Glasgow Coma Scale

Objective
The Glasgow Coma Scale (GCS) was first created by Graham Teasdale and Bryan Jennett
in 1974. It is a clinical scale to assess a patient's

"depth and duration of impaired consciousness and coma"

following an acute brain injury

Healthcare practitioners can monitor the motor responsiveness, verbal performance, and

eye-opening of the patient in the form of a simple chart. The GCS is the most commonly

used tool internationally for this assessment and has been translated into 30 languages.
It should not, however, be confused with the Glasgow Outcome Scale (GOS), which
evaluates persistent disability after brain damage. l2

Intended Population

The Glasgow Coma Scale was originally developed to help determine the severity of a

coma or dysfunction following a traumatic brain injury, but can be useful for any

condition leading to impaired consciousness. I3

Today, it is consistently used for many conditions including:

stroke (subarachnoid haemorrhage, intracerebral haemorrhage, or ischemic stroke),

infection,
seizures,
brain abscess,
general traumas and ITU patients

non-traumatic coma,

overdose

poisonings)
It can also be administered in a variety of settings such as pre-hospital, arrival at the
emergency department and in the hours following admission, giving it the ability to
monitor changes and trends in patient consciousness over time.31
Modified scales have been developed for use in other populations. The Glasgow Coma

Scale- Extended (GCS -E) includes the use of an amnesia scale in order to avoid the
premature discharge of patients with mild traumatie brain injury. 4| There have also

been modified scales developed for use in the paediat ric population.

The motor scale has proved the most useful for assessment in both older children and
preverbal children when studying blunt trauma, 15l Research has indicated that using the

motor scale alone can simplify the assessment process while maintaining the accuracy of
the score. l61

Method of Use

The GCS Assessment Aid has four steps to the assessment process: Check, observe,
stimulate, rate. 17

CHECK O8SERVE STIMULATE RATE

For factors lnterfering with
communication,
ability to respond and other
injuries
Eye opening, content of
speech and movements of
right and left sides
Sound: spoken or shouted Assign according to highest
response observed
request
Physical: Pressure on finger tip,
trapezius or supraorbital notch

The assessor should evaluate each of the subscales as listed in the Assessment Aid. Each
subscale has several components. Based on the level of consciousness, a score is assigned.
A higher score indicates a greater level of consciousness.

Eyes Verbal Motor

Spontaneous Oriented Obey commands

To sound Confused Localising

To pressure Words Nomal Flexion

None Sounds Abnormal Flexion

None Extension
None

The GCS uses three sites for stimulation. This includes fingertip pressure, trapezius
pinch and supraorbital notch. When stimulating these areas, health care practitioners
should look for one of two responses: an abnormal flezion response or a normal flexion
response. 7

ites For Physical Stimulation Features of Flexion Responses

Modifed with permission from Van Der Naalt 2004
Finger tip pressure Trapezius Pinch Supraorbital notch Ned yaschr Geneeskd

Abnormal Flexion Normal flexion

Slow Sterotyped Rapid
Arm across chest Variable
Arm away from body
Forearm rotates
humb clenched
Leg extends
The National Institute for Health Care and Excellence (NICE) published Clinical
Guidelines on Head Injuries for Assessment and Early Management. NICE recommends

the following Clinical Guidelines:

Until a patient has achieved a GCS score of 15 on the GCS, patients should be observed

every half hour.

Once the GCS Score has reached 15, the patient should be re-assessed using the GCs

every half hour for two consecutive hours.

I f the patient's GCS score remains above 15, the patient should then be observed once

every hour for four hours and then every 2 hours after that.

Note: If at any time a patient's GCS score drops below 15, the healthcare practitioners

should revert to observing the patient every halfhour.l8

The Institute of Neurological Sciences NHS Greater Glasgow and Clyde created a YouTube
video to demonstrate how to properly use the outcome measure.

Evidence

Reliability

The inter-rater reliability ofthe total Glasgow Coma Scale is p 0.86. Some research has
subdivided the inter-rater reliability for each subscale. For the eye score the inter-rater
reliability is p = 0.76, the verbal score is p 0.67, and the motor score is p=o.81. 10 The

research for test-retest reliability is not recent and should be updated, however, the best

available evidence is k =0.66 - 0.77

Based on a recent systematic review, the total score is typically less reliable than the

individual components with a total Kappa value of 77% as compared to the eye, motor,
and verbal scores which had Kappa values of 89%, 94%, and 88% respectively. I2]
Validity

The validity of the Glasgow Coma Scale comes under fire because a lot of hospitals

administer the test while patients have been sedated, often underestimating patient
scores. It's also difficult to elicit accurate scores when patients are intubated. 131 Recent

research has refuted that intubation elicits significantly different survival rates with the
verbal score of r = 0.90 and the total score of r = 0.97. |14 The motor score is consistently

the most predictive component of the GCS. 15

Responsiveness

Given the current best available evidence, the GCS has a low sensitivity (56.1%) anda
high specificity (82.2%). Therefore, there are very few false positives predicting a low
rate of survival in healthy individuals. ln6
It is argued that the GCS does not accurately score patients who are intubated and does
not assess brainstem reflexes, which may account for its low predictive capacity. A GCS
administered at 24 hours post-injury has an odds ratio of o.4 for predicting in-hospital

mortality. When administered at 72 hours post-injury, the odds ratio improves to o.59
for predicting in-hospital mortality.17

Evidence suggests that the Glasgow Coma Scale has a 71% accuracy in predicting
functional independence post-injury. The GCS also modestly correlates with the
Disability Rating Scale (-0.28) and the Cognitive component of the Functional
Independence Measure (o.37). 18]