Glasgow Coma Score of 5: Critical Neurological Emergency
A Glasgow Coma Score of 5 indicates very severe traumatic brain injury with extremely high mortality risk, requiring immediate transport to a trauma center and consideration for neurosurgical intervention, though prognosis remains grave with mortality rates approaching 100% in certain subgroups. 1, 2
Severity Classification and Clinical Significance
A GCS of 5 falls within the severe traumatic brain injury category (GCS ≤8), specifically in the "very severe" subcategory (GCS 3-5) that carries the worst prognosis. 3, 2
This score indicates the patient is in a comatose state, as coma diagnosis is only possible with GCS total scores of 3-6. 4
The scale ranges from 3 (deep coma) to 15 (normal consciousness), placing a score of 5 near the most severe end of the spectrum. 1
Immediate Clinical Implications
Transport and Triage Requirements:
Any patient with GCS <14 meets critical physiologic criteria requiring immediate transport to a trauma center, with GCS of 5 representing far more severe compromise. 1, 5
Patients meeting GCS <14 criteria have documented mortality rates of 24.7%, though this increases substantially for GCS 3-5 patients. 1, 6
Airway Management:
- A GCS of 5 typically indicates the need for immediate airway protection and possible intubation, as GCS ≤8 generally requires these interventions. 3
Mortality and Outcome Data
Mortality rates for very severe TBI (GCS 3-5) are extremely high, reaching up to 100% for specific subgroups, particularly those with GCS 3 and bilaterally fixed dilated pupils. 2
Functional outcome is generally poor for this patient population, though occasionally favorable outcomes occur in specific subgroups after neurosurgical intervention. 2
The presence of additional factors like pupillary abnormalities and advanced age are associated with even worse outcomes. 2
Essential Monitoring Requirements
Serial Assessment Protocol:
Serial GCS assessments provide substantially more valuable clinical information than single determinations, with declining or persistently low scores indicating poorer prognosis. 5, 6
For patients with severe TBI, monitoring should occur every 15 minutes during the first 2 hours, then hourly for the following 12 hours according to Scandinavian protocols. 6
A decrease of at least two points in GCS score should prompt immediate repeat CT scanning. 6
Component Documentation:
Individual component scores (Eye, Motor, Verbal) must be documented at each assessment rather than just the sum score, as patients with identical totals but different component profiles may have different outcomes. 5, 6
The motor component has the highest predictive value in severe TBI and should be specifically tracked. 5
Pupillary size and reactivity must be documented at each assessment as key prognostic indicators. 6
Critical Pitfalls to Avoid
Never base treatment decisions on GCS alone - clinical decision making, particularly regarding treatment limitations, should never rely solely on the GCS score. 2
Account for confounding factors including sedation, intubation, facial trauma, intoxication, and metabolic disturbances that may affect the accuracy of GCS assessment. 5, 3, 7
Recognize the limitations - the GCS was originally designed for comatose patients and serial evaluations, not for single-point severity determination. 1
Don't assume uniformity - all GCS total scores between 4-14 are associated with more than one disorder of consciousness diagnosis, meaning the total score alone doesn't accurately reflect level of consciousness. 4
Neurosurgical Considerations
Immediate neurosurgical consultation is warranted, though the decision to operate remains complex given the grave prognosis. 2
While overall outcomes are poor, some studies report relatively low mortality rates with "good" outcome for specific groups of very severe TBI patients after neurosurgical intervention, making nihilistic approaches inappropriate. 2
The question of "whether to surgically treat or not" frequently poses a dilemma, requiring consideration of multiple factors beyond GCS including pupillary response, age, and CT findings. 2