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Although the Glasgow Coma Scale (GCS) has been used for the purpose of quantification of altered level of consciousness both in patients with traumatic brain injury (1) and in those with non traumatic brain injury (1) (2), its continuing use has been questioned on the grounds of its undue complexity (3) (4) and its poor interrater reliability (1) (5).
One consequence of the undue complexity of the GCS is that it is not consistently remembered (3). In one study only 15% of military physicians calculated the GCS correctly in spite of the fact that all of them were were familiar with the scale and most had completed the advanced trauma life support course (3). In another study only 48% of clinicians correctly scored the GCS in a written clinical scenario, with neurosurgeons correct in only 56% of the time (4).
Poor interrater reliability is exemplified by a study in which independent paired assessments by attending emergency physicians showed that GCS scores were the same in only 38% of instances, and were 2 or more points apart in 33% (1). A prospective observational study examined the interrator reliability of the GCS and three other scales including the Simplified Motor Scale, when measured by 2 physicians within 5 minutes, in 120 adults presenting in the Emergency Department with altered levels of consciousness (5). Percentage agreement was 83% for the Simplified Motor Scale and only 42% for the GCS. The kappa statistic was 0.70 for the former, and 0.32 for the latter (5).
The GCS is also only grossly predictive of outcomes in patients with traumatic brain injury (6), and might, arguably, be even less predictive of outcomes in non-traumatic head injury patients such as the one in the vignette (2). "Indeed", to quote one authority, "it remains unstudied whether the GCS yields any independent contribution above and beyond unstructured clinical judgment alone" (6). Perhaps it is time we said "Cheerio, Laddie", and bade farewell to the GCS (6).
References
(1) Gill MR., Reiley DG., Green SM. Interrater Reliability of Glasgow Coma Scale Scores in the Emergency Department. Ann Emerg Med 2004;43:215-223
(2) Zhao X-h., Liu Y-m., Yang X., Wang S-z., Wang S-j. An older amn with memory impiarment an convulsions. BMJ 2017;358:j2824
(3) Riechers RG., Ramage A., Brown W et al. Physici8an knowledge of the Glagow Coma Scale. J Neurotrauma 2005;22:1327-1334
(4) Bassi S., Buxton N., Punt JA et al. Glasgow Coma Scale: a help or a hinderance? Nr J Neurosurg 1999;13:526-539
(5) Gill M., Martens K., Lynch EL., Salih A., Green SM. 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
(6) Green SM. Cheerio, Laddie! Bidding farewell to the Glasgow Coma Scale. Ann Emerg Med 2011;58:427-430
Competing interests:
No competing interests
07 July 2017
Oscar M Jolobe
retired geritrician
manchester medical society
Simon Building, Brunswick street, Manchester M13 9PL
Re: An older man with memory impairment and convulsions and the use of the Glasgow Coma Scale
Although the Glasgow Coma Scale (GCS) has been used for the purpose of quantification of altered level of consciousness both in patients with traumatic brain injury (1) and in those with non traumatic brain injury (1) (2), its continuing use has been questioned on the grounds of its undue complexity (3) (4) and its poor interrater reliability (1) (5).
One consequence of the undue complexity of the GCS is that it is not consistently remembered (3). In one study only 15% of military physicians calculated the GCS correctly in spite of the fact that all of them were were familiar with the scale and most had completed the advanced trauma life support course (3). In another study only 48% of clinicians correctly scored the GCS in a written clinical scenario, with neurosurgeons correct in only 56% of the time (4).
Poor interrater reliability is exemplified by a study in which independent paired assessments by attending emergency physicians showed that GCS scores were the same in only 38% of instances, and were 2 or more points apart in 33% (1). A prospective observational study examined the interrator reliability of the GCS and three other scales including the Simplified Motor Scale, when measured by 2 physicians within 5 minutes, in 120 adults presenting in the Emergency Department with altered levels of consciousness (5). Percentage agreement was 83% for the Simplified Motor Scale and only 42% for the GCS. The kappa statistic was 0.70 for the former, and 0.32 for the latter (5).
The GCS is also only grossly predictive of outcomes in patients with traumatic brain injury (6), and might, arguably, be even less predictive of outcomes in non-traumatic head injury patients such as the one in the vignette (2). "Indeed", to quote one authority, "it remains unstudied whether the GCS yields any independent contribution above and beyond unstructured clinical judgment alone" (6). Perhaps it is time we said "Cheerio, Laddie", and bade farewell to the GCS (6).
References
(1) Gill MR., Reiley DG., Green SM. Interrater Reliability of Glasgow Coma Scale Scores in the Emergency Department. Ann Emerg Med 2004;43:215-223
(2) Zhao X-h., Liu Y-m., Yang X., Wang S-z., Wang S-j. An older amn with memory impiarment an convulsions. BMJ 2017;358:j2824
(3) Riechers RG., Ramage A., Brown W et al. Physici8an knowledge of the Glagow Coma Scale. J Neurotrauma 2005;22:1327-1334
(4) Bassi S., Buxton N., Punt JA et al. Glasgow Coma Scale: a help or a hinderance? Nr J Neurosurg 1999;13:526-539
(5) Gill M., Martens K., Lynch EL., Salih A., Green SM. 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
(6) Green SM. Cheerio, Laddie! Bidding farewell to the Glasgow Coma Scale. Ann Emerg Med 2011;58:427-430
Competing interests: No competing interests