Station Title & Timing

  • Title: Assessment of Glasgow Coma Scale (GCS) in Acute Head Injury
  • Duration: 10 minutes (2 minutes reading time + 8 minutes performance)

Learning Objectives

  • Examination Skills: Demonstrate a systematic, step-by-step assessment of the Glasgow Coma Scale with a formal running commentary.
  • Clinical Reasoning: Interpret the score correctly, identify clinical deterioration, and recognize the threshold for airway intervention.
  • Professionalism: Maintain patient dignity and demonstrate safe, professional techniques for painful stimuli.

Patient Profile

  • Name: Mr. Ryan Miller
  • Age: 30 years old
  • Ethnicity: Any
  • Occupation: Courier
  • Relevant Social History: Generally healthy, non-smoker, active lifestyle.

Presenting Complaint

Ryan fell from his bicycle while traveling at moderate speed 45 minutes ago. He was wearing a helmet, but it was damaged. He had a brief loss of consciousness at the scene.

Contextual Information

  • HPC: Paramedics reported an initial GCS of 13 at the scene, which dropped to 10 upon arrival at the Emergency Department (E2, V3, M5).
  • PMH: No history of epilepsy, diabetes, or previous head injuries.
  • Medications: Nil.
  • Allergies: No known drug allergies.

Exam Instructions

Candidate Instructions

You are the HMO (House Medical Officer) in a regional Emergency Department. Mr. Miller is in the resuscitation bay.

  1. Perform a formal Glasgow Coma Scale (GCS) assessment on the patient (mannequin).
  2. Provide a running commentary for the examiner as you perform the test.
  3. Calculate the final score and explain its clinical significance and your immediate management priorities to the examiner.

Standardised Patient (SP) / Mannequin Instructions

  • Eyes: Remain closed throughout. If the candidate shouts the name, eyes remain closed. When a trapezius squeeze (pressure) is applied, the eyes open briefly then close again.
  • Verbal: When spoken to or stimulated, the patient moans or grunts but does not use any recognizable words.
  • Motor: When asked to “squeeze fingers,” there is no response. When a trapezius squeeze is applied, the patient flexes his arm at the elbow and pulls the arm away from the stimulus (Withdrawal).

Examiner Checklist Items

  • Verbalizes the check for Spontaneous Eye Opening first.
  • Uses a systematic escalating approach (Voice $\rightarrow$ Pressure).
  • Uses appropriate professional sites for pressure (Trapezius or Supraorbital).
  • Correctly assesses Verbal Response (Incomprehensible sounds).
  • Correctly distinguishes between Localizing and Withdrawal for Motor Response.
  • Calculates the total GCS (E2, V2, M4 = GCS 8).
  • Identifies the drop from GCS 10 to GCS 8 as a clinical deterioration.
  • States the threshold: “GCS 8, Intubate.”

Key Clinical Findings (Current Assessment)

ComponentFindingScore
Eyes (E)Opens only to pressure stimulus.2
Verbal (V)Incomprehensible sounds (moaning) only.2
Motor (M)Normal flexion/Withdrawal from pain.4
TOTALGCS 8

Communication Triggers (Examiner Interaction)

  • Running Commentary: “I am now checking the verbal response by asking Ryan: ‘Ryan, can you hear me? Do you know where you are?'”
  • Professional Stimulus: “As there is no response to voice, I am now applying a central painful stimulus via a trapezius squeeze to check for motor and eye response.”
  • Summarizing to Examiner: “To summarize, the patient’s GCS is 8. This represents a drop of 2 points from his arrival score, which is a significant deterioration.”

Assessment & Marking Guide

DomainKey Performance Indicators
TechniqueAvoided aggressive stimuli; used systematic E-V-M order.
AccuracyCorrectly assigned V2 (sounds) and M4 (withdrawal).
Clinical InterpretationRecognized the patient’s GCS is now 8.
SafetyExplicitly mentioned the risk to the airway and the need for senior/anaesthetic support.
Global RatingPass: Systematic, accurate, and identifies the airway emergency. Fail: Guesses the score without checking, uses unsafe stimuli, or fails to recognize GCS 8 threshold.

Sample Answers / Model Performance

The GCS Running Commentary:

“I am beginning the GCS assessment.

  • Eyes: I observe no spontaneous eye-opening. Ryan, can you open your eyes? No response to voice. I am now applying pressure to the trapezius muscle. The eyes open briefly. That is an E2.
  • Verbal: Ryan, can you tell me your name? Where are we? The patient is making moaning sounds but no words are formed. That is a V2.
  • Motor: Ryan, squeeze my fingers and let go. There is no response to commands. I am applying a trapezius squeeze again. The patient pulls his arm away from me. This is normal flexion/withdrawal, not localizing above the chin. That is an M4.
  • Total: The total GCS is 8.”

Explaining Clinical Significance:

“The patient’s GCS has deteriorated from 10 to 8. This is a medical emergency for two reasons:

  1. Airway: A GCS of 8 is the critical level where a patient may lose their protective airway reflexes. I must follow the principle: ‘GCS of 8, Intubate.’
  2. Intracranial Pressure: This drop suggests increasing intracranial pressure or an expanding hematoma.

My immediate management plan is:

  • Call for an urgent ‘Code Blue’ or Anaesthetic/ICU review for airway protection.
  • Ensure 100% Oxygen and maintain hemodynamic stability.
  • Arrange an urgent non-contrast CT Brain once the airway is secure.
  • Notify the Neurosurgical team.”