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This article addresses the gap between the literature and practice in relation to the use of the Glasgow Coma Scale (GCS). It will explore level of consciousness and the GCS. The instigation of both central and peripheral painful stimuli is analyzed in an effort to prevent ritualistic practice. Attention is also given to the importance of including...
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Citations
... We categorized impaired consciousness (i.e., diminished arousal and response to stimulation) on the basis of severity using the Glasgow Coma Scale, classifying symptoms as either lethargy, obtundation, stupor, or coma (23). Lethargy is a mild reduction in alertness, obtundation is a moderate reduction in alertness, stupor is a condition of deep sleep in which the patient can only be aroused by vigorous external stimulation, and coma refers to a complete lack of motor response to any stimuli from the external environment (23,24). We abstracted key laboratory variables related to the severity of infection. ...
Babesiosis is a globally distributed parasitic infection caused by intraerythrocytic protozoa. The full spectrum of neurologic symptoms, the underlying neuropathophysiology, and neurologic risk factors are poorly understood. Our study sought to describe the type and frequency of neurologic complications of babesiosis in a group of hospitalized patients and assess risk factors that might predispose patients to neurologic complications. We reviewed medical records of adult patients who were admitted to Yale-New Haven Hospital, New Haven, Connecticut, USA, during January 2011-October 2021 with laboratory-confirmed babesiosis. More than half of the 163 patients experienced >1 neurologic symptoms during their hospital admissions. The most frequent symptoms were headache, confusion/delirium, and impaired consciousness. Neurologic symptoms were associated with high-grade parasitemia, renal failure, and history of diabetes mellitus. Clinicians working in endemic areas should recognize the range of symptoms associated with babesiosis, including neurologic.
... Although this tool is highly popular in clinical settings, it has various limitations that reduce its applicability in certain situations. The inability of GCS to assess verbal responses in intubated patients, and not taking the reflexes and breathing pattern of patient into account are some of the limitations of GCS [3][4][5]. ...
Background
Currently, Glasgow Coma Scale (GCS) is used to assess patients’ level of consciousness. Although this tool is highly popular in clinical settings, it has various limitations that reduce its applicability in certain situations. This had led researchers to look for alternative scoring systems. This study aims to compare the value of GCS and Full Outline of UnResponsiveness (FOUR) score for prediction of mortality in traumatic brain injury (TBI) patients through a systematic review and meta-analysis.Method
Online databases of Medline, Embase, Scopus, and Web of Science were searched until the end of July 2022 for studies that had compared GCS and FOUR score in TBI patients. Interested outcomes were mortality and unfavorable outcome (mortality + disability). Findings are reported as area under the curve (AUC) sensitivity, specificity, and diagnostic odds ratio.Results20 articles (comprised of 2083 patients) were included in this study. AUC of GCS and FOUR score for prediction of in-hospital mortality after TBI was 0.92 (95% CI 0.80–0.91) and 0.91 (95% CI 0.88–0.93) respectively. The diagnostic odds ratio of the two scores for prediction of in-hospital mortality after TBI was 44.51 (95% CI 23.58–84.03) for GCS and 45.16 (95% CI 24.25–84.09) for FOUR score. As for prediction of unfavorable outcome after TBI, AUC of GCS and FOUR score were 0.95 (95% CI 0.93 to 0.97) and 0.93 (95% CI 0.91–0.95), respectively. The diagnostic odds ratios for prediction of unfavorable outcome after TBI were 66.31 (95% CI 35.05–125.45) for GCS and 45.39 (95% CI 23.09–89.23) for FOUR score.Conclusion
Moderate level of evidence showed that the value of GCS and FOUR score in the prediction of in-hospital mortality and unfavorable outcome is comparable. The similar performance of these scores in assessment of TBI patients gives the medical staff the option to use either one of them according to the situation at hand.
... Barata e eficaz, foi a primeira escala padronizada e de importância para avaliação da consciência em pacientes traumatizados (Ross et al., 1998;Ingram, 1994;Mcnarry & Goldhill, 2004;Jain & Iverson, 2021). Avaliando os aspectos da consciência de excitação e cognição indiretamente por meio de observação da resposta perante os diferentes estímulos (Stewart, 1996;Shah, 1999;Hickey, 1997), onde a excitação mede a consciência do ambiente e a cognição demonstra a compreensão do meio pela habilidade de realizar tarefas (Edwards, 2001). ...
... A avaliação do nível de consciência faz parte da rotina dos profissionais da área da saúde (Edwards, 2001;Ellis & Cavanagh, 1992;Jain & Iverson, 2021). O conhecimento e habilidade de uso da ECG são essenciais para estes profissionais, e a falha no uso da escala resulta em imprecisões na avaliação e conduta (Shoqirat, 2006), além de falhas na comunicação entre a equipe multiprofissional (Jain & Iverson, 2021). ...
Introdução: os estudantes da área da saúde precisam ter pleno conhecimento dos métodos de avaliação de consciência para excelência do exercício profissional e atendimento ao paciente, no entanto a literatura relata deficiências dos profissionais de saúde na utilização da Escala de Coma de Glasgow (ECG). Objetivo: o objetivo do presente estudo foi analisar e avaliar o conhecimento de estudantes da área da saúde sobre a função e aplicabilidade da Escala de Coma de Glasgow (ECG). Métodos: os dados foram gerados pela aplicação de questionário aos acadêmicos do último ano dos cursos de Medicina, Enfermagem, Odontologia e Farmácia da Universidade Federal de Alfenas. Resultados e Discussão: os resultados revelam que os futuros médicos e enfermeiros apresentam maior conhecimento dos parâmetros e aplicação da ECG quando comparado aos demais estudantes avaliados, isso é um empecilho para excelência do cuidado em saúde, visto que as equipes multiprofissionais são de extrema importância para o cuidado, e seus membros necessitam de um conhecimento ampliado sobre ECG para fornecer ao paciente um monitoramento seriado e evitar problemas de comunicação entre a equipe. Conclusão: ocorre um déficit de aprendizado sobre a ECG entre os estudantes da área da saúde e para supri-lo as universidades devem se comprometer com a oferta de cursos teóricos e práticos sobre o uso da ECG.
... This study did not address whether this effect size is clinically meaningful; we suspect there exists a threshold to which the predictive performance of the GCS can increase because it is an imperfect predictor of mortality. Other studies have recognized the limitations of the GCS score, [20][21][22] especially for risk prognostication. [23][24][25][26] The majority of the TBI population presented to the ED with GCS scores at the extreme end of the range (GCS 3, GCS 15) where revision of the GCS categories was not affected. ...
Background
The Glasgow Coma Scale (GCS) score has been adapted into categories of severity (mild, moderate, and severe) and are ubiquitous in the trauma setting. This study sought to revise the GCS categories to account for an interaction by age and to determine the discrimination of the revised categories compared with the standard GCS categories.
Methods
The American College of Surgeons National Trauma Data Bank registry was used to identify patients with traumatic brain injury (TBI; ICD-9 codes 850–854.19) who were admitted to participating trauma centers from 2010 to 2015. The primary exposure variables were GCS score and age, categorized by decade (teens, 20s, 30s…, 80s). In-hospital mortality was the primary outcome for examining TBI severity/prognostication. Logistic regression was used to calculate the conditional probability of death by age decade and GCS in a development dataset (75% of patients). These probabilities were used to create a points-based revision of the GCS, categorized as low (mild), moderate, and high (severe). Performance of the revised versus standard GCS categories was compared in the validation dataset using area under the receiver operating characteristic (AUC) curves.
Results
The final population included 539,032 patients with TBI. Age modified the performance of the GCS, resulting in a novel categorization schema for each age decile. For patients in their 50s, performance of the revised GCS categories mirrored the standard GCS categorization (3–8, 9–12, 13–15); all other revised GCS categories were heavily modified by age. Model validation demonstrated the revised GCS categories statistically significantly outperformed the standard GCS categories at predicting mortality (AUC: 0.800 vs 0.755, p<0.001). The revised GCS categorization also outperformed the standard GCS categories for mortality within pre-specified subpopulations: blunt mechanism, isolated TBI, falls, non-transferred patients.
Discussion
We propose the revised age-adjusted GCS categories will improve severity assessment and provide a more uniform early prognostic indicator of mortality following traumatic brain injury.
Level of evidence
III epidemiologic/prognostic.
... Combined with the ambiguity of where to apply a noxious stimulus, there is also a lack of clarity about whether a central or peripheral stimulus is the most effective at detecting signs of altered consciousness. Some sources report that the spine responds to peripheral stimuli whereas the brain responds to central stimulus (Edwards, 2001;McLeod, 2004). Teasdale and Jennett (1974) advised peripheral stimulation such as nail bed pressure for motor and eye-opening components of the GCS, later revised to fingertip pressure. ...
... This would suggest a lack of dissemination and understanding of the physiological parameters regarding the length of time for noxious stimuli to be relayed to the brain. However, considering several authors have stated that duration of stimuli should not exceed 30 s (Edwards, 2001;Lower, 1992;Woodward, 1997) or should be increased for a maximum duration of 10-20 s (Waterhouse, 2009), this practice, although not evidence-informed, is unsurprising. In addressing this matter, the ambiguity around central and peripheral noxious stimuli can also be addressed; understanding the physiology of pain reception, transmission and processing through effective education and explicit clinical guidelines is the foundation for ensuring that practitioners are not just guided with regard to how to practise but understand the rationale. ...
Aims and objectives:
To evaluate nurses' application, understanding and experience of applying painful stimuli when assessing components of the Glasgow Coma Scale.
Background:
The Glasgow Coma Scale has been subjected to much scrutiny and debate since its publication in 1974. However, criticism, confusion and misunderstandings in relation to the use of painful stimuli and its application remain. An absence of evidence-informed guidance on the use and duration of application of painful stimuli remains, with the potential to negatively impact on decision-making, delay responsiveness to neurological deterioration and result in adverse incidents.
Design and methods:
This international study used an online self-reported survey design to ascertain neuroscience nurses' perceptions and experiences around the application of painful stimuli as part of a GCS assessment (n = 273). The STROBE checklist was used.
Results:
Data revealed varied practices and a sense of confusion from participants. Anatomical sites for the assessment of pain varied, but most respondents identified the trapezius grip/pinch in assessing eye-opening and motor responses. Most respondents identified they assess eye-opening and motor responses together and apply pain for <6 s to elicit a response. Witnessed complications secondary to applying a painful stimulus were varied and of concern.
Conclusion:
Neuroscience nurses in this study clearly required evidence-informed guidelines to underpin practice both in applying painful stimuli and in managing the experience of the person in their care and the family response. A standardised approach to education is necessary to ensure greater interrater reliability of assessment not only within nursing but across professions.
Relevance to practice:
Results of this study illustrate inconsistency and confusion when using the Glasgow Coma Scale in practice; this has the potential to compromise care. Clarity around the issues highlighted is necessary. Moreover, these results can inform future guidelines and education required for supporting nurses in practice.
... 3,4 There is a question as to whether the GCS is a reliable indicator given that each clinician may conduct and interpret results slightly differently. 5 There have also been attempts to replace or supplement it with alternative tools such as the Full Outline of Unresponsiveness score. 6Y8 The neurological examination is notoriously subjective, and the results depend a great deal on the clinician's skills in the examination techniques as well as in interpreting the results. ...
Background:
The Glasgow Coma Scale (GCS) is a tool used to aid in objectively measuring the neurological status of a patient. This study aimed to evaluate the limitations and discrepancies in GCS use among nurses in an academic medical center neurological intensive care unit and compile evidence for development of a standardized GCS educational program.
Methods:
Twenty nurse participants completed a survey before attending an educational intervention. Participants then attended a 90-minute educational intervention. In follow-up, participants were asked to complete a postsurvey.
Results:
The standardized GCS educational program significantly improved nurse knowledge of the GCS as measured by presurvey and postsurvey general GCS question scores. Educational programming improved application of the GCS as measured by presurvey and postsurvey GCS verbal component, motor component, and sum scores. GCS motor score performance was the least accurate component.
Conclusion:
Participants reported that the education has informed the unit culture and emboldened clinical nurses to speak to their practice with more authority. Educational interventions should be aimed toward applied transfer of knowledge to the case-based scenarios in the clinical setting.
... Scoring the GCS in intubated patients or patients with a tracheostomy is challenging. It is suggested to assign an Endotracheal Tube (ETT) or T to score verbal responses of this group of patients (18), given this case the maximum score for intubated patients will be 10+ ETT or 10+ T. The GCS score was calculated from the worst scores in 24 h of MICU admission and the GAP was derived from age/GCS. After registering all GCS scores in the data collection form, the calculation of the GAP score was also performed, and then the data entered the SPSS statistical software (IBM Corp., Released 2013, IBM SPSS Statistics for Windows, Version 22.0, Armonk, NY). ...
Background: Recent data have shown that the proportion of older adult patients admitted to intensive care units is increased and the severity of illness is an independent risk factor associated with mortality. The aim of the current study was to compare the prognostic value of the Glasgow Coma Scale (GCS) and GCS-Age Prognosis (GAP) scores in older adult patients (aged [greater than or equal to]65 years) admitted to Medical Intensive Care Unit (MICU).
Methods: This was a prospective study of 168 consecutive older adult patients admitted to the medical ICU during a 14-month period. For each patient, the GCS and GAP score in the first 24hours of admission and demographic characteristics were calculated and recorded. For statistical analysis, the logistic regression, Receiver operator characteristic (ROC) curve, and Hosmer-Lemeshow test were used (95% confidence interval).
Results: Survivors had significantly higher GCS and GAP scores in the first 24h of MICU admission compared with nonsurvivors (p Conclusions: For older adult patients admitted to the MICU, GCS and GAP scores reliably predict outcomes. Based on AUCs the discrimination power of models was good, but the calibration was acceptable just for GCS, thus the GCS is the better predictive model than GAP and useful in determining the prognosis of older adult patients in MICU.
Keywords: GCS, GAP, older adult, MICU
... GCS dapat digunakan untuk menentukan prognosis seorang pasien, mengukur disfungsi serebral, dan dapat mengevaluasi tingkat kesadaran pasien. Selain itu GCS dapat melakukan pengukuran dalam waktu yang relatif singkat dan mudah digunakan.Akan tetapi GCS memiliki beberapa keterbatasan salah satunya adalah GCS kurang efektif dalam mengukur respon verbal pada pasien dengan keadaan koma dan terpasang alat bantu napas seperti pasien terintubasi ataupun pada pasien yang terpasang ventilator yang biasa terpasang pada pasien yang di rawat di ruang ICU (Edwards, 2001). ...
Penilaian kesadaran penting dilakukan pada pasien yang mengalami penurunan kesadaran pada pasien di ICU, hal ini bertujuan untuk memperkirakan prognosis pada seorang pasien. Penentuan prognosis pasien di unit perawatan intensive merupakan suatu hal yang perlu diperhatikan. Jika terjadi kesalahan dalam menentukan prognosis maka dapat mengakibatkan kesalahan dalam pemberian terapi, khususnya yang berkaitan dengan pengobatan penyakit, berdasarkan studi meta - analysis terdapat tiga alat ukur yang paling baik diantara alat-alat ukur lainnya yang digunakan untuk menilai tingkat kesadaran yaitu Glasgow Coma Scale (GCS), The Full Outline UnResponsiveness (FOUR) Score, Coma Recovery Scale - Revised (CRS-R). Ketiga alat ukur ini telah tervalidasi dan telah digunakan di beberapa rumah sakit oleh tenaga kesehatan. Dengan memperhatikan hal-hal tersebut, maka peneliti tertarik untuk melakukan penelitian di RSUD Raden Mattaher Jambi untuk melihat efektifitas antara alat ukur Coma Recovery Scale – Revised (CRS-R), Full Outline UnResponsiveness (FOUR) score, dan Glasgow Coma Scale (GCS)dalam menilai tingkat kesadaran pasien di unit perawatan intensif RSUD Raden Mattaher Jambi Tahun. Jenis penelitian yang digunakan oleh peneliti adalah penelitian studi perbandingan (comparative) dimana penelitian ini tidak memberikan perlakuan kepada subjek penelitian, penelitian ini hanya akan membandingkan 3 instrument pengkajian tingkat kesadaran. Rancangan penelitian yang digunakan adalah longitudinall, yaitu pengamatan tidak hanya dilakukan sekali. Pengambilan sampel pada penelitian ini dilakukan dengan consecutive sampling. Dalam penelitian ini menggunakan tiga instrument skala yaitu Coma Recovery Scale – Revised (CRS-R), Full Outline UnResponsiveness (FOUR) score, dan Glasgow Coma Scale (GCS). Analisis yang digunakan dalam penelitian ini adalah uji beda.Berdasarkan hasil penelitian dari 76 responden dengan penurunan kesadaran Ada perbedaan validitas dan reliabilitas antara alat ukur Glasgow Coma Scale (GCS) dan Coma Recovery Scale – Revised (CRS-R) dalam menilai tingkat kesadaran pasien di Unit Perawatan Intensive RSUD Raden Mattaher Jambi tahun 2017 terdapat satu komponen pada alat ukur GCS yaitu respon verbal yang memiliki nilai kesepakatan antar penenliti yang moderate dan terdapat dua komponen dalam alat ukur CRS-R yaitu skala fungsi oromotor/verbal dan skala fungsi komunikasi yang memiliki nilai kesepakatan antar peneliti yang baik.
... Thus same scores can reflect different status and different prognosis (e.g. GCS of 4 can be either E1/V1/M2 which corresponds to 48% mortality in TBI cases or E2/V1/M1 which corresponds to 19 % mortality in the same patients) 10 . The scale can be challenging to non-trained personnel, especially when assessing motor response or when assessing children 11 . ...
... Dentro de los objetivos y principales usos de esta escala encontramos: señalar el nivel de la lesión y enfermedad, permitir el buen proceder e inminente intervención de los pacientes heridos, describir y cuantificar la evaluación del coma, indicar la gravedad de la lesión, facilitar el pronóstico de la condición, monitorear el avance de los pacientes, y posibilitar la comunicación y comprensión entre los profesionales de la salud. Todo esto se realiza con la ayuda de observaciones sencillas en vez de procedimientos complejos o invasivos 1,2,9,11,12 . El presente artículo pretende analizar las bases neuroanatómicas de la GCS. ...
... En la apertura ocular se evalúa la integridad de los mecanismos de respuesta en el tronco encefálico; la respuesta motora nos indica el estado de las funciones del Sistema Nervioso Central; y la respuesta verbal, valora especialmente la respuesta de integración del tronco encefálico y la corteza cerebral 8,12,14,16,17 . ...
... Puede existir cierto error de juicio en ciertas condiciones específicas del paciente como la intubación, cambios en el nivel de la conciencia; que afectan la fiabilidad de la interpretación 9,17,21 . Por otro lado la tasa de error del personal inexperto al momento de la recolección de los datos o en su interpretación constituye también una importante y muy frecuente limitante del uso de esta escala 12 . Otra aspecto importante es la incapacidad para evaluar reflejos del tronco encefálico 14 , y el hecho de que su uso aislado no sea predictor suficiente de gravedad cuando nos enfrentamos a pacientes de trauma 5 . ...
Resumen: La evaluación del estado de conciencia es uno de los aspectos que hacen parte del abordaje del paciente neurológico y neuroquirúrgico. Una de las herramientas básicas desde hace algunas décadas es la escala de Glasgow. La utilización de este recurso se ha hecho para establecer la extensión de la lesión neurológica en pacientes afectados con diversas pa-tologías. El conocimiento de los aspectos básicos de su evaluación y el sustrato anatómico se consideran necesarios para los residentes de neurocirugía y neu-rocirujanos quienes manejamos pacientes de cual-quier complejidad en las ciencias neurológicas. Palabras claves: Escala de glasgow, neurocirugía, neurología. The evaluation of the state of consciousness is one of the aspects that are part of the neurological and neurosurgical patient approach. One of the basic tools for some decades is the Glasgow scale. The use of this resource has been made to establish the extent of neurological injury in patients affected with various pathologies. Knowledge of the basics of their assessment and the anatomical substrate are considered necessary for residents of neurosurgery and neurosurgeons who handle patients of any complexity in the neurological sciences.
