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The Journal of Emergency Medicine, Vol. 19, No. 1, pp.

67–71, 2000
Copyright © 2000 Elsevier Science Inc.
Printed in the USA. All rights reserved
0736-4679/00 $–see front matter

PII S0736-4679(00)00182-7


George L. Sternbach,


Department of Emergency Medicine, Stanford University Medical Center, Stanford, California
Reprint Address: George L. Sternbach, MD, 539 15th Avenue, Menlo Park, CA 94025

e Abstract—Teasdale and Jennett first presented the
Glasgow Coma Scale in 1974 as an aid in the clinical
assessment of unconsciousness. It was devised as a formal
scheme to overcome the ambiguities and misunderstandings that arose when information about comatose patients
was presented and groups of patients were compared. Since
then, the Glasgow Coma Scale has been used extensively,
being used to grade individual patients, compare effectiveness of treatments, and as a prognostic indicator. It has
been incorporated into numerous trauma and critical illness classification systems. However, a number of competing scales have been developed to overcome its perceived
deficiencies. These scales are generally more complex. One
of the expressed reservations regarding the Glasgow Coma
Scale has been its failure to incorporate brainstem reflexes.
The scale also includes a numerical skew toward the motor
response. An important current issue is the appropriate
application of the Glasgow Coma Scale to intubated patients. A number of approaches have been used to assign the
verbal score to such patients. The timing of initial scoring is
another area of discussion. Despite its drawbacks, the Glasgow Coma Scale remains the most universally utilized level
of consciousness scale worldwide. It seems destined to be
used in emergency medicine for some time. © 2000
Elsevier Science Inc.

1974, that “may be due to agents acting diffusely . . . or
to the combination of remote and local effects produced
by brain damage which was initially focal” (1). The
authors were from the Glasgow University Department
of Neurosurgery Institute of Neurologic Sciences. In
their view, the clinical assessment of unconsciousness
suffered from the practice by many physicians to “retreat
from any formal scheme in favor of a general description
of the patient’s state, without clear guidelines as to what
to describe and how to describe it” (1). This in turn led
to “ambiguities and misunderstandings when information about patients is exchanged and when groups of
patients treated by alternative methods are compared”
Did the Glaswegians have a remedy for this state of
affairs? Indeed they did. They presented the Glasgow
Coma Scale (GCS), and rationalized its three components by the following reasoning:

e Keywords— coma; head injury


“Impaired consciousness is an expression of dysfunction
in the brain as a whole,” wrote Teasdale and Jennett in

Medical Classics is coordinated by George Sternbach,

RECEIVED: 6 July 1999; FINAL
ACCEPTED: 8 February 2000



Motor response: “The ease with which motor responses can be elicited in the limbs, together with the
wide range of different patterns which can occur,
makes motor activity a suitable guide to the functioning state of the central nervous system” (1).
Verbal response: “Probably the commonest definition
of the end of a coma, or the recovery of consciousness,
is the patient’s first understandable utterance” (1).
Eye opening: “Spontaneous eye opening . . . indicates
that the arousal mechanisms in the brainstem are active” (1).

of Stanford University Medical Center, Stanford, California

20 January 2000;

responsive to strong stimulation Very drowsy or confused. withdrawing movements on pain stimulation Unconscious. except to report that physician and nurse examiners at their institution were highly consistent in its use. moderate (9 –12). It is a component of the Acute Physiology and Chronic Health Evaluation Table 1. The scale was simple. Despite the widespread acceptance of the GCS. Respiration. This scale has subsequently been faulted for being too simple (4). five each for best verbal and best motor response. Speech (CRAMS) Scale. Ommaya described a five-point level of consciousness scale he had used in conjunction with a clinical study of head trauma (3). incorporated it into the Trauma Score in 1981 and the Revised Trauma Score 8 years later (6. though they cautioned that “the search for simplicity must not be the excuse for seeking absolute distinctions where none exist” (1). The GCS has been used to grade individual levels of consciousness. This was to follow in 1976 (2).” The three levels in between were defined by descending combinations of orientation and responses to stimuli.68 G. L.” the RLS85 bears some resemblance to Ommaya’s level of consciousness scale. and severe (8 or less) (9.10). stereotype flexion movements on pain stimulation Unconscious. DISCUSSION The Glasgow group was not the first to have formulated a coma scale. the Trauma and Injury Severity Score (TRISS) and the Circulation. Teasdale and Jennett did not. to reassure the reader that it was “no part of our case to deny the value of a detailed appraisal of the patient as a whole. The GCS was initially developed to gauge coma deterioration or improvement as well as a predictor of ultimate outcome (1). Glasgow Coma Scale Eye opening Spontaneous To speech To pain None Best verbal response Oriented Confused conversation Inappropriate words Incomprehensible sounds None Best motor response Obeys commands Localizes pain Withdrawal (normal flexion) Abnormal flexion (decorticate) Extension (decerebrate) None 4 3 2 1 5 4 3 2 1 6 5 4 3 2 1 (APACHE) II score. four for eye opening. no delay in response Drowsy or confused. and of neurologic function in particular” (1). compare effectiveness of treatment. Another use is the categorical division of severity of head injury by GCS score of mild (13–15). at this point. becoming an integral part of the American College of Surgeons Advanced Trauma Life Support courses. The Reaction Level Scale (RLS85) represents one such attempt to improve upon the GCS (see Table 2). It has.7). An eight-point scale that ranges between “alert” and “unconscious. It has been praised Table 2. a feature the authors deemed essential. inasmuch as “repeated observations of conscious level are usually made by relatively inexperienced doctors and nurses” (1). Champion et al. It has been accused of occupying a “privileged but unwarranted position in clinical and investigative contexts” (11). Disagreement among these observers was rare. down to “totally unresponsive to all stimuli. it appears to suffer from the “general description of the patient’s state” deficiency that Teasdale and Jennett raised. This was desirable. Sternbach The clinical scale consisted of 14 points. It is used to codify injury severity by the International Coma Data Bank and the United States National Traumatic Coma Data Bank (5). A sixth point on the motor response scale (“withdrawal from painful stimulus”) was to be added 2 years later (2). In 1966. Nor did they present any data demonstrating the scale’s validity or reliability. Motor. localizes but does not ward off pain Unconscious. responsive to strong stimulation Unconscious. never achieved widespread use. has prospered. Reaction Level Scale (RLS85) 1 2 3 4 5 6 7 8 Alert. Abdomen. on the other hand. They were quick. The GCS (see Table 1). It has subsequently been utilized as a clinical indicator for management. The stages of this scale ranged from “the state of normal consciousness” at the top. the scale has not been embraced entirely without reservation. A number of competing scales have been developed to overcome its perceived deficiencies. stereotype extension movements on pain stimulation Unconscious. It has enjoyed extensive acceptance as an important tool in the care of trauma patients. and as a prognostic indicator. in any event. The authors anticipated criticism of a system that seemed to “undervalue the niceties of a full neurologic examination” (1). therefore. Moreover. no response to pain stimulation . assign numerical scores to the various aspects of their scale. The best known example of this use is the well-known recommendation that a patient with a GCS score of 8 or less is unable to protect the airway and requires endotracheal intubation (8).

Although it is only an eight-item scale. with verbal and eye scores being more pertinent in patients who are not. and general responsiveness. though their construction differs. The information content of the GCS and the RSL85 is similar. The disappearance of the last. The use of early intubation and administration of neuromuscular paralyzing agents in the pre-hospital phase of care has . as well as a grading of the nature of the stimulus required to elicit motor and verbal responses (19). The five reflexes selected disappear in descending order during rostral-caudal deterioration. Another 100point head injury scale was developed by Bouzarth in 1968 and modified in 1978 (14.e. eye position at rest. and communicative effort. eye response has the least influence on the total and the motor response the most. Its eight items allow for a maximum of 23 points (20). They view a total score as “merely a convenient method for summarizing data. it assesses posture. The Innsbruck Coma Scale contains pupillary size and reaction.. A simpler system is the Glasgow-Liege Scale (see Table 3). Bhatty and Kapoor note that. because there are only four units assigned to the eye responses.The Glasgow Coma Scale for improving discriminatory ability by combining eye. Anesthesiology and Intensive Care have recommended replacement of the GCS with the RLS85 in that country’s hospitals (13).18). The Swedish Societies of Neurosurgery. comatose (i. allowing for a potential high score of 48 (16). in fact. and oculovestibular) reflexes. † Deviation of at least one eye is induced by repeated flexion and extension (vertical) or horizontal neck movement (horizontal). brainstem (pupillary. indicating a similar ranking order of neurologic defect severity (12).26).15). This effort to provide mathematical parity for the three components of the GCS has abutted against studies that have stressed the particular importance of the motor portion of the score. The Comprehensive Level of Consciousness Scale is a behavioral scale that includes brainstem indicators. eye opening. The GCS has been criticized for lacking reliability in monitoring levels of consciousness or predicting outcome in patients with middle range (GCS 9 –12) scores 69 Table 3. The resulting scales generally have been more complex than the GCS. The RLS85 has been touted as demonstrating greater accuracy and higher inter-observer agreement than the GCS (11). abnormal ocular movements. The maximum possible score is 101 points (17). reaction to acoustic stimuli. Glasgow-Liege Scale Glasgow Coma Scale score: and the presence of the following brainstem reflexes: Fronto-orbicular* Vertical oculovestibular† Pupillary light Horizontal oculovestibular† Oculocardiac‡ No response Points 5 4 3 2 1 0 * The reflex is considered present when percussion of the glabella produces contraction of the orbicularis oculi muscle. an attempt is made to elicit ocular motion by simultaneous external auditory canal irrigation using iced water. A number of investigators have disagreed with Teasdale and Jennett that spontaneous eye opening is sufficiently indicative of brainstem arousal systems activity and have fashioned coma scales that include brainstem responses (11. One of the most important current issues regarding the GCS is its application to intubated patients. The Clinical Neurologic Assessment Tool is a 21-item scale that includes various motor. the maximum score for each category ranges from 4 to 8 points. reflex. The Maryland Coma Scale incorporates aspects of the GCS. in which the presence of five brainstem reflexes has been appended to the GCS. The Glasgow group admits to “limitations inherent in the summation of the three responses” (27). It also has been critiqued on a purely mathematical basis. verbal. coincides with brain death (21). the scale incorporates a numerical skew toward motor response (4). There is a high correlation between the two scales. ‡ Pressure on the eyeball causes the heart rate to slow. There is some controversy over whether accuracy is diminished by adding the numerical scores of the three components (22. and motor responses in such a way that each would have a minimum contribution of one point and a maximum of five. and motor responses. One of the expressed reservations regarding the GCS has been its failure to incorporate brainstem reflexes.” Indeed. corneal. with verbal response being intermediate. motor function. In achieving a sum score. pupillary light reflexes. The motor response alone is considered by some to be the best predictor of short-term outcome from head injury. If the cervical spine is immobilized. In addition to eye opening. and communication categories. verbal and motor responses into a single scale (11). They have suggested weighting individual scores for eye. Consequently. those with a GCS of 9 –15) (22).14). the oculocardiac. movement and position of the eyes. this scale has been used in this way in Sweden since 1984 (13. The conclusion of a number of investigators has been that the motor score is more important than either of the other two components in predicting the magnitude of neurologic injury for patients with severe head injury (22–25). as well as pupillary findings. versus five to the verbal and six to the motor responses. they point out that “in Glasgow patients under treatment are always described by the three separate responses and never by the total” (27). (11). but excludes verbal response. This relies heavily on vital signs and variables of the GCS.

most notably the RLS85. Lindermuth JR.15:581– 604. J Neurosurg 1983. Lancet 1991. Emerg Med Clin North Am 1997. have markedly reduced the time between injury and definitive treatment. Linear regression prediction of the verbal scores based on the other two scores also has been utilized (30). Gouview WD. Mitterschiffthaler G. such as hypoxia. did correlate with significant improvement in emergency department GCS score over that calculated in the field (32). but has since gained greater acceptance.29). White JG. Rosander B. Waiting 6 h avoided overestimating the extent of brain damage produced by transient influences such as shock and respiratory insufficiency. Benzer A. D. Heart Lung 1992. Holmgren E. Becker DP. Neurosurgical watch sheet for craniocerebral trauma. Assessment and prognosis of coma after head injury. Neurosurgery 1982. J Neurosurg 1984. 12. A practical scale. 5. Stalhammar. 20. A study of victims of blunt head injury for whom paramedic response times averaged 5 min revealed that GCS scores calculated by paramedics on the scene had no prognostic value (30).” he replied (28). 16. 11. Stanczak DE. Way C. A favorable outcome.36:89 – 95.337:1042–3. One method involves assigning an arbitrary score of one point to all patients on mechanical ventilation (5). et al. In 1977. 9. et al. Head injury watch sheet modified for a digital scale. Copes WS. Champion HR. Lancet 1991. in which the average value of the testable scores is calculated and added to the sum in lieu of the verbal score (28). Ann Roy Coll Surg Engl 1966. The National Traumatic Coma Data Bank.39:317– 47.70 G. and results. Jennett and Teasdale specified that the initial score be assigned 6 h after head injury had been sustained (29). both because it has been widely disseminated and because it “is so entrenched in all of the mathematics and all the computer studies” of head trauma (29). the GCS remains the most universally utilized level of consciousness scale worldwide. due to factors other than head injury. The timing of the initial evaluation is another area of discussion. or alcohol intoxication (31). “It sounds like a hand cleaner. Neurosurgery 1981. Teasdale G.34:45–55. seems destined to be used in emergency medicine for some time.2:81– 4. Despite its drawbacks. J Trauma 1989. Assessment of coma and impaired consciousness. Disability caused by minor head injury Neurosurgery 1981. 338:977– 8. Acta Neurochir 1993. Rimel RR. REFERENCES 1. . when asked his opinion of the RLS85. Starmark JE. Stalhammar D. L. hypotension. A com- 13. Part I: design. 6. 17. goals. Calculated recovery rates in severe head injury. et al.9:221– 8. Bowers SA. Trauma score. Assessment of level of consciousness following severe neurological insult. These assessments were apparently performed too early in the course of the injury. Schepp RS. Sacco WJ. the GCS. they reflected an initial generalized depression of neurologic status that did not necessarily correlate with the severity of head injury or with outcome (14). Ducker TB. Clinical neurologic assessment tool: development and testing of an instrument to index neurologic status. Trauma to the nervous system. Barth JT.11: 344 –51. 19. by virtue of its simplicity. Acta Neurochir 1976.59:276 – 84. Starmark JE.8:301– 8. Sternbach rendered the verbal response portion of the scale unmeasurable in these cases. Parsons LC. Chesnut RM. Many major head injury centers in the United States use a nonnumerical designation of “T” for the verbal score in intubated patients (14.69:699 –706. Giordani NP. Though some of the more detailed scales may be more suitable for assessment of inpatients. Bouzarth WF. et al. Lancet 1974.120:132–5. This time period was chosen to exclude patients who might display coma temporarily. Prediction of non-survival after trauma: Innsbruck Coma Scale. Crit Care Med 1981. 2. Early treatment was uncommon when the GCS was first described. 7. Carnazzo AJ. A presenter at the 1997 meeting of the American Association for the Surgery of Trauma.8:29 –31. Holmgren E. J Neurosurg 1988. Teasdale G. J Trauma 1978. This treatment is now far more likely to occur in under 6 h. The Glasgow Coma Scale: a mathematical critique. Several techniques have been proposed to designate the verbal score in intubated patients. et al. parison of the Glasgow Coma Scale and the Reaction Level Scale (RLS85). 14. as well as advances in diagnostic and treatment modalities. Reliability and accuracy of the Glasgow coma scale. Sacco WJ. 4. 10. Bhatty GB. Kapoor N.21:548 –57. The management of severe traumatic brain injury. 8. Crosby L. Problems with initial Glasgow Coma Scale assessment caused by prehospital treatment of patients with head injuries: results of a national survey. Progress since then in pre-hospital and inter-hospital transport. Carlier PM. Bouzarth WF. 18. Jennett B. Moderate head injury: completing the spectrum of brain trauma. The popularity of RLS85 in Sweden notwithstanding. 15. Salcman M. A number of approaches have been used to overcome this limitation. They felt this time interval allowed for the diagnosis and management of other injuries that might affect neurologic function.9:672– 6. A comparison of the psychometric qualities of the Glasgow Coma Scale and the Comprehensive Level of Consciousness Scale.29:623–9. the GCS is unlikely to be supplanted soon. As such. Another suggestion has been that a “pseudo-score” be applied. et al.18:571–9.60:955– 60. The Glasgow Coma Scale: time for a change. J Trauma 1968. Giordani NP. Heart Lung 1989. Jane JJ. Some of the alternate scales described above. Marosi M. Rimel RR. J Trauma 1994. et al. A revision of the Trauma Score.18:121–9. 3. purpose. on the other hand. Marshall LF. Barth JT. admitted no knowledge of it. Marion DW. Segatore M. do not include a verbal response criterion. Jennett B. Champion HR. Assigning the GCS score too soon after injury may also be problematic. Ommaya AK.

Choi SC. et al. The Glasgow-Liege Scale. Fakhry SM. Born JD. Glasgow Coma Scale: to sum or not to sum? [letter] Lancet 1983. Teasdale G. et al. Murray L. J Neurosurg 1982. Acta Neurochir. Prognosis of severe head injuries. 30. 1988. Narayan RK. 22. . Levati A. J Neurosurg 1989. Teasdale G. Galbraith S. The Glasgow Coma Scale and some comments on alternative methods.69: 381–5. Vacchi G. J Neurosurg 1988. 24.71:202–7. J Trauma 1998. 26.44:839 – 45. 29.The Glasgow Coma Scale 21. The Glasgow Coma Scale: to sum or not to sum? [letter] Lancet 1983. Murray G. Harrington T. J Emerg Med 1984. J Neurol Neurosurg Psych 1977.57:779 – 83. Civilian gunshot wounds to the head: a prospective study. et al. The conundrum of the Glasgow Coma Scale in intubated patients: a linear regression prediction of the Glasgow verbal score from the Glasgow eye and motor scores.36:91– 4. Jagger J. Stalhammar D. et al. Neurosurgery 1990.40:291– 8. Farina ML.1:878 – 81. 32. Rutledge R. Jane JA. Jennett B. Acta Neurochir. Rimel R.27:696 –700. Prehospital use of the Glasgow Coma Scale in severe head injury. Head injury mortality in two centers with different emergency medical services and intensive care. Alfry EJ. Colohan ART. Assessment of responsiveness in head injury patients.2:1– 6. Meredith W. Gross CR. 71 27. Grahm TW.91:1– 11. 31. Jennett B. Aspects of coma after severe head injury. Enhanced specificity of prognosis in severe head injury. Winkler JV. Starmark JE. Teasdale G. Anderson RL. Lancet 1977. 23. 1986. Severe head injuries in three countries.2:678. Alves WM. Rosen P. 28. Jennett B. 25. Williams FC.2:97. Ward JD. Spetzler RF.