Various scales for assessment of coma

1. NEUROLOGICAL SCALES FOR
ASSESSMENT OF
CONSCIOUSNESS
DR. VIJAY PRAKASH HAWA
SR NEUROLOGY
GOVT. MEDICAL COLLEGE KOTA

2. Consciousness defined as a state of awareness of self and surroundings.
Alterations in consciousness are conceptualized into two types.
The first type affects arousal
The second type involves cognitive and affective mental function, sometimes
referred to as the “content” of mental function.

4. Alterations in arousal, although often referred to as altered levels of consciousness
Four points on the continuum of arousal are often used in describing the clinical state of a
patient:
Alert refers to a perfectly normal state of arousal.
Lethargy lies between alertness and stupor. Patient Often Aroused By Verbal Stimuli
Stupor is a state of baseline unresponsiveness that requires repeated application of vigorous
stimuli to achieve arousal.
Coma is a state of complete unresponsiveness to arousal.

5. Neurological scales
Glasgow coma scale

6. Teasdale g, jennet b assessment of coma and impaired consciousness; A practical scale : the lancet:1974 July 13;304 (7872)
81:4

7. The GCS uses a triple criteria scoring system:
best eye opening (maximum 4 points)
best verbal response (maximum 5 points)
best motor response (maximum 6 points)
These scores are added together to provide a total score between 3 and
15

8. Eye responses in the Glasgow coma scale. Adapted from Teasdale G. Forty years on: updating the Glasgow coma scale. Nursing
Times 2014;110:42;12-16

9. Eye opening response- pain stimuli should be given over nail
/shoulder pinch to avoid grimace causes closure of eyes.

10. Verbal responses in the Glasgow coma scale. Adapted from Teasdale G. Forty years on: updating the Glasgow coma scale.
Nursing Times 2014;110:42;12-16

11. Motor responses in the Glasgow coma scale. Adapted from Teasdale G. Forty years on: updating the Glasgow coma scale.
Nursing Times 2014;110:42;12-16

12. Motor responses in the Glasgow coma scale. Adapted from Teasdale G. Forty years on: updating the Glasgow coma scale.
Nursing Times 2014;110:42;12-16

15. M3 vs M4

17. Confounding factors rendering one or more components of the Glasgow
Coma Scale untestable
• Drugs (anaesthetics, sedatives, neuromuscular blockade, etc)
• Cranial nerve injuries
• Intoxication (alcohol or drugs)
• Hearing impairment
• Intubation or tracheostomy
• Limb or spinal-cord injuries
• Dysphasia
• Pre-existing disorders (dementia or psychiatric disorders)
• Ocular or maxilla facial trauma
• Language and culture
• Orbital swelling

18. Other Limitations of the GCS
1. A GCS score relies on the skill of the observer
2. The GCS can only be carried out if scores for all three elements can be
completed
3. The GCS is non-parametric
4. The clinical significance of the GCS outside of trauma and neurosurgery is
debatable

20. ADVANTAGES:
1. A SIMPLE AND STANDARIZED SYSTEM TO DETECT IN CHANGE IN LOC
2. QUICK, EASY, OBJECTIVE, ACCURATE
3. NUMERICAL, EASY TO CHART AND ANALYZE
4. IS DESIGNED TO REDUCE OBSERVER VARIABILITY
5. HELP TO MAKE MANAGEMENT DECISION
6. GCS CAN PREDICT OUTCOME

22. GCS Pupils Score (GCS-P)
The GCS-P is calculated by subtracting the Pupil Reactivity Score (PRS) from the
Glasgow Coma Scale (GCS) total score:
Pupils Unreactive to Light Pupil Reactivity Score
Both Pupils 2
One Pupil 1
Neither Pupil 0
GCS-P = GCS - PRS

25. Sessler et al, AM J Repir Crit Care Med 2002 166 : 1338-1344

26. Neurological scales
FOUR SCORE
•.
•.

27. In 2005, Wijdicks et al.devised a new coma score, the Full Outline of
UnResponsiveness (FOUR) score, which addressed the pitfalls of the
GCS.
FOUR stands for Full Outline of UnResponsiveness, and it measures four
domains of neurological function: eye responses, motor responses,
brainstem reflexes, and respiratory patterns.
The FOUR Score is calculated by adding the scores of each domain,
which range from 0 to 4. The lowest possible score is 0, indicating no
neurological function, and the highest possible score is 16, indicating
normal neurological function.

28. Eye Responses (E)
Eyelids open or opened, tracking, or blinking to command: 4 points
Eyelids open but not tracking: 3 points
Eyelids closed but open to loud voice: 2 points
Eyelids closed but open to pain: 1 point
Eyelids remain closed with pain: 0 points
Motor Responses (M)
Thumbs-up, fist, or peace sign: 4 points
Localizing to pain: 3 points
Flexion response to pain: 2 points
Extension response to pain: 1 point
No response to pain or generalized myoclonus status: 0 points

29. Brainstem Reflexes (B)
Pupil and corneal reflexes present: 4 points
One pupil wide and fixed: 3 points
Pupil OR corneal reflex absent: 2 points
Pupil AND corneal reflexes absent: 1 point
Absent pupil, corneal, and cough reflexes: 0 points
Respiration Pattern (R)
Not intubated, regular breathing pattern: 4 points
Not intubated, Cheyne-Stokes breathing pattern: 3 points
Not intubated, irregular breathing: 2 points
Breathes above ventilatory rate: 1 point
Breathes at ventilator rate or apnea: 0 points

30. Criteria FOUR Score GCS
Domains
Eye responses, motor responses,
brainstem reflexes, respiratory
pattern
Eye responses, motor responses,
verbal responses
Range 0-16 3-15
Verbal responses Not required Required
Brainstem reflexes Included Not included
Respiratory pattern Included Not included
Locked-in syndrome Can detect Cannot detect
Brain herniation Can detect Cannot detect
Validation Less widely used and validated More widely used and validated
Complexity More complex and time-consuming Less complex and time-consuming
Difference Between FOUR Score Vs GCS

31. The FOUR Score has several advantages over the GCS:
1.It does not require verbal responses, which may be impaired by
intubation, aphasia, or language barriers.
2.It evaluates brainstem reflexes and respiratory patterns, which
may reflect the location and severity of brain lesions.
3.It can differentiate between locked-in syndrome and vegetative
state, which have different prognoses and ethical implications.
4.It can detect signs of brain herniation, which may require
immediate treatment.
5.It can better discriminate between different levels of coma,
especially in the lower range of scores.

32. The FOUR Score also has some limitations :
1. It is not widely used or validated in different populations and settings, unlike
the GCS, which has been extensively studied and standardized.
2. It may be influenced by external factors that affect the neurological
examination, such as sedation, hypothermia, metabolic disturbances, or
drug intoxication.
3. It may be more complex and time-consuming to perform than the GCS,
which may limit its feasibility and reliability in busy or resource-limited
settings.
4. It may not capture some aspects of neurological function that are assessed
by other scales, such as the Glasgow Outcome Scale (GOS), which measures
the level of disability and dependence.

33. A New Approach in Intensive Care Unit Consciousness Assessment: FIVE Score
Full Intracranial Validity Evaluation Score
FOUR score +
MEAN ARTERIAL PRESSURE
between 60-130mmHg - 2 points
patients under inotropic support with a mean arterial pressure between 60-130mmHg - 1 point
patients with a mean arterial pressure below 60mmHg or above 130mmHg - 0 points.
Additionally,,
GAG REFLEX (for patients with infratentorial mass)
If the reflex is absent,-0 points are given
if it is unilateral-1 point
if it is preserved- 2 points .

34. REFERENCES:
1. Bradley’s Neurology in clinical practice, Eighth edition
2. Assessment of coma and impaired consciousness; A practical scale, Teasdale g, jennet
b : the lancet:1974 July 13;304 (7872) 81:4
3. The Glasgow Coma Scale at 40 years: standing the test of time Graham Teasdale,
Andrew Maas, Fiona Lecky, Geoff rey Manley, Nino Stocchetti, Gordon Murray;
Lancet Neurol 2014; 13: 844–54
4. Jennett & Teasdale. Lancet 1977;i:878-881.
5. James & Trauner. Brain insults in infants and children. Orlando: Grune & Stratton,
1985:179-182.
6. Tatman, Warren, Williams, Powell, Whitehouse. Archives of Disease in Childhood
1997;77:519-521
7. The Full Outline of UnResponsiveness (FOUR) Score and Its Use in Outcome
Prediction: A Scoping Systematic Review of the Adult Literature: Neurocrit care 2019
aug 31(1) 162-175
8. Sessler et al, AM J Repir Crit Care Med 2002 166 : 1338-1344
9. A New Approach in Intensive Care Unit Consciousness Assessment: FIVE Score,
Clinical trials. Gov .in ,14 sept. 2023

35. THANK YOU