Goodbye GCS! Summary by: Mark Wilson Consciousness comprises “wakefulness” (that’s the brain stem, opening your eyes component) and “content” (that’s the supratentorial, thinking, “someone’s home” component). You can have wakefulness without content (e.g. persistent vegetative state) but not content without wakefulness. Describing a “level” of consciousness, converting this multifaceted human brain ability into a linear scale was possibly the biggest neuroscience break through of the 20th Century. The 1974 Lancet paper in which Brian Jennet and Sir Graham Teasdale proposed the Glasgow Coma Scale (GCS) is certainly the most cited neuroscience paper. We had even put a man on the moon before this had been created. It’s relative simplicity and repeatability meant GCS was rapidly taken up across the world. Now 40 years on, is it out of date? There are problems with the GCS – it doesn’t include pupil response, it doesn’t look at ventilation or other autonomic functions hence other systems such as the 4 score system have been proposed. But these take longer, and are poorly known so cannot be used like GCS to rapidly convey in a meaningful way the level of consciousness of a patient between clinicians. In this talk Mark Wilson goes through the history of the GCS and other conscious measures… is it time to say Goodbye to GCS?

1. G O O D B Y E G C S
M A R K W I L S O N
Scale = individual components
Score = the total

2. What is consciousness?
Wakefulness
Content

3. “ L E V E L S O F
C O N S C I O U S N E S S "
• Metaconscious
• Conscious
• Confused
• Delirious
• Somnolent
• Obtunded
• Stuporous
• Comatose.
Bart Hughes 1962
Children have a higher state of consciousness and
since children's skulls are not fully closed one can
return to an earlier child like state of consciousness
by self trephination

4. Bryan Jennett 1926-2008
Sir Graham Teasdale

5. cited > 6,000 times

6. What was it meant for?
“The assessment of coma and impaired conciousness”

7. TREND MONITOR
NOT A TOTAL NUMBER

8. But what do we use it for now?
• Communication about all neuro patients
• Head Injury Severity Measure
• Prognostication tool
• Sedation Scale
• Depth of Coma
• All cause MENTAL STATUS MONITOR

9. • Mild - GCS 13-15
• Moderate - GCS 9-12
• Severe - GCS < 8
(trauma coma data
bank)
But PVS can be E4, V2, M3
Brain Injury Severity Subarachnoid Severity
WFNS scale
Grade GCS Motor Deficit
1 15 -
2 13-14 -
3 13-14 +
4 12-7 +/-
5 3-6 +/-

11. E1􏰶 V1 M􏰶2 =
48%
E1 􏰶V2􏰶 M1 =
27%
E2􏰶 V1􏰶 M1 =
19%
Mortality of GCS 4
Healey C, Osler TM, Rogers FB, et al. Improving the Glasgow Coma Scale score: motor score alone is a better predictor J Trauma. 2003;54:671-678.

12. ITU GCS “12” is not the same as Pre-Hospital “12”
E3, V4, M5

13. S C O R I N G S Y S T E M S I N C O R P O R A T I N G G C S
• APACHE II
• RTS
• TRISS
• CRAMS
• + TBI Models eg
IMPACT (motor score)

14. P R O B L E M S W I T H G C S
• People Intubated prior Arrival
• No V when intubated
• Nothing about Brain Stem Reflexes
• The abnormal flexion bit…
• It is not linear - M score “more
important”
• Low Interrupter reliability (30% of
paired assessments are > 2 different)

15. 3 , 8 , 1 5
0
22.5
45
67.5
90
3 4 5 6 7 8 9 10 11 12 13 14 15

17. H I S T O R Y O F
S C O R E S
• Jouvet Coma Scale
• Moscow Coma Scale
• Glasgow Coma Scale
• Japan Coma Scale
• Bozza-Marrumbini Scale
• Grady Coma Scale
• Four Score

18. Full Outline of UnResponsiveness Score

24. S I M P L E A S S E S S M E N T S C A L E S
• Alert
• Voice
• Pain
• Unresponsive
• Alert
• Confused
• Drowsy
• Unresponsive
• Obeys Commands
• Localises
• Less (/ withdrawal)
Simplified Motor Scales

25. W H A T C A U S E S
F I X E D D I L A T E D
P U P I L S
• Hypoxia
• Seizures
• Drugs
• Orbital Trauma
• Brain Stem Injury
… and pressure on the occulomotor
nerve.

26. FUCD Meta-Analysis
EDH
SDH
Mortality
Good Outcome
Good Outcome
Mortality
29%
54%
66%
7%

28. It is underlying pathology that should predict outcome - not a “score”

29. W H A T ’ S T H E F U T U R E ?

31. • NIRS
• Ultrasound
• Mobile CT

32. T R Y T O L O O K T H R O U G H P A T I E N T S

33. W H Y S T I C K W I T H G C S ?
• It’s understood
• Do you really want different coma scores for TBI, stroke, sedation…?
• It is ingrained in so many scoring systems / models.

34. T A K E H O M E M E S S A G E
DESCRIBE WHAT YOU SEE
using the scale + pupils
But also think about the underlying pathology
@markhwilson