About a GCS...

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Ops Paramedic

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I was not sure whether to put this tread on the BLS or an ALS discussion side of it, but ended up on the BLS side as I believe that the responses could be generated by both.

The first question is straight forward: Would you be able to recite and apply the scoring of the GCS now?? A lot of practitioners can not, and it is very obvious. When qeustioned about the GCS of the patient, I often get:"It is ABOUT 9/15". The GCS cannot be an "About" as it is a score graded against very specific responses of the patient. If one says "about 9/15" it implies that you don't know the GCS and how to apply it, or you haven't done it yet. With that response I have to think now, well is it: 8/15, 9/15 or 10/15...

As far as I am aware, the GCS is scored against the best response of the patient. Correct?? So what if you get a patient who has a GCS of 3/15 until such a time you start shuving Oropherangeal Airway(OPA) in, and the patient now presents with a gag reflex and you see some form of motor response in the limbs?? The next question is: does that then raise the GCS from 3/15??

The last question is more for the ALS replying to this thread. How do you document the GCS (or calculate) of a patient who is now intbated. Do you still calculate it out of 15, or do you reduce it 10?

Lets see what happens...
 
As far as documentation goes, I never use the sum of the numbers for a GCS - I use each individual score. In other words, I'll document "pt. had GCS of 4/5/6". This way, if you say "GCS of 13", there's no confusion as to if they're verbally responsive with confused answers, or if they're alert but confused with appropriate response to painful stimuli. Also, I'll document their initial GCS, and any changes during treatment. You can verbalize the change in GCS to the ER staff by saying something like "initial GCS was 'x', and changed to 'y' after inserting an OPA and ventilating by BVM". If I intubate the pt, I report the verbal response at a 1 after intubation (there are no 0's in the GCS), but I will report their verbal response before intubation as well.

In regards to your initial question - The GCS is pretty straightforward, yes. If you do a quality assessment, the GCS will present itself to you...you won't need to strain to figure it out. On our PCR's, there is a small diagram of the GCS scale on the back; a quick glance at that combined with a quality assessment is all I needed to figure it out...although at this point in my career I have it pretty well memorized.
 
while some do report individual scores, there is nothing wrong with reporting the "sum"... the total number is used to infer degree of TBI and ICP...

for example, a score of 8 theoretically important because it implies severe brain herniation. does not matter what parts make up the total of 8.

it is important to note that the GCS was not devised for the purpose it serves in the field, so there is debate on it's importance.

studies have also shown GCS to be overused in medical cases and underused in Trauma. it serves little purpose in medical cases, other than perhaps a brain bleed due to ICH.

in trauma cases, if the initial number is not accurate, the the trending becomes useless.

is should be straightforward, but trying to put people into "little boxes" has it's own difficulties... in the field, many can not always make a differential between "confused" and "inappropriate words"... well, that is a difference of one point.
 
We use GCS on a BLS assessment. Our PCRs require we put down a GCS score. Medics use the same PCR so their's also requires a GCS score. I never though of it as BLS or ALS. I didn't realize not everyone used it.

I also break down the score into the 3 groups but only if there is a deficiency. If there isn't, I just put 15.
 
Ops Paramedic said:
I was not sure whether to put this tread on the BLS or an ALS discussion side of it, but ended up on the BLS side as I believe that the responses could be generated by both.

The first question is straight forward: Would you be able to recite and apply the scoring of the GCS now?? A lot of practitioners can not, and it is very obvious. When qeustioned about the GCS of the patient, I often get:"It is ABOUT 9/15". The GCS cannot be an "About" as it is a score graded against very specific responses of the patient. If one says "about 9/15" it implies that you don't know the GCS and how to apply it, or you haven't done it yet. With that response I have to think now, well is it: 8/15, 9/15 or 10/15...

As far as I am aware, the GCS is scored against the best response of the patient. Correct?? So what if you get a patient who has a GCS of 3/15 until such a time you start shuving Oropherangeal Airway(OPA) in, and the patient now presents with a gag reflex and you see some form of motor response in the limbs?? The next question is: does that then raise the GCS from 3/15??

The last question is more for the ALS replying to this thread. How do you document the GCS (or calculate) of a patient who is now intbated. Do you still calculate it out of 15, or do you reduce it 10?

Lets see what happens...
Click to expand...

As far as calculating the GCS, some multitask better than others. When I give the receiving an "about X/15", then that is a calculation while I was performing other duties simply because the pt was that critical and I was that busy.

When it comes to a GCS of 3 and you then note a gag reflex, you will still have a GCS of 3, but you will also have an accompanying gag reflex.

If I have an intubated pt, the verbal response ranges change to the following:

5T - responds appropriately with gestures
3T - does not respond appropriately with gestures
1T - does not respond at all

Eyes and Motor and unchanged. For those ICU pts who are ready to wean off the vent, you can get a GCS of 15T.
 
as patients with a GCS of 3 are as comatose as you can be, i'd would like to know, especially from medics, how common it is to have a pt with a GCS of 3 and a gag reflex...

even dead folks get a GCS of 3.
 
Simple. Any response of GCS deals with spontaneous, verbal, or "painful" stimuli, not noxious. Gagging does not hurt.
 
I honestly cannot remember the scoring scale, which is why I'm glad they have it on the back of the PCR's, so if it is needed I will look it up there and document it accordingly..
 
Reciting the GCS is probably not that difficult. It become difficult when you suddenly need to apply it to the patient at hand, and that should not be the case. I agree the GCS should be a precise and accurate measurement of what the patient is presenting.

I have used the "about" term before. I was very quickly educated by my then instructor - Mr. Paolini - what is that!? I understand why it cant be "about", because its a precise score and its set out according to fixed measurements. Anyone can see the patient is opening his/her eyes or the patient's speech is confused - and this can be confirmed by history.

Regarding the change in GCS with intubation to 10. I think the most logical reason for changing the GCS to 10 is because you remove the patient's capability to use verbal actions - in a manner of speaking. If a patient is not intubated he/she would be able to use verbal actions in normal circumstances, but whilst intubated this action would be neutralized even if the patient was awake.
 
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