Reliability and accuracy of the Glasgow coma scale.
Explore the source record for details and available documents.
Glasgow Coma Scale↗
SEARCH · Search PubMed
Results for “Glasgow Coma Scale”
Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.
Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.
Searching for signs of revival. Uses and abuses of the Glasgow coma scale.
The Glasgow coma scale is widely used to measure patients' levels of consciousness. Attention to detail and an understanding of the scale's assessment criteria are essential to avoid misuse.
Glasgow Coma Scale↗
The status of the Glasgow Coma Scale.
The Glasgow Coma Scale (GCS) was first introduced in the 1970s to provide a simple and reliable method of recording and monitoring change in the level of consciousness of head injured patients. Since its introduction, the GCS has been widely utilized in the trauma community and its use expanded beyond the original intentions of the score. In the context of traumatic injury, this paper discusses the use of the GCS as a predictor of outcome, the limitations of the GCS, the reliability of the GCS and potential alternatives through a critical review of the literature. The relevance to Australian trauma populations is also addressed.
Emergency Service, Hospital↗
Aspects of neurosurgical assessment using the Glasgow Coma Scale.
The Glasgow Coma Scale (GCS) has become a cornerstone of the neurological/surgical assessment of patients used by both nursing and medical staff. Since its development in the 1970s it has been used in a variety of clinical situations to monitor changes in a number of key neurological functions, including level of consciousness, pupil reaction and limb movement. During this time, however, there have been suggestions that there are problems with some of the measurement principles underlying its use, which in part has stimulated the development of other neuro-assessment tools. Irrespective of measurement device, there is always the possibility of error or incorrect assessment. In the field of neurosurgery, as with other high dependency environments, a patient's condition can change rapidly. Additionally, there is the association of certain assessment responses with nursing and medical interventions. Thus, accuracy in all aspects of assessment and recording is paramount. Despite the growing body of literature surrounding the GCS, little is known about the pattern of errors made by nursing staff using the GCS to assess neurosurgical patients. This study compared the assessment findings of Registered General Nurses (RGNs), Enrolled Nurses and Student Nurses after viewing videotaped neuro-assessments of patients in a high dependency unit. The criterion for judging the accuracy of subject's assessments was established by a panel of experts. As expected, RGNs had the highest proportion of correct assessments and students the least. Subjects were identified as having difficulty in determining the relative amounts of weakness that a patient exhibited, and in correctly distinguishing between flexion and extension.
Glasgow Coma Scale↗
Assessing the conscious level in infants and young children: a paediatric version of the Glasgow Coma Scale.
The Glasgow Coma Scale is widely accepted as a measure of impaired consciousness both in clinical practice and in research. In its standard form, the scale is inapplicable to infants and children below the age of 5 years. We have devised a paediatric coma scale, which recognises that the expected normal verbal and motor responses must be related to the patient's age. This scale has been routinely used in a paediatric teaching hospital over a 10-year period and has appeared to be satisfactory, although it is less sensitive to changes in the conscious level than the adult scale. We have assessed the consistency of observer evaluation, using video tapes of infants and children exhibiting varying levels of consciousness: when conducted after formal instruction, assessments were reasonably consistent.
Child, Preschool↗
Initial Glasgow Coma Scale score predicts outcome following thrombolysis for posterior circulation stroke.
BACKGROUND: Randomized trials of thrombolytic stroke treatment have either excluded patients with posterior circulation ischemia or used inclusion criteria making enrollment of these patients less likely. Consequently, there is less published information on thrombolytic therapy for posterior circulation stroke. OBJECTIVE: To determine effective thrombolytic treatment times for posterior circulation stroke and factors that might help predict clinical outcome. DESIGN: We describe our experience treating 21 consecutive patients with either intravenous or intra-arterial thrombolytic therapy for posterior circulation ischemic stroke between October 9, 1993, and February 19, 2001. MAIN OUTCOME MEASURES: National Institutes of Health Stroke Scale, Glasgow Coma Scale, and modified Rankin Scale scores were evaluated at baseline, and the modified Rankin Scale was measured 3 months after stroke, with a good outcome being a modified Rankin Scale score of 2 or less. RESULTS: Nine patients received intravenous therapy; 12 patients received intra-arterial therapy. The median National Institutes of Health Stroke Scale score at onset was 20 (range, 2-39), and the median Glasgow Coma Scale score was 9 (range, 3-15). Twelve patients were treated within 8 hours of symptom onset (range, 1 1/2 hours to 16 days). Nine patients (43%) had a modified Rankin Scale score of 2 or less at 3 months. The initial Glasgow Coma Scale score and treatment within 8 hours of symptom onset were each associated with good outcome, but the initial National Institutes of Health Stroke Scale score was not predictive. CONCLUSIONS: Thrombolytic therapy for posterior circulation stroke may be beneficial even when initiated 8 hours after symptom onset. Level of consciousness, as measured by Glasgow Coma Scale score, seems to be a more important predictor of outcome than the initial National Institutes of Health Stroke Scale score.
Adult↗
A comparative study of the Reaction Level Scale (RLS85) with Glasgow Coma Scale (GCS) and Edinburgh-2 Coma Scale (modified) (E2CS(M)).
In this work a new coma scale for the assessment of responsiveness in acute brain disorders, constructed near the year 1985 by Scandinavian investigators, the Reaction Level Scale (RLS85), is compared with two other coma scales namely: (i) the Glasgow Coma Scale: (GCS); (ii) the Edinburgh-2 Coma Scale, after modification: (E2CS(M)). The study proceeded in the form of a statistical analysis of assessments made on 46 patients according to RLS85 and GCS (i.e., when comparison was with GCS) and on 28 patients according to RLS85 and E2CS(M). In all 74 cases two physicians participating as "observers" carried out the assessments. They were both contacting the patient--not together but--successively within a time interval of less than 20'. Hence the data appeared as "pairwise" observations for any of the three scales above. The results of the analysis, arising from a rather strict statistical reasoning, can be summarized as follows: (1) The rank correlation coefficient r(s) between: (i) RLS85 and GCS sum score, (ii) RLS85 and E2CS(M), was found to be at a satisfactory level meaning that all three scales indicate almost the same "ranking order of severity". (2) Reliability was compared by taking into account as to what extent the two observers agreed on RLS85 and--simultaneously--disagreed on the other scale. The "sign" test was applied and as a result RLS85 proved to be more reliable than; (i) GCS (EMY profile), (ii) GCS sum score, and (iii) E2CS(M), in all the above mentioned at a high level of significance. (3) Apart from the test above, some values of the index kappa (kappa) of interobserver agreement were calculated. Those corresponding to RLS85 are considerably higher. In particular the overall value based on 74 pairwise assessments amounted to kappa = 0.733 associated with a standard error sigma(kappa) = 0.061. This was a satisfactory result regarding the features of RLS85. (4) As far as coverage is concerned, again--by the "sign" test--the predominance of RLS85 versus GCS (EMY profile) was accepted.
Acute Disease↗
Vigilance scoring in children with acquired brain injury: Vienna Vigilance Score in comparison with usual coma scales.
An instrument in neurologic rehabilitation for the assessment of a person's clarity of consciousness must fulfill the need to provide the rehabilitation team with some information regarding the structuring of the rehabilitation process. The Vienna Vigilance Score is oriented toward cooperation within the rehabilitation team with the specific advantage of focus on the subject status of the patient on the basis of the dialogue. It does not use painful stimuli and is oriented toward the next developmental step of the rehabilitation process. The first extensive application of the Vienna Vigilance Score was carried out in a 3-year study of 38 children and adolescents. We report the comparison with other coma scales (Glasgow Coma Scale, Children's Coma Score, and Modified Glasgow Coma Scale) on 24 children and adolescents (1.4-16.8 years of age). The results showed satisfying statistical parameters: measuring range comparable with other scales; a Kendall tau correlation of .59 on both the Modified Glasgow Coma Scale and the Children's Coma Scale and of .66 on the Glasgow Coma Scale; a Spearman's rank order correlation of .70 to both the Modified Glasgow Coma Scale and the Children's Coma Scale and of .78 on the Glasgow Coma Scale. By accepting the Glasgow Coma Scale as a gold standard for classification of the level of coma, we can confirm satisfactory measuring qualities for the Vienna Vigilance Score.
Adolescent↗
Limitations of the Glasgow Coma Scale in predicting outcome in children with traumatic brain injury.
OBJECTIVE: To study the hypothesis that, in the absence of an ischemic-hypoxic state, children with severe traumatic brain injury and with unfavorable Glasgow Coma Scale scores may have good recovery. DESIGN: Retrospective, observational, cross-sectional study with factorial design. SETTING: Inpatient population in a university hospital. PATIENTS: Seventy-nine children with traumatic brain injury admitted to the intensive care unit. INTERVENTIONS: All patients received close monitoring and strict control of intracranial pressure (less than 20 mm Hg) and cerebral perfusion pressure (greater than 60 mm Hg). MEASUREMENTS AND RESULTS: Admission Glasgow Coma Scale score, survival, need for cardiopulmonary resuscitation, presence of shock, peak intracranial pressure, duration of coma, Glasgow Outcome Scale score, and the results of neuropsychologic tests were analyzed. Of 79 children, 70 (89%) survived. Although the mortality rate was higher among patients with Glasgow Coma Scale scores of 3 to 5, 14 (64%) of 22 of these children survived. Nonsurvivors had a significantly higher incidence of shock and need for cardiopulmonary resuscitation. Except for two patients who had prolonged hypoxemia, all children, including those with Glasgow Coma Scale scores of 3 to 5, had a satisfactory outcome (Glasgow Outcome Scale scores of 4 or 5). Neuropsychologic outcome was not significantly different in the survivors with Glasgow Coma Scale scores of 3 to 5 and those with Glasgow Coma Scale scores of 6 or more. CONCLUSIONS: A low Glasgow Coma Scale score does not always accurately predict the outcome of severe traumatic brain injury; in the absence of hypoxic-ischemic injury, children with traumatic brain injury and Glasgow Coma Scale scores of 3 to 5 can recover independent function.
Adolescent↗
Comparison of consciousness level assessment in the poisoned patient using the alert/verbal/painful/unresponsive scale and the Glasgow Coma Scale.
STUDY OBJECTIVE: We determine how the alert/verbal/painful/unresponsive (AVPU) responsiveness scale (alert, responsive to verbal stimulation, responsive to painful stimulation, and unresponsive) corresponds to the Glasgow Coma Scale (GCS) when assessing consciousness level in the poisoned patient. METHODS: Consciousness level was assessed using the AVPU responsiveness scale and the GCS in all patients admitted to the hospital during a 6-month period with deliberate or accidental poisoning. An AVPU responsiveness scale algorithm and details of the individual components of the GCS were provided. Data were recorded prospectively on admission to the toxicology ward by nursing staff in the majority of cases and from case records for the small number of patients admitted directly to the ICU. Nursing staff also recorded any difficulty assessing consciousness level using either scoring system. RESULTS: Of the 1,384 patients studied, 1,138 patients were alert, 114 patients responded to a verbal stimulus, 87 patients responded to a painful stimulus, and 15 patients were unresponsive. The median GCS scores with interquartile ranges (IQR) for each AVPU responsiveness category were 15 (IQR 15), 13 (IQR 12 to 14), 8 (IQR 7 to 9), and 3 (IQR 3), respectively. There was a degree of overlap between the range of GCS scores for each category. Nursing staff recorded more difficulty using the GCS than the AVPU responsiveness scale. Alcohol-intoxicated patients proved to be the most difficult to assess. All patients who were unresponsive required intubation. No patient with a GCS score greater than 6 was intubated. CONCLUSION: Each AVPU category can be shown to correspond to a range of GCS scores. The AVPU responsiveness scale appears to provide a rapid simple method of assessing consciousness level in most poisoned patients, but difficulty was still observed in assessing alcohol-intoxicated patients.
Cohort Studies↗
A comparison of the Glasgow Coma Scale and the Swedish Reaction Level Scale.
The Glasgow Coma Scale (GCS) and the Swedish Reaction Level Scale (RLS85), two level-of-consciousness scales used in the assessment of patients with head injury, were compared in a prospective study of 239 patients admitted to a regional head injury unit over a 4-month period. Assessments were made by nine staff members ranging from house officer to registrar, after briefing about the two scales. Data were also collected on age, nature of injuries, surgical treatment, and condition at discharge or transfer using the Glasgow Outcome Scale. Both the GCS and the RLS85 reliably identified comatose patients and those with minor head injury, but were much less effective in defining the response level in patients considered to have a moderate head injury. Only 41% of the patients allocated to a moderate-head-injury category by the GCS and the RLS85 were common to both groups. Where a mismatch occurred, neither scale allocated patients to a 'better' or 'worse' category more frequently than the other. Assessment of patients' conscious levels using the GCS was difficult in only two cases. One patient had facial injuries, and the other was intubated. The RLS85 was reported by all users to be simpler to use than the GCS, but the latter is much more widespread in use. Both scales function well in cases of severe and minor head injury, but have weaknesses when defining moderate head injury. Level-of-consciousness scales are only an aid to assessment and the final choice between the two scales must remain a matter of personal or departmental preference.
Activities of Daily Living↗
Simple bedside assessment of level of consciousness: comparison of two simple assessment scales with the Glasgow Coma scale.
Neurological assessment is an essential component of early warning scores used to identify seriously ill ward patients. We investigated how two simple scales (ACDU - Alert, Confused, Drowsy, Unresponsive; and AVPU - Alert, responds to Voice, responds to Pain, Unresponsive) compared to each other and also to the more complicated Glasgow Coma Scale (GCS). Neurosurgical nurses recorded patients' conscious level with each of the three scales. Over 7 months, 1020 analysable measurements were collected. Both simple scales identified distinct GCS ranges, although some overlap occurred (p < 0.001). Median GCS scores associated with AVPU were 15, 13, 8 and 6 and for ACDU were 15, 13, 10 and 6. The median values of ACDU were more evenly distributed than AVPU and may therefore be better at identifying early deteriorations in conscious level when they occur in critically ill ward patients.
Attitude of Health Personnel↗
[Correlation of brain stem evoked response audiometry (BERA) with Glasgow Coma Scale (GCS) and Glasgow Outcome Scale (GOS)].
The diagnostic value of electric responses from the brain stem (BERA) in neurosurgical patients is still a matter for debate in the literature. Therefore in the study an attempt was made to determine the relationship between GCS scores and BERA recordings. Participants in the study were 64 patients with various types of brain damage. Evoked potentials from the brain stem were registered using the Hortmann BERAmodul apparatus. To facilitate the interpretation of results a special scale was developed for quantitative measurement of changes in BERA recordings. Abnormalities in BERA recordings were reflected in changes in GCS scores, and correlation between the two dimensions was found to be statistically significant. The relationship between BERA recordings and GOS scores was also significant: pathological changes in BERA recordings assessed as severe were associated with an unfavorable therapeutic outcome in the GOS. The presented findings indicate auditory evoked brain stem response (BERA) usefulness for objective evaluation of brain-damaged patients' clinical state.
Adolescent↗
Clinical scales for comatose patients: the Glasgow Coma Scale in historical context and the new FOUR Score.
The Glasgow Coma Scale (GCS) has been the gold standard for assessing the level of consciousness in patients with significant brain injury. Prior efforts to modify or replace this scale have been unsuccessful because no scale could improve on its simplicity and practical usefulness. This review provides a historical perspective on coma scales and introduces a new and simple, but more comprehensive, scale: the Full Outline of UnResponsiveness (FOUR) Score, which has been recently validated. The FOUR Score has 4 components with "4" as a maximal score for each item. The individual components are eye responses (eye opening and eye tracking), motor responses (responses to pain and following simple hand commands), brainstem reflexes (pupil, cornea, and cough reflexes), and respiration (breathing rhythm and respiratory drive in ventilated patients). The FOUR Score is a further improvement on previous scales for classifying and communicating impaired consciousness.
Brain Injuries↗
The Glasgow coma scale.
Teasdale and Jennett first presented the Glasgow Coma Scale in 1974 as an aid in the clinical assessment of unconsciousness. It was devised as a formal scheme to overcome the ambiguities and misunderstandings that arose when information about comatose patients was presented and groups of patients were compared. Since then, the Glasgow Coma Scale has been used extensively, being used to grade individual patients, compare effectiveness of treatments, and as a prognostic indicator. It has been incorporated into numerous trauma and critical illness classification systems. However, a number of competing scales have been developed to overcome its perceived deficiencies. These scales are generally more complex. One of the expressed reservations regarding the Glasgow Coma Scale has been its failure to incorporate brainstem reflexes. The scale also includes a numerical skew toward the motor response. An important current issue is the appropriate application of the Glasgow Coma Scale to intubated patients. A number of approaches have been used to assign the verbal score to such patients. The timing of initial scoring is another area of discussion. Despite its drawbacks, the Glasgow Coma Scale remains the most universally utilized level of consciousness scale worldwide. It seems destined to be used in emergency medicine for some time.
Glasgow Coma Scale↗
A comparison of the Glasgow Coma Scale and the Reaction Level Scale (RLS85).
The Glasgow Coma Scale (GCS) and the Reaction Level Scale (RLS85) were compared for rating neurosurgical patients in regard to ranking order of deficit severity, interobserver variability, and coverage for relevant factors. Four physicians, four registered nurses, and four assistant nurses performed 72 pairwise ratings on 47 neurosurgical patients. The rank correlation between the GCS sum score and the RLS85 was -0.94, suggesting the same ranking order of severity and indicating that the underlying concepts of somnolence, delirium, and motor responses in coma are evaluated in the same way. By the sign test, the RLS85 was shown to have better interobserver agreement than the GCS sum score and the eye-motor-verbal (EMV) profile. The interobserver grading disagreements in both scales were distributed over the entire range of responsiveness, and for the GCS sum score they were slanted to combined segments 9 to 15. The RLS85 showed full coverage of relevant factors, while 43 (60%) of the 72 test occasions in the GCS sum score and the EMV profiles showed untestable features, most often because of patient intubation. The pseudoscore (that is, the choice of value given to untestable features) affects interobserver agreement as well as the estimated overall patient responsiveness in the GCS sum score. Assessment by the order of applying the scales showed a significant effect on the GCS eye-opening scale (p = 0.01) and the GCS sum score (p = 0.03), indicating a sensitivity to environmental stimuli unrelated to the patient's status. This study demonstrates that basically the same information as that found in the separate eye, motor, and verbal scales of the GCS can be combined directly into the RLS85, which has better interobserver agreement and better coverage than the GCS sum score.
Coma↗
The prognostic value of the modified Glasgow Coma Scale in head trauma in dogs.
A clinical coma scale modified from the Glasgow Coma Scale used for humans has been suggested as a useful predictor of outcome in the head trauma patient. The objective of this study was to correlate the modified Glasgow Coma Scale (MGCS) score of dogs with head trauma with their probability of survival. Thirty-eight dogs with head trauma were selected and retrospectively evaluated. The information retrieved from the medical record of each dog included signalment, body weight, cause of head trauma, MGCS, presence of concurrent neck pain, and outcome (dead or alive) after 48 hours. Logistic regression was used to model survival in the 1st 48 hours as a function of MGCS, gender, weight, and calvarial fractures. The MGCS ranged from 5 to 18. Seven dogs died within 48 hours of the head trauma. The MGCS could predict the probability of survival in the 1st 48 hrs after head trauma with 50% probability in a patient with a score of 8. Gender, weight, and presence of skull fractures did not predict survival. In conclusion, the MGCS is a useful index for prediction of outcome in dogs with head trauma.
Animals↗
The history of the Glasgow Coma Scale: implications for practice.
The Glasgow Coma Scale (GCS) has been the gold standard of neurologic assessment for trauma patients since its development by Jennett and Teasdale in the early 1970s. The GCS was found to be a simple tool to use. It became the method of choice for trauma care practitioners to document neurologic findings over time and predict functional outcome. Although the scale has been shown to be effective, many authors have cited weaknesses in the scale including the inability to predict outcome, variation in inter-rater reliability, and the inconsistent use by caregivers in the prehospital and hospital settings. This article outlines the components of the GCS and how practitioners can best use the scale, particularly in patients whose injuries and treatments make them difficult to assess.
Adult↗