font-style:Italic" align="center" valign="bottom" | 6
 
|-  
|-  
| height="14"  valign="bottom" | &nbsp;
|| 1 oriented + conv.|| 5
|  valign="bottom" | &nbsp;
|style="font-style:Italic" align="center" valign="bottom" | &nbsp;
 
|-  
|-  
|style="font-size:11pt;font-weight:bold" height="14" valign="bottom" | Verbal
|| 2 disoriented + conv. || 4
| valign="bottom" | &nbsp;
|style="font-size:11pt;font-weight:bold;font-style:Italic" align="center" valign="bottom" | Points
 
|-  
|-  
| height="14" valign="bottom" | 1
|| 3 inappropriate words || 3
| valign="bottom" | oriented + conv.
|style="font-size:11pt;font-style:Italic" align="center" valign="bottom" | 5
 
|-  
|-  
| height="14" valign="bottom" | 2
|| 4 incomp. Sounds || 2
| valign="bottom" | disoriented + conv.
|style="font-size:11pt;font-style:Italic" align="center" valign="bottom" | 4
 
|-  
|-  
| height="14" valign="bottom" | 3
|| 5 no response || 1
| valign="bottom" | inappropriate words
|style="font-size:11pt;font-style:Italic" align="center" valign="bottom" | 3
 
|-  
|-  
| height="14" valign="bottom" | 4
|| 6 ''ventilated''-appear oriented || 5
| valign="bottom" | incomp. Sounds
|style="font-size:11pt;font-style:Italic" align="center" valign="bottom" | 2
 
|-  
|-  
| height="14" valign="bottom" | 5
|| 7 ''ventilated''-?questionably oriented || 3
| valign="bottom" | no response
|style="font-size:11pt;font-style:Italic" align="center" valign="bottom" | 1
 
|-  
|-  
| height="14" valign="bottom" | 6
|| 8 ''ventilated''-no response || 1
| valign="bottom" | ventilated-appear oriented
|}
|style="font-size:11pt;font-style:Italic" align="center" valign="bottom" | 5


|-
== Implementation ==
| height="14" valign="bottom" | 7
In CCMDB:
| valign="bottom" | ventilated-?questionably oriented
* L_Log populated by lookup from [[s_GCS table]]:
|style="font-size:11pt;font-style:Italic" align="center" valign="bottom" | 3
**ap_eye text(13) lookup "1 None;2 To Pain;3 To Speech;4 Spontaneous"
**ap_motor text(19) lookup "1 None;2 Abn. Extension;3 Abn Flexion;4 Withdraws to Pain;5 Localizes Pain;6 Obeys Commands"
**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"
*** '''The list sorting numbers for this one are opposite to scoring'''


|-
== Background ==
| height="14" valign="bottom" | 8
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.
| valign="bottom" | ventilated-no response
*http://www.brainline.org/content/2010/10/what-is-the-glasgow-coma-scale.html
|style="font-size:11pt;font-style:Italic" align="center" valign="bottom" | 1
*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


|}
== Related articles ==
{{Related Articles}}


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

Latest revision as of 15:53, 2021 June 15

The Glasgow Coma Scale (GCS) ([1], [2]) is a commmon neurological assessment scale used to quantify 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.

  • The Glasgow Coma Score is also used as part of the APACHE II assessment score for Critical Care Program and the ALERT Scale for Medicine Program.
  • 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

Special notes regarding sedated patients:

  1. 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.
  2. 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.
  3. If a non-sedated GCS is unavailable in the first 24 hours, use the previous un-sedated GCS if possible.
  4. If there is absolutely no un-sedated GCS available (e.g. Lost/missing chart), default to a normal GCS.

Special Cases

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.

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)

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. Same is true for patients whose eyes are swollen shut etc. [3]

GSC dropdown list and scores

Best Eye

Value Points
1 none 1
2 to pain 2
3 to speech 3
4 spontaneous 4

Best Motor

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

Best Verbal

Value Points
1 oriented + conv. 5
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

Implementation

In CCMDB:

  • L_Log populated by lookup from s_GCS table:
    • ap_eye text(13) lookup "1 None;2 To Pain;3 To Speech;4 Spontaneous"
    • ap_motor text(19) lookup "1 None;2 Abn. Extension;3 Abn Flexion;4 Withdraws to Pain;5 Localizes Pain;6 Obeys Commands"
    • 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"
      • The list sorting numbers for this one are opposite to scoring

Background

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.

Related articles

Related articles:
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