Glasgow Coma Scale Flashcards
What is ACVPU ?
A very simple way to gain a rapid assessment of conscious level.
ACVPU
Alert - 15
Level of confusion - 14 (10-14)
Responding to voice - 13 (12-14)
Responding to pain - 8 (7-9)
Unresponsive : 3-6
Why should the Glasgow coma scale be used rather than ACVPU when handing over the care of a person ?
ACVPU gives no objective method of recording and comparing responses over time or handing over to other medical personnel.
What are the 3 different components of the Glasgow coma scale ?
Eye opening
Verbal
Motor
What is the max number of points for eye opening ?
4
What is the max number of points for verbal response ?
5
What is the max number of points for motor response ?
6
What does a point of 1 mean on the GCS ?
NO response
E1
Not opening eyes
E2
Open to pressure
E3
Open to sound
E4
Open spontaneously
V1
No verbal response
V2
Incomprehensible sounds - moaning/ groaning
V3
Inappropriate words
V4
Confused speech / disoriented
V5
Normal speech / oriented
M1
No motor response
M2
Extending to pain
M3
Abnormal flexion to pain (difficult to asses, so often not used)
M4
Normal flexion to pain - withdrawal
M5
Localising to pain
M6
Obeying commands
Name the 3 methods for eyes and verbal response
Passive observation
Active observation
Active pressure stimulus
Passive observation
Stand and watch the person for a short time
If eyes are open : E4 as there is no stimulus
Active observation
Talking to the person
(you may need to illicit a response)
Active pressure stimulus
Last step of assessment and is only necessary if the person has not responded to your voice.
Apply pressure to the finger over the nail tip.
What is the max GCS score ?
15
What is the min GCS score ?
3
GCS 14-15 : relating to head injury
Mild brain injury
GCS 9-13 : relating to head injury
Moderate brain injury
GCS 3-8 : relating to head injury
Severe brain injury
Said to be in a coma if GCS score <8
What actions should be taken for a person with a GCS score of < 8 ?
Steps must be taken to protect and secure the airway
What should you do to apply pressure ?
Trapezius pinch
Squeeze nail bed
supraorbital notch