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Table of Contents
Year : 2019  |  Volume : 22  |  Issue : 2  |  Page : 149-150
In search of a better measuring scale of consciousness

Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Click here for correspondence address and email

Date of Web Publication9-Apr-2019

How to cite this article:
Kalita J, Misra UK. In search of a better measuring scale of consciousness. Ann Card Anaesth 2019;22:149-50

How to cite this URL:
Kalita J, Misra UK. In search of a better measuring scale of consciousness. Ann Card Anaesth [serial online] 2019 [cited 2023 Feb 1];22:149-50. Available from:

Coma is a robust predictor of death and poor outcome of any disease. Consciousness has two components: wakefulness and awareness. Wakefulness depends on the degree of consciousness and anatomical substrates of wakefulness are tegmentum of pons and mesencephalon with their projection ascending reticular fibers to the diencephalon and cortex. Awareness is a qualitative function of cortex after being wakeful.[1],[2] The contents of consciousness depend on the functions of various cortical structures and subcortical connections. Consciousness may range from alert to obtundation, delirium, torpor, stupor, and coma. Impaired consciousness may be due to diffuse cortical or pontomesencephalic dysfunction, which may be anatomical or physiological. The function of these anatomical structures may be evaluated by assessing consciousness, respiration pattern, papillary changes, eye movement, motor response, and cranial nerve functions. Coma scales are developed since 1969 to standardize these responses with an aim to predict severity, disease course, and outcome. The scale should easy and quick to apply and interpret in an emergency setting.

In the last five decades, five validated scales are available:

  1. Jouvet Coma Scale
  2. Moscow Coma Scale
  3. Glasgow Coma Scale (GCS)
  4. Bozza-Marrubini Scale
  5. Full Outline of UnResponsiveness (FOUR) Scale.

There are other coma scales such as Japanese Coma Scale and Innsbruck Coma Scale, which are not used internationally.

Jouvet Coma Scale has been reported in 1969 and is based on two parameters as follows: (1) perception to written and verbal command and orientation to time. (2) Reactivity to specific, nonspecific and autonomic stimuli. The overall score ranges between 4 and 14, and higher score suggests more severe coma.[3] This scale gives good clinicoanatomical correlation but is complex, difficult to use and time-consuming, hence not suitable for emergency setting.

Moscow Coma Scale has been reported in 1991 and is based on 15 clinical parameters with a total score of 15–75. Patients with a score of 15 often die.[4] This scale has excellent predictive value but not used outside Russia probably because of political and language isolation.

Bozza-Marrubini Coma Scale has been developed in 1983 and is based on reactivity to voice and pain, and brain stem reflexes (pupillary and the vestibulo-ocular reflex). The Bozza-Marrubini Coma Scale ranges between 3 and 37, lower the better.[5]

GCS was developed in 1974 by Teasdale and Jennett as a practical guide for assessing the level of consciousness in traumatic brain injury by the emergency doctor and health professionals. The GCS score ranges between 3 and 15 based on the eye (4), verbal (5) and motor (6) response. Lower the score, worse is the outcome; a cutoff of ≤8 is considered serious condition.[6] Since then, the GCS score has been enjoying its dominance throughout the world. Its use has been extended beyond the traumatic brain injury to stroke, encephalopathy, central nervous system infection, septicemia, or any disease with altered sensorium. The widespread use of GCS in the last four decades is because of its ability to predict death, functional outcomes, ease and quick to perform, and ability to show day-to-day variation.[7],[8],[9] The GCS, however, has been criticized for the following reasons: (a) eye-opening present in vegetative state, (b) verbal response is not possible to assess in the patients with aphasia, endotracheal tube, and orofacial trauma, (c) does not assess all the anatomical correlates of consciousness, and (d) high inter-rater and intra-rater variability. The accuracy of GCS score and its component has been reported by assessing 10 video vignettes, 2084 observations made by 217 emergency providers. Overall GCS scoring accuracy was only 33.1%. Verbal response had higher accuracy (69.2%) followed by eye-opening (61.2%) and motor response (59.8%).[10] Similar results have also been reported by other studies as well.[11],[12],[13]

To overcome these limitations of the GCS score, FOUR score was developed in 2005 by Wijdicks et al.[14] Instead of verbal response, FOUR score includes brainstem reflexes and respiration. Each of four domains (eye response, motor response, brain stem reflexes, and respiration) is given equal weight 0–4 marks, 0 being for the worst, and four being the best. The total score range between 0 and 16. It has an advantage of being easy to perform, assesses more detail neurological status than GCS, can predict herniation due to the inclusion of pupillary and vestibulo-ocular reflex and has a higher predictive value in intensive care unit (ICU) patients.[15] These advantages, however, were not found valid in a recent study. Kasprowick et al. compared utility of FOUR score and GCS score in predicting the outcome of the patients with traumatic brain injury. The FOUR score along with age, systolic arterial blood presence, the computed tomography (CT) Rotterdam score and need of mechanical ventilation on day 1 predicted ICU mortality. The GCS score also had similar predictive values for ICU mortality with the same set of predictors in addition to pupillary reflex. This highlights the advantage of the inclusion of pupillary reflex in the FOUR score. The CT Rotterdam score, age and either the FOUR or GCS score equally predicted unfavorable outcome at 3 months. The FOUR or GCS score at discharge rather than at admission had higher predictive value for the unfavorable outcome at 3 months. This study highlight equal predictive value of GCS score and FOUR score in multivariate analysis.[13] The verbal response in GCS and respiration in FOUR were found to be insignificant for mortality prediction in traumatic brain injury.[15] Wijdicks et al., however, found the good predictive value of FOUR score in different etiologies of ICU patients, and suggested that this may be due to the inclusion of brainstem reflex and respiration component.[16] It may be prudent to replace verbal response in GCS with pupillary reflex and to evaluate predictive model; or using permutation and combination of various coma scale parameters to derive a robust, short, and easy to apply scale if it is better than the most commonly used GCS for coma assessment.

The outcome of any critically ill patient, however, depends on reversibility, treatable etiology and extent of structural brain damage. The patients with malaria and scrub typhus in spite of being deeply comatose, on a mechanical ventilator have lower death and better outcome compared to tuberculous meningitis, as tuberculous meningitis is associated with infarction, hydrocephalous, and granuloma.[17],[18] Reversible metabolic coma such as hyponatremia and hyperosmolar coma has a better outcome than the patients with end-stage renal or hepatic failure.[19] Therefore, a single scale may assess severity and to some extent prognosis, but cannot give everything. Same cork may not be fitted to every bottle. Therefore, there is the role of human skill and intuition which help in knowing the deterioration before the scale scores the deterioration. Intuition is knowing without knowing how we know.


We would like to thank Mr. Shakti Kumar for secretarial help.

   References Top

Posner JB, Saper CB, Schiff ND, Plum F, Plum F, Posner JB. Diagnosis of Stupor and Coma. Contemporary Neurology Series. 4th ed. New York: Oxford University Press; 2007.  Back to cited text no. 1
Bateman DE. Neurological assessment of coma. J Neurol Neurosurg Psychiatry 2001;71 (Suppl 1):i13-7.  Back to cited text no. 2
Jouvet M. Coma and other Disorders of Consciousness. Handbook of Clinical Neurology. Vinken PJ, Bruyn GW, eds. Amsterdam: North-Holland Publishing Company; 1969:3.  Back to cited text no. 3
Shakhnovich AR, Mamadaliev AM, Abakumova LI. The prognosis of the outcomes of comatose states in the first 24 hours following craniocerebral trauma. Zh Vopr Neirokhir Im N N Burdenko 1991;6:11-2.  Back to cited text no. 4
Bozza Marrubini M. Classifications of coma. Intensive Care Med 1984;10:217-26.  Back to cited text no. 5
Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974;2:81-4.  Back to cited text no. 6
Teasdale G, Maas A, Lecky F, Manley G, Stocchetti N, Murray G, et al. The Glasgow coma scale at 40 years: Standing the test of time. Lancet Neurol 2014;13:844-54.  Back to cited text no. 7
Knaus WA, Zimmerman JE, Wagner DP, Draper EA, Lawrence DE. APACHE-acute physiology and chronic health evaluation: A physiologically based classification system. Crit Care Med 1981;9:591-7.  Back to cited text no. 8
Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli TA, Flanagan ME, et al. Arevision of the trauma score. J Trauma 1989;29:623-9.  Back to cited text no. 9
Bledsoe BE, Casey MJ, Feldman J, Johnson L, Diel S, Forred W, et al. Glasgow coma scale scoring is often inaccurate. Prehosp Disaster Med 2015;30:46-53.  Back to cited text no. 10
Gill MR, Reiley DG, Green SM. Interrater reliability of Glasgow coma scale scores in the emergency department. Ann Emerg Med 2004;43:215-23.  Back to cited text no. 11
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 Australas 2006;18:379-84.  Back to cited text no. 12
Bazarian JJ, Eirich MA, Salhanick SD. The relationship between pre-hospital and emergency department Glasgow coma scale scores. Brain Inj 2003;17:553-60.  Back to cited text no. 13
Wijdicks EF, Bamlet WR, Maramattom BV, Manno EM, McClelland RL. Validation of a new coma scale: The FOUR score. Ann Neurol 2005;58:585-93.  Back to cited text no. 14
Wijdicks EF, Kramer AA, Rohs T Jr. Hanna S, Sadaka F, O'Brien J, et al. Comparison of the full outline of UnResponsiveness score and the Glasgow coma scale in predicting mortality in critically ill patients. Crit Care Med 2015;43:439-44.  Back to cited text no. 15
Kasprowicz M, Burzynska M, Melcer T, Kübler A. A comparison of the full outline of unResponsiveness (FOUR) score and Glasgow coma score (GCS) in predictive modelling in traumatic brain injury. Br J Neurosurg 2016;30:211-20.  Back to cited text no. 16
Misra UK, Kalita J, Betai S, Bhoi SK. Outcome of tuberculous meningitis patients requiring mechanical ventilation. J Crit Care 2015;30:1365-9.  Back to cited text no. 17
Kalita J, Mani VE, Bhoi SK, Misra UK. Spectrum and outcome of acute infectious encephalitis/encephalopathy in an intensive care unit from India. QJM 2017;110:141-8.  Back to cited text no. 18
Misra UK, Kalita J, Bhoi SK, Dubey D. Spectrum of hyperosmolar hyperglycaemic state in neurology practice. Indian J Med Res 2017;146 Supplement:S1-7.  Back to cited text no. 19

Correspondence Address:
Jayantee Kalita
Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareily Road, Lucknow - 226 014, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aca.ACA_193_18

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