Glasgow Coma Scale (GCS)

The GCS is a standardized tool used to assess level of consciousness in patients with suspicion of acute brain injury or neurological compromise. It is especially important in trauma, stroke, encephalopathy, or any situation where neurological status may deteriorate. 
 
Components of GCS 
 
The GCS has three components: 




Total GCS score: 3–15 
 
Note: Motor response is the strongest predictor of outcome. 

Post Fall protocol 
 
Initially every 15 minutes post fall for first hour, then 30 minutes for 2 hrs and then hourly thereafter if stable – refer to  local falls protocol 
 
Tip: Always document the exact GCS score, not just “patient alert” or “drowsy.” 
 
Escalation Guidelines 
Immediate escalation is required if: 
 
Drop in GCS by ≥2 points 
New neurological signs: pupillary changes, limb weakness, seizures 
GCS ≤8 (consider airway protection/intubation) 
Inability to maintain airway or oxygenation 
 
Escalation steps may include: 
Rapid notification of senior medical staff / on-call medical team 
Escalation to ICU if not already admitted 
Immediate neuroimaging (CT/MRI) if indicated 
Airway management if GCS ≤8 
 
Key point: Trend in GCS is more important than a single reading. 
 
Practical Tips 
 
Always assess and document all three components; avoid estimating total GCS from partial assessment. 
Use pain stimulus appropriately (e.g., trapezius squeeze or supraorbital pressure) if patient is unresponsive. 
Record both score (broken down by component) and date/time. 
Use consistent method and same observer for reliable trends. 
Integrate GCS with other observations: vital signs, pupils, symmetry of limb movements. 

Always escalate any abnormality immediately – time is critical