The document discusses the Glasgow Coma Scale (GCS) and its application in assessing levels of consciousness from wakefulness to coma. It highlights the significance of GCS in communication, prognosis, and measuring head injury severity, while also addressing its limitations and the need for considering underlying pathologies. Future directions include exploring advanced imaging and assessment techniques beyond traditional scoring methods.

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