Remembering The Glasgow Coma Score

Post What By: Duckiemonster

Post What? By: Duckiemonster

It’s a basic skill that many advanced caregivers struggle with. The patients who need accurate Glasgow scores tend to be critical. You’re moving fast. You’ve got a lot of priorities on your mind and now you need to calculate an accurate Glasgow score. What’s an EMT to do?

Let me give you some tips and tricks to keep in mind when it comes time to rapidly calculate this number.

I’ll admit that for years I had a big beef with the Glasgow Coma Scale (or score). My annoyance with the assessment came, not from the technique itself, but my perceived overuse of it by my local base station MICNs. Right there on the base station report sheet, below BP and respiratory rate, was GCS and the nurses demanded it on every call in report. Regardless of how detailed a description the EMT gave of the patients level of consciousness you could be certain to hear the question, “What’s the Glasgow?” if you failed to include it.

So I did become a little anti-Glasgow early in my career. I never understood how this somewhat arbitrary number could be more meaningful than my detailed descriptions of the mental status of my patient.

I have since come to recognize the Glasgow as a useful clinical tool and I’m more forgiving of hospitals that request the patients score. The Glasgow has proven itself a useful predictor of survivability in head injury and a meaningful measure of end organ profusion, especially in pediatrics. It’s also helpful when looking for clinical tipping points for more aggressive treatments and interventions. I’ve found the phrase, “If the Glasgow is less that eight … intubate.” to be fairly reliable.

Let’s not forget the purpose of the Glasgow. The Glasgow is a general measure of brain function. It’s intended to rapidly communicate the patients level of consciousness. So we’re testing how well the brain is working, both at cognition and motor function. That is to say, how well is the patient able to process information and move their body.

The total score gives us a value between three and fifteen. As a side note, the statue of liberty gets a six. (Her eyes are open.) Unless you consider holding the torch overhead to be purposeful movement in which case she gets an 11. I digress.

My first recommendation is to start thinking of the three categories as Eye / Verbal / Motor. I’m not sure why textbooks insist on listing the categories as Eye / Motor / Verbal, but that is the way it has traditionally been taught. The advantage of the EVM order is it helps you recall the maximum score for each category Eye – 4, verbal – 5, motor – 6. Sometimes I feel that we try to make this stuff harder than it needs to be. I don’t know about you but in my mind, EVM 4,5,6 has always been easier to recall than EMV, 4,6,5. So make life easier on yourself. Say it with me E – V – M.   4 – 5 – 6!

Second, don’t think of the Glasgow as fifteen criteria that all need to be remembered. Many of those criteria are a snap. Take a closer look.

The top score in each category could be summed up with the word normal. Picture interacting with someone who has no neurological deficits. Their eyes are spontaneously open, they converse normally and they respond to verbal commands. If you know what normal looks like you’ve got three criteria covered.

The bottom score in each category is summoned up with the word none. If you know what the absence of a response looks like, you’ve got three more criteria covered.

Now those “in-between” criteria become a bit more complex, so let’s look at them with some detail.

Eyes: There really are very few choice for getting someone to open their eyes when their eyes are closed, wouldn’t you agree? You can talk to them and you can physically stimulate them. That’s about it. There are a few subtleties however. Voice means loud voice. If someone is simply relaxing and you speak to them and they open their eyes, we score them as spontaneous (4). Likewise, pain means painful or noxious stimuli. If we give someone a gentle shake and they open their eyes we’re still going to score them as verbal (3).

Verbal Response: The patients verbal responses are somewhat more complex. The range of possible verbal responses are considerably more varied so we add an additional criteria. People who are oriented (5) speak in context and understand the classic who, where, what questions of orientation. People who are confused (4) still form sentences in context with the conversation. When they speak they reveal that they are misunderstanding their reality. They are at the bus stop but they think they are at home. They are unable to tell you who they are, etc. Inappropriate words (3) doesn’t imply that the patient is being profane. Patients can be socially inappropriate and still be completely oriented. Inappropriate implies that they speak completely out of context or they speak word salad. You ask, “Where are you?” and they reply, “Potato salad.” or, to quote Steve Martin, “Can I go mambo dog-face to the banana patch?” They speak real words, but those words are out of order or context. When the real words turn into sounds we transition to incomprehensible (2). If the patients response is comprised completely of vowels, or words that don’t belong to any language, they are incomprehensible.

Motor Response: This one can be challenging as well. The confusion with the lower motor scores often lies with recognizing the difference between localizing pain (5) and withdrawing from pain (4), and the difference between decorticate (flexion) (3) and decerebrate (extension) (2) posturing. Let’s look at both pairings.

Localizing pain (5) is not recognition of where the pain is located. That’s a common misconception. The patient who is able to localize pain can cross the midline and use resources on the other side of their body to remove that pain. Let’s take the example of starting an IV on a confused patient. If your patient simply pulls the hand that you are starting the IV in away from you, they have withdrawn from pain (4). If they use the opposite hand to cross the midline and try to push the stimulus away, they have localized the pain. In both cases they recognize where the pain is located but only in the second example did they recognize and use resources on the opposite side of their body to cross the midline and attempt to remove the stimulus.

If the painful or noxious stimulus is on the head (ie. insertion of a nasopharangeal airway) the clavicals are used as a marker. If the patients hand is able to rise above the level of the clavicle, the patient has localized the pain.

Decorticate Posturing By: Scleroplex

Decorticate Posturing By: Scleroplex

Flexion (3), also known as decorticate posturing and extension (2), also known as decerebrate posturing are both signs of increased intracranial pressure, or occasionally, brain hypoxia. They tend to be associated with poor outcomes in head injury patients. Flexion (3) involves the contraction of the muscle groups in the anterior arms and the relaxation of the muscle groups in the posterior arms. The arm curl inward toward the midline and the wrists flex. Extension (2) is the contraction of the posterior arm muscle groups and the relaxation of the anterior arm muscles.  The arms straiten. The shoulder flexes inward and the hands drift away from the body. The wrists straiten as well. Posturing may also be seen in the legs.

The last thought I’ll leave you with on the Glasgow is one that I repeat frequently in my writings. If you want to be good at anything you need to practice. When you encounter disoriented, confused, combative or unconscious patients, practice factoring in the Glasgow. If you find that you’re not ready to do it on the fly yet, write it down and work through it on your trip report after the fact. The more you practice, the more at ease you’ll become, and perhaps you’ll be ready when you’re calling that trauma alert and the surgeon requests a quick Glasgow Score.

Comments

  1. My son Lindsay was 35 years old and had an insulin overdose, he is dead now, they gave him GCS 4-5, and I spent a month with Lindsay to see if I could talk him through this, He cried twice and put his arm arounf me three times, he also made a kissing sound and pursed his lips when I requested……is this normal….did I kill my only son Lindsay…they said he had no chance as he was a severe diabetic…………….Pattie

  2. Florian says:

    Coincidentally, I was just wondering about the GCS yesterday whilst filling out my case sheets – this article just clears al the Q’s up in one scoop – cheers mate!

    A good tip I picked up from school regarding flexion and extension:
    “Decorticate” rhymes with “Caught a Cat” – inward movement as in holding the cat tight.
    “Decerebrate” is phonetically similar to “celebrate” – you throw your hands up in the air, extending them 🙂

  3. hi,
    Ihad a chronic problem with that thanks you helped much

  4. The way I always remember Decorticate and Decerabrate are : Decorticate(Flexion)- Towards the core of the Body and Decerabrate(Extension)-Celebrate away from body. Hope that helps…

  5. Great review. The way I remeber it is…

    E4 – “spontaneous”
    E3 – verbal
    E2 – pain
    E1 – none
    V5 – “spontaneous”
    V4 – Confused
    V3 – Random Words
    V2 – Gibberish
    V1 – none
    M6 – “spontaneous” / obeys
    M5 – Pain “in” (localizes)
    M4 – Pain “out” (withdraws)
    M3 – Core “in” (decorticate)
    M2 – Core “out” (decerebrate)
    M1 – none

    … instead of remembering 15, you’re really only remembering 9 or so.

  6. Steve Whitehead says:

    Thanks for the chart Scott. I agree that there really are fewer criterion than you might think at first glance.

  7. Thank u for this compete explanation.
    @Florian gr8 idea with “celebrate” 🙂

  8. I came up with a more functional method to get a baseline.

    Ask patient “Clyde, where are you?” If he answers correctly, Clyde is an immediate 9 – His eyes are open getting you an E5, and he’s answering correctly getting you a V4. Not to mention getting your A and B out of the way.

    Next, ask him “Clyde, give me your hand.” If he does it, Clyde gets 6 more satisfying M6. Clyde’s a 15. Take his radial while you have his hand, and you’ve knocked out C.

    Then you can adjust downward as necessary depending on his responses.

  9. BTW – in decorticate, the hands move toward the “core”.

  10. Shelley Thomas says:

    Hi there,

    I stumbled on your site in error this evening and it has been truly enlightening. I have narcolepsy and on occasions experience severe cataplexy attacks which usually result in panic by those around me. Being an unusual condition it can often confuse paramedics, and their actions have certainly confused me at times.! Reading through your site has given me a far better understanding of the actions they take that at times seem cruel – I have had my arm dropped in my face on more than one occasion but effectively paralysed I am unable to alert them to my condition which is really not a cause for concern at all. I guess I am unusual in that my GCS score of 3 or 4 (thanks, I now understand what that means) doesn’t require the urgency of most other patients. Thank you for the education and keep up the good work – it has been a real eye opener.

    Shelley, UK.

  11. What about gcs of a patient with spontaneous eye opening, oriented, obeys motor movement but with trache. The patient can’t speak beacause of trache. What should be the GCS for his verbal?

  12. Verbal GCS for trache patient would be V1- Trache. Just explain the reason for the patient being non verbal in your handover to hospital.

  13. I am just beginning paramedic school, and this web site has help me out alot. Thanks for this site and please, please keep this info. coming. I will continue to view this site on a daily basis throught out my training.

    Thanks.

  14. Hi Steve,

    Amazing article as always, although I do have something of a dispute with the example given for motor score 5/4. Even in a fully conscious person, peripheral pain can bring about a peripheral response, and rightly so. If someone jabbed my hand, the most sensible thing to do is to withdraw that hand from the stimulus and I will likely do so without thinking. Central painful stimulus should be the only way to go here, noting that the sternal rub can also bring about a peripheral response, making it effectively useless as well.

  15. Hey, loved the explanation! That really clears things up a lot. Especially differentiating between “localizes pain” and “withdraws from pain”. Never really understood the dif before.
    How I like to look at GCS is to think of your pt. as having a score of 15, and withdraw points as necessary, rather than seeing them as a GCS 3 and trying to add up all the points. Saves brainpower at 3 in the morning. 🙂
    An instructor also once told me to look at the Eye Response as a GCS equivalent to the AVPU scale. It clears things up a bit – at least in my head. 🙂
    Cheers,
    Kate

  16. Duke Powell says:

    Excellent post.

    First of all, I think ER nurses want GCS documented to establish a baseline. It’s an important part of the “trauma registry” follow up.

    Just yesterday I picked up a “one down” drunk 25 yr old patient that had a Glascow of 6 and with very stable vitals and 100% saturation on room air.

    If I had not evaluated the GCS closely, I would have undoubtedly made a mistake in my treatments and the patient disposition.

  17. Brooke/ Raleigh, NC says:

    Suuuuuper helpful explanations, thank you!

  18. very interesting article

  19. Ken unfortunately your scale is incorrect your eyes are out of 4 not 5 and your verbal is out of 5 not 4

  20. Baby Emt if you cannot speak that equals to not being verbal so 1

  21. Karik it depends on the side injured if on your palm you are more likely to close it but if on the outside your more likely to withdraw as taught in basic fire management and prevention courses

  22. Andrew Przepioski says:

    Since AVPU is commonly taught as part of the patient assessment skill in EMT class, I find it easy to remember Eyes for the Glascow Coma Scale by using AVPU. A = 4, V = 3, P = 2, U = 1.

  23. Hi, what would the eye score be for someone with fixed open eyes? Not continuously fixed, occasionally they would close and then open again with slight changes in condition, but not in response to me. The patient had a head injury and had suffered multiple seizures. Verbal was 1 and again, movement in the form of spasms and some posturing occurred, but had no relation to painful stimuli. However, technically the eyes being open classes as ‘spontaneous’, as mentioned about the Statue of Liberty. Any ideas?

  24. ok this article has realy helped….but realy what to know what type of nerves are involved when carring the GCS.

  25. Thank you. I will love you if I get a question about GCS in tomorrow’s exam!!

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