Glasgow scale and assessment of neurological status

The Glasgow Coma Scale (GCS) was proposed in 1974 as a practical method for assessing coma. Impaired consciousness is classified based on the impairment of 3 reflexes: pupillary, motor and speech. Over the past 20 years, the GCS has become a universal tool for reliably assessing patients with impaired consciousness in reproductive terms. In addition, a point assessment of the degree of impairment of the pupillary, motor and speech reflexes allows for a 13-point GCS in the range from 3 to 15. When conducting a total assessment of brain function, the GCS assesses a person as normotensive, normoxic, and not receiving any paralytic, narcotic or other drugs that artificially reduce the neurological status. Since the scale can be used to describe impaired consciousness in many therapeutic or surgical diseases.

The Glasgow Coma Scale is the most widely used and well-known severity scoring system. Pupillary, motor, and speech responses are included in the GCS, and these data have been used alone or in combination with other neurologic data to describe the severity of brain injury in patients with head trauma, cardiac arrest, intracerebral hemorrhage, cerebral infarction, sepsis, and other nontraumatic comas. The Glasgow Coma Scale has also been incorporated into most modern severity scoring systems, including the Probability of Death Score (PMS II); the Simplified Acute Performance Score (SAPS II); the Pediatric Risk of Mortality (PRISM), and the Acute Physiology and Chronic Health Evaluation (APACHE II and III).

The Glasgow Scale has also been used to create computer programs to determine outcome in patients with severe head injury and to measure changes in these scores in patients during treatment (Murray et al., 1993).

Glasgow Coma Scale (Teasdale GM, Jennett B., 1974)

Sign	Points
1. Opening the eyes:
Spontaneous	4
For verbal stimulation	3
For pain	2
No reaction	1
2. Verbal response:
Corresponding	5
Confused	4
Incoherent words	3
Inarticulate sounds	2
No reaction	1
3. Motor reaction:
Follows verbal commands	6
Localizes pain	5
Twitching response to pain	4
flexion of the upper limbs in response to pain (decortication posture)	3
Extension of the upper limbs in response to pain	2
No reaction	1

The initial Glasgow Severity Scale score correlates with the severity of brain injury and prognosis.

Thus, the Glasgow scale is an important criterion for assessing the level of consciousness. Each individual reaction is assessed in points, and the level of consciousness is expressed by the sum of points for each of the parameters. The lowest score is 3 points, and the highest is 15 points. A score of 8 points and below is defined as coma.

A score of 3-5 points on a scale is prognostically extremely unfavorable, especially if it is combined with dilated pupils and the absence of the oculovestibular reflex.

Correlation of outcomes with Glasgow scale score

Highest scores within the first 24 hours after cerebral injury	Good recovery or minor neuropsychiatric deficit	Vegetative state or death
3-4	7%	87%
5-7	34%	53%
8-10	68%	27%
11-15	82%	12%

Despite its worldwide acceptance and prognostic utility, the Glasgow Score has several important limitations.

First, the scale is not suitable for the initial assessment of patients with severe head injury. This is because highly trained emergency medical personnel must intubate, sedate, or myoplegic these patients before transporting them to a hospital. As a result, it is impossible to accurately determine the Glasgow Coma Scale score in almost 50% of patients with brain injury who are comatose at the emergency stage.

Second, patients with severe head trauma often require the use of sedatives, narcotics, and muscle relaxants to control elevated intracranial pressure, making it difficult to accurately determine the GCS score for these patients on a daily basis while they are in the ICU.

Third, periorbital swelling, hypotension, hypoxia, and intubation may be associated with distortion of the scale assessment.

Recommendations to address these issues include:

1. Determine the GCS scores within 1-2 hours after the injury.
2. Do not determine until hypotension or hypoxia is stabilized.
3. Use eye reactions - 1 point in patients with severe periorbital swelling.
4. Strictly adhere to the instructions set out in the original GCS.
5. Delay rating on the scale for 10-20 minutes until the half-life of the drugs that caused sedation or paralysis has been established.
6. Record GCS score (15) if there is no previous determination and sedatives and myoplegics cannot be reduced.

Currently, there are no sensitive scales that allow assessing the state of cerebral functions. Therefore, independently or in combination with APACH EIII or another prognostic system (for example, PRISM), the GCS is an important prognostic criterion for the outcome of the disease.

This is why every effort should be made to implement the GCS assessment in all ICUs.

Pittsburgh Brainstem Reflex Scale

Pittsburgh Brain Stem Score (PBSS) (Kelsey SF et al 1991)

The Pittsburgh Brainstem Scale (PBSS) can be used to assess brainstem reflexes in comatose patients.

Stem reflexes	Signs	Points
Presence of eyelash reflex	Can be determined on any side	2
	Missing on both sides	1
Corneal reflex	Can be determined on any side	2
	Missing on both sides	1
Oculocephalic and/or oculovestibular reflex	Can be determined on any side	2
	Missing on both sides	1
Reaction of the right pupil to light	Eat	2
	No	1
Left pupil reaction to light	Eat	2
	No	1
Gag and/or cough reflex	Eat	2
	No	1

Total score on the brainstem reflex assessment scale = Sum of scores for all indicators. The minimum score is 6, and the maximum is 12 points. The higher the score on the scale, the better the patient's condition.

The PB55 scale can be added to the Glasgow Coma Scale, then the combined scale will be called the Glasgow-Pittsburgh Coma Scale. In this case, the total score will be 9-27 points. 3.

Glasgow-Liege scale

The Glasgow-Liege Scale (BomJ.D., 1988)

In 1982, Bom JD developed and adapted the Glasgow-Liege scale (GLS), which is a combination of the Glasgow Coma Scale (GCS) with a quantitative assessment of five brainstem reflexes. The author showed that the motor reaction and brainstem reflexes are the most objective and prognostically significant for assessing cerebral functions after severe TBI.

Stem reflexes	Signs	Points
Fronto-orbicular	On one side	5
Vertical oculocephalic reflex	At least on one side	4
Pupillary reflex	At least on one side	3
Horizontal oculocephalic reflex	At least on one side	2
Oculocardial reflex	Eat	1
Oculocardial reflex	No	0

Glasgow-Liege scale score = Glasgow scale score + + Brainstem reflex score.

Maximum GLS score = Maximum Glasgow Score + Maximum Brainstem Reflex Score = 15 + 5 = 20.

Minimum GLS score = Minimum Glasgow Score + Minimum Brainstem Reflex Score = 3 + 0 = 3.

Probability of good recovery and minor disruptions = (1/(1 + (e (S1)) + (e (S2))));

Probability of severe disorders and vegetative state = (e (S2)) (1/(1+(e (S1)) + (e (S2))));

Probability of death = (e (S1)) (1/(1+(e (S1)+ (e (S2)))),

Where S1 = 10.00 - (1.63 (GLS)) + (0.16 (Age in years)); S2 = 6.30 - (1.00 (GLS)) + (0.08 (Age in years)).

Raimondi Coma Scale for Children

The Children's Coma Score from Children's Memorial Hospital for Young Children (Raimondi AJ Hirschauer J., 1984)

Sign	Points
1. Eye movement:
Follows the object with his eyes	4
The functions of the oculomotor muscles and pupillary reflexes are preserved.	3
Pupillary reflexes are lost or there are oculomotor disorders	2
Pupillary reflexes are lost or the oculomotor muscles are paralyzed	1
2. Verbal response:
The scream is saved	3
Spontaneous breathing is maintained	2
Apnea	1
3. Motor reaction
Flexes and extends limbs	4
Withdraws limbs when subjected to painful stimulation	3
Hypertonicity	2
Atony	1

The maximum score on the scale is 11 points, the minimum is 3 points.

The higher the score on the scale, the better the state of consciousness.

Correspondence between the Pediatric Coma Scale and the Glasgow Coma Scale

Coma Scale for Children	Glasgow Coma Scale score
11	From 9 to 15
8, 9 or 10	From 5 to 8
From 3 to 7	3-4

Pediatric Coma Scale

Pediatric Coma Scale (Simpson D., Reilly P., 1982)

Sign	Points
1. Opening the eyes:
Spontaneous	4
In response to the appeal	3
In response to pain	2
No reaction	1
2. Best verbal response:
Oriented	5
Pronounces individual words	4
Pronounces individual sounds	3
Scream, cry	2
No reaction	1
3. Best motor response
Executes commands	5
Localizes the source of pain	4
Flexion of limbs in response to pain	3
Extension of limbs in response to pain	2
No reaction

Adjustment according to the child's age

The first 6 months of life

Normally, the best verbal response is crying, although some children at this age produce isolated sounds. The expected normal verbal scale score is 2.

The best motor response is usually flexion of the limbs. The expected normal motor scale score is 3.

6-12 months.

A typical child at this age coos: the expected normal score on the verbal scale is 3 points.

The infant usually localizes the source of pain but does not follow commands: the expected normal score on the motor scale is 4 points.

12 months - 2 years.

The child should be expected to pronounce words clearly: the expected normal score on the verbal scale is 4 points.

The child usually localizes the source of pain, but does not follow commands: the expected normal score on the motor scale is 4 points.

2 years - 5 years.

The child should be expected to pronounce words clearly: the expected normal score on the verbal scale is 4 points.

The child usually completes tasks: the expected normal score on the motor scale is 5 points.

Over 5 years old.

Orientation is defined as awareness that the child is in hospital: the expected normal verbal scale score is 5.

Age norms for total score

Age	Points
0-6 months	9
6-12 months	11
1-2 years	12
2-5 years	13
Over 5 years old	14

[ 1 ], [ 2 ], [ 3 ]

Coma scale for children (modification of Glasgow Coma Scale, Adelaide Coma Scale, Pediatric Coma Scale)

(Hahn YS, 1988)

One component of the Glasgow Coma Scale is best verbal response, which cannot be assessed in young children who cannot yet speak. A modification of the original Glasgow Coma Scale was created to assess children who are too young to speak.

Parameters:

1. Opening eyes.
2. The best verbal or non-verbal response (depending on the child's level of development).
3. Best motor response.

Characteristic
Best verbal response
A child who cannot speak	Child who can speak (assessed according to Glasgow Coma Scale)
Smiles, retains orienting response to sounds, follows objects with eyes, reacts to others	Oriented, available for speech contact
Cries, but the child can be calmed down; reacts inappropriately to others	Disoriented but available for verbal contact
Cries, and the child cannot always be calmed down; moans, makes individual sounds	Spoke incoherently
Continuously cries, restless, hypersensitive to stimuli	Pronounces individual sounds
NO VERBAL REACTIONS
Best motor response
Executes commands
Localizes the source of pain
Withdraws limbs when subjected to painful stimulation
Tonic flexion (decorticate rigidity)
Tonic extension (decerebrate rigidity)
NO RESPONSE TO PAIN

Additional prognostic factors:

1. oculovestibular reflexes (if these reflexes are absent, all children die; if they are impaired, 50% die; if reflexes are preserved, 25% of children die);
2. impaired pupillary response to light (77% of patients with bilateral pupil dilation without response to light die);
3. intracranial pressure (in observations, ICP exceeding 40 mm Hg, with an assessment on the Glasgow Coma Scale of 3, 4 or 5, was fatal in all cases).

Pediatric Coma Scale Score = (Eye Opening Score) + (Non-Verbal or Verbal Response Score) + + (Motor Response Score). Interpretation:

• The minimum score is 3 points, which means the worst prognosis.
• The maximum score is 15 points; the prognosis is the best.
• If the total score is 7 or more, the patient has a good chance of recovery.
• With a score of 3-5, the outcome is potentially fatal, especially if there is no pupillary response to light, oculovestibular reflexes, or increased intracranial pressure.
• Normally, the sum of points in children under 5 years of age is less than in adults, since they have a limited range of speech and motor reactions.

Blantyre Coma Scale for Young Children

(Krishna W. S. et al., 1995; Molyneux M. E. et al., 1989)

The Blantyre Coma Scale is a modification of the Glasgow Coma Scale adapted for use in children who have not yet learned to speak. It uses assessments of reactions to pain stimuli (motor activity and crying) and the ability to fixate the gaze on an object.

Estimated parameter	Inspection data	Grade
Physical activity	Localization of pain irritation (pressure with the blunt end of a pencil on the sternum or supraorbital arches)	2
	Spreading the boundary of pain irritation (pressure with a pencil on the nail bed of the finger)	1
	No response or inadequate response	0
Scream	Screams regardless of painful irritation or pronounces words	2
	Moaning or inappropriate crying when stimulating pain	1
	Lack of vocal response to pain	0
Eye movements	Observes (for example, mother's face)	1
	Unable to observe	0

Rating (best ratings for each parameter are used):

Motor activity assessment + Scream assessment + Eye movement assessment.

Interpretation:

• Minimum possible: 0 (bad).
• Maximum possible: 5 (good).
• Deviation from the norm: <4. 8.

Children's Orthopedic Hospital Coma Scale

SONMS Coma Scale for Brain-Injured Children (Morray JP et al., 1984)

Considering that the Glasgow scale has serious limitations for use in children, since it requires verbalization, which is not always possible, especially in an intubated child, and based on the fact that assessment of eye opening, verbalization and skeletal muscle movement is clearly insufficient to take into account the entire spectrum of neurological symptoms, Morray JP et al. (1984) proposed the COMS scale. This scale is devoid of such limitations. Cortical function is assessed from 6 (purposeful, spontaneous movements) to 0 (lethargy), the functional state of the brainstem is assessed from 3 (intact) to 0 (absence of reflex activity and apnea). The maximum overall score is 9. This scale was called the Children's Orthopedic Hospital and Medical Center Coma Scale (COMS) and was tested over the period from 1978 to 1982.

Function	Signs	Grade
Function of the cortex	Purposeful, spontaneous movements	6
	Purposeful movements on command	5
	Localization of pain	4
	Aimless movements, withdrawal reaction	3
	Decortication pose	2
	Decerebrate posture	1
	Agony	0
Function of the brain stem	Pupillary, corneal, oculocephalic and oculovestibular reflexes are preserved.	3
	Depressed (pupillary, corneal reflexes and oculovestibular or oculocephalic reflexes are depressed or absent, or some reflexes are present while others are absent)	2
	All reflexes are absent, but spontaneous breathing remains	1
	Areflexia, apnea (with normal PaCO2)	0

Scale score = (Points for cortex function) + (Points for trunk function).

Interpretation:

• Minimum rating: 0 (bad).
• Maximum rating: 9 (good).

Children with a score of less than 3 on the scale have an extremely high mortality rate.

The given assessment scale, in contrast to the generally accepted Glasgow scale, evaluates the state of both the cortical and the stem part of the brain to a much greater extent. It shows sufficient efficiency and sensitivity to changes in neurological functions. Greater attention to the cortical function of the brain is based on the concept that the integration of cortical functions is most important for a positive outcome.

The SONMS scale was a better predictor of outcome in children with hypoxic encephalopathy and head injury than in children with Reye's syndrome, meningitis, or encephalitis, which is apparently determined by the greater dependence of prognosis on the condition at admission in the first two cases, without uncertain dynamics of the condition in the latter. In patients with hypoxic encephalopathy, the assessment of cortical function was closer to the prognosis than the assessment on the entire scale. For other pathologies, the total assessment was more reliable.

With a score of less than 2 points, a fatal outcome was observed regardless of the intensity of the treatment. Most of these patients were atonic, with depression or absence of brainstem reflexes. A fatal outcome was also observed in the case of atony on admission. 9.

Wolpe scale of consciousness in newborns

Level of consciousness	Type of child	Answer to awakening	Motor response
			Quantity	Quality
Norm	Doesn't sleep	Norm	Norm	Norm
Mild stupor	Sleepy	Reduced	Slightly reduced	High
Average	Sleeping	Significantly reduced	Moderately reduced	High
Heavy	Sleeping	Absent	Significantly reduced	High
Coma	Sleeping	Absent	Significantly reduced or absent	Low

Glasgow Outcome Scale

Glasgow Outcome Scale (Jennett B., Bond M., 1975)

The GOS is used as a standard to assess outcomes of head injury (Jennett B. et al., 1975). The GOS has key advantages as an assessment method: (1) the scale produces one summary score and covers all possible outcomes, including death and vegetative state; (2) it contains broadly understood and easily applicable criteria; (3) the scale forms a hierarchy and clinically significant differences in criteria; (4) information can be obtained from the patient or his representative.

Treatment result	Characteristics of the patient
Death	Death
Chronic vegetative state	Restoration of the sleep-wake cycle in the complete absence of speech and cognitive functions in a patient who appears awake and spontaneously opens his eyes.
Poor recovery	A state of low consciousness, the patient is unable to care for himself and requires constant care
Satisfactory recovery	The patient is disabled, but can continue to work in his previous profession, usually stays at home, but takes care of himself and does not require constant care.
Good recovery	The patient returned to his previous lifestyle and previous activities (work)

Glasgow Outcome Scale Extended

Glasgow Outcome Scale extended (Wilson JT etal., 1998)

Expanded Glasgow Outcome Scale criteria:

1. Dead - death.
2. Vegetative state (VS) - vegetative state.
3. Lower severe disability (Lower SD) - minor severe disabilities.
4. Upper severe disability (Upper SD) - significant severe impairments.
5. Lower moderate disability (Lower MD) - minor moderate impairments.
6. Upper moderate disability (Upper MD) - significant moderate impairments.
7. Lower good recovery (Lower GR) - slightly good recovery.
8. Upper good recovery (Upper GR) - significant good recovery.

Pediatric Brain Recovery Scale

Pediatric Cerebral Performance Category Scale (Fiser DH, 1992)

Clinical signs	Category	Grade
Normal level for this age A school-age child attends classes at school	Norm	1
Aware of impairments and able to influence them in an age-appropriate manner School-age child attends school; grade level may not be age appropriate May have mild neurological impairments	Minor violations	2
Impaired consciousness Important brain functions typical for age do not depend on daily routine The child attends a special educational institution Reduced learning ability	Moderate violations	3
Disorders of consciousness Dependence on help from others due to impaired brain function	Severe violations	4
Coma of any degree without signs of brain death Does not awaken without external intervention No reactions No cortical functions, does not awaken with vocal stimulation Possible presence of reflexive eye opening and sleep/wake cycles	Coma or vegetative state	5
Apnea OR Areflexia OR Isoelectric line on EEG	Brain death	6

Pediatric Global Functional Recovery Scale

Pediatric Overall Performance Category Scale (POPC) (FiserD.H., 1992)

Grade	Category	Description
1	Good condition	Norm; normal activity appropriate to age. Medical and somatic problems do not interfere with normal activity
2	Minor violations	Mild condition; minor chronic physical or medical problems impose few limitations but are compatible with normal living (e.g., asthma); preschool-aged child has a physical disability that is not incompatible with future independent living (e.g., single amputation) and is able to perform more than 75% of age-appropriate daily activities; school-aged child can perform all age-appropriate daily activities
3	Moderate violations	Moderately severe condition; there are some limitations: a preschool-aged child is unable to perform most age-appropriate daily activities; a school-aged child can perform most age-appropriate daily activities but has significant physical disabilities (e.g., cannot participate in competitive play)
4	Severe violations	Severe condition; preschool-aged child unable to perform most age-appropriate daily activities; school-aged child dependent on others for most age-appropriate daily activities
5	Coma/vegetative state	Coma/vegetative state.
6		Death