The Glasgow Coma Scale (GCS) describes an individual's level of consciousness. It is often used to gauge the severity of an acute brain injury due to trauma or medical reasons. The test is simple, reliable, and correlates well with outcomes following brain injury. It is composed of 3 domains, each assessed separately and given numerical scores. The sum of these scores is the Glasgow Coma Score.

The three areas are

1. Eye Opening,
2. Verbal Response, and
3. Motor Activity.

• EYE-OPENING (1-4 Points)

1. Does not open eyes in response to anything.
2. Opens eyes in response to painful stimuli.
3. Opens eyes in response to voice.
4. Opens eyes spontaneously.

• VERBAL RESPONSE (1-5 Points)

1. Makes no sounds.
2. Incomprehensible sounds.
3. Utters incoherent words.
4. Confused, disoriented.
5. Oriented, converses normally.

• MOTOR ACTIVITY (1-6 Points)

1. Makes no movements.
2. Decerebrate (extensor) posture (an abnormal posture that can include rigidity, arms and legs held straight out, toes pointed downward, head and neck arched backward).
3. Decorticate (flexor) posture (an abnormal posture that can include rigidity, clenched fists, legs held straight out, and arms bent inward toward the body with the wrists and fingers bend and held on the chest).
4. Withdrawal from painful stimuli.
5. Localizes to painful stimuli.
6. Obeys commands.

EXAMPLE: So a patient who has scores of Eye = 3, Verbal = 4 and Motor = 5 is said to have a GCS of 12.

You would express this as a GCS 12 = E3, V4, M5.

Significant GCS Scores to Memorize:

• 3: The lowest possible GCS, indicating the patient is wholly unresponsive.
• 8: The threshold for intubation; patients with a GCS of 8 or lower are strongly considered for intubation, as they are unlikely to maintain a patent airway.
• 15: The highest GCS score, indicating the patient opens their eyes spontaneously, is oriented and alert, and obeys commands.

Modifiers:

Modifiers help eliminate misleading scores and improve accuracy, especially in terms of outcomes:

• V1t: Indicates the patient makes no verbal sounds due to intubation (endotracheal tube).
• E1c: "C" stands for closed due to swelling or damage. Sometimes, the "1" is omitted, so "Vt" can be used instead of "V1t" to avoid redundancy.

 

Pediatric Considerations:

A child's reaction to a health crisis differs from an adult's. Understanding commands and cooperating can be compromised due to pain or immaturity. The GCS is not well-validated in children and cannot solely predict the need for airway interventions. The best approach in considering intubation for childhood trauma is to assess valid indications for intubation, such as a child's ability to maintain their airway, determined by phonation and swallowing, not just the gag reflex.

A separate Pediatric Glasgow Coma Scale was created because young children can be harder to assess for verbal and motor function as they may not be able to answer your questions or follow instructions adequately. 

 

 

GCS in Plain English:

We are assessing responsiveness because being able to react to stimuli means the brain is working.

MEMORY TOOL:  For GCS SCORING, Remember  1,2,3,4,5,6  (Three Questions and 3 Scores) 

There are 3 questions: 1) Do his eyes respond?  2) Does he verbally respond? 3) Does he respond with his body?

There are 3 max points: 4) Eyes get a max of 4 points, 5) verbal gets 5 points,  6) motor gets 6 points.

So, 1, 2, 3, 4, 5, 6

Just start PRACTICING with using E4, V5, M6.  Get in the habit of looking at a patient and judging his response. If he's responsive, he's E4, V5, M6. If he's a little confused, like after a concussion, but his eyes open, and he has purposeful movements, then you only have to take 1 from speech. So the confused guy is E4, V4, M6. 

Use it like a checklist. Do his eyes open? If yes, then score a 4. If no, then score a 1. If "kinda," then look at the criteria. Same with the other 2. Check yes or no or kinda. If "kinda," then check out that specific list and proceed.

DO HIS EYES OPEN? (Max 4) (Eyes are easy; you're assessing eye AVPU)

1. No matter what I do, his eyes don't open.
2. Eyes open when I inflict pain.
3. Eyes open when I call his name
4. Eyes are normally open

IS HE TALKING CORRECTLY? (Max 5)

1. He's not talking at all
2. He's just making sounds
3. He's saying words, but they don't make sense
4. He's talking, but he's confused
5. He's talking normally

IS HE ABLE TO MOVE HIS OWN BODY? (Max 6)

1. He's not moving, no matter what I do.
2. If I apply pain, his body flexes away from his core. Extension.
3. If I apply pain, his body tightens towards his core. Flexion.
4. If I apply pain, his body tries to back away from the pain spot.
5. If I apply pain, he moves his hand to the pain spot.
6. He is moving on his own.