CNS Flashcards
GCS categories
Eye opening
Verbal response
Motor response
GCS Eye Opening
4 Spontaneous
3 To speech
2 To pain
1 None
GCS Verbal Response
5 Oriented 4 Confused 3 Inappropriate 2 Incomprehensible 1 None
GCS Motor Response
6 Obeying commands 5 Localizing to pain 4 Withdrawal to pain 3 Decorticate (flexion) 2 Decerebrate (extension) 1 None
Highest GCS when intubated
11T (E4V1TM6)
RASS +4
Combative
Violent
Danger to staff
RASS +3
Very agitated
Pulls to remove tubes
Aggressive
RASS +2
Agitated
Frequent nonpurposeful movements
Fights ventilator
RASS +1
Restless
Anxious, apprehensive
Movements not aggressive
RASS 0
Alert & Calm
Spontaneously pays attention to caregiver
RASS -1
Drowsy
Sustained awakening to voice (>10sec)
RASS -2
Light sedation
Briefly awakens to voice (<10sec)
RASS -3
Moderate sedation
Movement or eye opening to voice (no eye contact)
RASS -4
Deep sedation
No response to voice but movement or eye opening to pain
RASS -5
Unarousable
No response to voice or pain