Vous êtes sur la page 1sur 5

Nursing Practice Keywords: Consciousness/Glasgow

Coma Scale/Clinical assessment/


Review Standardisation
● This article has been double-blind
Neurology peer reviewed

Forty years after its initial implementation, the Glasgow Coma Scale has been
updated to address variations in technique that have developed over time

Forty years on: updating


the Glasgow Coma Scale
In this article... 5 key
 ariations in the use of the Glasgow Coma Scale
V
points
Review of the scale’s composition and its application 1 The Glasgow
Coma Scale is
an integral part of
Structured approach to assessment
assessing levels of
consciousness
Author Sir Graham Teasdale is emeritus
professor of neurosurgery, Institute of
Health and Wellbeing, University of
part of the care of patients with acute brain
injury from head trauma, intracranial
haemorrhage and many other causes.
2 It uses a simple
standardised
approach
Glasgow; Douglas Allan was senior lecturer,
School of Health and Life Sciences,
Glasgow Caledonian University; Paul
The GCS reflects the initial severity of
brain dysfunction, while serial assess-
ments demonstrate the evolution of the
3 The scale has
been revised
to make sure it
Brennan, is clinical lecturer in neurosurgery, injury. Each is crucial for decision making. remains an
Department of Clinical Neurosciences, The GCS is also a guide to prognosis and an accurate tool
NHS Lothian, IGMM, University of
Edinburgh; Evelyn McElhinney is lecturer,
School of Health and Life Sciences,
essential tool for research studies.
Four decades after its introduction, the
GCS has gained worldwide acceptance
4 The overall
coma score
should not be used
Glasgow Caledonian University; Laura (Teasdale et al, 2014). It is now employed in to convey clinical
Mackinnon is senior charge nurse, more than 80 countries, has been trans- findings
Department of Neurosurgery, Institute of
Neurological Sciences, Southern General
Hospital, Glasgow.
lated into more than 60 languages and
there are more than 18,000 references to its
use (Middleton, 2012).
5 The scale can
be used with
children who are
Abstract Teasdale G (2014) Forty years on: Unfortunately, this widespread use has over 5 years old
updating the Glasgow Coma Scale.
Nursing Times; 110: 42, 12-16. Table 1. GCS terms of 1974 and 2014
Since the Glasgow Coma Scale was
developed 40 years ago it has been Indicator of level of consciousness Term used
accepted throughout the world as a 1974 2014
method for assessing impaired
Eye opening Spontaneous Spontaneous
consciousness. This article addresses the
variations in technique that have To speech To sound
developed since the scale was published. To pain To pressure
The details of the composition of the scale
None None
and its application are reviewed, and a
structured approach to assessment set Verbal response Orientation Orientated
out. These provide a basis for Confused conversation Confused
standardising practice and ensure the scale Inappropriate speech Words
is useful, in a practical sense, in the future.
Incomprehensible speech Sounds

T
he Glasgow Coma Scale (GCS) None None
was developed in 1974 to provide Motor response Obeying commands Obey commands
a practical method for the assess- Localising Localising
ment of impaired consciousness
(Teasdale and Jennett, 1974). Nursing, Flexor Normal flexion
medical and other staff welcomed its Abnormal flexion
straightforward approach and use of Extensor posturing Extension
simple terms to record and communicate
None None
their findings; the scale became an integral

12 Nursing Times 15.10.14 / Vol 110 No 42 / www.nursingtimes.net


Nursing For more articles on neurology,

Times.net
go to nursingtimes.net/neurology

FIG 1. Motor responses in Glasgow Coma Scale

None Extension Abnormal Normal Localising Obey commands

Flexion
Source: adapted from Van Der Naalt, 2004 (modified with permission)

been accompanied by: opening, verbal response and motor fields of information:
» Increasing variations in the way it is response. The findings in each response are » Person – their name;
used; and described in clear terms, aimed at mini- » Place – their location, for example in
» Decreasing reliability of assessment and mising ambiguity. However, the precise hospital or other specific location; and
communication (McLernon, 2014; Reith wording used in the GCS has varied over » Time – the month.
et al, 2014; Middleton, 2012; Baker, 2008). time; Table 1 outlines the terms used 40 The person is confused if any one of the
years ago and those used today. This incor- three items of information is not provided
Standardised approach porates the expansion of the motor compo- correctly, even if communication is
To promote a more consistent use of the nent of the assessment that was introduced through coherent phrases or sentences. If
GCS, we have set out a standardised, struc- soon after the GCS was originally described the patient’s response lacks structured
tured approach to assessment. (Teasdale and Jennett, 1976). sentences or phrases, it is classified as
This re-emphasises some of the original “words”; this moves away from use of the
principles in the application of the scale Changes to the GCS term “inappropriate”, which requires a
(Teasdale, 1975) and draws on subsequent Eye opening: Spontaneous opening – that potentially subjective interpretation. Like-
reviews and proposals for practice is, in the absence of stimulation – is the wise, an “incomprehensible speech” is
(McLernon, 2014; Middleton, 2012; Zue- highest response that can be recorded on now classified simply as “sounds”.
rcher et al, 2009; Palmer and Knight, 2006; the scale but should not be equated to Motor response: Five kinds of active
Fairley and Jake, 2005; Lacono and Lyons, “alertness” or “awareness”. motor response are now identified (Fig 1).
2005; Waterhouse, 2005; Edwards, 2001; The next step in the scale is now termed Classifying a patient as “obeys commands”
Shah, 1999). opening eyes “to sound”, and a response to means establishing that they make a spe-
a specific spoken command is not cific response to a request and not an auto-
Composition of the GCS required. When a physical stimulus is matic or reflex reaction.
The principle of assessing an individual’s needed, this is done through the applica- The instruction is, therefore, complex
Catherine Hollick

level of consciousness is about determining tion of graded pressure (see below). and must specify movement in two parts,
the degree of (increasing) stimulation that Verbal response: An orientated such as:
is required to elicit a response from them, verbal response requires the patient to pro- » Squeeze and release the examiner’s
based on three modes of behaviour: eye vide a defined minimum in three fingers;

www.nursingtimes.net / Vol 110 No 42 / Nursing Times 15.10.14 13


Nursing Practice
Review

» Raise and lower your arms; or suited to the clinical circumstances. FIG 2. Where to apply
» Put out and put back your tongue. Reflecting this, the component steps in physical pressure to
The term “localising” implies a connec- each response were set out in terms of elicit responses
tion between the location of the sensory “typical” features, to which observations
input and the specific movement made in were matched subjectively. This flexibility (A) Fingertip pressure
response; the recommended standard is may have initially helped with acceptance,
that a hand is brought above the clavicle but did so at the cost of subjective inter-
towards a stimulus on the head or neck. pretation and inconsistent use. To address
Bringing a hand to the opposite side of the this, the new recommendations set out a
body is not sufficient. standard approach to examination,
Bending the elbow in a flexion motor applying a structured set of defined cri-
response can be classed as either normal or teria for allocating ratings.
abnormal (Fig 1). This differentiation was There are four stages in assessment:
not in the GCS described in 1974 because » Check;
studies of observer variability showed that » Observe;
the distinction was difficult for nurses and » Stimulate; and
junior doctors, who are usually respon- » Rate.
sible for routine clinical monitoring (Teas- Check: A preliminary check is needed (B) Trapezius pinch
dale et al, 1978). to identify factors that might interfere
However, although rarely a key factor in with assessment. Impediments may exist
decision-making about individual before the episode of acute intracranial
patients, it became clear that the distinc- damage as a consequence of existing treat-
tion does differentiate degrees of severity ment and impairments from injuries or
of brain damage and hence prognosis deficits not relating to acute diffuse brain
(Marmarou et al, 2007; Teasdale et al, 1979). dysfunction. Impairments include:
This led to its incorporation in an extended » Pre-existing limitations such as
scale that was used in research and pro- language and cultural differences,
gressively taken up in routine clinical care; intellectual neurological deficits,
it is now used by most nursing and med- hearing loss or speech impediments;
ical disciplines (Reith et al, 2014). » Effects of current treatments, such as
Incorporating both normal and physical interventions including (C) Supraorbital notch
abnormal flexion into the motor compo- intubation or tracheostomy, or
nent is now standard for clinical and pharmacological treatments including
research purposes. To help keep practice sedation; and
consistent, normal flexion should be » Effects of other injuries or lesions
selected unless it is clear that movement including orbital/cranial fractures,
closely matches the features of an abnormal dysphasia or hemiplegia and spinal
response (Table 2, Fig 1). Straightening the cord damage.
elbow constitutes an “extension” response. Observe: Observation means the
assessor must look for evidence of sponta-
Standard structured assessment neous behaviours in each of the three
When the GCS was first introduced, the domains of the scale and then in response
focus was on describing its components. to stimulation.
In the accounts by Teasdale and Jennett Stimulate: Stimulation is applied with
(1974), and Teasdale (1975), little was said increasing intensity until a response is stimulus is physical.
about the practical approach to assessing obtained, with an upper cut-off point for There are differing views about the
and assigning findings. Indeed, there was a assigning lack of response. An auditory appropriate method to use when applying
wish to avoid appearing to try to impose stimulus should be used first to assess the physical stimulus (Waterhouse, 2009); the
a “straightjacket”, in the expectation patient’s responses to spoken or shouted need for standardisation was highlighted
that experienced staff would use their requests. If this does not result in a by the recent finding that at least seven dif-
skills to apply the scale in the way most response to a specific instruction, the next ferent techniques are currently in use (Reith
et al, 2014).
Table 2. Features of different types of flexion The recommendations are pressure on
motor response the fingertip and on the trapezius muscle
or supraorbital notch (Teasdale et al, 1975).
Abnormal Flexion Normal Flexion These are often respectively termed
● Slow ● Rapid “peripheral” and “central” but it should be
noted that this refers to locations on the
● Stereotyped (the same response each time) ● Variable (or varying)
body, not the peripheral or central nervous
● Arm moves across chest ● Arm moves away from body systems.
● Forearm rotates, thumb clenched
The appropriate sequence in practice is
first a peripheral stimulus to assess eye
● Leg extends opening, followed – if needed – by central

14 Nursing Times 15.10.14 / Vol 110 No 42 / www.nursingtimes.net


“There should be compulsory
dementia training for all”
Helen Goldsmith p26

FIG 3. Chart summarising structured assessment better of the two is taken into account; the
of the GCS worse is an indication of the location of
focal brain damage. Sometimes patients’
GlaSGOw COMa SCalE: DO it thiS way responses change during an examination –
Institute of Neurological Sciences Glasgow usually increasing when compared with
the initial performance (Edwards, 2001).

?
Check Observe Stimulate

Rate
When this is observed, it is the highest
level of performance that is taken as the
best motor response. The observer should
For factors Interfering Eye opening, content Sound: spoken or Assign according
with communication, of speech and move- shouted request to highest response satisfy him/herself that they have stimu-
ability to respond and
other injuries
ments of right and left
sides
Physical: pressure on
fingertip, trapezius or
observed lated the highest level of responsiveness
supraorbital notch achievable for their patient. If there is a dif-
Eye opening ference in the motor response to central or
Criterion Observed Rating Score peripheral stimulus, the former takes pri-
Open before stimulus Spontaneous 4

ority. There is, in practice, a lack of infor-
After spoken or shouted request ✓ To sound 3
After fingertip stimulus ✓ To pressure 2 mation about the relative performance of
No opening at any time, no interfering factor ✓ None 1 different methods of stimulus and this
Closed by local factor ✓ Not testable NT would be a useful topic for research.
Verbal response Rate: Rating is performed against
Criterion Observed Rating Score
defined criteria in a standard, structured
Correctly gives name, place and date ✓ Orientated 5
Not orientated but communication coherent ✓ Confused 4
sequence; firstly, whether the patient’s
Intelligible single words ✓ Words 3 findings meet the criterion for the top step
Only moans/groans ✓ Sounds 2 for each mode of behaviour measured in
No audible response, no interfering factor ✓ None 1
Factor interfering with communication ✓ Not testable NT
the GCS is considered. If it is met, the
appropriate rating is allocated; if not, sub-
Best motor response
Criterion Observed Rating Score
sequent steps are considered in a
Obey 2-part request ✓ Obeys commands 6 descending sequence until an absence of
Brings hand above clavicle to stimulus on head neck ✓ Localising 5 response is established. The criteria and
Bends arm at elbow rapidly but features not predominantly abnormal ✓ Normal flexion 4
Bends arm at elbow, features clearly predominantly abnormal ✓ Abnormal flexion 3
ratings for each step of each mode of
Extends arm at elbow ✓ Extension 2 behaviour are set out in Fig 3.
No movement in arms/legs, no interfering factor ✓ None 1 If the initial check identifies that the
Paralysed or other limiting factor ✓ Not testable NT response to a mode of behaviour cannot be
Sites for physical stimulation Features of flexion responses
validly assessed, the rating is classified as
Fingertip Trapezius Supraorbital Modified with permission from Van Der Naalt 2004 “not testable” and recorded as “NT”.
pressure pinch notch Ned Tijdschr Geneeskd
A patient’s ratings can be denoted by a
abnormal flexion Normal flexion
Slow Sterotyped
corresponding numeral or score; although
Rapid
Arm across chest Variable this allows for quick communication, it
Forearm rotates Arm away from body
Thumb clenched
also carries the risk of introducing varia-
Leg extends bility through errors in numbering and is
For further information and video demonstration visit www.glasgowcomascale.org not a substitute for reporting the patient’s
responses in full.
Fig 3 summarises the sequence in the
assessment and the allocation of ratings in
a chart that can be displayed as a poster,
stimulus for additional information about happen, the next step is to apply pressure pocket flashcard or other aid to practice.
motor response. to the supraorbital notch (Fig 2c). This is
The fingernail is the recommended site located by feeling along the lower edge of Factors affecting assessment
for peripheral stimulus. Pressure on the the upper rim of the orbit until a groove is When the initial check identifies a factor
side of the finger has been proposed as an felt. This site should not be used if the that interferes with assessment, it may be
alternative to the nail bed because of con- patient has a fracture in this region. possible to compensate by modifying the
cerns that undue force can result in Pressure behind the angle of the jaw approach. If there is a barrier to communi-
damage (Waterhouse, 2009; Palmer and (also referred to as retromandibular or sty- cation, the method of interaction can be
Knight, 2006). However, instances of loid process pressure) is difficult to apply varied, for example by choice of language,
damage to the nail are extremely rare and accurately and is, therefore, not recom- examination by a culturally acceptable
there is a lack of evidence that responses to mended for routine use. Stimulation by person or through written communication.
the different sites are equivalent. Applying rubbing the knuckles on the sternum is When it comes to problems resulting
pressure to the distal part of the nail (Fig strongly discouraged; it can cause bruising from treatment, the most common is
2a) and varying the finger that is used and responses can be difficult to interpret endotracheal intubation. If the patient
should minimise the potential for harm. (Shah, 1999). obeys commands, it may be possible to
Central stimulation is first applied by Identification of the best motor obtain information about orientation and
pinching the trapezius muscle in the neck response is done by comparing the move- quality of language via a written response.
to determine whether this leads to a local- ments of each arm. When the responses If the patient has been sedated and para-
ising movement (Fig 2b). If this does not from the right and left sides differ, the lysed, treatment can be reversed

www.nursingtimes.net / Vol 110 No 42 / Nursing Times 15.10.14 15


Nursing Practice
Review

temporarily (a “wake-up test”) when it is This remains the proper approach in assess patient conscious levels. Nursing Times;
101: 2: 38-41.
necessary to assess the patient’s progress. the care of an individual patient (Teasdale Fielding K, Rowley G (1990) Reliability of
If other injuries interfere with the and Murray, 2000) and, as such, we do not assessments by skilled observers using the
standard technique, another approach advocate the use of score alone to convey Glasgow Coma Scale. Australian Journal of
may be possible – for example, assessing clinical findings. Advanced Nursing; 7: 13-17.
Lacono LA, Lyons KA (2005) Making GCS as easy
whether a patient obeys commands as 1,2,3,4,5,6. Journal of Trauma Nursing; 12: 77–81.
through eye or tongue movements in a Online education and support Kirkham FJ et al (2008) Paediatric coma scales.
patient with a high cervical spinal cord Experience and education significantly Developmental Medicine and Child Neurology; 50:
267–274.
lesion. If it proves impossible to test a enhance the reliability of assessment of Marmarou A et al (2007) Prognostic value of the
component – as, for example, when the patient using the GCS (McLernon, Glasgow Coma Scale and pupil reactivity in
swelling due to injury prevents eye 2014; Martin, 1999; Fielding and Rowley, traumatic brain injury assessed pre-hospital and
opening – this should be documented in 1990). The approach to assessment on enrolment: an IMPACT analysis. Journal of
Neurotrauma; 24: 270–280.
the patient’s clinical record. described here is demonstrated in a video Martin L (1999) The Glasgow Coma scale: a
Even if one component of the GCS package, which is available free of charge sensitive tool in experienced hands. Nursing
cannot be examined, it is important to online, along with background informa- Times; 95: 38, 20.
McLernon S (2014) The GCS 40 years on: a
understand that the findings in the tion and a self-assessment tool (www.glas- review of its practical use. British Journal of
remaining components can still yield infor- gowcomascale.org). Neuroscience Nursing; in press.
mation that can inform clinical decisions. This website also provides a download- Middleton PM (2012) Practical use of the Glasgow
Coma Scale; a comprehensive narrative review of
able summary of the recommendation. GCS methodology. Australasian Emergency
Assessment of children These materials are copyright-free for Nursing Journal; 15: 170–183.
These recommendations on how to use the use in clinical care, education and aca- Palmer R, Knight J (2006) Assessment of altered
GCS need not be modified for children who demic work. They support the education, conscious level in clinical practice. British Journal
of Nursing; 15: 1255–1259.
are aged over 5 years. In younger children training and assurance in competency in Reith F et al (2014) Lack of standardization in
and infants, however, an assessment of a the use of the GCS that are prerequisites applying painful stimuli for assessment the GCS.
verbal response as “orientated” and motor for all staff members responsible for Journal of Neurotrauma; 31: 5, A17.
Shah S (1999) Neurological assessment. Nursing
response as “obeys commands” is usually assessing patients who may have an acute Standard; 13: 49–54.
not possible. intracranial disorder. Simpson D, Reilly P (1982) Pediatric Coma Scale.
Several modified paediatric coma scales The Lancet; 2: 8295, 450.
have been described (Kirkham et al, 2008); Conclusion Teasdale G et al (2014) The Glasgow Coma Scale
at 40 years: standing the test of time. The Lancet
the Adelaide Coma Scale (Simpson and Forty years after it was introduced, a wide- Neurology; 13: 844–854.
Reilly, 1982) has remained popular but ranging review of the GCS pointed to the Teasdale G et al (1979) Adding up the Glasgow
none have gained universal acceptance. need to set out recommendations for its Coma Score. Acta Neurochirurgica Supplement
(Wein); 28: 13–16.
practical use to sustain and enhance its Teasdale G et al (1978) Observer variability in
Relating coma scale to coma score unique position in clinical care and assessing impaired consciousness and coma.
The coma score developed from the GCS. research (Teasdale et al, 2014). A standard, Journal of Neurology, Neurosurgery and
Psychiatry; 41: 603–10.
Numbers were attached to the results of good-practice, structured examination Teasdale G (1975) Acute impairment of brain
the responses as a way of facilitating entry sequence is set out to counteract varia- function-1. Assessing ‘conscious level’. Nursing
of clinical findings into a databank for tions in technique. The assignment of rat- Times; 71: 24, 914-917.
research purposes. ings on the basis of a subjective compar- Teasdale G et al (1975) Acute impairment of brain
function-2. Observation record chart. Nursing
Each step in the eye, verbal and motor ison with “typical” responses has been Times; 71: 972-973.
sub-scales was assigned a number – the replaced by explicit decisions based on the Teasdale G, Jennett B (1976) Assessment and
worse the response, the lower the number presence or absence of clearly stated cri- Prognosis of coma after head injury. Acta
Neurochirurgica Supplement (Wien); 34: 45–55.
– and recorded separately as, for example, teria for each step. Teasdale G, Jennett B (1974) Assessment of coma
as E=1 V=1 M=1. For the foreseeable future, the GCS is and impaired consciousness: a practical scale. The
Although these numbers strictly repre- likely to remain a fundamental part of the Lancet; 2: 81–84.
sent ranking in a system of ordering rather clinical care of a patient at risk of acute Teasdale GM, Murray L (2000) Revisiting the
Glasgow Coma Scale and coma score. Intensive
than absolute values, aggregating the sepa- brain damage and further refinements and Care Medicine; 26: 153–154.
rate scores into a single total score was soon local variations can be expected. Their Van der Naalt J (2004) Physical diagnosis: the
taken up as a way to summarise a patient’s merits should be demonstrated by a Glasgow coma scale for the measurement of
disturbances of consciousness. Nederlands
responsiveness and to present findings in formal, objective study before the standard Tijdschrift voor Geneeskunde; 148: 472–476.
groups of patients (Teasdale et al, 1979). assessment approach is modified, so that Waterhouse C (2009) The use of painful stimulus in
The use of a total score to describe an variation in technique is not increased and relation to Glasgow Coma Scale observations. British
Journal of Neurological Nursing; 5: 2009–2015.
individual patient provides a quick overall the relationships between findings in dif- Waterhouse C (2005) The Glasgow Coma Scale
index of severity of dysfunction. ferent places and over different times are and other neurological observations. Nursing
The disadvantage is that it conveys less properly understood. NT Standard; 19: 55–64.
information than the description of the Zuercher M et al (2009) The use of Glasgow
References Coma Scale in injury assessment: a critical review.
three responses separately and is liable to Brain Injury; 23: 371–84.
Baker M (2008) Reviewing the application of the
be invalid if one component of the scale is Glasgow Coma Scale: does it have interrater
not testable. reliability? Journal of Neuroscience Nursing; 4: For more on this topic go online...
The core concept of the scale is that the 342–47.
Using a coma scale to assess
Edwards SL (2001) Using the Glasgow Coma
patient is described in simple, objective patient consciousness levels
Scale: analysis and limitations. British Journal of
terms to convey a clear, unambiguous pic- Nursing; 10: 92–101. B
 it.ly/1tvjTKZ
ture of their responsiveness. Fairley D, Jake T (2005) Using a coma scale to

16 Nursing Times 15.10.14 / Vol 110 No 42 / www.nursingtimes.net