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.
- Perform a formal Glasgow Coma Scale (GCS) assessment on the patient (mannequin).
- Provide a running commentary for the examiner as you perform the test.
- 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)
| Component | Finding | Score |
| Eyes (E) | Opens only to pressure stimulus. | 2 |
| Verbal (V) | Incomprehensible sounds (moaning) only. | 2 |
| Motor (M) | Normal flexion/Withdrawal from pain. | 4 |
| TOTAL | GCS 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
| Domain | Key Performance Indicators |
| Technique | Avoided aggressive stimuli; used systematic E-V-M order. |
| Accuracy | Correctly assigned V2 (sounds) and M4 (withdrawal). |
| Clinical Interpretation | Recognized the patient’s GCS is now 8. |
| Safety | Explicitly mentioned the risk to the airway and the need for senior/anaesthetic support. |
| Global Rating | Pass: 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:
- 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.’
- 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.”