Practical use of the Glasgow Coma Scale; a comprehensive narrative review of GCS methodology

Published:August 06, 2012DOI:



      Narrative review of Glasgow Coma Scale (GCS) methodology.


      Narrative review of published papers describing methodological aspects of the GCS, from Premedline, Medline, EMBASE, CINAHL and Ovid Nursing databases from 1950 to May 2012.


      Examination of 18,851 references limited to descriptions of GCS development, pathophysiological correlations, examination techniques, complications or clinician agreement gave a final set of 33, which were summarised in this review.


      The GCS was designed for the objective measurement of level of consciousness, assessment of trend, and to facilitate accurate and valid communication between clinicians. Concerns have been raised about the potential for misleading levels of precision engendered by the use of the GCS, and the use of simpler scales suggested. This review discusses the GCS and conditions affecting calculation of domain and summary scores, and recommends a method of implementation and interpretation.


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        • Jennett B.
        • Teasdale G.
        Aspects of coma after severe head injury.
        Lancet. 1977; 1: 878-881
        • Ogungbo B.
        The World Federation of Neurological Surgeons scale for subarachnoid haemorrhage.
        Surg Neurol. 2003; 59: 236-237
        • Zuercher M.
        • Ummenhofer W.
        • Baltussen A.
        • Walder B.
        The use of the Glasgow Coma Scale in injury assessment: a critical review.
        Brain Inj. 2009; 23: 371-384
        • Gabbe B.J.
        • Cameron P.A.
        • Finch C.F.
        The status of the Glasgow Coma Scale.
        Emerg Med (Fremantle). 2003; 15: 353-360
        • Green S.M.
        Cheerio Laddie! Bidding farewell to the Glasgow Coma Scale.
        Ann Emerg Med. 2011; 58: 427-430
        • Rimel R.W.
        • Jane J.A.
        • Edlich R.F.
        An injury severity scale for comprehensive management of central nervous system trauma.
        JACEP. 1979; 8: 64-67
        • Hahn Y.S.
        • Chyung C.
        • Barthel M.J.
        • Flannery A.M.
        • McLone D.G.
        Head injuries in children under 36 months of age: demography and outcome.
        Child's Nerv Syst. 1988; 4: 34-40
        • Simpson D.A.
        • Cockington R.A.
        • Hanieh A.
        • Raftos J.
        • Reilly P.L.
        Head injuries in infants and young children – the value of the Paediatric Coma Scale.
        Child's Nerv Syst. 1991; 7: 183-190
        • Livingston B.M.
        • Mackenzie S.J.
        • MacKirdy F.N.
        • Howie J.C.
        Should the pre-sedation Glasgow Coma Scale value be used when calculating Acute Physiology and Chronic Health Evaluation scores for sedated patients?.
        Crit Care Med. 2000; 28: 389-394
        • Kelly C.A.
        • Upex A.
        • Bateman D.N.
        Comparison of consciousness level assessment in the poisoned patient using the alert verbal painful unresponsive scale and the Glasgow Coma Scale.
        Ann Emerg Med. 2004; 44: 108-113
        • Kerby J.D.
        • MacLennan P.A.
        • Burton J.N.
        • McGwin G.
        • Rue L.W.
        Agreement between prehospital and emergency department Glasgow Coma scores.
        J Trauma. 2007; 63: 1026-1031
        • Fortune P.-M.
        • Shann F.
        The motor response to stimulation predicts outcome as well as the full Glasgow Coma Scale in children with severe head injury.
        Pediatr Crit Care Med. 2010; 11: 339-342
        • Teasdale G.
        • Knill-Jones R.
        • van der Sande J.
        Observer variability in assessing impaired consciousness and coma.
        J Neurol Neurosurg Psychiatry. 1978; 41: 603-610
        • Teasdale G.
        • Jennett B.
        • Murray L.
        • Murray G.
        Glasgow Coma Scale: to sum or not o sum?.
        Lancet. 1983; 2: 678
        • Bhatty G.B.
        • Kapoor N.
        The Glasgow Coma Scale: a mathematical critique.
        Acta Neurochir (Wien). 1993; 120: 132-135
        • Hartley C.
        • Cozens A.
        • Mendelow A.D.
        • Stevenson J.C.
        The Apache II scoring system in neurosurgical patients: a comparison with simple Glasgow Coma Scoring.
        Br J Neurosurg. 1995; 9: 179-187
        • Meredith W.
        • Rutledge R.
        • Fakhry S.M.
        • Emery S.
        • Kromhout-Schiro S.
        The conundrum of the Glasgow Coma Scale in intubated patients – a linear regression prediction of the Glasgow verbal score from the Glasgow eye and motor scores.
        J Trauma. 1998; 44: 839-845
        • Healey C.
        • Osler T.M.
        • Rogers F.B.
        • Healey M.A.
        • Glance L.G.
        • Kilgo P.D.
        • et al.
        Improving the Glasgow Coma Scale score: motor score alone is a better predictor.
        J Trauma. 2003; 54: 671-680
        • Gill M.
        • Windemuth R.
        • Steele R.
        • Green S.M.
        A comparison of the Glasgow Coma Scale score to simplified alternative scores for the prediction of traumatic brain injury outcomes.
        Ann Emerg Med. 2005; 45: 37-45
        • Davis D.P.
        • Serrano J.A.
        • Vilke G.M.
        • Sise M.J.
        • Kennedy F.
        • Eastman A.B.
        • et al.
        The predictive value of field versus arrival Glasgow Coma Scale score and TRISS calculations in moderate-to-severe traumatic brain injury.
        J Trauma. 2006; 60: 985-990
        • Moore L.
        • Lavoie A.
        • Camden S.
        • Le Sage N.
        • Sampalis J.S.
        • Bergeron E.
        • et al.
        Statistical Validation of the Glasgow Coma Score.
        J Trauma. 2006; 60: 1238-1244
        • Haukoos J.S.
        • Gill M.R.
        • Rabon R.E.
        • Gravitz C.S.
        • Green S.M.
        Validation of the Simplified Motor Score for the prediction of brain injury outcomes after trauma.
        Ann Emerg Med. 2007; 50: 18-24
        • Holmes J.F.
        • Palchak M.J.
        • MacFarlane T.
        • Kuppermann N.
        Performance of the Pediatric Glasgow Coma Scale with blunt head trauma.
        Acad Emerg Med. 2005; 12: 814-819
        • Holdgate A.
        • Ching N.
        • Angonese L.
        Variability in agreement between physicians and nurses when measuring the Glasgow Coma Scale in the emergency department limits its clinical usefulness.
        Emerg Med Aust. 2006; 18: 379-384
        • Gill M.
        • Martens K.
        • Lynch E.L.
        • Salih A.
        • Green S.M.
        Interrater reliability of 3 simplified neurologic scales applied to adults presenting to the emergency department with altered levels of consciousness.
        Ann Emerg Med. 2007; 49: 403-407
        • Gorelick M.H.
        • Atabaki S.M.
        • Hoyle J.
        • Dayan P.S.
        • Holmes J.F.
        • Holubkov R.
        • et al.
        Interobserver agreement in assessment of clinical variables in children with blunt head trauma.
        Acad Emerg Med. 2008; 15: 812-818
        • Takahashi C.
        • Okudera H.
        • Origasa H.
        • Takeuchi E.
        • Nakamura K.
        • Fukuda O.
        • et al.
        A simple and useful coma scale for patients with neurologic emergencies – the Emergency Coma Scale.
        Am J Emerg Med. 2011; 29: 196-202
        • Fischer J.
        • Mathieson C.
        The history of the Glasgow Coma Scale: implications for practice.
        Crit Care Nurs Q. 2001; 23: 52-58
        • Iacono L.A.
        • Lyons K.A.
        Making GCS as easy as 1, 2, 3, 4, 5, 6.
        J Trauma Nursing. 2005; 12: 77-81
        • Iankova A.
        The Glasgow Coma Scale Clinical application in emergency departments.
        Emerg Nurse. 2006; 14: 30-35
        • Matis G.
        • Birbilis T.
        The Glasgow Coma Scale – a brief review Past, present, future.
        Acta Neurol Belg. 2008; 108: 75-89
        • Batchelor J.
        • McGuinness A.
        A meta-analysis of GCS 15 head injured patients with loss of consciousness or post-traumatic amnesia.
        Emerg Med J. 2002; 19: 515-519
      1. Advanced Life Support Group. Advanced Paediatric Life Support (APLS): the practical approach. 5th edition. Oxford. BMJ Books; 2011. 117 p.