There are several types of scoring used to evaluate the severity of
injury and progress of the trauma victim. The initial assessment uses the Trauma Score for prehospital and trauma
resuscitation rating of severity of injury. The Glasgow Coma Scale is incorporated into the Trauma Score and can
also be used alone in following the neurological progress of the head-injured client. The Rancho Los Amigos Scale
rates the cognitive functioning of the head injured client post stabilization through rehabilitation. Each of these
rating scales provides a simple, rapid, and objective method of scoring to be used in communicating within the
health care team, provides a method of documenting the actual progress of the trauma victim, and provides a value
of predictive potential outcome.6 Part I of this three part series of articles discusses the Glascow Coma Scale. The Trauma
Score and Rancho Los Amigos Scale will be discussed in Parts II and III.
The Glasgow Coma Scale, which is based upon eye opening, verbal, and motor responses is a practical means of monitoring
changes in level of consciousness. If each response on the scale is given a number (high for normal and low for
impaired responses), the responsiveness of the patient can be expressed by the summation of the figures. The lowest
score is 3 and the highest is 15.
The Glasgow Coma Scale, which is based upon eye opening, verbal, and motor responses
is a practical means of monitoring changes in level of consciousness. If each response on the scale is given a
number (high for normal and low for impaired responses), the responsiveness of the patient can be expressed by
the summation of the figures. The lowest score is 3 and the highest is 15.
Glasgow Coma Scale
Eyes
Open
Spontaneously
4
To verbal command
3
To pain
2
No response
1
Best Motor Response
To verbal command
Obeys
6
To painful stimulus
Localizes pain
5
Flexion-withdrawal
4
Flexion-abnormal (decorticate rigidity)
3
Extension (decerebrate rigidity)
2
No response
1
Best Verbal Response
Oriented and converses
5
Disoriented and onverses
4
Inappropriate words
3
Incomprehensible sounds
2
No response
1
TOTAL:
3-15
Figure 1: Example Worksheet for the Glasgow Coma Scale.5
Neuro-trauma is filled with vague and subjective terms such as comatose, semicomatose,
lethargic, etc. An objective rating scale was needed to make initial triage decisions from the scene of the accident
as well as throughout the hospitalization. The Glasgow Coma Scale was developed to fill the need for a standardized
neurological assessment tool.3
The scale incorporates the three easily assessable variables of eye opening, best motor response, and best verbal
response. Points are assigned to the spectrum of possible responses for each variable. Then the awarded points
are totaled giving a Glasgow Coma Scale score of 3 for the flaccid and comatose, up to 15 for the grossly neurologically
intact.3
The Glasgow Coma Scale (see Figure 1) rates eye opening as being either spontaneous (4 points), in response to
speech (3 points), in response to painful stimuli (2 points), or no response at all (1 point). The best motor response
is scored as either follows commands (6 points), localization of painful stimuli (5 points), flexion - withdrawal
response to painful stimuli (4 points), decorticate posturing (3 points), decerebrate posturing (2 points), or
no response at all (1 point).3
Initial Glasgow Coma Scale scores of 3-5 are associated with mortality rates of 60%. Initial scores of 5-8 have
mortality rates of 12% with severe head injuries. Initial scores of 9-12 are associated with mortality rates of
2% with moderate head injuries. Initial Glasgow Coma Scale scores of 13-15 have mild head injuries and deaths related
to head injury are rare according to the research of Marshall & Bowers.1
Taking it one step further, Jennett & Bond developed the Glasgow Outcome Scale. Using retrospective study of
actual outcomes, they took the Glasgow Coma Scale score at 24 hours post injury and correlated it with the eventual
outcome.2 The Glasgow Outcome Scale has become one of the strongest predictive indexes in medicine.1
Glasgow Coma Scale at 24 hours
Good Recovery or moderate disability
Vegetative or dead
11-15
91%
6%
8-10
59%
27%
5-7
28%
54%
3-4
13%
80%
Figure 2: Glasgow Outcome Scale.4
According to the Outcome Scale (see figure 2), with a 24 hour post injury Glasgow
Coma Scale score of 11-15, 91% will have a good recovery or moderate disability, and 6% will have a severe disability
or remain in a vegetative state. With 24 hour scores of 8-10, 59% will have a good recovery or moderate disability,
and 27% will have a severe disability or remain in a vegetative state. With 24 hour scores of 5-7, 28% will have
a good recovery or moderate disability, and 54% will have a severe disability or remain in a vegetative state.
With 24 hour scores of 3-4,13% will have a good outcome or moderate disability and 80% will have a severe disability
or remain in a vegetative state.4
A good recovery was defined as being able to participate in normal social life and can return to work. A moderate
disability was defined as being independent but disabled. A severe disability was defined as being conscious but
dependent. A vegetative state was defined as without cortical functioning as judged by the observed behavior.2
The Glascow Coma Scale has become the gold standard in neuro-trauma assessment. It provides a clear and objective
tool to describe and track a trauma victim's level of consciousness. The addition of the Glascow Outcome Scale
allows for appropriate allocation of resources based upon the severity of injury.
REFERENCES
Geisler, F. & Salcman, M. (1986). Initial Neurotrauma Scoring of Head Injury.
Trauma Quarterly, 3(1),51-60.
Jennett, B. & Bond, M. (1975). Assessment of Outcome After Severe Brain Damage:
A Practical Scale. Lancet, 1, 480-484.
Jennett, B. & Teasdale, G. (1974). Assessment of Coma and Impaired Consciousness:
A Practical Scale. Lancet, 1, 81-84.
Jennett, B. & Teasdale, G. (1976). Predicting Outcome in Individual Patients
After Severe Head Injury. Lancet, 1, 1031-1034.
Jennett, B. & Teasdale, G. (1977). Aspects of Coma After Severe Head Injury.
Lancet, 1, 878-881.
Shaffer, M & Walraven, G. (Eds.). (1986). Trauma Assessment and Scoring.
Trauma Quarterly, 3(1).
