Scale of Glasgow and evaluation of neurological status

The Glasgow scale (SCG) was proposed in 1974 as a practical method for assessing coma. The disturbed consciousness is classified based on the violation of 3 responses: pupillary, motor and speech. For the last 20 years, the SHG has become universal for the reliable evaluation of patients with impaired consciousness in the reproductive plan. In addition, a graded assessment of the degree of impaired pupillary, motor and speech reflexes makes it possible to compile a 13-point SHG in the range from 3 to 15. When conducting a summary evaluation of brain function, the SHG assesses a person as normotensive, normoxic, not receiving any paralytic, narcotic or other drugs that are artificially reduce the neurological status. Since the scale can be used to describe a disorder of consciousness in many therapeutic or surgical diseases.

The Glasgow scale is the most common and known system for assessing the severity of a condition. Pupillary, motor and speech responses are included in the CGT, and these data were used alone or in combination with other neurological data to describe the severity of brain damage in patients with head trauma, cardiac arrest, intracerebral hemorrhages, cerebral infarction, sepsis, and other non-traumatic coma. The Glasgow scale was also included in the most advanced systems for assessing the severity of the condition, including an estimate of the likelihood of a lethal outcome (MPM II); simplified scale of acute conditions (SAPS II); the risk of mortality in pediatrics (PRISM) and the scale of assessment of acute physiological disorders and chronic disorders (APACHE II and III).

The Glasgow scale was also used to create computer programs to determine the outcome in patients with severe head trauma and to measure abnormalities of these indicators in patients during treatment (Murray et al., 1993).

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

Symptom	Points
1. Opening of the eyes:
Spontaneous	4
For verbal stimulation	3
For pain	2
No reaction	1
2. Verbal reaction:
Corresponding	5
Confused	4
Incoherent words	3
Inarticulate sounds	2
No reaction	1
3. The motor reaction:
Performs verbal commands	6th
Localizes pain	5
Writhing response to pain	4
flexion of the upper extremities in response to pain (decortication posture)	3
Extension of upper extremities in response to pain	2
No reaction	1

The initial assessment according to the Glasgow scale correlates with the severity of cerebral injury and the 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 the scores for each of the parameters. The lowest score is 3 points, and the highest is 15 points. Score 8 points and below is defined as a coma.

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

Correlation of outcomes with a Glasgow score

The highest scores, within the first 24 h after cerebral injury	A good recovery or a minor psychoneurological deficit	Vegetative state or death
3-4	7%	87%
5-7	34%	53%
8-10	68%	27%
11-15	82%	12%

Despite world recognition and prognostic benefits, the Glasgow Scale has several important limitations.

First, the scale is not suitable for initial assessment of patients with severe head trauma. This is due to the fact that highly qualified medical personnel of the "first aid" should intubate, sedate or mioplegiruat these patients before transportation to the hospital. As a result, it is not possible to accurately determine the Glasgow score in almost 50% of patients with brain trauma who are in a coma in the "first aid" stage.

Secondly, patients with severe head trauma often have to use sedatives, narcotics and muscle relaxants to control increased intracranial pressure. Thus, it is difficult to determine accurately the CLH assessment for these patients on a daily basis while they are in the ICU.

Thirdly, periorbital tumor, hypotension, hypoxia and intubation may be associated with a distortion of the evaluation on a scale.

Recommendations for solving these problems include:

1. Determine the SCG scores within 1-2 h after the injury.
2. Do not determine until the stabilization of hypotension or hypoxia.
3. To use reactions from the eyes - 1 point in patients with severe periorbital tumor.
4. Clearly adhere to the guidelines set forth in the original SDG.
5. Postpone the assessment on a scale of 10-20 min until the half-life of the drugs that led to sedation or paralysis is established.
6. Write down the SCH score (15), if there is no previous definition, and sedatives and myoplegics can not be reduced.

At present, there are no sensitive scales that allow one to assess the state of cerebral functions. Thus, alone or in combination with APACH EIII or another prognostic system (for example, PRISM), the SDG is an important prognostic criterion for the outcome of the disease.

That is why everything possible should be done to implement the evaluation of the SDG in all ICUs.

The Pittsburgh Scale of Stem Reflexes

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

The Pittsburgh Rating Scale of the Brainstem Function (PBSS) can be used to evaluate stem reflexes in comatose patients.

Stem reflexes	Symptoms	Points
Presence of ciliary reflex	Determined on either side	2
	Missing from both sides	1
Corneal reflex	Determined on either side	2
	Missing from both sides	1
The oculocephalic and / or oculovestibular reflex	Determined on either side	2
	Missing from both sides	1
The reaction of the right pupil to light	There is	2
	No	1
Response of the left pupil to light	There is	2
	No	1
Emetic and / or cough reflex	There is	2
	No	1

Total score on the scale of assessment of stem reflexes = Sum of estimates for all indicators. The minimum score is 6, and the maximum is 12 points. The higher the score, 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 coma scale of Glasgow-Pittsburgh. In this case, the total score will be 9-27 points. 3.

Scale of Glasgow-Liege

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

In 1982 r. Bom JD, developed and adapted the Glasgow-Liege scale (GLS), which is a combination of the Glasgow coma scale (GCS) with a quantitative evaluation of five brain stem reflections. The author showed that the motor reaction and stem reflexes are the most objective and prognostically significant for evaluation of cerebral functions after severe head injury.

Stem reflexes	Symptoms	Points
Front-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	There is	1
Oculocardial reflex	No	0

Score rating Glasgow-Liege = Score on the Glasgow scale + + Score for stem reflexes.

Maximum score GLS = Maximum score on the Glasgow scale + Maximum score for stem reflexes = 15 + 5 = 20.

Minimum score GLS = Minimum score on the Glasgow scale + Minimum score for stem reflexes = 3 + 0 = 3.

The probability of a good recovery and minor violations = (1 / (1 + (e (S1)) + (e (S2))));

The probability of severe disturbances and the vegetative state = (e (S2)) (1 / (1+ (e (S1)) + (e (S2))));

The probability of death is = (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)).

Scale of coma for children Raimondi

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

Symptom	Points
1. Movement of the eyes:
Watch the subject	4
Functions of oculomotor muscles and pupillary reflexes are preserved	3
Lost pupillary reflexes or there are oculomotor disorders	2
Lost pupillary reflexes or paralyzed oculomotor muscles	1
2. Verbal reaction:
Saved scream	3
Spontaneous breathing preserved	2
Apnea	1
3. The motor reaction
Flexes and unbends limbs	4
Pulls off the limbs with pain stimulation	3
Hypertonicity	2
Atony	1

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

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

Correspondence of the scores on the coma scale for children and on the coma scale Glasgow

Score on the coma scale for children	Score on the Coma Scale Glasgow
Eleven	9 to 15
8, 9, or 10	5 to 8
3 to 7	3-4

Pediatric Coma Scale

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

Symptom	Points
1. Opening of the eyes:
Spontaneous	4
In response to a request	3
In response to pain	2
No reaction	1
2. The best verbal reaction:
Oriented	5
Utters single words	4
Pronounces individual sounds	3
Screaming, crying	2
No reaction	1
3. The 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

Correction according to the age of the child

The first 6 months of life

Normally, the best verbal response is crying, although some children at this age say individual sounds. The expected normal assessment by the verbal scale is 2 points.

The best motor response is usually the flexion of the limbs. The expected normal assessment on the motor scale is 3 points.

6-12 months.

An ordinary child at this age gulit: the expected normal score on the verbal scale is 3 points.

A baby child, as a rule, localizes the source of pain, but does not perform the commands: the expected normal assessment on the motor scale is 4 points.

12 months - 2 years.

It should be expected that the child clearly pronounces the words: the expected normal score on the verbal scale is 4 points.

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

2 years-5 years.

It should be expected that the child clearly pronounces the words: the expected normal score on the verbal scale is 4 points.

The child usually performs the tasks: the expected normal assessment on the motor scale is 5 points.

Older than 5 years.

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

Age norms of the total score

Age	Points
0-6 months	9
6-12 months	Eleven
1-2 years	12
2-5 years	13
Older than 5 years	14

[1], [2], [3],

The coma scale for children (modification of the Glasgow coma scale, Adelaide coma scale, pediatric coma scale)

(Hahn YS, 1988)

One of the components of the Glasgow coma scale is the best verbal reaction that can not be evaluated in young children who are not yet able to speak. Modification of the original coma scale Glasgow was created to evaluate children who are too young to talk.

Options:

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

Characteristic
The best verbal reaction
A child who can not speak	A child who can speak (score corresponds to the Glasgow coma scale)
Smiling, an approximate reaction to sounds is preserved, eyes are kept on the objects, reacts to others	Oriented, available to voice contact
Cries, but the child can be reassured; inadequately responds to others	Disoriented, but available to speech contact
Cries, while the child can not always be reassured; moans, produces individual sounds	Speaks incoherent words
Continuously crying, restless, highly sensitive to irritants	Speaks individual sounds
NO VERBAL REACTIONS
The best motor response
Executes commands
Localizes the source of pain
Lifts limbs with pain stimulation
Tonic flexion (decortication rigidity)
Tonic extension (decerebrate rigidity)
NO REACTION FOR PAIN

Additional prognostic factors:

1. oculovestibular reflexes (in the absence of these reflexes, all children die, 50% die if they are violated, 25% of children die with preserved reflexes);
2. the pupil's reaction to light is disturbed (77% of patients who have bilateral dilated pupils without reaction to light die);
3. intracranial pressure (in ICP observations greater than 40 mm Hg, Glasgow 3, 4 or 5 in all cases was fatal in assessing the coma scale).

Score on the coma scale for children = (Points for opening eyes) + (Points for non-verbal or verbal reaction) + + (Points for motor response). Interpretation:

• The minimum score is 3 points, while the forecast is the worst.
• The maximum score is 15 points; forecast the best.
• With a score of 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, oculo- vestibular reflexes, or increased intracranial pressure.
• Normally, the sum of scores in children under 5 years is less than in adults, since they have a limited amount of speech and motor reactions.

Scale for children Blantyre Blantyre Coma Scale for Young Children

(Krishna WS 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. Evaluations of reactions to pain stimulation (motor activity and scream) and the ability to fix a glance on the subject are used.

Estimated parameter	Inspection data	Evaluation
Motor activity	Localization of painful irritation (pressure by the blunt end of a pencil on the sternum or supraorbital arches)	2
	Spreading the border of pain irritation (pencil pressure on the nail bed of the finger)	1
	No response or inadequate response	0
Scream	Screams regardless of painful irritation or pronounces words	2
	Groaning or inadequate cry with pain irritation	1
	Absence of a voice reaction to pain	0
Eye movements	Observes (for example, the mother's face)	1
	Not able to observe	0

Evaluation (the best estimates for each parameter are used):

Assessment of motor activity + Evaluation of scream + Evaluation of eye movement.

Interpretation:

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

Scale of coma of children's orthopedic hospital

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

Given that the Glasgow scale has serious limitations for use in children, as it requires verbalization, which is not always possible, especially in an intubated child, and on the basis that assessments of eye opening, verbalization, and skeletal muscle movement are clearly not enough to consider the full range of neurological symptoms, Morray JP et al. (1984) proposed the scale of SONMS. This scale is devoid of such restrictions. The cortical function is estimated from 6 (purposeful, spontaneous movements) to 0 (lethargy), the functional state of the trunk is estimated from 3 (intact) to 0 (absence of reflex activity and apnea). The maximum overall score is 9. This scale was called the comatose state scale of the Children's Orthopedic Hospital and Medical Center (SONMS), and was tested during the period from 1978 to 1982.

Function	Symptoms	Evaluation
Bark function	Purposeful, spontaneous movements	6th
	Targeted movement on the team	5
	Localization of pain	4
	Aimless movements, withdrawal reaction	3
	Decortication posture	2
	Decaeration Disease	1
	Agony	0
Function of the brain stem	Pupillary, corneal, oculocephalic and oculo- vestibular reflexes are preserved	3
	Oppressed (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 is preserved	1
	Aureflexia, apnea (with normal PaCO2)	0

Score on the scale = (Points for the bark function) + (Points for the function of the trunk).

Interpretation:

• The minimum score is 0 (bad).
• The maximum score is 9 (good).

Children with a score of less than 3 points are very likely to die.

The scoring scale, in contrast to the generally accepted Glasgow scale, appreciably assesses the condition of both the cortical and the trunk of the brain. It shows sufficient effectiveness and sensitivity to changes in neurological functions. More attention to the cortical function of the brain is based on the concept that for the positive outcome, the integrality of the cortical functions is most important.

The SONMS score was the best way to predict outcome in children with hypoxic encephalopathy and head trauma than in children with Reye's syndrome, meningitis or encephalitis, which is obviously determined by the greater dependence of the prognosis on the condition of admission in the first two cases, without undetermined dynamics of the condition in the latter . In patients with hypoxic encephalopathy, the evaluation of cortical function was closer to the prognosis than the score on the entire scale. For another pathology, the overall score was more reliable.

At an estimation less than 2 points the lethal outcome was observed without dependence from intensity of spent treatment. Most of these patients were atonic, with depression or lack of stem reflexes. A lethal outcome was also in the case of atony upon admission. 9.

Scale of consciousness evaluation in newborns

Level of consciousness	Type of child	Response to awakening	Motor response
			Quantity	Quality
Norm	Do not sleep	Norm	Norm	Norm
Stupor easy	Sleepy	Decreased	Slightly reduced	High
Average	Sleeping	Significantly reduced	Moderately reduced	High
Heavy	Sleeping	Absent	Significantly reduced	High
Coma	Sleeping	Absent	Significantly reduced or absent	Low

The outcome scale of Glasgow

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

To assess the outcomes of a head injury, SHIG is used as a reference (Jennett B. Et al., 1975). SHIG has key advantages as an evaluation method: (1) the scale displays one summary score and covers all possible outcomes, including death and vegetative state; (2) contains widely understood and easily applicable criteria; (3) the scale forms a hierarchy and clinically significant differences in the criteria; (4) information can be obtained from the patient or his representative.

Result of treatment	Characteristics of the patient
Death	Death
Chronic vegetative state	Restoring the cycle of sleep and wakefulness in the complete absence of speech and cognitive functions in a patient who appears to be awake and opens his eyes spontaneously.
Poor Recovery	Practically the state of small consciousness, the patient is unable to service himself, needs constant care
Satisfactory recovery	The patient is an invalid, but can engage in the former profession, as a rule, is at home, but he himself serves and in constant care does not need
Good recovery	The patient returned to his former way of life and to his previous studies (work)

The outcome scale of Glasgow is extended

Glasgow Outcome Scale extended (Wilson JT et al., 1998)

Criteria for an extended outcome scale for Glasgow:

1. Dead is death.
2. Vegetative state (VS) - vegetative state.
3. Lower severe disability (Lower SD) - minor severe disabilities.
4. Upper severe disability (Upper SD) - significant severe disorders.
5. Lower moderate disability (Lower MD) - minor mean disabilities.
6. Upper moderate disability (Upper MD) is a significant average disorder.
7. Lower good recovery (Lower GR) - a slight good recovery.
8. Upper good recovery (Upper GR) is a significant good recovery.

Pediatric scale of brain function recovery

Pediatric Cerebral Performance Category Scale (Fiser DH, 1992)

Clinical signs	Category	Evaluation
Normal for a given age level A child of school age attends classes at school	Norm	1
Realizes violations and is able to influence them according to age. A child of school age attends school; the class may not correspond to age May have mild neurological disorders	Light violations	2
Disturbances of consciousness Important brain functions characteristic for the age do not depend on the daily routine The child attends a special educational institution The learning ability is reduced	Moderate violations	3
Disorders of consciousness Dependence on the help of others in connection with impaired brain functions	Severe Violations	4
Coma of any degree without signs of brain death Not awakened without external interference Absence of reactions Absence of cortical functions, not awakened by voice irritation Possibility of reflex opening of eyes and sleep / awakening cycles	Coma or vegetative state	5
Apnea, OR Areflexia, OR Isoelectric line on EEG	Death of the brain	6th

Pediatric scale of general function recovery

Pediatric Overall Performance Category Scale (POPC) (Fiser D., 1992)

Evaluation	Category	Description
1	Good condition	Norm; normal activity, corresponding to age. Medical and physical problems do not interfere with normal activities
2	Light violations	Not a light condition; minor chronic medical or medical problems impose small limitations, but are compatible with normal life (eg, asthma); a child of preschool age has a physical ailment that does not contradict future independent existence (for example, single amputation) and is able to perform more than 75% of daily activities corresponding to age; a school-age child can perform all daily activities corresponding to age
3	Moderate violations	State of moderate severity; there are certain limitations: a preschool child is not able to perform most of the daily activities appropriate to age; a school-age child can perform most of the daily activities appropriate to age, but has pronounced physical disabilities (for example, can not participate in competitive games)
4	Severe Violations	Severe condition; a preschool child is not able to perform most of the daily activities appropriate to age; a school-age child is dependent on others in most daily activities appropriate to age
5	Coma / vegetative state	Coma / vegetative state.
6th		Death