Glasgow Coma Scale Score: 5
This patient has a Glasgow Coma Scale score of 5, indicating very severe traumatic brain injury with extremely high mortality risk requiring immediate intensive care and neurosurgical consultation. 1, 2, 3
GCS Component Breakdown
The GCS consists of three components that must be assessed and documented separately: 1, 2
Eye Response (E): 1 point
- No eye opening to any stimulus = 1 2
Verbal Response (V): 1 point
- No verbal output (does not speak) = 1 2
Motor Response (M): 3 points
- Critical clinical finding: The occasional sidelying positioning when supine represents spontaneous, purposeless movement that does NOT constitute withdrawal to pain or purposeful movement 2, 4
- This abnormal flexion/posturing without pain stimulus = 3 points 2, 5
- The patient does NOT respond to pain stimuli, which rules out higher motor scores (4-6 points) 2
Total GCS: E1 + V1 + M3 = 5 2, 3
Clinical Significance and Severity Classification
- A GCS of 5 falls within the "very severe" traumatic brain injury subcategory (GCS 3-5), which carries the worst prognosis with mortality rates approaching 100% in certain subgroups 3
- This score is well below the severe TBI threshold of GCS ≤8 and far below the critical physiologic criterion of GCS <14 that mandates trauma center transport 1, 3
- Patients with GCS 3-5 have substantially higher mortality than the 24.7% mortality documented for GCS <14 patients 3
Immediate Management Requirements
Airway protection is mandatory: 2
- GCS ≤8 typically indicates need for definitive airway management and possible neurosurgical intervention 2
Serial monitoring protocol: 3
- Assess GCS every 15 minutes for the first 2 hours, then hourly for 12 hours 3
- Document individual component scores (E, M, V) at each assessment, not just the sum 3
- Document pupillary size and reactivity as key prognostic indicators 3
- A decrease of ≥2 points in GCS warrants immediate repeat CT scanning 3
Critical Pitfalls to Avoid
Do not rely solely on GCS for clinical decision-making: 3
- Account for confounding factors: sedation, intubation, facial trauma, intoxication, metabolic disturbances 3
- The motor component (M=3) provides the highest predictive value in severe TBI 1
- Serial assessments provide substantially more valuable information than single determinations 1, 3
Common assessment errors: 2
- Failing to assess each component separately before calculating total score 2
- Misinterpreting spontaneous abnormal movements as purposeful motor responses 4, 5
- Using single GCS score rather than serial assessments to monitor trends 2
Alternative Assessment Consideration
The FOUR Score may provide additional prognostic information in this deeply comatose patient, as it can distinguish patients with the lowest GCS scores and includes brainstem reflex assessment 4, 5. The FOUR Score has excellent interrater reliability (kappa = 0.82) and superior ability to recognize different stages of herniation 5.