Verbal. 1= does not make sound, 2 = make incomprehensible sounds, 3 = inappropriate words, 4 = confused or disoriented, 5 = oriented and normal Motor. 1 = makes no movements, 2 = extends to pain (decerebrate), 3 = abnormal flexion to pain (decorticate), 4 = flexion withdrawal to pain, 5 = localizes pain, 6 = obeys command.
GCS (continued 1)GCS is the sum of eyes (1-4), verbal (1-5), and motor (1-6) scores: 3 is the lowest score and 15 is highest Pain testing done by pressure on fingernail bed, then supraorbital pressure, sternal nub (knuckle) Best verbal response: “incomprehensible” includes moaning without words, “inappropriate” response has words but no conversation, “confused” indicates coherent disoriented response, and “oriented” means correct name, age, where, and when.
GCS (continued 2)Best motor response (to pain): No response to pain; “extension” (abduct arm, rotate shoulder internally, pronate forearm, extend wrist); “abnormal flexion” (adduct arm, rotate shoulder internally, pronate forearm, flex wrist); “flexion withdrawal” (flex elbow, supinate forearm, flex wrist with supraorbital pressure or nail bed pressure); “localizes pain” (purposeful movement towards pain) “obeys commands” (grasp fingers, etc.).
GCS (continued 3)GCS indicates brain injury severity GCS ≤8 = severe brain injury GCS ≤9-12 = moderate head injury GCS ≥13 = minor head injury Unreliable when there is severe facial/eye swelling (E1c) intubation prevents verbal tests (V1t) children <36 months (Pediatric Glasgow Coma Scale) Modified GCS. Original GCS scale did not include abnormal flexion and was a 14 point scale.
Coma & Vegetative StatesComa is not well-understood. Greek word koma means “deep sleep” but coma is not sleep. Coma may last several days to weeks. Most patients come out of coma to a “vegetative” state. Recovery chance is related to length of state. 4-month vegetative state, recovery chance is 15% People have “awaken” after as long as 19 years A person in “vegetative state” may show sleep-wake cycles, opens eyes, but lacks cognitive function.
Persistent Vegetative States“Persistent vegetative state” (PVS) term was coined by Fred Plum and Bryan Jennet in 1972. Royal College of Physicians recommended terms: Continuous vegetative state >4 weeks. Permanent vegetative state >12 months and a medical diagnosis that it is “impossible” for informed medical expectation for mental state improvement. Australia uses “unresponsiveness”, not vegetative American Neurological Association wants PVS to mean “permanent vegetative state” after 3 months.
PVS DiagnosisThe prevalence of persistent vegetative state (PVS) is not known. In the U.S., 15,000-40,000 patients may have PVS (Hirsch, et al., 2005). Many doctors don’t know the difference between American Neurological Association and British criteria for permanent vegetative state (3m vs 1 year).