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    Glasgow Coma Scale/Score (GCS)

    Coma severity based on Eye (4), Verbal (5), and Motor (6) criteria.
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    INSTRUCTIONS

    Note that this calculator has been updated as of May 2019 in order to add more supporting references and to distinguish between the Glasgow Coma Score (total score, only applicable when all three components are testable) and the Glasgow Coma Scale (component scores, applicable if any of three components is not testable).

    When to Use
    Pearls/Pitfalls
    Why Use
    • Designed for use in serial assessments of patients with coma from either medical or surgical causes to be widely applicable.
    • The GCS is commonly used in the pre-hospital and acute care setting as well as over a patient’s hospital course to evaluate for mental status assessment in both traumatic and non-traumatic presentations.
    • In the care of an individual patient, the ratings of the three criteria in the Scale should be assessed, monitored, reported, and communicated separately.
    • The combined Score is an index of the net severity of impairment and is useful as a summary of a patients condition, in classifying groups of different severity, for triage, and in research. The Score cannot be calculated if one or other of the component criteria is not testable.
    • The GCS allows providers in multiple settings and with varied levels of training to communicate succinctly about a patient’s mental status.
    • The GCS has been shown to have statistical correlation with a broad array of adverse neurologic outcomes, including brain injury, need for neurosurgery, and mortality.
    • The GCS has been incorporated into numerous guidelines and assessment scores (e.g. ACLS, ATLS, APACHE I-III, TRISS and WNS SAH Grading Scale).
    • In some patients, it may be impossible to assess one or more of the three components of the coma scale. The reasons include, but are not limited to:
      • Eye: local injury and/or edema.
      • Verbal: intubation.
      • All (eye, verbal, motor): sedation, paralysis, and ventilation eliminating all responses. 
    • If a component is untestable, a score of 1 should not be assigned (Teasdale 2014). In this circumstance, summation of the findings into a total Glasgow Coma Score is invalid.
    • The 3 parts of the Glasgow Coma Scale are charted independently, and the position can be recorded as NT (not testable), with an option of indicating the reason, e.g. C for eye closure and T for intubation.

    Points to keep in mind:

    • Correlation with outcome and severity is most accurate when applied to an individual patient over time; the patient’s trend is important.
    • A GCS of 8 should not be used in isolation to make a determination of whether to intubate a patient, but does suggest a level of obtundation that should be evaluated carefully.
    • Reproducibility is usually good (Reith 2016). if individual institutions have concerns about agreement among providers, training and education are available from the GCS creators at glasgowcomascale.org.
    • Simpler scores have been shown to perform as well as the GCS in the prehospital and emergency department setting (for initial evaluation). These are often contracted versions of the GCS itself (the Simplified Motor Score (SMS) uses the motor portion of the GCS only) and are less well studied than the GCS for outcomes like long-term mortality, and the GCS has been studied trended over time, while the SMS has not.

    The Glasgow Coma Scale is an adopted standard for assessment of impaired consciousness and coma in the acutely ill trauma and non-trauma patient and assists with predictions of neurological outcomes (complications, impaired recovery) and mortality.

    Spontaneously (+4)
    To verbal command (+3)
    To pain (+2)
    No eye opening (+1)
    Not testable (NT)
    Oriented (+5)
    Confused (+4)
    Inappropriate words (+3)
    Incomprehensible sounds (+2)
    No verbal response (+1)
    Not testable (NT)
    Obeys commands (+6)
    Localizes pain (+5)
    Withdrawal from pain (+4)
    Flexion to pain (+3)
    Extension to pain (+2)
    No motor response (+1)
    Not testable (NT)

    Result:

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    Next Steps
    Evidence
    Creator Insights

    Advice

    The GCS score can be indicative of how critically ill a patient is.

    • Trauma patients presenting with GCS <15 warrant close attention and reassessment.
    • A declining GCS is concerning in any setting and should prompt assessment of the airway and possible intervention.

    Conversely, a GCS of 15 should not be taken as an indication that a patient (trauma or medical) is not critically ill. Decisions about the aggressiveness of the management and treatment plans should be made based on clinical presentation and context and not in any way overridden by the GCS score.

    Management

    • Clinical management decisions should not be based solely on the GCS score in the acute setting.
    • If a trauma patient has a GCS ≤8 and there is clinical concern that they are unable to protect their airway or that they have an expected worsening clinical course based on exam or imaging findings, then intubation can be considered.
    • In any patient, a rapidly declining or waxing and waning GCS is concerning and intubation should be considered in the context of the patient's overall clinical picture.

    Critical Actions

    • Although it has been adopted widely and in a variety of settings, the GCS score is not intended for quantitative use.
    • Clinical management decisions should not be based solely on the GCS score in the acute setting.

    From the creators of the GCS:

    “We have never recommended using the GCS alone, either as a means of monitoring coma, or to assess the severity of brain damage or predict outcome.” (Teasdale 2014)

    Content Contributors
    About the Creator
    Dr. Graham Teasdale
    Dr. Bryan Jennett
    Are you Dr. Bryan Jennett?
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