My patient is conscious, alert and oriented and we will be to your facility in five minutes. Does this sound familiar? I wouldn’t doubt that if you have been in this profession for a year that you have said these very similar words at least 100 times, about once a shift.
If you have ever transported to an academic medical center or regional trauma center, you already know their response. What is their GCS?
Getting back to the basics, it is important to discuss the purpose of the Glasgow Coma Scale (GCS). It is more than just a number. There is significance behind the individual category, the individual number and the total, especially when it comes to prehospital emergency medicine.
Information regarding the Glasgow Coma Scale was first published in 1974 by a group of neurosurgery professors that were at the University of Glasgow, a research university located in Glasgow Scotland.
The design of the Glasgow Coma Score is to be an easily used clinical tool to assess a patient’s level of consciousness after a head injury or in various medical conditions.1
The original authors, Teasdale and Jennet stated that “the scale facilitates consultations between general and special units in case of recent brain damage.”2
The Glasgow Coma Scale is an important part of the neurologic assessment of a patient as a means to look up any problems with the two main parts of your nervous system, the central and peripheral nervous system.3
Starting with the basics, look at the components that make up the sum number. While the overall score ends up being between 3-15, with 15 being the highest an individual can score and 3 being the lowest, there are three primary components that are used to make up that total, that include the eye, verbal and motor response of our patients.
Best Eye Response (Max 4, Min 1)
Rated similar to assessing for level of consciousness during the physical assessment of the patient, the eye response is rate as 1-4 with 4 being the best response.
If the patient is conscious, and their eyes open eyes without prompting they would receive a rated of 4 with ratings decreasing to 3 if they must be aroused to consciousness by verbal stimuli, 2 if that same arousal must be from pain, and then a 1 if they have no response.
Best Verbal Response (Max 5, Min 1)
How is your patient responding to the questions they ask? Are they spot on, need a little prompting, or is it inappropriate altogether. The highest-level score you can assign in the verbal response category is 5.
Think about this as having a regular conversation with somebody, just happens that now they have called you because something is wrong. Before you start to assign a numerical value for this category, make sure that you know what the patient’s know normal is.
If the person is not able to carry on a normal conversation due to regularly prescribed medications or an underlying medical condition that may bias your result here.
As we look at the lower responses a rating of 4 would be able to carry that conversation but exhibit some confusion in their response. A 3 would drop due to the patient using inappropriate words.
Now, we are not talking about the addition of colorful language that could be considered rude, but more along the lines that they no longer reflect the environment that we are in.
A rating of 2 would be appropriate if they include incomprehensible sounds and the lowest rating of 1 would be no response at all.
Best Motor Response (Max 6, Min 1)
The highest rating in this last section of GCS would be to assign a 6 for being able to follow commands.
As earlier, this is the point in which the individual would be able to move, lift or adjust based upon the conversation you were having with the patient.
Moving through the spectrum of ratings for motor response, 5 is associated with the localization of pain while 4 is a withdrawal from said pain.
A 3 is where we get into some additional key features of this section. A rating of 3 is associated with abnormal flexion to pain, while 2 is abnormal extension to pain. The last is no motor response at all.
Going Beyond the Basics
At the beginning, a sample radio report was used in which the trauma center shot back the age-old question of what is their GCS? Many providers would simply include one of three number when passing this along.
It would be 3 if they weren’t responding at all, 15 if everything was close to being good, and a number between 7 and 10 should they be on the spectrum between the 3 and 15.
However, if we took this assessment value and looked at it similar to a vital sign in our patients, we could use as is part of our patient’s trend analysis. Are they bad and getting better, bad and staying the same, or bad and getting worse.
The overall number may not change, but numbers in each of the three categories might.
Putting it altogether, this information normally gets recited as a sum. If their eye opened to a painful stimulus, you would assign 3, verbal resulted in confusion you would assign 4, and then motor response withdrew from pain assigning a 4. This would be E:3, V:4, M:4 Total 11).
“The findings for the eye, verbal, and motor responses also related to the outcome but in distinctive ways so that assessment of each separately yields more information that the aggregate total score.”4
This means that while you are in the process of calculating the sum, you should look at the individual parts, and pass that along as well as listed above. As providers in the field, we need to look at what is behind each of those numbers. Think of this as the reversible causes of pulseless electrical activity in cardiac arrest management.
It is key to note that while a cardiac arrest patient is a 3, you don’t have to be in arrest to get that number, which is a crucial reason to understand the values and how to use this in the clinical continuum.
Limitations to Accuracy in the Glasgow Coma Scale Calculation
While the calculation of GCS is based off an unconscious patient, limitations to these calculations can be due to treatments that have been provided to the patient.
Should the patient be sedated pharmacologically, or intubated, or have other explainable limitations such as spinal cord damage or prolonged exposure to cold temperatures, the calculations will not be accurate and should be considered when passing along that information in the continuum of care.
“It is essential that the total score is not reported without testing and including all components because the score will be low and could cause confusion.”1
Furthermore, if we are treating pediatric patients this scale may need to be altered to facilitate their communication abilities.
While the question of what a patient’s GCS might be, there are substantial levels of detail that can be obtained about a patient while assessing these three areas and give each of our providers an opportunity to see deeper into a patient’s condition.
More Getting Back to Basics
I Was Wrong…And It Is OK If You Are Too!
Obtaining Your First Set of Vital Signs
References
1. Jain S, Iverson LM. Glasgow Coma Scale. [Updated 2023 Jun 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513298/
2. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974 Jul 13;2(7872):81-4. doi: 10.1016/s0140-6736(74)91639-0. PMID: 4136544.
3. Professional, C. C. medical. (n.d.). The Glasgow Coma Scale and how experts use it. Cleveland Clinic. https://my.clevelandclinic.org/health/diagnostics/24848-glasgow-coma-scale-gcs
4. Reith FCM, Lingsma HF, Gabbe BJ, Lecky FE, Roberts I, Maas AIR. Differential effects of the Glasgow Coma Scale Score and its Components: An analysis of 54,069 patients with traumatic brain injury. Injury. 2017 Sep;48(9):1932-1943. doi: 10.1016/j.injury.2017.05.038. Epub 2017 Jun 1. PMID: 28602178.
