Assessing patients with acute brain injury: the Glasgow Coma Scale explained

Posted: 08/12/2015

The Glasgow Coma Scale (GCS) is 40 years old this year and has been widely used to make an initial assessment of the level of consciousness of patients with acute brain injury. GCS is measured on a scale of 3 to 15, with a score of 3 being the most serious and a score of 15 for a normal level of consciousness. Scores are made according to three areas of assessment: 

• Scores from 4 to 1 are given for ‘eye opening’ with a rating of 4 when the patient opens their eyes spontaneously before stimulus; 3 after being spoken to/ shouted at; 2 after fingertip stimulus; and 1 for no eye opening at all and no interfering factor.
• The second area of assessment is ‘verbal response’ and scores are given from 5 to 1. A rating of 5 is for an orientated patient who can give names, places and dates; 4 is for a confused patient who is communicating coherently but is not orientated; 3 is where the patient makes intelligible single words; 2 is for moans and groans only; and 1 is where there is no verbal response and no interfering factor.
• The third area of assessment is ‘motor response’ and scores are given in a range from 6 to 1. A scoring of 6 is given where the patient can obey a two part request; 5 for localised pain; 4 where the patient withdraws to feelings of pain; 3 where the patient has an abnormal posture that can include rigidity, clenched fists, legs straight out and arms inwards with fingers bent and held on chest; 2 a decerbrate posture with arms and legs straight out and head and neck arched backwards; and 1 where the patient cannot move their arms and legs with there being no interfering factor. 

It should be noted that each criterion stipulates that there must be no interfering factor because a patient may not always be capable of assessment for a reason totally unconnected with brain injury and so any interfering factor affecting responses would, in these circumstances, give a misleading score. 

Although GCS is a useful tool and medical practitioners and lawyers look out for GCS scores in ambulance and A&E records when making their own assessments later on in claim, there are limitations. Because GCS requires observation of a verbal score, GCS is often not available in ICU and so cannot be used. Also, GCS is said to be insensitive to more subtle derangements of consciousness such as delirium. Critics say the relationship between outcome and GCS is not always linear, meaning a score of 14 or 15 can often underlie a much more serious brain injury. Where there are infering factors, GCS cannot be assessed and, in most serious cases where a patient is paralysed, GCS cannot be used. 

The Penningtons Manches personal injury team has a number of specialists in acquired brain injury claims who work with clients who have suffered serious head injuries or debilitating conditons, obtaining funding and making provision for their therapy, long term care and financial needs.

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