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Intensive Care Medicine

, Volume 29, Issue 6, pp 933–938 | Cite as

Comparison of the Glasgow Coma Scale and the Reaction Level Scale for assessment of cerebral responsiveness in the critically ill

  • Sten M. WaltherEmail author
  • Ulla Jonasson
  • Hans Gill
Original

Abstract

Objective

The Glasgow Coma Scale (GCS) is a well-known source of error in outcome prediction models. We compared assessment of cerebral responsiveness with the GCS and the Reaction Level Scale (RLS) in two otherwise similar outcome prediction models.

Design and setting

Prospective, observational study in a general intensive care unit.

Patients and participants

All admissions of patients with or at risk of developing impaired brain function between 1997 and 1998 (n=534).

Measurements and results

Admissions were scored by RLS and APACHE II (includes scoring with the GCS). The RLS scores were transformed to APACHE II central nervous system scores according to a predetermined protocol. APACHE II estimated probability of death was calculated conventionally with the GCS and the RLS. Vital status 90 days after admission was secured from a national database. Bias and precision was 0.5% and 16.6%, respectively. The area under receiver operating characteristic curves was slightly but significantly greater with the RLS-based APACHE II model than with the GCS-based model (0.92 vs. 0.90). Discrimination was improved primarily in admissions with low and intermediate probability of death.

Conclusions

Scoring of cerebral responsiveness with the RLS instead of the GCS was associated with minimal bias of the APACHE II probability of death estimate. Assessment of consciousness in critically ill with the RLS deserves further evaluation

Keywords

Intensive care Severity of illness index Outcome prediction Acute Physiology and Chronic Health Evaluation Glasgow Coma Scale Reaction Level Scale 

Notes

Acknowledgements

This work was performed at the Intensive Care Unit, Department of Anesthesia and Intensive Care, Norrköping Hospital, Norrköping, Sweden. The research was supported by a grant from the Norrköping Hospital Research Board.

References

  1. 1.
    Gunning K, Rowan K (1999) ABC of intensive care: outcome data and scoring systems. BMJ 319:241–244PubMedGoogle Scholar
  2. 2.
    Knaus WA, Draper EA, Wagner DP, Zimmerman JE (1985) APACHE II: a severity of disease classification system. Crit Care Med 13:818–829PubMedGoogle Scholar
  3. 3.
    Teasdale G, Jennett B (1974) Assessment of coma and impaired consciousness. A practical scale. Lancet II:81–84Google Scholar
  4. 4.
    Starmark JE, Stalhammar D, Holmgren E, Rosander B (1988) A comparison of the Glasgow Coma Scale and the Reaction Level Scale (RLS85). J Neurosurg 69:699–706PubMedGoogle Scholar
  5. 5.
    Prasad K (1996) The Glasgow Coma Scale: a critical appraisal of its clinimetric properties. J Clin Epidemiol 49:755–763PubMedGoogle Scholar
  6. 6.
    Chen LM, Martin CM, Morrison TL, Sibbald WJ (1999) Interobserver variability in data collection of the APACHE II score in teaching and community hospitals. Crit Care Med 27:1999–2004PubMedGoogle Scholar
  7. 7.
    Holt AW, Bury LK, Bersten AD, Skowronski GA, Vedig AE (1992) Prospective evaluation of residents and nurses as severity score data collectors. Crit Care Med 20:1688–1691PubMedGoogle Scholar
  8. 8.
    Starmark JE, Stalhammar D, Holmgren E (1988) The Reaction Level Scale (RLS85). Manual and guidelines. Acta Neurochir (Wien) 91:12–20Google Scholar
  9. 9.
    Starmark JE, Heath A (1988) Severity grading in self-poisoning. Hum Toxicol 7:551–555PubMedGoogle Scholar
  10. 10.
    Tesseris J, Pantazidis N, Routsi C, Fragoulakis D (1991) A comparative study of the Reaction Level Scale (RLS85) with Glasgow Coma Scale (GCS) and Edinburgh-2 Coma Scale (modified) (E2CS (M)). Acta Neurochir (Wien) 110:65–76Google Scholar
  11. 11.
    Stalhammar D, Starmark JE, Holmgren E, Eriksson N, Nordstrom CH, Fedders O, Rosander B (1988) Assessment of responsiveness in acute cerebral disorders. A multicentre study on the reaction level scale (RLS 85). Acta Neurochir (Wien) 90:73–80Google Scholar
  12. 12.
    Rowley G, Fielding K (1991) Reliability and accuracy of the Glasgow Coma Scale with experienced and inexperienced users. Lancet 337:535–538PubMedGoogle Scholar
  13. 13.
    Bland JM, Altman DG (1986) Statistical methods for assessing agreement between two methods of clinical measurement. Lancet I:307–310Google Scholar
  14. 14.
    Hanley JA, McNeil BJ (1982) The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology 143:29–36PubMedGoogle Scholar
  15. 15.
    DeLong ER, DeLong DM, Clarke-Pearson DL (1988) Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics 44:837–845PubMedGoogle Scholar
  16. 16.
    Starmark JE, Holmgren E, Stalhammar D (1988) Current reporting of responsiveness in acute cerebral disorders. A survey of the neurosurgical literature. J Neurosurg 69:692–698PubMedGoogle Scholar
  17. 17.
    Teasdale G (1975) Acute impairment of brain function-1. Assessing 'conscious level'. Nurs Times 71:914–917PubMedGoogle Scholar
  18. 18.
    Knaus WA, Wagner DP, Draper EA, Zimmerman JE, Bergner M, Bastos PG, Sirio CA, Murphy DJ, Lotring T, Damiano A (1991) The APACHE III prognostic system. Risk prediction of hospital mortality for critically ill hospitalized adults. Chest 100:1619–1636PubMedGoogle Scholar
  19. 19.
    Bastos PG, Sun X, Wagner DP, Wu AW, Knaus WA (1993) Glasgow Coma Scale sum score in the evaluation of outcome in the intensive care unit: findings from the Acute Physiology and Chronic Health Evaluation III study. Crit Care Med 21:1459–1465Google Scholar
  20. 20.
    Livingston BM, Mackenzie SJ, MacKirdy FN, Howie JC (2000) Should the pre-sedation Glasgow Coma Scale value be used when calculating Acute Physiology and Chronic Health Evaluation scores for sedated patients? Scottish Intensive Care Society Audit Group. Crit Care Med 28:389–394PubMedGoogle Scholar
  21. 21.
    Teoh LS, Gowardman JR, Larsen PD, Green R, Galletly DC (2000) Glasgow Coma Scale: variation in mortality among permutations of specific total scores. Intensive Care Med 26:157–161PubMedGoogle Scholar
  22. 22.
    Gale JL, Dikmen S, Wyler A, Temkin N, McLean A (1983) Head injury in the Pacific Northwest. Neurosurgery 12:487–491PubMedGoogle Scholar
  23. 23.
    Polderman KH, Girbes AR, Thijs LG, Strack van Schijndel RJ (2001) Accuracy and reliability of APACHE II scoring in two intensive care units. Problems and pitfalls in the use of APACHE II and suggestions for improvement. Anaesthesia 56:47–50PubMedGoogle Scholar
  24. 24.
    Marshall LF, Marshall SB, Klauber MR, Van Berkum Clark M, Eisenberg H, Jane JA, Luerssen TG, Marmarou A, Foulkes MA (1992) The diagnosis of head injury requires a classification based on computed axial tomography. J Neurotrauma 9 [Suppl 1]:S287–S292Google Scholar
  25. 25.
    Arts D, De Keizer N, Scheffer GJ, De Jonge E (2002) Quality of data collected for severity of illness scores in the Dutch National Intensive Care Evaluation (NICE) registry. Intensive Care Med 28:656–659CrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2003

Authors and Affiliations

  1. 1.Department of Cardiothoracic Anaesthesia and Intensive CareUniversity HospitalLinköpingSweden
  2. 2.Department of Anaesthesia and Intensive CareNorrköping HospitalNorrköpingSweden
  3. 3.Department of Biomedical EngineeringLinköpings UniversitetLinköpingSweden

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