Glasgow Coma Scale

There are four grades starting with the most severe:

1. No opening of the eye
2. Eye opening in response to pain stimulus. A peripheral pain stimulus, such as squeezing the lunula area of the person's fingernail is more effective than a central stimulus such as a trapezius squeeze, due to a grimacing effect.[4]
3. Eye opening to speech. Not to be confused with the awakening of a sleeping person; such people receive a score of 4, not 3.
4. Eyes opening spontaneously

NT (Not testable). Examples for this would include severe damage to the eyes, sedation from drugs, and paralysis.

There are five grades starting with the most severe:

1. No verbal response
2. Incomprehensible sounds. Moaning but no words.
3. Inappropriate words. Random or exclamatory articulated speech, but no conversational exchange. Speaks words but no sentences.
4. Confused. The person responds to questions coherently but there is some disorientation and confusion.
5. Oriented. Person responds coherently and appropriately to questions such as the person's name and age, where they are and why, the year, month, etc.

NT (Not testable). Examples for this would include intubation, deafness, language barrier, sedation from drugs, and paralysis.

There are six grades starting with the most severe:

1. No motor response. Lack of any motor response should raise suspicion for spinal cord injury.
2. Abnormal Extension in response to pain. Different guidelines report different evaluation of abnormal extension. While some sources indicate extension at the elbow is sufficient,[5] other sources use the language "decerebrate posturing".[6] It is important to note that the original publication of the Glasgow Coma Scale explicitly avoided the term "decerebrate extension" because it implied specific anatomical findings.[1]
3. Abnormal Flexion in response to pain. Different guidelines report different evaluation. While some sources focus on arm movements,[5] other sources use the term "decorticate posturing".[6]
4. Normal Flexion (absence of abnormal posturing; unable to lift hand past chin with supraorbital pain but does pull away when nailbed is pinched)
5. Localises to pain (purposeful movements towards painful stimuli; e.g., brings hand up beyond chin when supraorbital pressure applied)
6. Obeys commands (the person does simple things as asked)

NT (Not testable). Examples for this would include spinal cord injury, sedation from drugs, and paralysis.

During the 1960s, assessment and management of head injuries became a topic of interest. The number of head injuries was rapidly increasing, in part because of increased use of motorised transport. Also, doctors recognised that after head trauma, many patients had poor recovery. This led to a concern that patients were not being assessed or medically managed correctly.[10] Appropriate assessment is a critical step in medical management for several reasons. First, a reliable assessment allows doctors to provide the appropriate treatment. Second, assessments let doctors keep track of how a patient is doing, and intervene if the patient is doing worse. Finally, a system of assessment allows researchers to define categories of patients. This makes it possible to determine which treatments are best for different types of patients.

A number of assessments for head injury (“coma scales”) were developed, though none were widely adopted. Of 13 scales that had been published by 1974, all involved linear scales that defined levels of consciousness.[11][12][13][14][15][16][17][18][19] These scales posed two problems. First, levels of consciousness in these scales were often poorly defined. This made it difficult for doctors and nurses to evaluate head injury patients. Second, different scales used overlapping and obscure terms that made communication difficult.[20]

In this setting, Bryan Jennett and Graham Teasdale began work on what became the Glasgow Coma Scale. Based on their experiences, they aimed to make a scale satisfying several criteria. First, it needed to be simple, so that it could be performed without special training. Second, it needed to be reliable, so that doctors could be confident in the results of the scale. Third, the scale needed to provide important information for managing a patient with a head injury.[20]

Their work resulted in the 1974 publication of the first iteration of the GCS.[1] The original scale involved three exam components (eye movement, motor control, and verbal control). These components were scored based on clearly defined behavioural responses. Clear instructions for administering the scale and interpreting results were also included. The original scale is identical to the current scale except for the motor assessment. The original motor assessment included only five levels, combining "flexion" and "abnormal flexion". This was done because Jennett and Teasdale found that many people struggled in distinguishing these two states.[1]

In 1976, Teasdale updated the motor component of the Glasgow Coma Scale to differentiate flexion movements.[2] This was because trained personnel could reliably distinguish flexion movements. Further research also demonstrated that normal and abnormal flexion have different clinical outcomes.[21] As a result, the six-point motor scale is now considered the standard.

Teasdale did not originally intend to use the sum score of the GCS components.[20] However, later work demonstrated that the sum of the GCS components, or the Glasgow Coma Score, had clinical significance. Specifically, the sum score was correlated with outcome (including death and disability).[21] As a result, the Glasgow Coma Score is used in research to define patient groups. It is also used in clinical practice as shorthand for the full scale.

The Glasgow Coma Scale was initially adopted by nursing staff in the Glasgow neurosurgical unit.[20] Especially following a 1975 nursing publication, it was adopted by other medical centres.[22] True widespread adoption of the GCS was attributed to two events in 1978.[20] First, Tom Langfitt, a leading figure in neurological trauma, wrote an editorial in Journal of Neurosurgery strongly encouraging neurosurgical units to adopt the GCS score.[23] Second, the GCS was included in the first version of Advanced Trauma Life Support (ATLS), which expanded the number of centres where staff were trained in performing the GCS.[24]