Trauma Resuscitation — Disability: Neurologic Evaluation — Clinical Pathway: Emergency

Trauma Resuscitation Clinical Pathway — Emergency Department

Disability: Neurologic Evaluation

Goals

  • Identify intracranial hypertension and lateralizing findings on cranial nerve in motor exam
  • Identify signs of spinal cord injury
  • Consider hypoglycemia and toxins as a potential cause of reduced consciousness

Glasgow Coma Score (GCS)

Assign according to highest response observed.

    ≥ 2 Years < 2 Years
Eye Opening 4 Spontaneous Spontaneous
3 To sound To sound
2 To pressure To pressure
1 None None
NT Not Testable – Unable to assess Not Testable – Unable to assess
Verbal Response
Spoken Words		   ≥ 2 Years < 2 Years
5 Oriented – normal for chronologic age Babbles, coos – normal for chronologic age
4 Confused – not normal for chronologic age Not normal for chronologic age
3 Words Inconsolable crying
2 Sounds Sounds
1 None None
NT Not Testable – Unable to assess Not Testable – Unable to assess
Motor Response   ≥ 2 Years < 2 Years
6 Obeys commands Normal spontaneous movement
5 Localizing Rapidly withdraws extremity to simulation
4 Normal flexion Normal flexion
3 Abnormal flexion Abnormal flexion
2 Extension Extension
1 None None
NT Not Testable – Unable to assess Not Testable – Unable to assess

AVPU Scale

Alert Can answer questions
Verbal Responds to verbal commands
Pain Responds to pressure/pain stimulus
Unresponsive Unresponsive to stimulus