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Agrawal, J Tradit Med Clin Natur 2018, 7:2


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Review Article Open Access

The Glasgow Coma Scale: A Breakthrough in the Assessment of the Level of


Consciousness
Sujan Narayan Agrawal1*
1
SBRKM Govt Medical College, Chhattisgarh, India

Abstract
The Glasgow Coma Scale (GCS) was introduced in 1974 as a measure of a patient’s level of consciousness. Before
the development of this scale the level of consciousness was described by the terms like stuperose, comatose, semi-
comatose, obtunded, decerebrate etc. These terms were ill-defined, confusing and not comparable between different
observers.
The GCS is a simple and reliable measure of level of consciousness. Once the medical and nursing staff is trained,
the inter-observer variability is low. This scale went on to be accepted and used by most of the neurosurgical unit
worldwide. The institute of Neurological sciences Glasgow is a world leader, in brain injury research and clinical care. In
1974, Professor Jennet and Mr. Teasdale of this institute published a paper in the lancet on the assessment of Coma
and impaired consciousness. This paper proposed a structured method of assessment called “the Glasgow Coma
Scale”. GCS is a component of the acute physiology and chronic health evaluation (APACHE) II score, the (revised)
trauma score, the trauma and injury severity score (TRISS) and Circulation, Respiration, Abdomen, Motor, Speech
(CRAMS) Scale, demonstrating the world wide adaptation of the scale.

Keywords: Glasgow coma scale; Level of consciousness; APACHE 4. Useful tool for initial triage and a guide for shifting to general or
score; TRISS; CRAMS specialist care.

Introduction 5. It acts as a basis for monitoring progress after acute insult and
helps in predicting the likely outcome.
The essence of the GCS is the independent assessment of responses
in three behavioural domains i.e. eye opening (E), Motor response 6. The database can be used to devise the guidelines and standard
(M), and verbal activity (V). These can be displayed as a bedside chart operating procedure (SOP) for management of traumatic brain injury.
just like charting of temperature, pulse and blood pressure. This leads It can be used to classify head injured patients in epidemiological
to early recognition of any deviation from previous reading and help studies worldwide [6].
to take appropriate action in time. The scores are given as statistical The Weakness
predictors of outcome. The original overall score was 14, after one year
‘abnormal flexion’ was added in motor response and the total GCS 1. The Glasgow study does not considers the other predictive
score become 15 [1-3]. factors like patient’s age, history of lucid interval, papillary reactions,
eye movements, pulse rate, Blood pressure, respiration and initial CT
The Scale findings etc. [7].
In a person who is fully conscious, alert and oriented, the Glasgow 2. It is not applicable in children.
coma scale will be E4 M6 V5 (15/15) and the reduction in the score
is indicative of deterioration in the state of consciousness (Table 1). 3. It records the best motor response (M6), yet the patient could be
The minimum score is E1 M1 V1 (3/15) who has no eye opening monoplegic, hemiplegic or tetraplegic.
(E1), no motor response (M1) and no verbal response (V1) to any 4. The response may be impaired due to language problem, alcohol
kind of stimuli. While recording the GCS, it is the best response at intoxication, shock, hypoxia, Intubation and tracheostomy. Moreover
that particular moment, which is recorded. The best response is the the verbal response cannot be elicited in intubated or tracheostomised
motor response. The severity of the head injury can be assessed and patients.
prognosis can be predicted. GCS score of 13-15 is considered a mild
head injury and this makes up almost 80% of cases. Score of 9-12 is 5. There is no check on cranial nerve functions.
moderately severe head injury and the incidence is 10%, score of 3-8 is 6. Eye opening and closing may be impaired by black eye and
severe head injury and is 10% of cases, the prognosis is worst in such conjunctival chemosis.
patients (Figure 1).

Strength
1. It helps the medics and paramedics to independently assess the *Corresponding author: Dr. Sujan Narayan Agrawal, SBRKM Govt Medical
College, Chhattisgarh, India, E-mail: drsujanagrawal@gmail.com
response in three behavioural domains i.e. eye opening (E), Motor
response (M), and verbal activity (V). Received March 21, 2018; Accepted April 05, 2018; Published April 14, 2018

2. They can readily be displayed as a bedside chart. Charting is easy Citation: Agrawal SN (2018) The Glasgow Coma Scale: A Breakthrough in the
Assessment of the Level of Consciousness. J Tradit Med Clin Natur 7: 273. doi:
just as the routine charting of Pulse, Temperature and blood pressure 10.4172/2573-4555.1000273
by nursing staff [4,5].
Copyright: © 2018 Agrawal SN. This is an open-access article distributed under
3. It also facilitates communication between doctors who can the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and
report a patient’s state, as E2, M4, and V3 for example.
source are credited.

J Tradit Med Clin Natur, an open access journal


Volume 7 • Issue 2 • 1000273
ISSN: 2573-4555
Citation: Agrawal SN (2018) The Glasgow Coma Scale: A Breakthrough in the Assessment of the Level of Consciousness. J Tradit Med Clin Natur
7: 273. doi: 10.4172/2573-4555.1000273

Page 2 of 2

Eye opening
S.N. Score Parameter Response
1 4 Spontaneous Indicates arousal, not necessarily awareness
2 3 To Speech When spoken to – not necessarily command to open eye
3 2 To Pain Applied to limbs and not face where grimacing can causes closure of eye
4 1 None  
Motor response
5 6 Obeys command Exclude grip reflex or postural adjustments
6 5 Localizes Other limb moves to site of nail bed pressure
7 4 Withdraws Normal flexion of Elbow or knee to local painful stimulus
8 3 Abnormal flexion Slow withdrawal with pronation of wrist, adduction of shoulder
9 2 Extensor response Extension of elbow with pronation and adduction
10 1 No Movement  
Verbal response
11 5 Oriented Knows who, where, when; year, season, month
12 4 Confused conversation Attends and responds but answers muddled/wrong
13 3 Inappropriate words Intelligible words but mostly expletive or random
14 2 Incomprehensible speech Moans and groans only-no words
15 1 None  
Table 1: Glasgow come scale with scores [3].

Figure 1: A representative bedside observation chart showing recovery from coma [3].

Conclusion References
1. Teasdale GM, Jennett B (1974) Assessment of coma and impaired
The Glasgow Coma Scale remains the most commonly used Consciousness: A practical scale. Lancet 2: 81-84.
method of assessing the level of consciousness in patients of traumatic 2. Jennett B, Teasdale G (1982) Management of Head Injuries. F. A. Davis
brain injury. Once learned it becomes a handy and reliable tool Company, Philadelphia. pp: 42: 361.
to asses, communicate and predict the likely outcome. Out of the 3. Jennett B (2005) Development of Glasgow coma and outcome scales. Nepal
three components the motor (M) response is most important. It Journal of Neuroscience 2: 24-28.
is also important to stress that for clinical use, patients should be 4. Teasdale G (1975) Acute impairment of brain function-1: Assessing conscious
communicated by the three separate scores (E, V, M) and never by level. Nursing Times 71: 914-917.
total sum. If eye or verbal response cannot be evaluated, this should 5. Teasdale G, Galbraith S, Clarke K (1975) Acute impairment of brain function-2:
be indicated by recording as “c” (Eye closed) or “T” (Intubated) Observation record chart. Nursing Times 71: 972-973.
respectively. The GC score is useful for research, audit, prognostic 6. Jennett B (1996) Epidemiology of head injury. J Neurol Neurosurg Psychiat
calculations and other type of data collection that requires digitising 60: 362-369.

and grouping of clinical information. 7. SK Kochar (2013) Principle and practice of Trauma care. Jaypee Brothers
Medical Publishers (P) ltd, 2nd edn, New Delhi. pp: 162-189.

J Tradit Med Clin Natur, an open access journal


Volume 7 • Issue 2 • 1000273
ISSN: 2573-4555

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