Glasgow Coma Scale
Glasgow Coma Scale is a neurological scale developed by Teasdale and Jennett and is also known as Glasgow Coma Score. Glasgow coma scale is used to record consciousness levels of the person.
Glasgow coma scale is routinely used in head injuries and other central nervous system conditions
The scale comprises three tests: eye, verbal and motor responses.
The three values separately, as well as their sum, are considered. The lowest possible GCS (the sum) is 3 (implies deep coma or death), whilst the highest is 15 (implies fully awake person).
Child’s Glasgow Coma Scale Revised BPNA 2001 Pain should be made by pressing hard on the supra-orbital notch (beneath medial end of. GCS.PDF Author: Unknown.
Best eye response (E)
There are 4 grades starting with the most severe:
- No eye opening
- Eye opening in response to pain. (Patient responds to pressure on the patient’s fingernail bed; if this does not elicit a response, supraorbital and sternal pressure or rub may be used.)
- Eye opening to speech. (This should not be confused with an awakening of a sleeping person. In such cases a score of 4 is given, not 3.)
- Eyes opening spontaneously
Best verbal response (V)
There are 5 grades starting with the most severe:
- No verbal response
- Incomprehensible sounds. (Moaning but no words.)
- Inappropriate words. (Random or exclamatory articulated speech, but no conversational exchange)
- Confused. (The patient responds to questions coherently but there is some disorientation and confusion.)
- Oriented. (Patient responds coherently and appropriately to questions such as the patient’s name and age, where they are and why, the year, month, etc.)
Best motor response (M)
There are 6 grades starting with the most severe:
- No motor response
- Extension to pain (adduction of arm, internal rotation of the shoulder, pronation of forearm, an extension of the wrist, decerebrate response)
- Abnormal flexion to pain (adduction of arm, internal rotation of the shoulder, pronation of forearm, flexion of wrist, decorticate response)
- Flexion/Withdrawal to pain (flexion of elbow, supination of the forearm, flexion of the wrist when supra-orbital pressure applied; pulls part of the body away when nailbed pinched)
- Localizes to pain. (Purposeful movements towards painful stimuli; e.g. hand crosses mid-line and gets above clavicle when supra-orbital pressure applied.)
- Obeys commands. (The patient does simple things as asked.)
How To Interpret The Score?
Individual elements, as well as the sum of the score, are important in the Glasgow Coma Scale. Hence, the score is expressed in the form “GCS 9 = E2 V4 M3 at 17:35”.
Generally, comas are classified as:
- Severe, with GCS less than or equal to 8
- Moderate, GCS 9 – 12
- Minor, GCS 13 or greater.
In a severely injured patient with intubation and severe facial/eye swelling or damage, it is not possible to test the verbal and eye responses. In these circumstances, 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’.
The Glasgow Coma Scale has limited applicability to children, especially below the age of 36 months because then the verbal performance of even a healthy child could be labeled to be poor).
To avoid this Pediatric Glasgow Coma Scale, a separate yet closely related scale, has been developed for assessing younger children.
Pediatric Glasgow Coma Scale
The Pediatric Glasgow Coma Scale or Pediatric Glasgow Coma Score (PGCS) is the equivalent of the Glasgow Coma Scale and is used to assess the consciousness of infants and children.
Pediatric Glasgow Coma Scale is used in cases of head injury of children mostly.
The scale has been modified from the original Glasgow coma scale as s many of the assessments for an adult patient would not be appropriate for infants and young children.
The Pediatric Glasgow Coma Scale comprises of three tests: eye, verbal and motor responses as in Glasgow coma scale(GCS).
Best eye response: (E)
4. Eyes opening spontaneously
3. Eye opening to speech
2. Eye opening to pain
1. No eye opening
3. Eye opening to speech
2. Eye opening to pain
1. No eye opening
Best verbal response: (V)
The main difference from adult Glasgow coma scale comes in the verbal response. Here the responses are different age wise
Age 0-23 Months
5. Infant coos or babbles or smiles appropriately (normal activity)
4. Infant cries but consolable
3. Persistent crying and or screaming
2. Infant moans to pain, grunts, agitated and restless
1. No verbal response
Age 2-5 Years
5. Appropriate words or phrases
4. Inappropriate words
3. Persistent Cries or screams
2. Grunts
1. No response
Age> 5 Years
5. Oriented
4. Disoriented, confused
3. Inappropriate words
2. Incomprehensible sounds
1. No response
In children greater than 5 years of age, the responses are similar to adult Glasgow Coma Scale.
Best motor responses: (M)
6. Infant moves spontaneously or purposefully
5. Infant withdraws from touch
4. Infant withdraws from pain
3. Abnormal flexion to pain for an infant (decorticate response)
2. Extension to pain (decerebrate response)
1. No motor response
5. Infant withdraws from touch
4. Infant withdraws from pain
3. Abnormal flexion to pain for an infant (decorticate response)
2. Extension to pain (decerebrate response)
1. No motor response
Interpretation of Pediatric Glasgow Coma Scale
A Coma Score of 13 or higher correlates with a mild brain injury, 9 to 12 is a moderate injury and 8 or less a severe brain injury. Any combined score of less than eight represents a significant risk of mortality.
In writing the score, along with total score individual components are also mentioned. For example E3V3M5, GCS 11.
- 3
- Shares
3
PMID: 27162843
This article has been cited by other articles in PMC.
Traumatic brain injuries in pediatrics are among the most common causes of pediatric emergency room visits and is usually associated with long-term disability and neurological sequelae []. Despite advances in prevention, diagnosis and management of traumatic brain injuries, the mortality and morbidity rates are high among pediatric population []. The epidemiological studies have revealed that alls, motor vehicle accidents and recreational activities are the most common causes of traumatic brain injuries in pediatrics [,]. The management of moderate to severe traumatic brain injuries include prolonged intensive care and rehabilitation although the prognosis and the outcome remains elusive. Thus, several scoring systems have been introduced and validated in order to determine the outcome of the pediatric patients with traumatic brain injuries []. Several factors have been reported to be related to the patient outcome including age, the duration of the coma, the type of the brain lesion, the pattern of the pupils, injury severity score, the motor patterns, impaired reflexes of the brain stem, hypotension, hypoxia and the Glasgow Coma Scale (GCS) []. Some laboratory and paraclinical investigations have also been used to predict the outcome including brainstem auditory evoked potentials and cognitive event-related potentials []. For instance, it has been shown that event-related potentials such as N400 could be reliably used to predict the post-traumatic language skills (subcortical and cortical systems) in those with severe traumatic brain injury suffering from aphasia [].
Several lines of evidence suggest that pediatric patients suffering from severe traumatic brain injury have better prognosis when compared to adults []. In other words, the recovery of pediatric patients with traumatic brain injury is significantly better than adults []. In addition, it has been demonstrated that younger children have better outcome compared to older ones []. The later fact, however, is a controversial issue while some studies have shown that younger children have worst prognosis after traumatic brain injuries []. Younger children have incomplete myelinization which makes them more susceptible to shearing injury []. It was shown that pediatric patients older than 6 years have better motor and cognitive function after traumatic brain injury []. The prognosis and mechanism of injury of the central nervous system depends extensively on the patients’ age at the time injury. This makes it hard for the physicians to predict the outcome of traumatic brain injury in pediatric population. Thus predicting the outcome of traumatic brain injury in pediatrics is of important value both clinically and morally [].
The Glasgow Coma Scale (GCS) score is the most commonly and widely used indicator of severity of traumatic brain injury in both adults and pediatrics []. GCS is also used to predict the outcome of brain injuries []. The GCS score less than 8 is referred to 'severe traumatic brain injury' which is associated with less favorable outcome and poor recovery []. Although the GCS is reliable in adult population, the reliability remain elusive in pediatrics. This is because the scoring system is based on the consciousness and patients' understanding of the orders and commends which is not applicable to pediatrics. Thus some modifications have been made in the GCS scoring system in order to be suitable for the children as well as neonates. In pediatrics another important issue that should be kept in mind when predicting the outcome is the hypoxic-ischemic insult at the time of injury which could be considered confounding factors in calculating GCS score and assessing the outcome []. In order to adjust the GCS scoring system for pediatrics, it has been suggested that the cut-off value be set at 5 as severe traumatic brain injury. In other words, the threshold for neurophysiologic dysfunction should be decreased in pediatric population []. It has also been reported that precise calculation of GCS is a reliable indicator of the patients’ outcome [,]. It has been reported by Lai et al. [] that the mortality rate was higher for traumatic brain injury children with GCS scores of 3-5 than those with scores greater than 5. Children with GCS scores of 3-5 subsequently died or developed severe disabilities, whereas those with a GCS score more than 5 had better outcomes []. Bruce et al. found that a GCS more than 5 was always associated with excellent recovery []. It has also been reported that the decision making for performing decompressive craniectomy in pediatric population should be based on the GCS scoring and brain CT-scan findings []. However this point should be kept in mind that the cut-off value for pediatrics should be decreased to 5 in order to be able to assess good reliability.
Taking all these together, this should be mentioned that GCS score is the most feasible, accessible and reliable predictor of traumatic brain injury outcome in pediatrics and despite its shortcomings, could be adjusted for this group. The cut-off value for severe traumatic injury should be set as 5 instead of 8 in order to be able to predict the outcome more precisely.
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