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Introduction

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The Glasgow Coma Score (or GCS) is a neurological scale used in many settings to objectively classify the level of consciousness of patients. It was initially developed for head-injured patients, but its use has been extrapolated to chronically critically ill patients, and it is one component of several different intensive care severity scoring systems (Figure 11-1).

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Definitions and Terms

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  • ▪  Eye response: Eye opening in response to various levels of stimulus
  • ▪  Verbal response: Verbal communication in terms of comprehensibility
  • ▪  Motor response: Movement in response to various stimuli

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Techniques

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  • ▪  Eye response (E)
    • —No eye opening = 1
    • —Eye opening in response to pain (ie, pressure on fingernail bed, mandible, supraorbital area, or sternum) = 2
    • —Eye opening to speech = 3
    • —Spontaneous eye opening = 4
  • ▪  Verbal response (V)
    • —No verbal response = 1
    • —Incomprehensible sounds (ie, moaning) = 2
    • —Inappropriate words (ie, random sounds or speech) = 3
    • —Confused, coherent speech (ie, disorientation or confusion) = 4
    • —Oriented = 5
  • ▪  Motor (M)
    • —No movements = 1
    • —Extension in response to painful stimuli (ie, decerebrate posturing) = 2
    • —Flexion in response to pain (ie, decorticate posturing) = 3
    • —Flexion withdrawal in response to pain (ie, withdrawal of body part in response to stimulus) = 4
    • —Localized movements in response to pain (ie, purposeful movements across midline toward painful stimulus) = 5
    • —Obeys commands = 6
  • ▪  GCS less than or equal to 8 is consistent with severe brain injury when applied to head injured population.
  • ▪  GCS 9 to 12 consistent with moderate brain injury.
  • ▪  GCS greater than or equal to 13 consistent with minor injury.
  • ▪  Modifiers are used in the presence of severe eye/facial swelling, spinal cord injury, or oral intubation to indicate that that portion of the exam cannot be performed (ie, 11T indicates a normal eye and motor exam in an intubated patient).

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Clinical Pearls and Pitfalls

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  • ▪  Some examiners break the score down by individual components (ie, E4V5M6) to precisely specify the components of the exam.
  • ▪  A variety of independent factors may interfere with the applicability of the GCS to traumatic brain injury because they act as confounders, such as intoxication, sepsis, and shock.
  • ▪  Alternative scores have been developed for use in children of various ages.
  • ▪  The GCS has been used successfully to predict outcome in a variety of settings

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Suggested Reading

Wijdicks EF. Clinical scales for comatose patients: the Glasgow Coma Scale in historical context and the new FOUR score. Rev Neurol Dis. 2006;3:109–117.  [PubMed: 17047576]

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