GCS Evaluation in Mute and Deaf Patients
In a fully mute and deaf patient, assess only the Eye Opening (E) and Motor Response (M) components of the Glasgow Coma Scale, document these individual scores separately, and use the combined EM score for clinical decision-making rather than attempting to derive or impute a total GCS sum score. 1, 2
Core Assessment Strategy
Components to Assess
Eye Opening Response (E): Score 1-4 based on spontaneous eye opening, opening to visual stimuli/touch, opening to painful stimulus, or no response—this component remains fully assessable in mute/deaf patients 1
Motor Response (M): Score 1-6 evaluating motor function from no response through localizing pain, withdrawing from pain, abnormal flexion, abnormal extension, to following commands (using visual demonstration rather than verbal commands) 1, 3
Verbal Response (V): This component cannot be assessed in a mute patient and should be documented as "not testable" (NT) rather than assigned a score 2, 4
Clinical Documentation Approach
Proper Recording Method
Document the EM score explicitly (e.g., "GCS: E3M5VNT") rather than attempting to create a sum score, as individual component scores provide more prognostic information than sum scores alone and patients with identical totals but different component profiles may have different outcomes 1, 5, 2
Serial EM assessments provide substantially more valuable clinical information than single determinations, with declining scores indicating poorer prognosis—this principle applies equally to mute/deaf patients 1, 5, 6
Imputation Considerations (Use With Caution)
If a sum score is absolutely required for prognostic models or trauma scoring systems, a validated imputation method exists: for EM scores 2-6 add 1; EM score 7 add 2; EM score 8-9 add 4; EM score 10 add 5 to derive an estimated GCS sum score 2
However, this imputation strategy should only be used when necessary for specific clinical tools requiring complete data—it does not add actual clinical information and should never replace documentation of actual EM scores 2
Modified Assessment Techniques for Deaf Patients
Motor Component Adaptation
For "obeys commands" (M6): Use visual demonstration and gestures rather than verbal commands—show the patient what you want them to do (e.g., demonstrate thumbs up, demonstrate raising two fingers) and assess if they can follow the visual instruction 1, 3
Pain response assessment (M2-M5): Apply standardized painful stimuli (trapezius squeeze, supraorbital pressure, nail bed pressure) and observe for localizing, withdrawing, or abnormal posturing responses—these assessments are identical to hearing patients 3
Critical Clinical Caveats
Limitations to Recognize
The GCS was originally designed for comatose patients with serial evaluations, not for single-point severity determination, and was never validated specifically for patients with pre-existing communication disabilities 1, 6, 4
Confounding factors must be documented: sedation, intubation, facial trauma, intoxication, and metabolic disturbances may affect accuracy of GCS assessment—these limitations apply equally to mute/deaf patients 6, 4
Complementary Assessment Tools
Document pupillary size and reactivity at each assessment as key prognostic indicators that are completely independent of hearing or speech ability 6
Use the GCS alongside other assessments for comprehensive evaluation rather than relying solely on the modified EM score for clinical decision-making 1
Monitoring Frequency Requirements
For severe compromise (EM ≤6): Monitor every 15 minutes for first 2 hours, then hourly for following 12 hours 5, 6
For moderate compromise (EM 7-8): Monitor every 30 minutes for first 2 hours, then hourly for following 4-12 hours 5
A decrease of ≥2 points in EM score represents a red flag requiring immediate repeat imaging and escalation of care 5, 6