Glasgow Coma Scale

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. [1] The Glasgow Coma Score is also used as part of the APACHE II assessment score for Critical Care Program and the MOST assessment score for Medicine Program.

Instructions

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.

• • Should this read "worst"?Mlaporte 11:50, 2012 November 29 (EST)

For reference only:

Score	6	5	4	3	2	1
EYE Response			Spontaneous	To Speech	To Pain	None
MOTOR Response	Obeys Command	Localizes Pain	Withdraws to Pain	Abnormal Flexion	Abnormal Extension	None
VERBAL Response		Oriented	Confused	Inappropriate words	Incomprehensible sounds	None
VERBAL Response -Ventilated		Appears Oriented		? Oriented		No response

Special Cases

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 cannot speak but are communicating

Patients who are aphasic or intubated but clearly can communicate in writing should be coded as functioning normally for Verbal assessment.

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.--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. --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"?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. --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? 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

• Could we improve the definition to reduce the special cases. Ttenbergen 14:13, 16 October 2008 (CDT)

GSC dropdown list in CCMDB.mdb

GCS Drop down list on laptops
Eye		Points
1	none	1
2	to pain	2
3	to speech	3
4	spontaneous	4
Motor		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
Verbal		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