Glasgow Coma Scale (GCS) Definition A Glasgow Coma Scale (GCS) is the most widely used scoring system

that determines the level of consciousness of an individual with a suspected or confirmed brain injury. Use of the GCS scale does not take place an in-depth neurologic assessment Purpose This scale is used to: 1. Address the three areas of neurologic functioning 2. Gives an overview of the patients level of consciousness (LOC) 3. Evaluates the neurologic status of patients who have had a head or brain injury This scale is not only used after a traumatic head or brain injury but is also utilized in first aid, Emergency medical services (EMS), acute cases and for the monitoring of chronic patients in intensive care units. What is assessed or measured in GCS? Use of the Glasgow Coma Scale does not take place an in-depth neurologic assessment rather it provides an evaluation of the patients responses in the following areas: 1. Eye-opening responses 2. Motor responses 3. Verbal responses The three areas are further divided into different levels where a number is assigned to each of the possible responses within the categories. A high number means that the response is normal while a low one denotes impairment of neurologic function. The calculated total figure indicates the severity of the coma a patient is experiencing. The lowest score is 3 (least responsive) suggests or reflects that a patient is in a deep coma, while the highest score of 15 (most responsive) means that the patient is fully intact. The Glasgow Coma Scale

Characteristic Eye Opening(E)

Best Motor Response (M)

Best Verbal Response (V) (arouse patient with painful stimuli if necessary)

Response Spontaneous 4 To verbal command or speech 3 To pain 2 Does not open eyes to painful 1 stimuli or no response Obeys commands 6 Localizes pain; pushes stimuli 5 away Flexes and withdraws 4 Abnormal flexion (decorticate 3 response) Abnormal extension response 2 (decerebrate response) No motor response 1 Oriented and converses 5 Disoriented and converses 4 (confused conversation) Uses inappropriate words 3 Makes incomprehensible sounds 2 No verbal response 1 Total: E + M + V 3 to 15

Score

Interpretation of Scores Individual categories or elements as wells as the sum of the score are important. The score is expressed in this form for a client who is most responsive: GCS 15 = E4 V5 M6 at 14:00 This means that the clients GCS total score is 15 where the Eye Opening is scored 4, Motor response of 6 and verbal response of 5 as of 2:00 in the afternoon or 14:00 in a 24-hour time format. Coma is suspected if the GCS score is equal to or less than 7. A score equal to 8 or less could also suggest a severe brain injury. GCS 9-12 indicates moderate brain injury and more than 13 denotes minor brain injury. Coma with the use of GCS is defined as not opening the eyes, not obeying commands and no verbal response.

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The Glasgow Coma Scale (GCS) is used to assess level of consciousness in a wide variety of clinical settings, particularly for patients with head injuries (NICE, 2007). In this practical procedure, assessment of the patient's best eye-opening response will be outlined and discussed, and, in next week's article, assessment of the patient's best verbal and motor responses will be described. What the GCS assesses The GCS assesses the two aspects of consciousness: Arousal or wakefulness: being aware of the environment; Awareness: demonstrating an understanding of what has been said. The 15-point scale assesses the patient's level of consciousness by evaluating three behavioural responses: Eye opening; Verbal response; Motor response. Eye opening Assessment of eye opening involves the evaluation of arousal (being aware of the environment): Score 4: eyes open spontaneously; Score 3: eyes open to speech; Score 2: eyes open in response to pain only, for example trapezium squeeze (caution if applying a painful stimulus); Score 1: eyes do not open to verbal or painful stimuli. Record 'C' if the patient is unable to open her or his eyes because of swelling, ptosis (drooping of the upper eye lid) or a dressing. Verbal response Assessment involves evaluating awareness: Score 5: orientated; Score 4: confused; Score 3: inappropriate words; Score 2: incomprehensible sounds; Score 1: no response. This is despite both verbal and physical stimuli. Record 'D' if the patient is dysphasic and 'T' if the patient has a tracheal or tracheostomy tube in situ. Motor response Assessment of motor response is designed to determine the patient's ability to obey a command and to localise, and to withdraw or assume abnormal body positions, in response to a painful stimulus (Adam and Osborne, 2005): Score 6: obeys commands. The patient can perform two different movements; Score 5: localises to central pain. The patient does not respond to a verbal stimulus but purposely moves an arm to remove the cause of a central painful stimulus; Score 4: withdraws from pain. The patient flexes or bends the arm towards the source of the pain but fails to locate the source of the pain (no wrist rotation); Score 3: flexion to pain. The patient flexes or bends the arm; characterised by internal rotation and adduction of the shoulder and flexion of the elbow, much slower than normal flexion; Score 2: extension to pain. The patient extends the arm by straightening the elbow and may be associated with internal shoulder and wrist rotation; Score 1: no response to painful stimuli. Painful stimulus A true localising response to pain involves the patient bringing an arm up to chin level. Painful stimuli that can elicit this response include trapezium squeeze (Fig 4), suborbital ridge pressure (Fig 5) (not recommended if there is a suspected/confirmed facial fracture) and sternal rub (caution, not recommended in some organisations) (Fig 6) (Jevon, 2007). The procedure Explain the procedure to the patient. Ascertain the patient's acuity of hearing. Ideally, use an interpreter if the patient does not speak English. Check the patient's notes for any medical condition that may affect the accuracy of the GCS, for example previous stroke, affecting the movement of the patient's arms (Fig 1). Check the neurological observation chart for the GCS scale (Fig 2). Check if the patient opens their eyes without the need to speak or to touch them; if the patient does, then the score is 4E. If the patient does not open their eyes, talk to them (Fig 3). Start off with a normal volume and speak louder if necessary. If they now open their eyes, the score is 3E. If the patient does not open their eyes to speech, administer a painful stimuli, for example trapezium squeeze (using the thumb and two fingers grasp the trapezius muscle where the neck meets the shoulder and twist ) (Fig 4). Or apply suborbital pressure (locate the notch on the suborbital margin and apply pressure to it) (Fig 5). An alternative is the sternal rub (using the knuckles of a clenched fist to apply grinding pressure to the sternum; not recommended for repeated assessment) (Fig 6). If the patient opens their eyes to a painful stimulus record the score as 2E (Dougherty and Lister, 2005). If the patient does not respond, then the score is 1E.