The following are examples of how to perform a GCS assessment on an infant, child, and adolescent. The GCS is assessed during the primary survey. The GCS should be reassessed at minute five of the trauma resuscitation and again prior to the patient leaving the code room. Additional GCS assessments should be done if there is a notable change in mental status.
This is an eight-month-old. You can see that they are awake and their eyes are open. Note the infant interacting and babbling with the resident.
Note the normal spontaneous movement of the infant. Watch how the resident looks at the poster as they perform each section of the GCS. Make sure to call out each part of the GCS out loud so that everyone in the room can hear you. Eyes are open spontaneously.
Four. Baby is cooing, babbling. Verbal is a five. Has spontaneous movement. Motor is a six.
The nurse documenting in the code room will add the scores together and will state the total. The documenting nurse will respond with the GCS is 15. This is a four-year-old. You can see that they are aware of their surroundings and their eyes are open spontaneously.
Note that this child is interacting and appropriate with a resident. Note the child is following directions. Watch how the resident looks at the poster as they perform each section of the GCS. Make sure to call out each part of the GCS out loud so that everyone in the room can hear you. Eyes are open spontaneously for...
Patient is interactive and appropriate. Verbal is a 5. Obeys commands. Motor is a 6. The nurse documenting in the code room will add the scores together and will state the total. The documenting nurse will respond with, The GCS is 15. This is a 10-year-old. Note the adolescent's eyes are closed.
The adolescent opens eyes when the resident is talking. Note the adolescent interacting with the resident. The adolescent appears confused but is answering the resident's questions. Note that the adolescent is not following commands. The resident elicits a pain response and the patient reaches across the body towards the clavicle to push the surgical resident's hand away.
Watch how the resident looks at the poster as they perform each section of the GCS. Make sure to call out each part of the GCS out loud so that everyone in the room can hear you. Eyes are opening to voice. Eyes are three. Patient is disoriented but responding.
Verbal is a four. Patient is not obeying commands but is able to localize pain. Motor is a five.
The nurse documenting in the code room will add the scores together and will state the total. The documenting nurse will respond. bond with, the GCS is 12. It can be difficult to obtain a good GCS in infants and children. For best results, use the GCS poster in the code room.
When in doubt, ask for help. The senior surgical resident, fellow, or ED physician in the room can work with you to get the most accurate GCS assessment. Thank you.