Using the Glasgow Coma Scale (GCS

The only choice after this is to continue CPR until emergency medical services (EMS) arrives to manage the patient. The patient should be evaluated every minute or so to see if they are breathing spontaneously or to see if they have effectively dislodged the object.

Things that are definitely contraindicated in managing the unconscious patient is giving them anything to eat or drink, leaving them without constant supervision, placing a pillow under their head (this closes off the airway), or attempting to revive them by splashing them with cold water or hitting them across the face.

Indications for calling 911 immediately include the following:

• The patient is unconscious and is older than 50 years of age. • The patient is unconscious and is pregnant (at any gestational age). • The patient is unconscious and has no spontaneous respirations. • The patient has lost control of his or her bowels or bladder while unconscious. • The patient is having a seizure (particularly if you do not know if they have a known seizure disorder. • The patient is a diabetic (even if you haven’t documented hypoglycemia). • The patient has suffered some type of known or suspected trauma. • The patient has been unconscious for longer than a minute.

Even if the patient has regained consciousness fairly quickly, 911 should be contacted if the patient has an irregular heartbeat, chest pressure/pain, or has any type of focal neurological deficit (such as aphasia or paralysis).

Using the Glasgow Coma Scale (GCS)

In actuality, most patients are not fully conscious or fully awake but is somewhere in between the two. The Glasgow Coma Scale (GCS) can easily provide an objective and reliable measurement of the individual’s level of consciousness. It can be done repeatedly and as often as necessary to judge the patient’s neurological status.

The revised GCS includes a point range between three and fifteen, where three indicates a deep level of unconsciousness and fifteen represents total alertness. It was first developed to gauge the level of consciousness following a head injury but has expanded to include the assessment of anyone who has an altered level of consciousness for any reason. It is a widely used by first responders, EMS crewmembers, and emergency medicine personnel to indicate to each other the person’s level of consciousness. It is also used in other hospital settings where level of consciousness might be altered.

There are three basic elements to the GCS, which are separately assessed and scored into what total score the patient gets. These include eye opening, verbal reaction, and motor function. The scoring is done like this:

Points Eye Opening Verbal Response Motor Response

1 Doesn’t open eyes Makes no response No movement

2 Opens to pain stimulus Is incomprehensible Decerebrate response

3 Opens to voice command Speak incoherently Decorticate response

4 Opens spontaneously Is confused or disoriented

5 Is fully oriented Local withdrawal to pain

6 Voluntary movements Broad withdrawal to pain

In assessing the eye-opening response, a painful stimulus should be given peripherally, such as squeezing the lunula of the fingernail. The patient, in order to score a 4 for eye opening must have both the ability to open their eyes to speech AND spontaneously. The patient does not score a 4 if they have their eyes open but do not have the ability to open and close them with volition.

In assessing the verbal response, there is a gray area between speaking incomprehensibly, speaking incoherently, and being confused or disoriented. Incomprehensive speaking would basically be moaning only, while incoherent speaking involves speaking words that are recognizable but not a pattern of sentence or phrase-utterance. Confused speech involves the ability to answer questions that do not make sense. The person only receives the full five points if they answer questions coherently.

In assessing the motor response, decerebrate posturing involves an extensor response that is exacerbated by pain, while a decorticate response is an exaggerated flexor response to the application of pain. A decorticate response is considered a worse prognostic indicator than a decerebrate response. These are classical responses in patients with severe head injuries. The patient will receive extra points when they are able to indicate where the painful stimulus was given (such as making the appropriate withdrawal response).

The patient is likely to be dead or nearly dead if they receive a score of 3, which is the lowest possible score. Severe impairment is a GCS of less than eight; moderate impairment is a GCS of