gcs - the fundamentals for nurses and nursing students
TRANSCRIPT
Glasgow Coma Scale (GCS) – The fundamentals for nurses
Dr Ravi DadlaniConsultant Neurosurgeon
05th October 2015
Past: Background• In 1974– (Sir) Graham Teasdale (1940 - ) – Bryan Jennett (1926-2008)Neurosurgeons in Glasgow
Clinical Implications I
• Severity of Head Injury (HI):
– 13-15 (mild HI) – 9-12 (moderate HI) – < 8 (severe HI)
Clinical Implications II
• Prognostic Significance• Glasgow Outcome Score (GOS)
GCS – The Stimuli
• 1. Spontaneously – No stimuli
• 2. To Verbal stimuli
• 3. To painful stimuli
Where do you give painful stimuli?
1. Supra-orbital notch ---- Central stimulation2. Sternal rub - A V O I D3. Nipple4. Trapezius squeeze ---- Central stimulation5. Nail bed ---- Peripheral stimulation6. Retromandibular /Styloid process (behind the jaw)---difficult to apply and interpret
GCS – The responses
• Patients may localize or exhibit a variety of responses, asymmetry is important
• GCS is about the responses
Glasgow Coma Scale (GCS)Best eye
response (E) Best verbal
response (V) Best motor
response (M) 4 spontaneously 5 Oriented 6 Obeys commands
3 to speech 4 Confused 5 Localizes to pain
2 to pain 3 Inappropriate words
4 Withdraws from pain
1 No eye opening 2 Incomprehensible sounds
3 Flexion in response to pain
1 None 2 Extension to pain
1 No motor response
1976
How are the components assessed?
• Eyes Opening:– Score 4: eyes open spontaneously;– Score 3: eyes open to speech;– Score 2: eyes open in response to pain only, for
example trapezium squeeze (caution if applying a painful stimulus);
– Score 1: eyes do not open to verbal or painful stimuli.
– ‘C’ is recorded for patients unable to open eyes due to for example swelling
How are the components assessed?
• Verbal Response:– Score 5: orientated; must be able to tell you their full name,
the place in which they are and the date. If the patient doesn’t know any of these it is assumed they are confused.
– Score 4: confused; not able to answer orientation questions– Score 3: inappropriate words; swearing, aggression,
unrelated words to the questions being asked– Score 2: incomprehensible sounds;– Score 1: no verbal response. – ‘D’ is marked for patients who are dysphasic (unable to
speak coherently. ‘T’ is marked for those with a tracheostomy or ET tube
How are the components assessed?
Best Motor Response:• Score 6: obeys commands. The patient can perform two
different movements; primative reflexes should not be tested• Score 5: localises to central pain. The patient does not
respond to a verbal stimulus but purposely moves an arm to remove the cause of a central painful stimulus
• Score 4: normal flexion. The patient flexes or bends the arm towards the source of the pain but fails to locate the source of the pain (no wrist rotation)
• Score 3: abnormal flexion to pain • Score 2: extension to pain • Score 1: no response to painful stimuli.
M5- Attempts to remove the offending painful stimuli PURPOSIVE MOVEMENT
M4- Normal flexion – Withdrawal SEMI-PURPOSIVE MOVEMENT
M3 – Abnormal flexion– Decortication REFLEX NON-PURPOSIVE MOVEMENT
M2- Extensor REFLEX NON-PURPOSIVE MOVEMENT
Abnormal flexion and extension to pain
GCS – The Stimuli
• 1. Spontaneously – No stimuli E4 M V
• 2. To Verbal stimuli E3 M V4,V3,V2
• 3. To painful stimuli E2,E1 M5-1 V1,V2
The pediatric scale
Resources
• www.glasgowcomascale.org
Thank you for
your attention