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The Glasgow Coma Scale is a critical assessment tool for traumatic brain injury and altered mental status. It should NOT be the sole basis for clinical decisions. Serial assessments are essential to detect deterioration. GCS may be unreliable in intoxication, sedation, or paralysis. Always correlate with clinical context.
Assess level of consciousness in trauma and neurological emergencies
| Component | Response | Score |
|---|---|---|
| Eye Opening (E) | Spontaneous | 4 |
| To verbal command | 3 | |
| To pain | 2 | |
| No response | 1 | |
| Verbal Response (V) | Oriented | 5 |
| Confused | 4 | |
| Inappropriate words | 3 | |
| Incomprehensible sounds | 2 | |
| No response | 1 | |
| Motor Response (M) | Obeys commands | 6 |
| Localizes to pain | 5 | |
| Withdraws from pain | 4 | |
| Flexion to pain (Decorticate) | 3 | |
| Extension to pain (Decerebrate) | 2 | |
| No response | 1 |
The Glasgow Coma Scale (GCS) is a neurological assessment tool developed in 1974 at the University of Glasgow. It provides a standardized, objective method to assess and monitor level of consciousness in patients with acute brain injury.
GCS ≤8 is traditionally considered an indication for definitive airway management (intubation):
GCS should be assessed serially to detect trends. A decrease of 2 or more points is clinically significant and may indicate expanding intracranial hemorrhage, cerebral edema, or other deterioration requiring immediate intervention.
| GCS Score | Severity | Management Considerations |
|---|---|---|
| 15 | Normal | Fully alert; observe for changes if trauma present |
| 13-14 | Mild TBI | Consider CT if high-risk features; close observation |
| 9-12 | Moderate TBI | CT scan mandatory; ICU or step-down monitoring; frequent reassessment |
| 3-8 | Severe TBI / Coma | Intubation; CT scan; ICU; consider ICP monitoring; neurosurgery consult |
| 3 | Deep coma | Worst prognosis; assess for brain death; discuss goals of care |
GCS 15 (E4V5M6) represents a fully conscious, alert individual who opens eyes spontaneously, is oriented to person/place/time, and follows commands. This is the normal, maximum score.
Traditionally, GCS ≤8 is considered an indication for intubation because patients cannot adequately protect their airway. However, clinical judgment is essential - some patients with GCS 9-10 may need intubation if declining rapidly, while some stable patients with GCS 8 might be managed conservatively.
Document the verbal component as "T" (intubated) or "VT" (verbal=tube). Score only eye opening and motor response, for a maximum of 10T. Some clinicians use a modified score or simply report E and M scores separately. Always document that the patient is intubated.
Decorticate posturing (M3): Abnormal flexion - arms flex inward toward chest, wrists/fingers flex. Suggests damage above the midbrain. Decerebrate posturing (M2): Abnormal extension - arms/legs extend rigidly, toes point down. Suggests damage to midbrain/brainstem. Decerebrate is worse prognosis.
Initial GCS correlates with prognosis but is not the sole predictor. Lower scores indicate worse outcomes, but age, CT findings, pupillary response, secondary injuries, and quality of care significantly affect outcomes. Some patients with GCS 3-5 can have good recovery, while some with GCS 13-15 may have lasting deficits.
In acute trauma, assess GCS initially, then every 15 minutes until stable, then hourly or more frequently based on clinical status. Any deterioration (drop of ≥2 points) requires immediate reassessment and intervention. Document each component separately (E, V, M) rather than just the total.
Yes. Intoxication can depress consciousness independently of trauma, making GCS less reliable. However, never assume altered consciousness is solely due to intoxication. Maintain high suspicion for traumatic brain injury, obtain CT imaging as indicated, and reassess serially. GCS should improve as intoxication clears.
The Pediatric GCS modifies the verbal component for pre-verbal children: oriented (age-appropriate) = 5, consolable crying = 4, inconsistently consolable = 3, inconsolable crying = 2, no response = 1. Eye opening and motor responses are assessed similarly to adults.