Surgery - Disability

Immediate Neurological Assessment

Neurological status should initially be assessed rapidly using the AVPU system, followed by a more definitive assessment using the Glasgow Coma Scale (GCS).

AVPU System

A – Alert: The patient is spontaneously alert and responsive. This is approximately equivalent to a GCS of 14–15.

V – Voice: The patient responds to verbal stimuli. This is approximately equivalent to a GCS of 9–10.

P – Pain: The patient responds only to painful stimuli. This is approximately equivalent to a GCS of 7–8.

U – Unresponsive: The patient does not respond to verbal or painful stimuli. This may correspond to a GCS as low as 3.

Glasgow Coma Scale

The Glasgow Coma Scale (GCS) provides a more detailed assessment of the patient’s level of consciousness.

It consists of three components: eye response, verbal response, and motor response.

The patient’s best response in each category is recorded, giving a maximum total score of 15.

Best Eye Response

No eye opening – 1 point.

Eye opening to painful stimuli – 2 points.

Eye opening to verbal stimuli – 3 points.

Spontaneous eye opening – 4 points.

Best Verbal Response

No verbal response – 1 point.

Incomprehensible sounds or noises – 2 points.

Inappropriate words – 3 points.

Confused conversation – 4 points.

Orientated and lucid response – 5 points.

Best Motor Response

No motor response – 1 point.

Abnormal extension to pain (decerebrate response) – 2 points.

Abnormal flexion to pain (decorticate response) – 3 points.

Withdrawal from pain – 4 points.

Localising to pain – 5 points.

Following commands – 6 points.

Highest GCS Score

The highest possible GCS score is 15.

A patient with a GCS of 15 is fully alert, awake, orientated, and appropriately responsive.

Lowest GCS Score

The lowest possible GCS score is 3, not zero.

A patient with a GCS of 3 is deeply unconscious and demonstrates no eye, verbal, or motor response.

GCS and Intubation

A GCS of 8 or less indicates severe impairment of consciousness and should prompt assessment of the patient’s ability to protect their airway.

In trauma, the traditional principle is “GCS 8, intubate,” although the decision to intubate should also take into account the patient’s airway, ventilation, oxygenation, clinical trajectory, and other injuries.

Reassessment of GCS in Trauma

The GCS should be reassessed frequently in a trauma patient, traditionally every 15 minutes during the acute phase.

Every GCS assessment should be clearly documented so that any improvement or deterioration in neurological status can be identified.