What is the assessment of the verbal component of the Glasgow Coma Scale (Glasgow Coma Scale, GCS)?

From the Guidelines

The voice component of the Glasgow Coma Scale (GCS) should be assessed by evaluating a patient's verbal response, with scores ranging from 1 to 5, as this provides valuable information about the patient's cognitive status and level of consciousness 1. To properly assess this component, first attempt to engage the patient in conversation by asking simple questions like their name, where they are, or the current year.

Key Points to Consider

• Score the response as follows:
  • 5 points for oriented responses (patient correctly identifies person, place, time)
  • 4 points for confused conversation (patient responds coherently but is disoriented)
  • 3 points for inappropriate words (random or exclamatory articulated speech)
  • 2 points for incomprehensible sounds (moaning, groaning)
  • 1 point for no verbal response
• When assessing intubated patients or those with speech impediments, document this limitation with a "T" (e.g., V1T or VT)
• Always assess the voice component alongside the eye and motor components to calculate the total GCS score This assessment helps evaluate brain function and consciousness level, with changes in verbal response potentially indicating neurological deterioration requiring prompt medical attention, as noted in the study by Teasdale and Jennett 1.

Clinical Application

The GCS score, including the voice component, continues to play a crucial role in diagnosing severe and moderate TBI and prioritizing interventions in these patients 1. However, for mild TBI, a single GCS score is of limited prognostic value and is insufficient to determine the degree of parenchymal injury after trauma 1. Serial GCS scores are quite valuable in patients with mild TBI, as a low GCS score that remains low or a high GCS score that decreases predicts a poorer outcome than a high GCS score that remains high or a low GCS score that progressively improves 1.

From the Research

Assessing the Voice Component of the Glasgow Coma Scale (GCS)

• The Glasgow Coma Scale (GCS) is a valuable tool in assessing the neurologic and physiologic status of critically ill patients, but its use is limited in intubated patients as it requires assessment of the verbal response of the patient 2.
• A study published in 1996 found that a linear regression model based on the eye and motor components of the GCS can accurately predict the verbal response of the GCS, allowing for the calculation of the GCS sum score in intubated patients 2.
• The model, which uses the equation Estimated GCS Verbal = (2.3976) + [GCS Motor x (-0.9253)] + [GCS Eye x (-0.9214)] + [(GCS Motor)2 x (0.2208)] + [(GCS Eye)2 x (0.2318)], was found to be an accurate predictor of the verbal score (Pearson's Correlation r = 0.9, R2 = 0.8, p = 0.0001) 2.

Challenges and Limitations

• Despite its widespread use, the GCS has been found to have inconsistencies in its application and interpretation, which can lead to variances in practice and potentially harmful outcomes 3, 4.
• The use of painful stimuli in assessing level of consciousness using the GCS is an area that requires further exploration and standardization 3.
• A robust educational strategy is necessary to maximize consistency in the use of the GCS in practice 3, 4.

Best Practices and Future Directions

• Clinicians should understand the importance of accurate GCS assessments and be aware of the factors that can affect their accuracy, such as human factors like distress 5, 4.
• A unified approach to education and standards for the use of the GCS, framed within a person-centered context, is necessary to enhance practice and ensure consistency in its application 4.
• The GCS remains a widely used and influential tool in the assessment of consciousness, with a 50-year history of use and over 10,000 citations 6.