Glasgow coma scale

グラスゴー昏睡尺度、Glasgow昏睡尺度

WordNet

1. take by attacking with scaling ladders; "The troops scaled the walls of the fort"
2. a specialized leaf or bract that protects a bud or catkin (同)scale leaf
3. an ordered reference standard; "judging on a scale of 1 to 10" (同)scale of measurement, graduated table, ordered series
4. relative magnitude; "they entertained on a grand scale"
5. size or measure according to a scale; "This model must be scaled down"
6. the ratio between the size of something and a representation of it; "the scale of the map"; "the scale of the model"
7. a measuring instrument for weighing; shows amount of mass (同)weighing machine
8. a flattened rigid plate forming part of the body covering of many animals
9. an indicator having a graduated sequence of marks
10. (music) a series of notes differing in pitch according to a specific scheme (usually within an octave) (同)musical scale
11. a thin flake of dead epidermis shed from the surface of the skin (同)scurf, exfoliation
12. remove the scales from; "scale fish" (同)descale
13. reach the highest point of; "We scaled the Mont Blanc" (同)surmount
14. climb up by means of a ladder
15. measure by or as if by a scale; "This bike scales only 25 pounds"
16. measure with or as if with scales; "scale the gold"
17. pattern, make, regulate, set, measure, or estimate according to some rate or standard
18. (botany) a usually terminal tuft of bracts (as in the pineapple) or tuft of hairs (especially on certain seeds)
19. a state of deep and often prolonged unconsciousness; usually the result of disease or injury (同)comatoseness
20. (astronomy) the luminous cloud of particles surrounding the frozen nucleus of a comet; forms as the comet approaches the sun and is warmed
21. the act of arranging in a graduated series (同)grading
22. act of measuring or arranging or adjusting according to a scale
23. ascent by or as if by a ladder
24. largest city in Scotland; a port on the Clyde in west central Scotland; one of the great shipbuilding centers of the world

PrepTutorEJDIC

1. 《しばしば複数形で》『てんびん』,はかり / てんびんのさら / 《重量を表す副詞[句]を伴って》…の目方(体重)がある / …‘を'てんびんではかる
2. (蛇・魚類などの)うろこ / うろこ状の物;(ペンキ・さび・ふけなどの)爆片 / 〈魚など〉‘の'うろこを取る;…‘の'皮をはぐ / (…から)〈ペンキなどの薄泰〉‘を'そぎ取る《+『名』+『off』(『from』)+『名』》 / (…から)〈ペンキなどが〉かげ落ちる《+『off』(『from』)+『名』》
3. 『段階』,等級,階級 / 『比率』,縮尺 / (物差しなどの)『目盛り』 / (目盛りの付いた)『物差し』;温度計,(各種の)スケール / 『規模』,スケール / 音階 / 記数法,…進法 / …‘を'よじ登る / (…に合わせて)…‘を'調整する《+『名』+『to』+『名』》 / …‘を'縮尺で製図(設計)する
4. こん睡状態
5. コマ(彗星(すいせい)の核の周囲の星雲状物質) / (レンズの)非対称収差 / (種子の)種綿(たねわた)
6. グラスゴー(Scotland南西部の港市)
7. 『来たるべき』,『次の』 / 《話》前途有望な,今売り出し中の;新進の / (…の)『到来』,接近,致着(arrival)《+『of』+『名』》

Wikipedia preview

出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2014/02/02 15:57:38」(JST)

wiki en

[Wiki en表示]

Not to be confused with Glasgow Outcome Scale.

The Glasgow Coma Scale or GCS is a neurological scale that aims to give a reliable, objective way of recording the conscious state of a person for initial as well as subsequent assessment. A patient is assessed against the criteria of the scale, and the resulting points give a patient score between 3 (indicating deep unconsciousness) and either 14 (original scale) or 15 (the more widely used modified or revised scale).

GCS was initially used to assess level of consciousness after head injury, and the scale is now used by first aid, EMS, nurses and doctors as being applicable to all acute medical and trauma patients. In hospitals it is also used in monitoring chronic patients in intensive care.

The scale was published in 1974 by Graham Teasdale and Bryan J. Jennett, professors of neurosurgery at the University of Glasgow's Institute of Neurological Sciences at the city's Southern General Hospital.

GCS is used as part of several ICU scoring systems, including APACHE II, SAPS II, and SOFA, to assess the status of the central nervous system. A similar scale, the Rancho Los Amigos Scale is used to assess the recovery of traumatic brain injury patients.

Elements of the scale

Glasgow Coma Scale

	1	2	3	4	5	6
Eye	Does not open eyes	Opens eyes in response to painful stimuli	Opens eyes in response to voice	Opens eyes spontaneously	N/A	N/A
Verbal	Makes no sounds	Incomprehensible sounds	Utters inappropriate words	Confused, disoriented	Oriented, converses normally	N/A
Motor	Makes no movements	Extension to painful stimuli (decerebrate response)	Abnormal flexion to painful stimuli (decorticate response)	Flexion / Withdrawal to painful stimuli	Localizes painful stimuli	Obeys commands

The scale is composed of three tests: eye, verbal and motor responses. The three values separately as well as their sum are considered. The lowest possible GCS (the sum) is 3 (deep coma or death), while the highest is 15 (fully awake person).

Eye response (E)

There are four grades starting with the most severe:

1. No eye opening
2. Eye opening in response to pain stimulus. (a peripheral pain stimulus, such as squeezing the lunula area of the patient's fingernail is more effective than a central stimulus such as a trapezius squeeze, due to a grimacing effect).
3. Eye opening to speech. (Not to be confused with the awakening of a sleeping person; such patients receive a score of 4, not 3.)
4. Eyes opening spontaneously

Verbal response (V)

There are five grades starting with the most severe:

1. No verbal response
2. Incomprehensible sounds. (Moaning but no words.)
3. Inappropriate words. (Random or exclamatory articulated speech, but no conversational exchange)
4. Confused. (The patient responds to questions coherently but there is some disorientation and confusion.)
5. Oriented. (Patient responds coherently and appropriately to questions such as the patient’s name and age, where they are and why, the year, month, etc.)

Motor response (M)

There are six grades:

1. No motor response
2. Extension to pain (extensor posturing: abduction of arm, external rotation of shoulder, supination of forearm, extension of wrist, decerebrate response)
3. Abnormal flexion to pain (flexor posturing: adduction of arm, internal rotation of shoulder, pronation of forearm, flexion of wrist, decorticate response)
4. Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist when supra-orbital pressure applied ; pulls part of body away when nailbed pinched)
5. Localizes to pain. (Purposeful movements towards painful stimuli; e.g., hand crosses mid-line and gets above clavicle when supra-orbital pressure applied.)
6. Obeys commands. (The patient does simple things as asked.)

Interpretation

Individual elements as well as the sum of the score are important. Hence, the score is expressed in the form "GCS 9 = E2 V4 M3 at 07:35".

Generally, brain injury is classified as:

• Severe, with GCS < 9
• Moderate, GCS 9–12 (controversial)
• Minor, GCS ≥ 13.

Tracheal intubation and severe facial/eye swelling or damage make it impossible to test the verbal and eye responses. In these circumstances, the score is given as 1 with a modifier attached e.g. "E1c" where "c" = closed, or "V1t" where t = tube. A composite might be "GCS 5tc". This would mean, for example, eyes closed because of swelling = 1, intubated = 1, leaving a motor score of 3 for "abnormal flexion". Often the 1 is left out, so the scale reads Ec or Vt.

The GCS has limited applicability to children, especially below the age of 36 months (where the verbal performance of even a healthy child would be expected to be poor). Consequently the Pediatric Glasgow Coma Scale, a separate yet closely related scale, was developed for assessing younger children.

Revisions

• Glasgow Coma Scale: While the 15-point scale is the predominant one in use, this is in fact a modification and is more correctly referred to as the Modified Glasgow Coma Scale. The original scale was a 14 point scale, omitting the category of "abnormal flexion". Some centres still use this older scale, but most (including the Glasgow unit where the original work was done) have adopted the modified one.
• The Rappaport Coma/Near Coma Scale made other changes.
• Meredith W., Rutledge R, Fakhry SM, EMery S, Kromhout-Schiro S have proposed calculating the verbal score based on the measurable eye and motor responses.

Controversy

The GCS has come under pressure from some researchers that take issue with the scale's issues, such as poor inter-rater reliability and lack of prognostic utility. Although there is not an agreed upon alternative, the general suggestion is a simplified motor scale be used instead.

See also

• Blantyre Coma Scale
• Paediatric Glasgow Coma Scale
• Rancho Los Amigos Scale
• Revised Trauma Score

References

• Teasdale G, Jennett B (1974). "Assessment of coma and impaired consciousness: A practical scale". The Lancet 2 (7872): 81–4. doi:10.1016/S0140-6736(74)91639-0. PMID 4136544. 
• Teasdale G, Murray G, Parker L, Jennett B (1979). "Adding up the Glasgow Coma Score". Acta Neurochir Suppl (Wien) 28 (1): 13–6. PMID 290137. 
• Meredith W, Rutledge R, Fakhry SM, Emery S, Kromhout-Schiro S. (1998). "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 44 (5): 839–44; discussion 844–5. PMID 9603086. 

External links

• Website to calculate the Glasgow Coma Scale
• Glasgow Coma Scale at the US National Library of Medicine Medical Subject Headings (MeSH)
• An Android app to calculate GCS / PGCS

UpToDate Contents

全文を閲覧するには購読必要です。 To read the full text you will need to subscribe.

• 1. 成人における昏迷および昏睡 stupor and coma in adults
• 2. 小児における外傷の分類 classification of trauma in children
• 3. くも膜下出血の重症度分類 subarachnoid hemorrhage grading scales
• 4. 急性重度外傷性脳損傷のマネージメント management of acute severe traumatic brain injury
• 5. 小児における重度の外傷性脳損傷に対する初期アプローチ initial approach to severe traumatic brain injury in children

English Journal

• Intensive care for pediatric traumatic brain injury.

• Sigurtà A, Zanaboni C, Canavesi K, Citerio G, Beretta L, Stocchetti N.SourceFondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Neurointensive Care Unit and University of Milan, Milan, Italy, anna.sigurta@unimi.it.
• Intensive care medicine.Intensive Care Med.2013 Jan;39(1):129-36. doi: 10.1007/s00134-012-2748-0. Epub 2012 Nov 21.
• PURPOSES: The aims of this study are to describe a cohort of head-injured pediatric patients, focusing on current practice for intracranial pressure (ICP) monitoring and treatment and to verify the relationship between clinical and radiological parameters and the six-month outcome in a multivariable
• PMID 23179331

• Referral to Rehabilitation After Severe Traumatic Brain Injury: Results From the PariS-TBI Study.

• Jourdan C, Bayen E, Bosserelle V, Azerad S, Genet F, Fermanian C, Aegerter P, Pradat-Diehl P, Weiss JJ, Azouvi P; the Members of the Steering Committee of the PariS-TBI Study.Source1AP-HP, Hôpital R. Poincaré, Service de Médecine Physique et Réadaptation, Garches, France.
• Neurorehabilitation and neural repair.Neurorehabil Neural Repair.2013 Jan;27(1):35-44. Epub 2012 Mar 28.
• BACKGROUND: . After a severe traumatic brain injury (TBI), some patients are discharged home without rehabilitation, although rehabilitation is assumed to improve outcome.OBJECTIVE: . To assess factors that predict referral to rehabilitation following acute care. This study is part of a larger incep
• PMID 22460612

Japanese Journal

• Lower Extracellular Glucose Level Prolonged in Elderly Patients With Severe Traumatic Brain Injury : A Microdialysis Study

• YOKOBORI Shoji,WATANABE Akihiro,MATSUMOTO Gaku,ONDA Hidetaka,MASUNO Tomohiko,FUSE Akira,KUSHIMOTO Shigeki,YOKOTA Hiroyuki
• Neurologia medico-chirurgica = 神経外科 51(4), 265-271, 2011-04-15
• … To clarify the differences between elderly and young patients with TBI, brain metabolism parameters were monitored with the microdialysis method in 30 patients with severe TBI (Glasgow Coma Scale scores 3-8). …
• NAID 10028105138

• Usefulness of Computed Tomography in the Diagnosis of an Overdose

• Yanagawa Youichi,Nishi Kouichirou,Imamura Tomonori,Sakamoto Toshihisa
• Acta Medica Okayama 65(1), 33-39, 2011-02
• … The average Glasgow Coma Scale in the OD group (n＝11) was significantly lower than that in the Control group (n＝137). …
• NAID 120002807410

Related Links

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Japan Coma Scale III群 刺激しても覚醒しない 300 まったく動かない 200 手足を少し動かしたり顔をしかめる（除脳硬直を含む） 100 はらいのける動作をする II群 刺激すると覚醒する 30 かろうじて開眼する 20 痛み刺激で開眼する 10 呼びかけで ...

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Related Pictures

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★リンクテーブル★

国試過去問	「108F020」「109C008」
リンク元	「意識障害」「グラスゴー・コーマ・スケール」「グラスゴー昏睡尺度」「Glasgow昏睡尺度」
関連記事	「scale」「scaling」

「108F020」

　　[★]

• 48歳の男性。意識障害と右片麻痺のため搬入された。自発開眼はなく、呼びかけでも開眼しないが、痛み刺激で開眼する。痛み刺激でうなり声をあげるが、意味のある発語はみられない。また、痛み刺激で右上下肢は全く動きがみられないが、左上下肢は払いのける動作を示す。
• Glasgow coma scaleによる評価の合計点として正しいのはどれか。

• a　3点
• b　6点
• c　9点
• d　12点
• e　15点

[正答]

C

※国試ナビ4※　［108F019］←［国試_108］→［108F021］

「109C008」

　　[★]

• 頭部外傷で救急搬送された患者が、痛み刺激で開眼せず、意味不明の発声があり、疼痛刺激部分からの逃避運動をするとき、Glasgow coma scaleによる評価で正しいのはどれか。

• a　E2
• b　V3
• c　M4
• d　合計点9
• e　合計点11

[正答]

C

※国試ナビ4※　［109C007］←［国試_109］→［109C009］

「意識障害」

　　[★]

英

consciousness disturbance, disturbance of consciousness

関

意識

分類

時間による分類

急性/慢性, 持続性/一過性

• 急性＋一過性：失神、てんかん
• 慢性＋持続性：植物状態、認知症

PSY.38

• 単純な意識障害

明識困難状態 < 昏蒙 < 傾眠 < 昏眠 < 昏睡

• 複雑な意識障害

• せん妄　　　　　意識混濁　＋　(高度)精神運動興奮

• 振戦せん妄

• 作業せん妄

• 夜間せん妄

• もうろう状態　　意識狭窄　＋　(軽度)精神運動興奮
• アメンチア

• 意識障害に関連した特殊な病態

• 失外套症候群
• 無動無言症
• 閉じ込め症候群

意識レベルの分類 覚醒度

Mayo Clinicの分類

• 清明：alert
• 傾眠：somnolence
• 昏迷：stupor
• 半昏睡：semicoma
• 昏睡：coma

救急 意識障害をみたら

• AIUEOTIPS (also see DIF.96)

	症候学プリント		DIF.95
A	alcohol	アルコール関連	accidents, arterial occlusions, arteriosclerosis, aneurysms, autoimmune disorders
I	insulin	インスリン関連(低血糖、糖尿病性ケトアシドーシス、非ケトン性高浸透圧性昏睡)	inflammatory, intoxication (encephalitis, cerebral abcess, meningitis, alcoholism, opiates, barbiturates)
U	uremia	尿毒症、電解質異常、内分泌異常、肝性脳症	undefined disorders (narcolepsy, conversion hysteria)
E	encephalopathy, endocrinopathy, electrolyte	脳症(脳炎、脳血管障害)、てんかん後	endocrine disorders(myxedema coma, hyperparathyroidism, diabetic coma, insulin shock), epileptic coma
O	opiate, other overdose of O2 & CO2	薬物中毒	organ failure(hepatic coma, respiratory failure, uremia)
T	trauma, tumor, temparature	頭部外傷、脳挫傷、硬膜外血腫、硬膜下血腫
I	infection	感染症、髄膜炎
P	psychogenic	精神疾患
S	syncope, seizure, stroke, shock, senile	失神、クモ膜下出血

意識障害を来した患者が来た場合：どのような疾患を鑑別に挙げるべきか(IMD.237)

• 1. 脳原発の疾患(一次性)

• a. テント上病変(脳幹の圧迫性病変ないし脳ヘルニアをきたす疾患)

• 1) 脳血管障害:脳出血、脳梗塞
• 2) 硬膜下血腫
• 3) 脳腫瘍:原発性、転移性
• 4) 脳膿瘍

• b. テント下病変(脳幹網様体の障害)

• 1) 脳幹出血、脳幹梗塞、小脳出血、小脳梗塞、脳腫痛、多発性硬化症など

• c. びまん性病変

• 1) くも膜下出血、中枢神経感染症:髄膜炎、脳炎、 播種性血管内凝固症候群など

• 2. 全身疾患に伴う病態(二次性)

• a. 代謝性またはびまん性病変

• 1) ショック:心筋梗塞、大出血など
• 2) 薬物、毒物
• 3) 無酸素ないし低酸素血症
• 4) DIC、全身性感染症:敗血症など
• 5) 肝不全、腎不全、糖尿病性高血糖、重症肝炎、内分泌疾患など
• 6) 低血糖、ビタミンB1欠乏: Wernicke脳症
• 7) 脳振盪、てんかん大発作後
• 8) 酸塩基平衡および電解質異常
• 9) 栄養障害

• b. 心因性無反応

• 1) ヒステリー、統合失調症

意識障害をきたす電解質異常

QB.D-345

カリウムは静止膜電位にかかわるが、ニューロンの活動にはそれほど関わらないから、意識障害はきたしにくいのかもしれない。

pHの異常も局所的に干渉されるため意識障害をきたしにくいのかもしれない。

• 高カルシウム血症　：ニューロンの活動に関わる？
• 高ナトリウム血症、低ナトリウム血症　：APの発生に関わる
• 低リン血症　　　：ATP産生↓
• 低酸素血症　　　：ATP産生↓
• 高炭酸ガス血症　：CO2麻酔

意識障害の評価法

英

evaluation of consciousness disturbance

• Glasgow coma scale GCS
• Japan coma scale JCS

「グラスゴー・コーマ・スケール」

　　[★]

英

Glasgow Coma Scale Glasgow coma scale GCS

同

グラスゴー昏睡尺度

関

日本昏睡尺度

概念

• 意識障害の評価法の一つ。
• イギリスで作成された。
• 15点満点で、最小が3点。
• 軽症障害の分類が細かいとされる。

• 脳血管障害にはJCS
• 外傷にはGCS。

GCS

	開眼		言葉による応答		運動による応答
	eye opening		best verbal response		best motor response
6					命令に従う	obeying
5			指南力良好	orientated	払いのける	localication
4	自発的に	spontaneous	会話困難	confused conversation	四肢の屈曲	withdraws
3	言葉により	to speech	不適当な言葉	inappropriate words	四肢の異常屈曲	abnormal flexion
2	痛み刺激により	to pain	意味不明の声	incomprehensible sounds	四肢伸展	extending
1	開眼しない	none	発話せず	none	全くなし	none

評価

• 15点：意識清明
• 13～15点(3)：軽症
• 9～12点(4)：中等症
• 　～ 8点 ：重症
• 　　　3点：最も状態がわるい。

• GCS8点以下では意識低下とみなす。
• 頭部外傷でGCS8点以下は重症
• GCS8点以下 あるいは GCSスコアで2点以上の急激な悪化・瞳孔不同・片麻痺がある場合には切迫脳ヘルニアであることが多い。(重症頭部外傷治療・管理のガイドライン 第2版)
• GCS8点以下の重度意識障害、急速な意識レベルの低下、脳ヘルニア徴候を認めた場合にはsecondary surveyの最初でCTを撮影。(重症頭部外傷治療・管理のガイドライン 第2版)
• GCSスコア8以下、あるいはFCSスコアの最良運動反応が5以下であれば気管挿管を原則とした確実な気道確保が望ましい。(重症頭部外傷治療・管理のガイドライン 第2版)

「グラスゴー昏睡尺度」

　　[★]

英

Glasgow coma scale

関

Glasgow昏睡尺度

• グラスゴー・コーマ・スケール

「Glasgow昏睡尺度」

　　[★]

英

Glasgow coma scale

関

グラスゴー昏睡尺度

「scale」

　　[★]

• n.

• 1. (魚・は虫類の)うろこ。(チョウ・ガの)鱗粉。(皮膚の)鱗屑。薄片。(植物)芽鱗、鱗片。(動物)カイガラムシ。(金属を熱したときにできる)薄い酸化膜、スケール。(ボイラーややかんの内側にできる)湯垢。歯石。
• 2. 目盛り、定規、物差し、尺度、基準。(地図などの)縮尺比、縮尺目盛り。階級、等級。規模、スケール
• 3. はかり、てんびん

• vt.
• vi.

　 　 　 　 　 　 　 　 　 　 　 　 　 　 　 　 　 　 　 　

「scaling」

　　[★]

• n.

• スケーリング

• 縮尺や変換係数を定めること、歯石とプラークを除去すること