GlasgowComaScale-v3.1(2017EN)

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General information

Name: nl.zorg.GlasgowComaScale
Version: 3.1
HCIM Status:Final
Publication: 2017
Release status: Prepublished
Publication date: 04-09-2017

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Metadata

DCM::CoderList Kerngroep Registratie aan de Bron
DCM::ContactInformation.Address *
DCM::ContactInformation.Name *
DCM::ContactInformation.Telecom *
DCM::ContentAuthorList Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
DCM::CreationDate 29-11-2012
DCM::DeprecatedDate
DCM::DescriptionLanguage nl
DCM::EndorsingAuthority.Address
DCM::EndorsingAuthority.Name PM
DCM::EndorsingAuthority.Telecom
DCM::Id 2.16.840.1.113883.2.4.3.11.60.40.3.12.8
DCM::KeywordList Glascow coma schaal
DCM::LifecycleStatus Final
DCM::ModelerList Kerngroep Registratie aan de Bron
DCM::Name nl.zorg.GlasgowComaScale
DCM::PublicationDate 04-09-2017
DCM::PublicationStatus Prepublished
DCM::ReviewerList Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
DCM::RevisionDate 04-09-2017
DCM::Superseeds nl.zorg.GlasgowComaScale-v3.0
DCM::Version 3.1
HCIM::PublicationLanguage EN

Revision History

Concept

Fifteen-point scale for expressing a person’s level of consciousness, from fully awake to deep unconsciousness, in a number: the so-called EMV score.
The Glasgow Coma Scale score or EMV (Eye-Motor-Verbal) score is a scale to measure the extent of consciousness, based on eye, verbal and motor responses to specific prescribed sound and pain stimuli.

Purpose

The GCS score provides the opportunity to document a clinical observation of a patient’s conscious state with a validated instrument which makes use of a patient’s responses to stimuli.

Evidence Base

The Glasgow Coma Scale is used to evaluate a patient’s consciousness by means of three elements:

  1. opening eyes (eye response);
  2. answering questions (verbal response);
  3. motor response.

The three response values are looked at individually and as a whole. The total is referred to as the EMV score. The minimum total score is 3 and the maximum is 15. A slightly altered scale is used for infants (age 0-2) and toddlers (age 2-5).

The EMV score can be expressed as a combination of each of the three individual scores, such as: E3M2V4 (opens eyes when spoken to, arms stretch in response to pain and patient produces incomprehensible sounds).
If one of the EMV elements cannot be evaluated - such as might be the case if a patient is intubated and incapable of verbally responding, or is paralyzed/weak and incapable of fulfilling the motor request, then the individual score is included (score 1), but with an extra comment.
V1T is used for an intubated patient, in which t = 'tube'.
Clinical decisions must be based on each of the specific data of the eyes, motor and verbal responses and, if evaluation is not possible, an explicit explanation.

Standard values for the total score, depending on age:
0-6 months : 9 and up
6-12 months : 11 and up
1-2 : 12 and up
2-5 : 13 and up
> 5 : 14 and up

Information Model



Type Id Concept Card. Definition DefinitionCode Reference
NL-CM:12.8.1 GlasgowComaScale Root concept of the GlasgowComaScale information model. This root concept contains all data elements of the GlasgowComaScale information model.
35088-4 Glasgow coma scale
NL-CM:12.8.8 GlasgowComaScaleDateTime 1 Time at which the EMV score was determined.
NL-CM:12.8.2 GCS_Eyes 0..1 Best eye response to a stimulus. The element is mandatory, but does not require a numerical value. If no value is given, the reason for this is to be provided in the ConditionsDuringMeasurement concept.
281395000 Glasgow coma score eye opening subscore (observable entity)
GCS_EyesCodelist
NL-CM:12.8.4 GCS_Motor 0..1 Best motor response to a stimulus. The element is mandatory, but does not require a numerical value. If no value is given, the reason for this is to be provided in the ConditionsDuringMeasurement concept.
281396004 Glasgow Coma Score motor response subscore
GCS_MotorCodelist
NL-CM:12.8.6 GCS_Verbal 0..1 Best verbal response to a stimulus. The element is mandatory, but does not require a numerical value. If no value is given, the reason for this is to be provided in the ConditionsDuringMeasurement concept.
281397008 Glasgow coma score verbal response subscore (observable entity)
GCS_VerbalCodelist
GCS_VerbalCodelistBaby
GCS_VerbalCodelistToddler
NL-CM:12.8.10 TotalScore 0..1 The sum of the EMV scores, expressed as a number on a scale from 3-15. The value does not have to be recorded, as it can always be calculated based on the individual scores, and as recording the total is not common for a difficult to determine individual score.
NL-CM:12.8.11 ConditionsDuringMeasurement 0..* Conditions during the measurement that prevent one or more of the subscores from being determined (non testable), such as,e.g. intubation during testing of GCS_Verbal.
ConditionsDuringMeasurementCodelist
NL-CM:12.8.9 Comment 0..1 Comment on (the context of) the EMV score measurement, such as any problems or factors that may influence interpretation.
48767-8 Annotation comment

Columns Concept and DefinitionCode: hover over the values for more information
For explanation of the symbols, please see the legend page

Example Instances

Only available in Dutch

GlasgowComa ScaleDatumTijd GCS_Eyes GCS_Motor GCS_ Verbal TotaalScore Toelichting
08-02-2013 6:43 2 4 5 11 Beste score voor intubatie, kleding stond in brand
GlasgowComa ScaleDatumTijd GCS_Eyes GCS_Motor GCS_ Verbal TotaalScore Toelichting
07-02-2013 11:34 4 4 1 Lijkt adequaat
GlasgowComa ScaleDatumTijd GCS_Eyes GCS_Motor GCS_ Verbal TotaalScore Toelichting
07-02-2013 8:00 1 1 1 3 Zonder spierverslappers na 2 uur reanimatie

References

1. openEHR-EHR-OBSERVATION.glasgow_coma.v1[Online] Beschikbaar op: http://www.openehr.org/knowledge/ [Geraadpleegd: 23 februari 2015].

2. Glasgow Coma Schaal [Online] Beschikbaar op: http://www.tabellenboekje.nl/menselijk-lichaam-tabel-glasgow-coma-schaal.php#glasgow-coma-schaal-volwassen [Geraadpleegd: 23 februari 2015].

Valuesets

ConditionsDuringMeasurementCodelist

Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.12.8.6
Conceptname Conceptcode Codesystem name Codesystem OID Description
sedated 17971005 SNOMED CT 2.16.840.1.113883.6.96 gesedeerd
Paralysis caused by muscle relaxant 40241000146103 SNOMED CT 2.16.840.1.113883.6.96 spierverslappers
aphasia 87486003 SNOMED CT 2.16.840.1.113883.6.96 afasie
endotracheal tube present 419991009 SNOMED CT 2.16.840.1.113883.6.96 tube aanwezig
tracheostomy present 302108003 SNOMED CT 2.16.840.1.113883.6.96 tracheostoma aanwezig
other OTH NullFlavor 2.16.840.1.113883.5.1008 anders

GCS_EyesCodelist

Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.12.8.1
Conceptname Conceptcode Conceptvalue Codesystem name Codesystem OID Description
Spontaneous E4 4 GCS_Eyes 2.16.840.1.113883.2.4.3.11.60.40.4.2.1 Spontaan [De ogen worden spontaan geopend]
To verbal stimuli, command, speech E3 3 GCS_Eyes 2.16.840.1.113883.2.4.3.11.60.40.4.2.1 Bij aanspreken of aanroepen [De ogen worden pas geopend op aanspreken van de patiënt]
To pain only E2 2 GCS_Eyes 2.16.840.1.113883.2.4.3.11.60.40.4.2.1 Bij pijn [De ogen worden pas geopend bij een pijnprikkel]
No response E1 1 GCS_Eyes 2.16.840.1.113883.2.4.3.11.60.40.4.2.1 Geen reactie [De ogen blijven gesloten]

GCS_MotorCodelist

Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.12.8.2
Conceptname Conceptcode Conceptvalue Codesystem name Codesystem OID Description
Obeys M6 6 GCS_Motor 2.16.840.1.113883.2.4.3.11.60.40.4.2.2 Voert opdracht uit [Een eenvoudig bevel wordt uitgevoerd]
Localises pain M5 5 GCS_Motor 2.16.840.1.113883.2.4.3.11.60.40.4.2.2 Lokaliseren [In staat zijn de pijn duidelijk te localiseren]
Withdrawal response M4 4 GCS_Motor 2.16.840.1.113883.2.4.3.11.60.40.4.2.2 Terugtrekken [In staat om een afwerende of wegtrekkende beweging te maken op een pijnprikkel]
Flexor response M3 3 GCS_Motor 2.16.840.1.113883.2.4.3.11.60.40.4.2.2 Buigreactie [Armen en handen op krampachtige manier geplooid. Meestal benen gestrekt.]
Extensor response M2 2 GCS_Motor 2.16.840.1.113883.2.4.3.11.60.40.4.2.2 Strekreactie [Armen en handen op krampachtige manier geplooid met naar buitengedraaide hand. Mogelijk alle spieren van het lichaam gespannen]
No response M1 1 GCS_Motor 2.16.840.1.113883.2.4.3.11.60.40.4.2.2 Geen reactie op pijnprikkel [Geen enkele lichamelijke reactie op een pijnprikkel]

GCS_VerbalCodelist

Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.12.8.3
Conceptname Conceptcode Conceptvalue Codesystem name Codesystem OID Description
Oriented V5 5 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Georiënteerd [Helder en duidelijk bewust van de situatie]
Confused V4 4 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Verward [Verwarde conversatie maar wel in staat om te antwoorden op de vragen]
Inappropriate speech V3 3 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Inadequaat [Woorden zijn te verstaan maar vormen geen zinnen]
Incomprehensible sounds V2 2 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Onverstaanbaar [De spraak is niet te verstaan]
No response V1 1 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Geen reactie [Geen enkel verbale response]

GCS_VerbalCodelistBaby

Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.12.8.5
Conceptname Conceptcode Conceptvalue Codesystem name Codesystem OID Description
Oriented V5 5 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Lachen en huilen [Lacht of huilt zachtjes]
Confused V4 4 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Huilen [Huilt en is onpasselijk]
Inappropriate speech V3 3 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Niet adequaat huilen [Aanhoudend huilen of krijsen]
Incomprehensible sounds V2 2 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Kreunen [Kreunen en onrustig/rusteloos]
No response V1 1 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Geen reactie [Geen enkel verbale response]

GCS_VerbalCodelistToddler

Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.12.8.4
Conceptname Conceptcode Conceptvalue Codesystem name Codesystem OID Description
Oriented V5 5 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Adequate woorden en zinnen [Woorden of kleine zinnen in context van de situatie]
Confused V4 4 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Onjuiste woorden [Verwarde woorden]
Inappropriate speech V3 3 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Huilen [Aanhoudend huilen of krijsen]
Incomprehensible sounds V2 2 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Kreunen [Alleen kreunen]
No response V1 1 GCS_Verbal 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 Geen reactie [Geen enkel verbale response]


More on this information model

More technical information and HL7/XML documentation you can find on the Nictiz Art-Decor page about this information model[1]
This information model is also available as pdf file or as spreadsheet

About this information

The information in this wikipage is based on Prerelease 2017 #1
Conditions for use are located on the mainpage
This page is generated on 21/09/2017 13:50:42

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