QuestionSBA
QuestionChoice
This is the correct total score, but incorrect in the constituent parts. The patient's eyes only open to pain, therefore, this scores a 2. She is able to articulate words, rather than mumbling so scores at least a 3. However, because she is not able to form sentences, confused or otherwise, she only scores a 3. Motor of 2 would be decerebrate rather than decorticate. Decorticate means abnormal flexion in response to pain, which is therefore, a 3. Decerebrate means abnormal extension in response to pain and would therefore, score a 2
32849
b
8 - Eyes 2, Verbal 4, Motor 2
QuestionChoice
This is the correct answer. The patient's eyes only open to pain, therefore, this scores a 2. She is able to articulate words, rather than mumbling so scores at least a 3. However, because she is not able to form sentences, confused or otherwise, she only scores a 3. Decorticate means abnormal flexion in response to pain, which is therefore, a 3
32848
a
8 - Eyes 2, Verbal 3, Motor 3
QuestionChoice
This is incorrect. The patient's eyes only open to pain, therefore, this scores a 2. She is able to articulate single words only and therefore, scores a 3 for verbal. Motor of 2 would be decerebrate rather than decorticate. Decorticate means abnormal flexion in response to pain, which is therefore, a 3. Decerebrate means abnormal extension in response to pain and would therefore, score a 2
32851
d
7 - Eyes 2, Verbal 3, Motor 2
QuestionChoice
This is incorrect. The patient's eyes only open to pain, therefore, this scores a 2. She is able to articulate words, rather than mumbling so scores at least a 3. However, because she is not able to form sentences, confused or otherwise, she only scores a 3. Decorticate means abnormal flexion in response to pain, which is therefore, a 3
32850
c
9 - Eyes 2, Verbal 4, Motor 3
QuestionChoice
This is incorrect. The patient's eyes only open to pain, therefore, this scores a 2. She is able to articulate words, rather than mumbling so scores at least a 3. However, because she is not able to form sentences, confused or otherwise, she only scores a 3. Motor of 2 would be decerebrate rather than decorticate. Decorticate means abnormal flexion in response to pain, which is therefore, a 3. Decerebrate means abnormal extension in response to pain and would therefore, score a 2
32852
e
6 - Eyes 2, Verbal 2, Motor 2
QuestionComment
A bit unfair to those of us who didn't know what decorticate meant
6222
QuestionComment
Easy to mix up decorticate and decerebrate at the best of times 
15535
User
subscriber
35CC
QuestionComment
decErebrate = Extension :) 
19550
User
subscriber
Neoplasia Dominant
User
subscriber
Maysha
QuestionComment
please just say abnormal flexion...
23588
User
subscriber
Myopathy Kinase
QuestionComment
even taking english lit at a-level didnt prepare me for tht word
26170
User
subscriber
canIhave12bottlesofbleachplease
Concept
Chapter
# Summary

The Glasgow Coma Scale (GCS) is a universal score used to standardise assessment of a patient's level of consciousness. The maximum score (normal level of consciousness) is 15 and the minimum score is 3 (comatose or dead patients). There are three components to the score: eye opening, verbal response and motor response. The score is presented as each of the three components and the total score, for example GCS 15 (E4 M6 V5). There are a wide variety of causes for a decreased GCS, and investigations should be targeted based on the clinical presentation e.g. a CT head in suspected head injury. Management again depends on the underlying cause, but supportive measures may be required, most importantly airway protection for patients with a GCS of 8 or below.

# Definition
 
The Glasgow Coma Scale (GCS) is a standardised way of assessing and communicating a patient's level of consciousness. Scores range from 3 (a comatose or dead patient who is unresponsive) to 15 (an oriented and fully conscious patient). 
 
# Classification

GCS is calculated as follows:

**Eye Opening Response:**

4 - Spontaneous
 
3 - To speech

2 - To pain

1 - No response
 
 
**Verbal Response:**

5 - Oriented

4 - Confused

3 - Inappropriate speech 

2 - Incomprehensible speech or sounds

1 - No response
 
**Motor Response:**

6 - Obeys commands

5 - Localises pain

4 - Withdraws from painful stimulus
 
3 - Abnormal flexion to pain (decorticate posture)
 
2 - Abnormal extension to pain (decerebrate posture)
 
1 - No response
 
**Note -** Appropriate painful stimuli are:

- Applying pressure to a fingertip
- Trapezius squeeze
- Supraorbital pressure

# Differential Diagnosis

Causes of a reduced GCS include:

- **Cerebral causes:** head injury, intracranial bleeding, space-occupying lesions, epilepsy
- **Respiratory causes:** hypoxia, hypercapnia, carbon monoxide poisoning
- **Cardiac causes:** arrhythmias, shock (leading to inadequate cerebral perfusion)
- **Toxic causes:** medications, illicit drugs, alcohol intoxication, overdoses
- **Metabolic causes:** hypo or hyperglycaemia, uraemia, hepatic encephalopathy
- **Infective causes:** encephalitis, sepsis, meningitis, cerebral malaria

# Investigations

One key consideration is what the patient's baseline GCS is - for example in a patient with dementia a normal GCS for them may be 14 due to confusion.

An A to E approach should be taken in most cases (especially if GCS is significantly reduced) and investigations targeted to suspected underlying causes.

Common investigations include:

**Bedside tests:**

- **Capillary blood glucose** for hypo or hyperglycaemia
- **Arterial blood gas** looking for hypoxia, hypercapnia and metabolic disturbances
- **Urinalysis** e.g. in suspected infection (urinary tract infections are a common cause of confusion)
- **ECG** for arrhythmia

**Blood tests:**

- **FBC** and **CRP** for inflammatory markers
- **U&Es** for uraemia and electrolyte imbalance
- **Bone profile** for hypercalcaemia
- **LFTs** for liver dysfunction that may precipitate hepatic encephalopathy
- **Ammonia** if hepatic encephalopathy is suspected
- **Blood cultures** if infection is suspected

**Imaging:**

- **Chest X-ray** as part of a septic screen if infection is suspected
- **CT head** or other intracranial imaging if the cause of reduced GCS is unclear or an intracranial cause is suspected

**Special tests:**

- **Lumbar puncture** e.g. in suspected meningitis or subarachnoid haemorrhage
- **EEG** in suspected encephalitis or non-convulsive status epilepticus

# Management
 
Management involves treating the cause of reduced GCS, e.g. giving dextrose in hypoglycaemia, giving naloxone in opiate overdose.

The patient's medications should be reviewed and contributing medications may need to be held (e.g. opiates).

Supportive management is also important especially if the cause is not immediately treatable - the priority is airway protection.

Patients with a GCS of 8 or below are generally thought to require airway protection (e.g. intubation and ventilation) - immediate assistance from anaesthetics should be sought.
 
# References

[MDCalc - GCS Calculator](https://www.mdcalc.com/calc/64/glasgow-coma-scale-score-gcs)

[Student BMJ - GCS explained](https://www.bmj.com/content/365/bmj.l1296)

[Life in the Fast Lane - GCS](https://litfl.com/glasgow-coma-scale-gcs/)

[Life in the Fast Lane - Examination of the Unconscious Patient](https://litfl.com/examination-of-the-unconscious-patient/)
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The Glasgow Coma Scale
Topic
39
Emergency Medicine
6570
To score the Glasgow Coma Scale (GCS), assess the patient’s eye opening (4 points), verbal response (5 points), and motor response (6 points) separately, and sum the scores to obtain a total between 3 (deep coma) and 15 (fully alert).
A 56-year-old woman is brought in to A&E after a motorcycle accident. On examination her eyes open after administering a trapezius squeeze; she is able to say words but no clear sentences; her movement is described a "decorticate".

What is her Glasgow Coma Scale score?
a