Glasgow Coma Scale Flashcards

1
Q

What is ACVPU ?

A

A very simple way to gain a rapid assessment of conscious level.

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2
Q

ACVPU

A

Alert - 15
Level of confusion - 14 (10-14)
Responding to voice - 13 (12-14)
Responding to pain - 8 (7-9)
Unresponsive : 3-6

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3
Q

Why should the Glasgow coma scale be used rather than ACVPU when handing over the care of a person ?

A

ACVPU gives no objective method of recording and comparing responses over time or handing over to other medical personnel.

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4
Q

What are the 3 different components of the Glasgow coma scale ?

A

Eye opening
Verbal
Motor

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5
Q

What is the max number of points for eye opening ?

A

4

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6
Q

What is the max number of points for verbal response ?

A

5

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7
Q

What is the max number of points for motor response ?

A

6

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8
Q

What does a point of 1 mean on the GCS ?

A

NO response

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9
Q

E1

A

Not opening eyes

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10
Q

E2

A

Open to pressure

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11
Q

E3

A

Open to sound

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12
Q

E4

A

Open spontaneously

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13
Q

V1

A

No verbal response

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14
Q

V2

A

Incomprehensible sounds - moaning/ groaning

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15
Q

V3

A

Inappropriate words

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16
Q

V4

A

Confused speech / disoriented

17
Q

V5

A

Normal speech / oriented

18
Q

M1

A

No motor response

19
Q

M2

A

Extending to pain

20
Q

M3

A

Abnormal flexion to pain (difficult to asses, so often not used)

21
Q

M4

A

Normal flexion to pain - withdrawal

22
Q

M5

A

Localising to pain

23
Q

M6

A

Obeying commands

24
Q

Name the 3 methods for eyes and verbal response

A

Passive observation
Active observation
Active pressure stimulus

25
Q

Passive observation

A

Stand and watch the person for a short time
If eyes are open : E4 as there is no stimulus

26
Q

Active observation

A

Talking to the person
(you may need to illicit a response)

27
Q

Active pressure stimulus

A

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.

28
Q

What is the max GCS score ?

A

15

29
Q

What is the min GCS score ?

A

3

30
Q

GCS 14-15 : relating to head injury

A

Mild brain injury

31
Q

GCS 9-13 : relating to head injury

A

Moderate brain injury

32
Q

GCS 3-8 : relating to head injury

A

Severe brain injury
Said to be in a coma if GCS score <8

33
Q

What actions should be taken for a person with a GCS score of < 8 ?

A

Steps must be taken to protect and secure the airway

34
Q

What should you do to apply pressure ?

A

Trapezius pinch
Squeeze nail bed
supraorbital notch