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Chapter 35: Neurosurgery

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An 18-year-old man presents to the emergency department (ED) by ambulance after a motor vehicle crash. He was unconscious at the scene with a Glasgow Coma Scale (GCS) score of 3. He was intubated and received 1 L of normal saline en route. On exam, he has obvious head trauma. With deep painful stimuli, he briefly opens his eyes, extends his right upper extremity, and reaches for the painful stimulus with his left upper extremity. His lower extremities are flaccid and do not move with any stimulation. He does not follow commands. His GCS now is

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(A) 5T

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(B) 6T

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(C) 7T

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(D) 8T

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(D) The GCS was developed as a means to quantify and communicate a patient’s overall neurologic status. It is generally used in trauma situations but also applies to medical illnesses affecting the nervous system. By no means does a documented GCS obviate the need for a thorough neurologic examination. Scoring is based on eye opening (4 possible total points), verbal response (5 possible total points), and motor response (6 possible total points) (Table 35-1). The best exam within each category is used. Generally, a GCS score of 8 or less is considered “comatose” and an indication for intubation.

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Table 35-1 Glasgow Coma Scale (GCS) Score
GCS Eye Opening Verbal Response Motor Response
1 None None (or intubated) None
2 To pain Incomprehensible Decerebrate posture
3 To voice Inappropriate words Decorticate posture
4 Spontaneous Confused Withdraws to pain
5   Normal, oriented Localizes pain
6     Follows commands

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Following the table, the minimum score is 3 and maximum score is 15. Head injuries are often classified according to the GCS, with the postresuscitation GCS being more accurate than the GCS at the scene. GCS of 13–15 is a mild head injury, 9–12 is moderate, and 3–8 is severe. Importantly, if a patient is intubated, they have no verbal exam and so receive a score of 1 (minimum), although with the designation of “T” at the end of the score.

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The score is designated by the best responses from the patient. This patient opens his eyes to pain (2 points out of a potential 4), is intubated (assumed nonverbal, so 1 point, but designated with “T”), and localizes to pain (5 points out a potential 6). Therefore, his GCS score is 8T.

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BIBLIOGRAPHY

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Greenberg M, Greenberg MS. Handbook of Neurosurgery, 7th ed. New York, NY: Thieme; 2010:279.

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Teasdale G, Jennett B. Assessment of coma and impaired consciousness: a practical scale. Lancet 1974;2:81–84.

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