GCS EVALUATION

1. ZIKRULLAH

2. Neurological scales
 Glasgow coma scale
 Pediatric GCS
 Glasgow coma scale – E
 Glasgow outcome scale
 FOUR Score Coma Scale
 Hunt and Hess scale
 World Federation of Neurologic Surgeons Scale (WFNS)
 Blantyre coma scale
 Rancho Los Amigos Scale

3. INTRODUCTION
 Glasgow Coma Scale (GCS) was introduced in 1974 by
Teasdale and Jennett , aiming at standardizing the
assessment of level of consciousness in head injured
patients.
 In 1976, addition of a sixth point in the motor response
subscale was made for “withdrawal from painful stimulus”
 Reliable, objective way of recording the conscious state of a
person.

4.  it is simple enough to be utilized by physicians, nurses,
and other care providers for initial and continuing
assessment.
 important part of the primary survey
 Designed for the evaluation of severe HT, the GCS is used
in assessment of coma due to any etiology.

6. EYE OPENING
 Spontaneous (4) : is indicative of activity of brainstem arousal
mechanisms.
 To speech (3) : tested by any verbal approach (spoken or
shouted).
 To pain (2) : tested by a stimulus in the limbs (supraorbital
pressure may cause grimacing and eye closure).
 None (1) : no response to speech or pain.

7.  Scores of 3 and 4 imply that cerebral cortex is processing
information
 Score of 2 shows that lower levels of brain are functioning .

8. BEST VERBAL RESPONSE
 Oriented (5) : awareness of the self and the environment
(who / where / when).
 Confused (4) : responses to questions with presence of
disorientation and confusion.
 Inappropriate words (3) : speech in a random way, no
conversational exchange.

9.  Incomprehensible sounds (2) :
moaning,groaning.
 None (1) : no response.
 Presence of speech indicates a high degree of
integration in the nervous system even though
lack of speech could be attributed to other
factors, i.e: dysphasia, tracheostomy.

10. BEST MOTOR RESPONSE
 Obeying commands (6)
 Localizing (5) : movement of limb as to attempt to remove the
stimulus, the arm crosses midline.
 Normal flexor response (4) : rapid withdrawal and abduction
of shoulder.

11.  Abnormal flexor response (3) :
adduction of upper extremities,
flexion of arms, wrists and fingers,
extension and internal rotation of
lower extremities, plantar flexion
of feet, and assumption of a
hemiplegic or decorticate posture.
 Extensor posturing (2) :
adduction and hyperpronation of
upper extremities, extension of
legs, plantar flexion of feet,
progress to opisthotonus
(decerebration).

12.  None (1) : rule out an inadequate stimulus or spinal
transection.
 Motor 3 lesion is located in the internal capsule or cerebral
hemispheres.
 Score of 2 describes a midbrain to upper pontine damage
 The motor response is considered a good indicator of the
ability of central nervous system (CNS) to function properly .

13.  Record best response from any limb when assessing altered
consciousness
 Arms are more useful to test since they present a wider range
of responses, while a spinal reflex may cause flexion of legs
if pain is applied locally.

14. EVALUATION OF CHILDREN
 The GCS predicts outcome in children with HT.
 It also predicts outcome of intracranial
hemorrhage in children with cancer.
 A decrease in GCS of more than 3 points at the
time of intracranial hemorrhage is an indicator of
increased mortality .

15.  The GCS is inapplicable to infants and children below the
age of 5 years.
 Using the standard GCS for adults, the normal aggregate
scores are 9 (at six months), 11 (at twelve months), and 13-
14 (at sixty months) .
 As for adults, emphasis should be placed on the accurate
measurement of the motor score before intubation by
physicians or paramedics.

17. 

19. CLINICAL OBSTACLES
 Several clinical conditions that have great impact on GCS
rating with sedation and intubation being of great
importance.
 Patient with a spinal cord injury will make the motor scale
invalid
 Use of paralytics and sedatives in rapid sequence intubation
introduces confounding factors.
 High blood alcohol concentrations (> 240 mg / 100 ml) are
associated with a 2-3 point reduction in GCS.

20.  Tracheal intubation and severe facial/eye
swelling or damage make it impossible to test
the verbal and eye responses.
 The score is given as 1 with a modifier
attached e.g. "E1c" where "c" = closed, or "V1t"
where t = tube.
 A composite might be "GCS 5tc". This would
mean, for example, eyes closed because of
swelling = 1, intubated = 1, leaving a motor
score of 3 for "abnormal flexion".
 Often the 1 is left out, so the scale reads Ec or
Vt

21.  Patients who are hypoxic, hypotensive, hypothermic, or
hypoglycemic , have depressed mental status due to a poor
environment for the brain and not due to brain pathology.
 These conditions should be corrected prior to relying on
the GCS for management decisions.
 The initial score should be assigned six hours after HT had
been sustained.
 GCS score recorded before giving sedation is preferable.

22.  Caregivers cannot score the person's body movements
if an injury causes pain with movement, or makes the
person unable to move.
 The GCS does not check if the person can learn and
remember new things. A person's ability to form new
memories is important in helping caregivers predict his
recovery after a TBI.

23. APPLICATIONS
 The GCS describes and assesses coma,
 Monitors changes in depth of coma,
 Indicator of severity of illness
 Facilitates information transfer
 Used as a triage tool in patients with HT .

24.  It facilitates monitoring in the early stages after injury,
 Allows rapid detection of complications even among patients
with a GCS score of 13 to 15,
 Discriminates between those more or less likely to be at risk
of complications.
 Aids in clinical decisions, such as intubation, for total GCS
score 8 or motor score 4.

25. Classification of severity of HT

26. Skull Radiography, CT scans and MRI
 Patients with GCS scores of 13-14 have a significantly higher
incidence of skull fracture, abnormal CT findings, need for
hospital admission, delayed neurological deterioration and
need for operation than patients with a GCS score of 15 .
 Patients with score 14 , with score of 15 with amnesia or of
advanced age should undergo MRI / CT scans.

27. Evaluation of hemorrhage
 The GCS is utilized in the comparative study of traumatic
and spontaneous intracerebral hemorrhage.
 Younger age and higher GCS scores at presentation related
to favorable outcome.
Evaluation of surgical or intensive care
demand

28. Evaluation of acute stroke & aneurysmal SAH
 In patients with acute stroke , Eye and motor subscales has
87% accuracy compared to 88% for the total GCS, for initial
period(< 14 days).
 Patients who underwent surgery for ruptured cerebral
aneurysms, in those with a GCS score of 14, a “confused”
verbal response indicated poorer prognosis.

29. Assessment of meningitis and CNS infections
 Most meningitis patients with a GCS score > 12 had a good
neurological outcome, while most patients with GCS score 8
had a poor outcome .
Evaluation of carotid artery injuries
 These injuries should only be repaired in patients with GCS
score > 9, since comatose patients with GCS score < 8 do
poorly regardless of management.

30. GCS in motor vehicle accidents
 It predicts hospitalization after motor vehicle collisions.
 Values of field GCS and arrival GCS scores were associated
with outcome of HT .
Evaluation of risk of aspiration pneumonia
Prediction of hospital mortality in ICU pts

32. Limitations
 Collectors’ experience and the inter-rater variability in
recording of GCS.
 LACK OF BRAINSTEM REFLEXES AND PUPILLARY
RESPONSE EVALUATION
 The Glasgow Liège Scale combined the GCS with five
brainstem reflexes (pupillary, fronto-orbicular, oculocardiac,
horizontal and vertical oculocephalic).

33. Does not measure concussion severity
 Many patients who are diagnosed with mild
traumatic brain injury have diminished brain function,
headaches and other symptoms that last for weeks or
even months.
 Alternatively, some patients diagnosed with 'moderate'
traumatic brain injury will recover completely within days
to weeks.

34. Glasgow Coma Scale-Extended
 The Glasgow Coma Scale-Extended (GCS-E), was
introduced for helping the acute assessment and
prognostication.
 GCS was not intended to distinguish among different types
of milder injury (13- 14 ), since many patients are orientated
by the time they are first assessed and therefore score at the
top of the GCS.

35.  Also some patients have a period of altered consciousness as
evidenced by their inability to recall events immediately
after injury.
 A numeric value between 0-7 was assigned based on the
duration of the posttraumatic amnesia.

37. Glasgow Outcome Score
 The GCS is often used in conjunction with Glasgow
Outcome Score (1975).
 Score applies to patients with brain damage allowing the
objective assessment of their recovery in five categories.
 This allows a prediction of the long-term course of
rehabilitation to return to work and everyday life.

39. FOUR Score Coma Scale
 GCS is not fully reliable in predicting patient outcomes
 FOUR score includes
 measurement of brainstem reflexes;
 determination of eye opening, blinking, and tracking
 motor responses
 presence of abnormal breath rhythms and a respiratory
drive.

44.  The HUNT AND HESS SCALE when applied to patients
with SAH offers classification and prognostication of
mortality.

45.  The World Federation of Neurologic Surgeons Scale
(WFNS) is the preferable rating because it uses the more
prevalent GCS but with a modifying component of focal
deficit .

46. Advanced Trauma Life Support AVPU Scale
 Alert,
 Response to Verbal
 Response to painful stimuli,
 Unresponsive scale
 ACDU Scale
 Alert,
 Confused
 Drowsy
 Unresponsive

47. Blantyre coma scale
 The Blantyre coma scale is a modification of the Pediatric
Glasgow Coma Scale, designed to assess malarial
coma in children
 The score assigned by the Blantyre coma scale is a number
from 0 to 5
 The minimum score is 0 which indicates poor results while
the maximum is 5 indicating good results

48.  Eye movement
 1 - Watches or follows
 0 - Fails to watch or follow
 Best motor response
 2 - Localizes painful stimulus
 1 - Withdraws limb from painful stimulus
 0 - No response or inappropriate response
 Best verbal response
 2 - Cries appropriately with pain, or, if verbal, speaks
 1 - Moan or abnormal cry with pain
 0 - No vocal response to pain

49. Rancho Los Amigos Scale
 The Rancho Los Amigos Scale a.k.a. the Rancho Los
Amigos Levels of Cognitive Functioning Scale (LOCF)
or Rancho Scale
 Used to assess individuals after a closed head injury,
including traumatic brain injury, based on cognitive and
behavioural presentations as they emerge from coma.
 Individuals with brain injury will receive a score from one
to eight.
 A score of one represents non-responsive cognitive
functioning, whereas a score of eight represents purposeful
and appropriate functioning

50.  Each of the eight levels represents the typical sequential progression
of recovery from brain damage. These patients will be scored based on
combinations of the following criteria
 responsiveness to stimuli
 ability to follow commands
 presence of non-purposeful behavior
 cooperation
 confusion
 Attention to environment
 focus
 coherence of verbalization
 appropriateness of verbalizations and actions
 memory recall
 orientation
 Judgement and reasoning

51. CONCLUSION
 The GCS carries valuable information about the
neurological status of patients and constitutes an element
of surveillance of their evolution.
 But it should not replace a thorough neurological
examination.
 Full knowledge of this scale’s strengths and limitations is
essential in order to assure its proper use.
 Above all, uniform scoring is imperative and should be
pursued.

52. Thank you