Changes to GCS

Hi all

As a response to criticism of the Glasgow Coma Scale, there have been some changes to the GCS, released by the Institute of Neurological Sciences of Greater Glasgow.

Please find the update to the GCS scoring here.

Another write up from someone smarter than me.

The GCS was originally developed for traumatic patients, and it’s in this cohort it remains as the most effective and objective tool. Particularly in trauma patients, any abnormal GCS score should warrant further observation.

Hilariously the GCS has been recognised as both the most important and the most insignificant vital sign. When used properly, it is a good assessment tool and indicator of severity, prognosis, and in some cases mortality. Many receiving hospitals (including CHED) use it in their early warning systems, which means assessing it effectively needs to happen. This widespread and systemic use appears to be out of context with the origins of the scale, yet we find ourselves as part of an international healthcare system which often uses it as a critical vital sign.

The biggest change from the Institute of Neuroscience is that it’s now perfectly acceptable to announce an aspect as not tested. At these times, you should not provide a total score. Instead, it should be conveyed why the aspect is not testable.  E3, M6, V not tested as the patient is intubated. It is important to note that the individual components are more useful to neurologists than the total score [this paragraph was edited].
I’d like to take the chance to remind us all that a thorough and effective GCS assessment does not constitute a neuro assessment. Take the chance to review the cranial nerve assessment and neurological discussion in the S is for Speech page.

The most recognised limitations for GCS (and associated warning points) are:

– motor score ranges of 3/4/5 can be very particularly subjective. The attached discussion document should provide some clarity on the issue, but it would be worth stating the method you used ‘M- 3, hand flexion’
– GCS alone may not be the best method of assessment (Teasdale, 1978). It should be used in conjunction with a physical examination and focused systemic assessment. It may be worth substituting for AVPU in for this fact alone (Green, 2011).

Anecdotally, and a personal favourite:
– it’s easier to fake a GCS of 3 than 6

As always, feel free to critique and contribute… suggestions for discussion points would be viable alternatives to GCS!

Green, S. (2011) Cheerio, Laddie! Bidding Farewell to the Glasgow Coma Scale. Annals of Emergency Medicine 58 (5) Full text

Institute of Neurosciences of Greater Glasgow and Clyde (2016) Glasgow Coma Scale: Do it this way retrieved 5 August 2017 from here

Teasdale, G., Bennett, B. (1978) Assessment and Severity of Brain Injury. Anesthesiology 49(3)

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5 Comments Add yours

  1. Tatsu Kuwasaki says:

    You must all watch the video. It’s brillant!

    Just to clarify, FAQs of the web site http://www.glasgowcomascale.org/faq/#faq-6 explains.

    Do not use number ‘1’ to record missing component; use ‘NT’ (Not testable).
    Do not report a total score when a component is Not Testable because the score will be low and this could be confusing to medical colleagues. This may also imply that the patient is more unwell than they actually are.

    This update contains big changes to the common language has been used for a long time, and it obviously needs universal/system-wide changes that require some time and extensive training.
    For now, this is a great reminder for the importance of high quality assessment and accurate reporting of the current GCS as we know.
    Don’t ‘guestimate’ GCS!

    Great blog, thanks Andrew!

    Liked by 2 people

    1. Andrew O says:

      Thanks for the clarification Tats… will update to reflect fact when people are reading it first time

      Like

  2. Tatsu Kuwasaki says:

    Someone you state is smarter than you is saying on his blog “GCS was never intended for use in trauma or emergency medicine”, contrary to your blog???

    Like

    1. Andrew O says:

      It was never intended to be used outside of the neuro intensive care units. From memory, GCS was created to measure trends across a 7-10 day period, and was introduced in the context of TBI. The Teasdale reference is the seminal article if you’d like to look into it further… please report back to us in 100 words or less…

      Liked by 1 person

  3. Miriam says:

    Cool! Interestingly enough GCS scoring is a component of upcoming CCE.

    Liked by 1 person

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