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CDE Detailed Report
This report contains detailed information about the selected CDEs.
Note: If at least one CDE was selected from a copyright- or trademark-protected instrument/scale then all of the CDEs from that instrument/scale are included in this report.
Disease: Traumatic Brain Injury
SubDisease: Comprehensive
Sub-Domain: Physical/Neurological Examination
CRF: Neurological Assessment: Glasgow Coma Scale (GCS) and Pupils
Item count: 16 (16 distinct CDEs)
CDE ID
CDE Name
Variable Name
Definition / Description
Question Text
Permissible Value
Description
Data Type
Instructions
References
Population
Classification (e.g., Core)
Version #
Version Date
Aliases for Variable Name
CRF Module / Guideline
© or TM
Sub-Domain
Domain
Previous Title
Size
Input Restrictions
Min Value
Max Value
Measurement Type
LOINC ID
SNOMED
caDSR ID
CDISC ID
C18399
Glasgow Coma Scale (GCS) - Scale type
GCSScaleTyp
Type of Glasgow Coma Scale (GCS) used.
Scale Used
Glasgow Coma Scale;Pediatric Glasgow Coma Scale;
Glasgow Coma Scale (GCS);Pediatric Glasgow Coma Scale(PGCS);
Alphanumeric
No instructions available
No references available
Adult;Pediatric
Supplemental
3.0
7/20/2013
Aliases for variable name not defined
Neurological Assessment: Glasgow Coma Scale (GCS) and Pupils
Physical/Neurological Examination
Assessments and Examinations
  
Single Pre-Defined Value Selected
       
C01000
Glasgow Coma Scale (GCS) - eye response scale
GCSEyeRespnsScale
Glasgow Coma Scale (GCS) - Best eye response (E). The GCS is a standardized instrument for assessing the level of consciousness. It evaluates three aspects of responsiveness: eye opening, motor response, verbal response.
Best eye response
1;2;3;4;Untestable;Unknown;
No eye opening;Eye opening to pain;Eye opening to speech/verbal command;Eyes open spontaneously;Untestable;Unknown;
Alphanumeric
Choose one
Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. Jul 1974;2(7872):81-4. Marmarou A, Lu J, Butcher I, et al. Prognostic value of the Glasgow Coma Scale and pupil reactivity in traumatic brain injury assessed pre-hospital and on enrollment: an IMPACT analysis. J Neurotrauma. Feb 2007;24(2):270-80. Stocchetti N, Pagan F, Calappi E, et al. Inaccurate early assessment of neurological severity in head injury. J Neurotrauma. Sep 2004:21(9):1131-40. Balestreri M, Czosnyka M, Chatfield DA, et al. Predictive value of Glasgow Coma Scale after brain trauma: change in trend over the past ten years. J Neurol Neurosurg Psychiatry. Jan 2004;75(1):161-2.
Adult;Pediatric
Core
3.0
7/20/2013
Aliases for variable name not defined
Neurological Assessment: Glasgow Coma Scale (GCS) and Pupils
Physical/Neurological Examination
Assessments and Examinations
GCS Eye response
 
Single Pre-Defined Value Selected
       
C01001
Glasgow Coma Scale (GCS) - motor response scale
GCSMotorRespnsScale
Glasgow Coma Scale (GCS) - Best motor response (M). The GCS is a standardized instrument for assessing the level of consciousness. It evaluates three aspects of responsiveness: eye opening, motor response, verbal response.
Motor response
1;2;3;4;5;6;Untestable;Unknown;
No motor response;Abnormal extension/Extensor response;Abnormal flexion;Flexion withdrawal/withdraws from pain;Localizes pain;Obeys command;Untestable;Unknown;
Alphanumeric
Choose one
Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. Jul 1974;2(7872):81-4. Marmarou A, Lu J, Butcher I, et al. Prognostic value of the Glasgow Coma Scale and pupil reactivity in traumatic brain injury assessed pre-hospital and on enrollment: an IMPACT analysis. J Neurotrauma. Feb 2007;24(2):270-80. Stocchetti N, Pagan F, Calappi E, et al. Inaccurate early assessment of neurological severity in head injury. J Neurotrauma. Sep 2004:21(9):1131-40. Balestreri M, Czosnyka M, Chatfield DA, et al. Predictive value of Glasgow Coma Scale after brain trauma: change in trend over the past ten years. J Neurol Neurosurg Psychiatry. Jan 2004;75(1):161-2. Steyerberg EW, Mushkudiani N, Perel P, et al. Predicting outcome after traumatic brain injury: development and international validation of prognostic scores based on admission characteristics. PLoS Med. Aug 2008;5(8):e165. MRC CRASH Trial Collaborators. Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients. BMJ. Feb 2008;336(7641):425-429.
Adult;Pediatric
Core
3.0
7/20/2013
Aliases for variable name not defined
Neurological Assessment: Glasgow Coma Scale (GCS) and Pupils
Physical/Neurological Examination
Assessments and Examinations
GCS Motor response
 
Single Pre-Defined Value Selected
       
C01002
Glasgow Coma Scale (GCS) - verbal response scale
GCSVerbalRspnsScale
Score that describes the participant's verbal response according to the Glasgow Coma Scale (GCS)
Verbal response
1;2;3;4;5;Untestable;Unknown;
No verbal response/sounds;Incomprehensible sound;Inappropriate words;Confused;Oriented;Untestable;Unknown;
Alphanumeric
Choose one
Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. Jul 1974;2(7872):81-4. Marmarou A, Lu J, Butcher I, et al. Prognostic value of the Glasgow Coma Scale and pupil reactivity in traumatic brain injury assessed pre-hospital and on enrollment: an IMPACT analysis. J Neurotrauma. Feb 2007;24(2):270-80. Stocchetti N, Pagan F, Calappi E, et al. Inaccurate early assessment of neurological severity in head injury. J Neurotrauma. Sep 2004:21(9):1131-40. Balestreri M, Czosnyka M, Chatfield DA, et al. Predictive value of Glasgow Coma Scale after brain trauma: change in trend over the past ten years. J Neurol Neurosurg Psychiatry. Jan 2004;75(1):161-2.
Adult;Pediatric
Core
3.0
7/20/2013
Aliases for variable name not defined
Neurological Assessment: Glasgow Coma Scale (GCS) and Pupils
Physical/Neurological Examination
Assessments and Examinations
GCS Verbal response
 
Single Pre-Defined Value Selected
       
C01016
Glasgow Coma Scale (GCS) - total score
GCSTotalScore
Glasgow Coma Scale (GCS) - Total Score. The GCS is a standardized instrument for assessing the level of consciousness. It evaluates three aspects of responsiveness: eye opening, motor response, verbal response. The total score is the sum of the scores for the three response types. (3-15)
Total score
3;4;5;6;7;8;9;10;11;12;13;14;15;Untestable;Unknown;
3;4;5;6;7;8;9;10;11;12;13;14;15;Untestable;Unknown;
Alphanumeric
3-15 calculated field----http://www.glasgowcomascale.org/faq/ ----*Dealing with missing information: There are various different strategies for dealing with information that is missing because of factors interfering with assessment such as those described above. 1.Assess, communicate and make decisions using the remaining components. Although guidelines are often expressed in terms of a total GCS ‘score,’ the trend in whichever of the components (eye, motor or verbal) can be assessed is still valuable. 2.Do not use number ‘1’ to record missing component; use ‘NT’ (Not testable). 3.Do not report a total score when a component is Not Testable because the score will be low and this could be confusing to medical colleagues. This may also imply that the patient is more unwell than they actually are. 4.It is possible using statistical methods to estimate a missing component from the findings in the other components. This is probably more relevant to research than clinical practice.
Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. Jul 1974;2(7872):81-4. Marmarou A, Lu J, Butcher I, et al. Prognostic value of the Glasgow Coma Scale and pupil reactivity in traumatic brain injury assessed pre-hospital and on enrollment: an IMPACT analysis. J Neurotrauma. Feb 2007;24(2):270-80. ---Stocchetti N, Pagan F, Calappi E, et al. Inaccurate early assessment of neurological severity in head injury. J Neurotrauma. Sep 2004:21(9):1131-40. ---Balestreri M, Czosnyka M, Chatfield DA, et al. Predictive value of Glasgow Coma Scale after brain trauma: change in trend over the past ten years. J Neurol Neurosurg Psychiatry. Jan 2004;75(1):161-2.
Adult;Pediatric
Core
3.0
7/20/2013
Aliases for variable name not defined
Neurological Assessment: Glasgow Coma Scale (GCS) and Pupils
Physical/Neurological Examination
Assessments and Examinations
GCS Total score
 
Single Pre-Defined Value Selected
       
C01020
Pediatric Glasgow Coma Scale (PGCS) - eye response score
PGCSEyeRespnsScore
Score for the participant's eye response according to the Pediatric Glasgow Coma Scale (PGCS) if the participant is under the age of 18.
Best eye response
1;2;3;4;Untestable;Unknown;
No eye opening;Eye opening to pain;Eye opening to speech;Eyes open spontaneously;Untestable;Unknown;
Alphanumeric
Choose one
Marcin J and Pollack M. (2002). Triage scoring systems, severity of illness measures, and mortality prediction models in pediatric trauma. Crit Care Med. 30:S457-S467.
Pediatric
Core
3.0
7/20/2013
Aliases for variable name not defined
Neurological Assessment: Glasgow Coma Scale (GCS) and Pupils
Physical/Neurological Examination
Assessments and Examinations
GCS-Pediatric Eye response
 
Single Pre-Defined Value Selected
       
C01021
Pediatric Glasgow Coma Scale (PGCS) - motor response score
PGCSMotorRespnsScore
Score for the participant's motor response according to the Pediatric Glasgow Coma Scale (PGCS) if the participant is under the age of 18.
Motor response
1;2;3;4;5;6;Untestable;Unknown;
No motor response;Extension to pain;Flexion to pain;Withdrawal from pain;Localizing pain;Obeys commands;Untestable;Unknown;
Alphanumeric
Choose one
Marcin J and Pollack M. (2002). Triage scoring systems, severity of illness measures, and mortality prediction models in pediatric trauma. Crit Care Med. 30:S457-S467.
Pediatric
Core
3.0
7/20/2013
Aliases for variable name not defined
Neurological Assessment: Glasgow Coma Scale (GCS) and Pupils
Physical/Neurological Examination
Assessments and Examinations
GCS-Pediatric Motor response
 
Single Pre-Defined Value Selected
       
C01022
Pediatric Glasgow Coma Scale (PGCS) - verbal response score
PGCSVerbalRespnsScore
Score for the participant's verbal response according to the Pediatric Glasgow Coma Scale (PGCS) if the participant is under the age of 18.
Verbal response
1;2;3;4;5;Untestable;Unknown;
No vocal response;Inconsolable, agitated;Inconsistently consolable, moaning;Cries, but is consolable, inappropriate interactions;Smiles, oriented to sounds, follows objects, interacts;Untestable;Unknown;
Alphanumeric
Choose one
Marcin J and Pollack M. (2002). Triage scoring systems, severity of illness measures, and mortality prediction models in pediatric trauma. Crit Care Med. 30:S457-S467.
Pediatric
Core
3.0
7/20/2013
Aliases for variable name not defined
Neurological Assessment: Glasgow Coma Scale (GCS) and Pupils
Physical/Neurological Examination
Assessments and Examinations
GCS-Pediatric Verbal response
 
Single Pre-Defined Value Selected
       
C01017
Pediatric Glasgow Coma Scale (PGCS) - total score
PGCSTotalScore
Score for the participant's total Pediatric Glasgow Coma Scale (PGCS) score of the 3 tests, eye, motor, and verbal responses. A score of less than 9 would indicate that that participant is in a severe coma while a score of greater than 9 is a mild or no coma at all.
Total score
3;4;5;6;7;8;9;10;11;12;13;14;15;Untestable;Unknown;
3;4;5;6;7;8;9;10;11;12;13;14;15;Untestable;Unknown;
Alphanumeric
3-15 calculated field
Marcin J and Pollack M. (2002). Triage scoring systems, severity of illness measures, and mortality prediction models in pediatric trauma. Crit Care Med. 30:S457-S467.
Pediatric
Core
3.0
7/20/2013
Aliases for variable name not defined
Neurological Assessment: Glasgow Coma Scale (GCS) and Pupils
Physical/Neurological Examination
Assessments and Examinations
GCS-Pediatric Total score
 
Single Pre-Defined Value Selected
       
C01011
Glasgow Coma Scale (GCS) - confounders type
GCSConfounderTyp
Type of confounders influencing participant's/subject's Glasgow Coma Scale (GCS) score
GCS confounders type
Alcohol/drugs of abuse;C-spine injury;Hypoxia/hypotension;Hypothermia;Sedation;Paralytic;Unknown;GCS Accurate;
Alcohol/drugs of abuse;C-spine injury;Hypoxia/hypotension;Hypothermia;Sedation;Paralytic;Unknown;GCS Accurate;
Alphanumeric
Choose all that apply.
No references available
Adult;Pediatric
Supplemental
3.0
7/20/2013
Aliases for variable name not defined
Neurological Assessment: Glasgow Coma Scale (GCS) and Pupils
Physical/Neurological Examination
Assessments and Examinations
GCS confounders type
 
Multiple Pre-Defined Values Selected
       
C01006
Pupil left eye measurement
PupilLftEyeMeasr
Measurement of the left pupil in millimeters
Left pupil measurement
  
Numeric Values
Pupil measurement recorded in millimeters (mm). Acceptable range is 1-10mm. This element is recommended for pediatric studies.
No references available
Adult;Pediatric
Supplemental
3.0
7/20/2013
Aliases for variable name not defined
Neurological Assessment: Glasgow Coma Scale (GCS) and Pupils
Physical/Neurological Examination
Assessments and Examinations
Pupil left eye measurement
 
Free-Form Entry
1
10
millimeter
    
C01005
Pupil right eye measurement
PupilRtEyeMeasr
Measurement of the right pupil in millimeters
Right pupil measurement
  
Numeric Values
Pupil measurement recorded in millimeters (mm). Acceptable range is 1-10mm. This element is recommended for pediatric studies.
No references available
Adult;Pediatric
Supplemental
3.0
7/20/2013
Aliases for variable name not defined
Neurological Assessment: Glasgow Coma Scale (GCS) and Pupils
Physical/Neurological Examination
Assessments and Examinations
Pupil right eye measurement
 
Free-Form Entry
1
10
millimeter
    
C01024
Pupil shape left eye type
PupilShapeLftEyeTyp
Type of shape of the pupil of the left eye
Left pupil shape
Round;Oval;Unknown;
Round;Oval;Unknown;
Alphanumeric
Choose one. Recommend collection at least at study hospital admission/discharge and protocol milestones. This element is recommended for pediatric studies.
No references available
Adult;Pediatric
Supplemental
3.0
7/20/2013
Aliases for variable name not defined
Neurological Assessment: Glasgow Coma Scale (GCS) and Pupils
Physical/Neurological Examination
Assessments and Examinations
Pupil shape left eye type
 
Single Pre-Defined Value Selected
       
C01023
Pupil shape right eye type
PupilShapeRtEyeTyp
Type of shape of the pupil of the right eye
Right pupil shape
Round;Oval;Unknown;
Round;Oval;Unknown;
Alphanumeric
Choose one. Recommend collection at least at study hospital admission/discharge and protocol milestones. This element is recommended for pediatric studies.
No references available
Adult;Pediatric
Supplemental
3.0
7/20/2013
Aliases for variable name not defined
Neurological Assessment: Glasgow Coma Scale (GCS) and Pupils
Physical/Neurological Examination
Assessments and Examinations
Pupil shape right eye type
 
Single Pre-Defined Value Selected
       
C01004
Pupil reactivity light left eye result
PupilReactivityLghtLftEyeReslt
Result of testing of the contraction of the participant's/subject's left pupil when a bright light is shone on it from an angle
Left pupil reactivity
Sluggish;Nonreactive;Brisk;Untestable;Unknown;
Abnormal but still responsive;Abnormal;Normal;;;
Alphanumeric
Choose one.
Marmarou A, Lu J, Butcher I, et al. Prognostic value of the Glasgow Coma Scale and pupil reactivity in traumatic brain injury assessed pre-hospital and on enrollment: an IMPACT analysis. J Neurotrauma. Feb 2007;24(2):270-80.
Adult;Pediatric
Supplemental
3.0
7/20/2013
Aliases for variable name not defined
Neurological Assessment: Glasgow Coma Scale (GCS) and Pupils
Physical/Neurological Examination
Assessments and Examinations
Pupil reactivity to light left eye result
 
Single Pre-Defined Value Selected
       
C01003
Pupil reactivity light right eye result
PupilReactivityLghtRtEyeReslt
Result of testing of the contraction of the participant's/subject's right pupil when a bright light is shone on it from an angle
Right pupil reactivity
Sluggish;Nonreactive;Brisk;Untestable;Unknown;
Abnormal but still responsive;Abnormal;Normal;;;
Alphanumeric
Choose one.
Marmarou A, Lu J, Butcher I, et al. Prognostic value of the Glasgow Coma Scale and pupil reactivity in traumatic brain injury assessed pre-hospital and on enrollment: an IMPACT analysis. J Neurotrauma. Feb 2007;24(2):270-80.
Adult;Pediatric
Supplemental
3.0
7/20/2013
Aliases for variable name not defined
Neurological Assessment: Glasgow Coma Scale (GCS) and Pupils
Physical/Neurological Examination
Assessments and Examinations
Pupil reactivity to light right eye result
 
Single Pre-Defined Value Selected
       
12-11-2018
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