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ReviewBritish Journal of Neuroscience Nursing August/September 2014 Vol 10 No 4 179© 2014 MA Healthcare LtdThe Glasgow Coma Scale 40 years on:a review of its practical usequestioned its ability to meet the standards of modernevidence-based medicine (Green, 2011).The widespread use of the GCS has perhaps led tonon-standardised practices and inappropriate use incertain settings. An exact understanding of its relevance and use, terminology and the method used toelicit responses is essential for health professionals touse the GCS appropriately and reliably in clinicalpractice. Variations and non-standardised practicehave potentially serious clinical implications forpatient safety.AimThe purpose of this paper is to review the use of theGCS in clinical practice 40 years after its creation.The paper aims to highlight and clarify some of thesubjective and confusing aspects of GCS use, with aparticular focus on the use of painful stimulus.Siobhan McLernonThe Glasgow Coma Scale (GCS) was originally devised by Teasdale and Jennett in 1974 to objectively determine the level of impairedconsciousness in a wide range of disorders. Thecentral edict of the GCS was that it could be quicklyand simply used by a wide range of healthprofessionals, enabling reliable repeated bedsideassessment. It was also intended to enable earlydetection of a deterioration in consciousness level,which is often the earliest and most sensitive indicatorof a change in neurological status (Hickey, 2009).Another aim was to improve communication betweenpractitioners caring for patients with altered levels ofconsciousness (Teasdale and Jennett, 1974).Prior to the development of the GCS, unstructuredterms and general descriptions were used to describepatients’ consciousness levels, such as ‘semi-comatose’,‘stuporose’ ‘obtunded’ and ‘decerebrate’. Thesedescriptions resulted in confusion, loss of informationand diffculties in communication between healthprofessionals (Matis and Birbilis, 2008).The GCS has been adopted worldwide and hasgained validated ubiquitous use in many clinicalconditions, such as overdose (Livingstone et al, 2000),infection (Holdgate et al, 2006), drowning (Brattonet al, 1994) and cardiac arrest (Schefold et al, 2009). Itforms the basis of the World Federation ofNeurological Surgeons (WFNS) grading scale forsubarachnoid haemorrhage (SAH) (Ogungbo, 2003)and is incorporated into several clinical guidelines tooptimise the care and triage of patients followingtraumatic brain injury (TBI) (Brain TraumaFoundation, 2007; National Institute for Health andCare Excellence (NICE), 2014).Over recent decades some criticisms surroundingthe GCS and its clinical applicability and reliabilityhave appeared in the literature. It has been suggestedthat its ease of use opens it up to misinterpretationand misapplication (Addison and Crawford, 1999).Concerns regarding inaccuracy in GCS scoring in dailypractice have been raised that threaten to diminish itsclinical value (Zuercher et al, 2009; Middleton, 2012).Several authors have argued that the GCS containsmultiple subjective elements, particularly around theapplication of painful stimuli and motor response(Gill et al, 2007; Barlow, 2012). These criticisms haveAbstractThis year sees the celebration of the 40th anniversary of the Glasgow ComaScale (GCS), which is as relevant in clinical decision making now as it was40 years ago. The GCS was originally devised in 1974 as a simple bedsidetool to improve clarity and consistency in communication about patientswith impaired consciousness in a wide range of disorders. Impairedconsciousness is an expression of dysfunction of the brain as a whole. Overthe decades there has been increasing evidence of variation in theconsistency of GCS assessment in clinical practice. Education and experiencein the use of the GCS are important factors that have been shown toimprove the reliability and accuracy of GCS scoring. The use of differentexamination techniques, especially the application of painful stimulation,contributes to inconsistency. A standardised approach is required for safetherapeutic clinical decision making and clear communication betweenhealth professionals. Novel approaches to education are required tostandardise practice, and explicit guidelines aimed at improving its overallapplication in clinical practice are needed.Key Words Glasgow Coma Scale, GCS, consciousness, brain injuriesAuthor Siobhan McLernon, Senior Lecturer, London Southbank UniversityCorrespondence [email protected] 30 June 2014This article has been subject to double-blind peer review.Downloaded from by on December 4, 2020.Review180 British Journal of Neuroscience Nursing August/September 2014 Vol 10 No 4© 2014 MA Healthcare Ltdemergency departments accurately and reliably identifythe small number of patients who will go on to haveserious acute complications.Further work by Gill et al (2004; 2005; 2007) reportedlow-to-moderate IR reliability when performing theGCS in patients with impaired consciousness in A&Esettings. These studies also identifed that the motorresponse rating to painful stimuli was problematic inrelation to IR reliability and accuracy. These fndingsconcur with Teasdale et al’s (1978) earlier work andperhaps indicate that the use of painful stimulusremains the most subjective and confusing aspect ofthe GCS’s performance.It remains unclear whether the GCS has adequateIR reliability as there is a lack of consistency in theresearch base (Baker, 2008; Zuercher et al, 2009).There is not a single ‘absolute’ value for the IR reliability of the GCS and, as discussed earlier, it may be highor low. However, of most relevance are the factors thatinfluence the GCS’s reliability, how prevalent they arein practice and what can be done to promote goodpractice. Clinical decisions need to be based on otherclinical and radiological fndings in conjunction withthe GCS. Neurological assessment should also includevital signs, pupillary response and limb movements.Effects of experience and educationon GCS performanceLack of experience and education have been found tocontribute to inaccurate scoring of the GCS in avariety of settings (Waterhouse, 2008; Zuercher et al,2009; Mattar et al, 2013). Teasdale and Jennett’s(1974) early work found that exposing observers to atraining flm on rating patients’ responses reduceddisagreement rates from 20% to 3%. They concludedthat the GCS required clearly defnable criteria toensure reliable rating. Subsequent studies have concluded that there is a need for education in the use ofthe GCS to improve IR reliability and that experiencein the use of the scale reduces variability (Teasdaleet al, 1978; Dewey et al, 1999; O’Farrell and Zou,2008; Waterhouse, 2008).Rowley and Fielding’s (1991) landmark study foundthat the reliability of the GCS increased with experienceand that inexperience was associated with a high rateof errors when using the GCS. Nurses with varyingamounts of experience and from several clinical settingshave also been found to have a lack of knowledgeregarding the underpinning pathophysiology of thethree components of the GCS (Waterhouse, 2008). It isunclear whether knowledge of relevant pathophysiologyimproves overall performance of GCS assessment andthis is perhaps an area for future research.It is imperative that the GCS has adequate reliabilityto ensure patient safety and inform diagnostic andtherapeutic clinical decision making. High variabilityof the GCS and its overall score may lead to underor over-treatment. Incorrectly low GCS scores mayFactors that affect the performance of the GCS arediscussed and recommendations for future use anddevelopment are presented.Literature reviewA literature search was conducted in the MEDLINE,CINAHL, Scopus and Cochrane library databases forarticles dating from 1974 to January 2014. Medicalsubject headings (MeSH) terms used in the searchwere ‘Glasgow Coma Scale’, ‘GCS’, ‘consciousness’and ‘brain injuries’ together with ‘education’, ‘assessment’ and ‘inter-rater reliability’. An internet searchfor recent policy and guidance documentation wasalso conducted, and Google Scholar was alsosearched. The reference lists of relevant GCS articleswere hand-searched for further relevant papers.Inter-rater reliability and accuracyof GCS scoringThe GCS should demonstrate high levels of agreementand consistency of scoring between observers(Teasdale and Jennett, 1974; Baker, 2008). Agreementbetween observers is known as inter-rater (IR) orinter-observer reliability. Reliability relates to consistency between observers but also consistency betweenscores (Baker, 2008). Inter-rater reliability for comascales is generally presented as a weighted kappavalue. This is a measure of agreement between two ormore observers accounting for variability based onchance alone (Kornbluth and Bhardwaj, 2011). Avalue of 1 indicates good agreement and a value of 0indicates agreement by chance alone. Therefore thehigher the kappa score the better the reliability. GoodIR reliability reduces the risk of error and enhancespatient safety.Teasdale et al’s (1978) original work described IRreliability in terms of a ‘disagreement rate’ as thekappa statistic was not in existence. The workdemonstrated good IR reliability between experiencedobservers. However, observations of motor responseselicited by supraorbital painful stimulus were notalways reliable among the observers. Subsequentstudies have demonstrated reliability to be high(Heard and Bebarta, 2004: Holdgate et al, 2006) tolow (Gill et al, 2007) with kappa indices in the rangeof 0.32 to 0.85 when including a variety of observersin several settings.Studies conducted in accident and emergency(A&E) departments have revealed highly variable IRreliability (Kelly et al, 2004; Kerby et al, 2007). Higherror rates have been found in patients with ‘intermediate’ levels of consciousness (i.e. GCS scores of9–12) (Rowley and Fielding, 1991; Kerby et al, 2007).This fnding has clinical signifcance as patients in thiscategory with fluctuating levels of consciousness areperhaps the most vulnerable—they are alreadycompromised and are therefore more likely to deteriorate (Jennett, 2002). It is therefore imperative thatDownloaded from by on December 4, 2020.ReviewBritish Journal of Neuroscience Nursing August/September 2014 Vol 10 No 4 181© 2014 MA Healthcare Ltdlead to unnecessary clinical decisions being made,such as unnecessary referral and imaging (Zuercheret al, 2009). At worst, under-treatment may lead toundetected clinical deterioration, which may have lifethreatening consequences. GCS assessments must bereproducible at a single point in time, and changes inthe patient’s condition reported in a timely fashion.Knowledge gained through education and previousneurosurgical experience have been found to be statistically signifcant with regard to nurses’ accuracy andability to perform assessment of consciousness whenusing the GCS (Heron et al, 2001; Chan et al, 2013;Mattar et al, 2013). Continuing education of healthprofessionals is essential to improve knowledge andunderstanding of GCS assessment in clinical practiceas well as standardisation across different clinicalsettings (Teasdale et al, 2014). Broad-reaching novelapproaches to education, such as web-based animations and algorithms on how to perform the GCS,may also enhance its use.Painful stimuliOver time the indications for applying ‘peripheral’ vs‘central’ painful stimuli to elicit a particular responsehave become obscured (Price, 2002). The confusionappears to be around when and where to use painfulstimuli. Variations of both the description of motorresponses and the methods used to elicit them haveappeared in the literature (Price, 2002; Holdgate et al,2006). The aim of applying painful stimuli is to assessthe level of consciousness of a patient who is in analtered state (Waterhouse, 2009). Only two sections ofthe GCS observation chart potentially require theapplication of painful stimulus: the eye openingsection (application of peripheral stimuli) and thebest motor response section (application of centralperipheral stimuli in the frst instance).Central or peripheral sites refer to parts of the bodyonly, as all painful stimulus is initially transmittedperipherally via spinal and cranial nerves to thecentral nervous system (Purves et al, 2008). Variouslocations have been used to apply painful stimuli,such as in the use of ear lobe pressure (Barlow, 2012),jaw margin pressure (Waterhouse, 2005; Palmer andKnight, 2006) and sternal rub (Iacono and Lyons,2005; Holdgate et al, 2006; Palmer and Knight, 2006).However, the use of these locations should be avoided(Teasdale and Jennett, 1974; Addison and Crawford,1999). Variability in the application of painful stimuliis a cause for concern as it may compromise thereliability of the scale.During the assessment of eye opening, if the patientdoes not eye open spontaneously or to speech thenpainful stimuli must be used. Central painful stimulisuch as supraorbital ridge pressure should be avoidedas they can cause reflex screwing up of the eyelids.Peripheral painful stimulus should therefore be usedto ascertain eye opening to pain. This was originallyperformed by applying pressure with a pen or pencilto the fngertip (i.e. nailbed) (Teasdale and Jennett,1974; Teasdale, 1975). However, concerns were raisedthat nailbed pressure can damage the nail, nailbedand underlying matrix, particularly when performedat frequent intervals (Price, 2002; Waterhouse, 2005).Experienced nurses have also reported that applyingregular painful stimuli to patients can be an emotionaland distressing experience for them even if they understand its necessity (Bartlett, 2000). More recently,application of pressure with a pen or pencil to thelateral outer aspect of the third or fourth digit has beenadvocated as this causes less local damage and elicitsthe same response (Waterhouse, 2008). Pressure shouldbe applied with gradually increasing intensity for up toa maximum of 10–15 seconds and then released. If thepatient is able to open his/her eyes to pain, this demonstrates the integrity of the spinal pathways to thereticular formation (Waterhouse, 2008). Local pathologymay cause the patient to be unable to open their eyes,therefore the enforced closure of the eye can be recordedas C (=eyes closed) on the chart.If the patient cannot obey commands and is unableto eye open spontaneously or to speech it is at thispoint that the observer would go on to assess bestmotor response. The word ‘best’ refers to the bestlevel of upper limb response shown at the time ofassessment and is a reflection of the integrity of thebrain as a whole (Middleton, 2012). To decide whetherthe best motor response is localising, a ‘centralperipheral’ painful stimulus (i.e. applied to the heador neck) is required (Teasdale et al, 1978).Supraorbital nerve pressure is often diffcult to applyas fnding the exact location requires expertise. It isalso contraindicated in the case of signifcant periorbital injury (Teasdale and Jennett, 1974). A suitablealternative is pinching the upper outer border of thetrapezius muscle (neck), as this stimulus is transmittedvia cervical sensory nerves, i.e. the spinal accessorynerve (cranial nerve XI) (Teasdale and Jennett, 1974;Barlow, 2012). The patient should raise one handabove the clavicle to the site of stimulation in anattempt to remove the stimulus, and this is recordedas localising. If the patient opens his/her eyes andmoves his/her arms, there is no need to use peripheralpainful stimulus (Waterhouse, 2009). However, if theydo not then application of peripheral painful stimuliallows the assessment of specifc limb function, suchas normal and abnormal flexion and extension topain. A normal flexion response is characterised byrapid flexion of the elbow, often accompanied by lifting the elbow clear of the body. An abnormal flexionresponse is characterised by elbow flexion accompanied by a spastic flexion of the wrist (Barlow, 2012).An extension response is indicated by extension of theelbow accompanied by pronation of the forearm(Waterhouse, 2005). The upper limb with the bestresponse (right/left) should be documented clearly.Downloaded from by on December 4, 2020.Review182 British Journal of Neuroscience Nursing August/September 2014 Vol 10 No 4© 2014 MA Healthcare LtdIn brainstem death, a spinal reflex may still bepresent and cause the legs to flex in response to painapplied locally. It is for this reason and because theupper limbs show a wide range of responses that bestupper limb response should always be documented(Teasdale et al, 1978). To ensure consistency the nursetaking over the patient’s care at handover shouldobserve how the GCS assessment was obtained anddocumented (Waterhouse, 2005). It is imperative thatthe method and location of painful stimulation usedto elicit patient responses is maintained until a maximum response is elicited so that the signifcance ofthe response is correctly interpreted (Barlow, 2012).Inconsistencies in application are perhaps a result ofimprecise, variable or absent defnitions.Changes in GCS assessment act as a clinicalindication for important clinical decision making,such as the need for medical review, when to seekneurosurgical opinion and when to intubate andventilate a patient prior to transfer (NICE, 2014). It istherefore of utmost importance that every aspect ofGCS assessment is conducted in a systematic andstandardised manner by competent health professionalsto avoid under- or over-treating patients and to ensurepatient safety. The practice of applying painful stimulito patients who have hemiplegic limbs who are awareand awake and are no longer in the acute phase ofneurological illness should be discouraged.Practical considerationsResponsiveness may fluctuate in the hours after acuteinjury or disease and so the GCS should be assessedas early as possible post-resuscitation to provide abaseline and for the early detection of clinicaldeterioration (Jennett, 2002; NICE, 2014).The GCS score is the numerical equivalent of theGCS and was designed for research and audit purposesas well as the development of guidelines (Barlow,2012). The GCS score is not intended to be used todescribe individual patients in a clinical situation.Sometimes the score cannot be calculated accuratelyas one or more of the individual components of theGCS are not measurable (e.g. if the patient has a tracheostomy the verbal response cannot be assessed).Additionally, using the GCS score rather than thescale may lead to a loss of useful information anddiminished clinical usefulness (Teoh et al, 2000). Adescription of individual patients in the case notes,during handovers and in referrals should always bemade in words using the GCS (e.g. a patient scoring13/15 should be documented as E4,V4,M5 (Jennett,2002; Barlow, 2012; NICE, 2014).The timing and frequency of observations shouldbe adjusted based on the following criteria: the risk ofcomplications, the patient’s condition, how much timehas passed since the injury or neurosurgical procedureand how much change is observed. The patient’sresponse indicates the level of cerebral functioningand must be graphed as the GCS is a measure oftrend and change not a static or exact level of consciousness (Middleton, 2012). Changes in the overalltrend demonstrated by a series of regular observationsprovide a powerful clinical reflection of neurologicalstate, which may act as a trigger for medical reviewand possible intervention (NICE, 2014).Experienced observers may identify subtle changesin the patient (Waterhouse, 2005). An increase in thestimulus needed to elicit the same response may indicate a reduction in the level of cerebral functioning,which may not alter the GCS score at the time ofassessment. However, this subtle change usuallyrequires an increase in the frequency of assessmentand must be documented (Palmer and Knight, 2006).GCS assessment should therefore be performed byknowledgeable and experienced health professionalsin a systematic and standardised way to ensure thatchanges in the patient’s neurological state are detectedrapidly and accurately.LimitationsOne of the most frequently documented limitationsof the GCS is its inability to assess verbal response inendotracheally intubated patients with analgesia andsedation (Brunker, 2006; Green, 2011; Kornbluth andBhardwaj, 2011). Patients with severe TBI (GCS 8 orless) require airway management via endotrachealintubation (NICE, 2014). TBI management makesGCS assessment challenging as patients often requireanalgesia, sedation and short-acting neuromuscularblockade to facilitate ventilation and ongoing management. GCS assessment is therefore inappropriatefor this group of patients (Teasdale and Murray,2000). In the intensive care setting, assessments suchas pupillary response, intracranial pressure trends andmultimodal monitoring techniques are used to assessfor increasing severity of cerebral injuries during theacute phase (Tisdall and Smith, 2007). However, it isoften still possible to assess ‘best’ motor responsewhen analgesia and sedation are reduced or discontinued. This has prognostic signifcance for mortality(Healey et al, 2003; Zuercher et al, 2009). Assessmentof sedated head-injured patients using the GCSinvolves disturbing them and often involves inflictingpain. Clinicians need to question daily and on anindividual basis the clinical need to carry out GCSassessment in this group of patients to avoidunnecessary and unjustifed use (Brunker, 2006).A language barrier is common in clinical settings,and can make verbal response diffcult to assess(Teasdale, 1975). However, this can normally beovercome by involving the family where possible aswell as by using non-verbal methods of communication such as writing to ascertain whether the patientunderstands and can interpret what is being asked.Dysphasia reflects focal damage to one of thespeech centres and can sometimes make it diffcult toDownloaded from by on December 4, 2020.ReviewBritish Journal of Neuroscience Nursing August/September 2014 Vol 10 No 4 183© 2014 MA Healthcare Ltddistinguish between confusion and disturbances inspeech function (Hickey, 2009). Existing speech disturbances prior to injury should be established anddocumented. Regardless of the aetiology and natureof dysphasia it is important to document ‘D’ in themost appropriate section of the GCS so that any deterioration in speech can be detected (Waterhouse,2005). Documentation must include the rationale forchoosing a particular section in the verbal componentand this must be clearly communicated at handoverand in the case notes. Patients with dementia, underlying chronic neurological disorders or learningdisabilities also challenge GCS assessment as the preinjury baseline may be less than 15. This should beestablished as soon as possible and taken into accountduring assessment (NICE, 2014).In an attempt to address some of the limitations ofthe GCS, several alternative scoring systems havebeen proposed (Kornbluth and Bhardwaj, 2011). TheFull Outline of Unresponsiveness (FOUR) scale hasgained most prominence as a suitable replacement tothe GCS for patients in the intensive care settingfollowing the acute phase of neurological injury ordisease (Wijdicks et al, 2005; Bruno et al, 2011).However, further research is required to determine thepredictive validity and reliability of the scale in avariety of patient populations. Despite the GCS’slimitations it remains the tool of choice in clinicalpractice worldwide. Consensus on methods to addressits limitations will maintain its role in clinical practiceand research in the future (Teasdale et al, 2014).Conclusion and recommendationsfor future practiceThe GCS is a quick and simple tool for assessingimpairment of consciousness during the acute phaseof neurological injury or disease. Its incorporationinto clinical guidelines recognises its correlation to theextent of damage and the risk of complications.Inconsistency in the use of the GCS in clinical practice, particularly around the application of painfulstimuli, indicates that further education is required.The quality assurance of adequate IR reliability isimportant as considerable variations have beenreported, particularly in the A&E setting. There is ageneral consensus in the literature that education andexperience improve reliability among observers andimprove the accuracy of GCS scoring. Observersperforming the GCS assessment must therefore beadequately trained and competent to ensure accurateand reliable assessment.The GCS is not an appropriate tool for use inchronic neurological conditions. Health professionalsmust therefore ensure that they are using the righttool for the right patient and the correct injury stateat the right time.Novel approaches to education are required on anongoing basis to maintain skills in the assessment ofconsciousness, particularly in acute care settings wherepatients are at risk of clinical deterioration. There is agrowing need for explicit standardised guidelines andprecise defnitions on how and when to perform theGCS assessment in clinical practice. These guidelineswould aim to resolve current inconsistencies andvariability in practice as well as improve IR reliabilityand patient safety. BJNNAcknowledgmentsI would like to thank Professor Sir Graham Teasdale for his help andsupport in the preparation of this paper.Declaration of interestsThis work had no external sources of funding. The author has noconflicts of interest to declare.Addison C, Crawford B (1999) Not bad, just misunderstood. NursTimes 95(43): 52–3Baker C (2008) Reviewing the application of the Glasgow ComaScale: Does it have interrater reliability? Br J Neurosci Nurs 4(7):342–7Barlow P (2012) A practical review of the Glasgow Coma Scaleand Score. Surgeon 10(2): 114–9. doi: 10.1016/j.surge.2011.12.003Bartlett A (2000) The Glasgow Coma Scale. Unpublisheddissertation. University of The West of England, BristolBrain Trauma Foundation (2007) Guidelines for the Management ofSevere Traumatic Brain Injury. 3rd edn. 8 July 2014)Bratton SL, Jardine DS, Morray JP (1994) Serial neurologicexaminations after near drowning and outcome. 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J Nurs Manag 21(1): 31–46.Key Points■ A standardised approach is required for safe therapeutic clinical decisionmaking and clear communication between health professionals.■ After 40 years, the Glascow Coma Scale (GCS) remains clinically relevantand is used ubiquitously worldwide for early detection of a deteriorationin consciousness level.■ Variations and discrepancies still exist in the application of painfulstimulus and this is an area for continued education.■ Experience and knowledge gained through education improve nurses’accuracy and ability in performing GCS assessment.■ Educational interventions and guidelines in using the GCS are essential toimprove knowledge and understanding of GCS assessment in clinicalpractice. Broad-reaching novel approaches to education such as webbased animations and algorithms on how to perform the GCS may alsoenhance its use.Downloaded from by on December 4, 2020.Review184 British Journal of Neuroscience Nursing August/September 2014 Vol 10 No 4© 2014 MA Healthcare Ltddoi: 10.1111/j.1365-2834.2011.01344.xDewey HM, Donnan GA, Freeman EJ et al (1999) Interraterreliability of the National Institutes of Health Stroke Scale:rating by neurologists and nurses in a community-based strokeincidence study. Cerebrovasc Dis 9(6): 323–7Gill MR, Reiley DG, Green SM (2004) Interrater reliability ofGlasgow Coma Scale scores in the emergency department. AnnEmerg Med 43(2): 215–23Gill M, Windemuth R, Steele R, Green SM (2005) A comparisonof the Glasgow Coma Scale score to simplifed alternative scoresfor the prediction of traumatic brain injury outcomes. 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Aust Crit Care 14(3): 100–5Holdgate A, Ching N, Angonese L (2006) Variability in agreementbetween physicians and nurses when measuring the GlasgowComa Scale in the emergency department limits its clinicalusefulness. Emerg Med Australas 18(4): 379–84Hickey JV (2009) The Clinical Practice of Neurological andNeurosurgical Nursing. 6th edn. Lippincott Williams and Wilkins,New YorkIacono LA, Lyons KA (2005) Making GCS as easy as 1, 2, 3, 4, 5,6. J Trauma Nurs 12(3): 77–81Jennett B (2002) The Glasgow Coma Scale: History and currentpractice. Trauma 4(2): 91–103Kelly CA, Upex A, Bateman DN (2004) Comparison ofconsciousness level assessment in the poisoned patient using thealert/verbal/painful/unresponsive scale and the Glasgow ComaScale. Ann Emerg Med 44(2): 108–13Kerby JD, MacLennan PA, Burton JN, McGwin G, Rue LW (2007)Agreement between prehospital and emergency departmentglasgow coma scores. J Trauma 63(5): 1026–31Kornbluth J, Bhardwaj A (2011) Evaluation of coma: a criticalappraisal of popular scoring systems. Neurocrit Care 14(1): 134–43. doi: 10.1007/s12028-010-9409-3Livingston BM, Mackenzie SJ, MacKirdy FN, Howie JC (2000)Should the pre-sedation Glasgow Coma Scale value be used whencalculating Acute Physiology and Chronic Health Evaluationscores for sedated patients? Crit Care Med 28(2): 389–94Matis G, Birbilis T (2008) The Glasgow Coma Scale–a briefreview. Past, present, future. Acta Neurol Belg 108(3): 75–89Mattar I, Liaw SY, Chan MF (2013) A study to explore nurses’knowledge in using the Glasgow Coma Scale in an acute carehospital. J Neurosci Nurs 45(5): 272–80. doi: 10.1097/JNN.0b013e31829db970Middelton PM (2012) Practical use of the Glasgow Coma Scale; acomprehensive narrative review of GCS methodology. AustralasEmerg Nurs J 15(3): 170–83. doi: 10.1016/j.aenj.2012.06.002National Institute for Health and Care Excellence (2014) HeadInjury: Triage, Assessment, Investigation and Early ManagementOf Head Injury In Infants, Children And Adults. NICE, LondonO’Farrell B, Zou GY (2008) Implementation of the CanadianNeurological Scale on an acute care neuroscience unit: aprogram evaluation. J Neurosci Nurs 40(4): 201–11Ogungbo B (2003) The World Federation of Neurological Surgeonsscale for subarachnoid haemorrhage. Surg Neurol 59(3): 236–7Palmer R, Knight J (2006) Assessment of altered conscious level inclinical practice. Br J Nurs 15(22): 1255–9Price T (2002) Painful Stimuli and the Glasgow Coma Scale. NursCrit Care 7(1): 19–23Purves D, Augustine GJ, Fitzpatrick D et al (2008) Neuroscience.4th edn. Sinauer Associates, MassachussettsRowley G, Fielding K (1991) Reliability and accuracy of theGlasgow Coma Scale with experienced and inexperienced users.Lancet 337(8740): 535–8Schefold JC, Storm C, Krüger A, Ploner CJ, Hasper D (2009) TheGlasgow Coma Score is a predictor of good outcome in cardiacarrest patients treated with therapeutic hypothermia.Resuscitation 80(6): 658–61. doi: 10.1016/j.resuscitation.2009.03.006Teasdale G (1975) Acute impairment of brain function-1. Assessing‘conscious level’. Nurs Times 71(24): 914–7Teasdale G, Jennett B (1974) Assessment of coma and impairedconsciousness. A practical scale. Lancet 2(7872): 81–4Teasdale GM, Murray L (2000) Revisiting the Glasgow Coma Scaleand Coma Score. Intensive Care Med 26(2): 153–4Teasdale G, Knill-Jones R, van der Sande J (1978) Observervariability in assessing impaired consciousness and coma.J Neurol Neurosurg Psychiatry 41(7): 603–10Teasdale G, Maas A, Lecky F, Manley G, Stochetti N, Murray G(2014) The Glasgow Coma Scale at 40 years: standing the test oftime. Lancet Neurol 13(8): 844–54Teoh LS, Gowardman JR, Larsen PD, Green R, Galletly DC (2000)Glasgow Coma Scale: variation in mortality among permutationsof specifc total scores. Intensive Care Med 26(2): 157–61Tisdall MM, Smith M (2007) Multimodal monitoring in traumaticbrain injury: current status and future directions. Br J Anaesth99(1): 61–7Waterhouse C (2005) The Glasgow Coma Scale and otherneurological observations. Nurs Stand 19(33): 55–64Waterhouse C (2008) An audit of nurses’ conduct and recording ofobservations using the Glasgow Coma Scale. Br J Neurosci Nurs4(10): 492–9Waterhouse C (2009) The use of painful stimulus in relation toGlasgow Coma Scale observations. Br J Neurosci Nurs 5(5):209–15Wijdicks EF, Bamlet WR, Maramattom BV, Manno EM,McClelland RL (2005) Validation of a new coma scale:theFOUR score. Ann Neurol 58(4): 585–93Zuercher M, Ummenhofer W, Baltussen A, Walder B (2009) Theuse of Glasgow Coma Scale in injury assessment: a criticalreview. Brain Inj 23(5): 371–84. doi: 10.1080/02699050902926267Call for peer reviewersThe British Journal of Neuroscience Nursing is very grateful for the advice providedby its pool of dedicated volunteer peer reviewers and always appreciates new offersfrom experienced clinicians and academics interested in helping out.If you would like to be considered for the peer review team, please send a brief CV and details of your particular areas ofexpertise or interest to the Editor, Craig Nicholson: [email protected] for reviewers are available.Downloaded from by on December 4, 2020.


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