The Glasgow Coma Scale (GCS) is a neurological scale used to assess level of consciousness. It evaluates eye opening, verbal response, and motor response on a scale of 3-15. Though widely used, it has limitations like not assessing brainstem function or distinguishing mild injuries. Several other scales have been developed, like the FOUR score which also evaluates brainstem reflexes and eye movements, and the Glasgow Outcome Scale which measures long-term recovery. The GCS remains valuable for initial assessment, monitoring changes, and predicting outcomes in various conditions like traumatic brain injury and stroke.

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