The GCS Sucks!

The Glasgow Coma Score (GCS) was developed in the 1970s initially as a research tool for admitted Neurosurgery patients. The original authors of the score and research advocated against it’s widespread use in acute care but nevertheless here we are: it is widely used in acute trauma and medical care.
Other than a score of 3 or a score of 15, there are multiple combinations of numbers that can get you various scores. This results in a poor ability to know what the patient is actually doing. The same combined score can represent two very different patients making the score difficult to interpret:
Patient 1
GCS = 10
Patient 2
GCS = 10
4 = spontaneous
2 = open to pain
5 = oriented
3 = inappropriate words
1 = No response
5 = localizes to pain
Which patient above are you more worried about?
There is some rationale to use GCS as triage tool for trauma center vs not:
GCS <13 –> level 1  (or highest available trauma center in your system)
GCS > 13 –> can go to lower level trauma center (if they don’t otherwise meet other system criteria for a level 1 trauma center)
In fact the most recent American College of Surgeons (the major trauma surgery body in the USA) field triage criteria have moved on to using a motor-GCS or M-GCS only:
M-GCS <6 –> level 1  (or highest available trauma center in your system)
M-GCS = 6 –> can go to lower level trauma center (if they don’t otherwise meet other system criteria for a level 1 trauma center):
Another score or called the Simplified Motor Score is something that is out there but it is pretty complex and not worth committing to memory. Stick to either total GCS or M-GCS.
With all of the above out of the way, the best thing to do is to be honest. The GCS is just trying to capture the exam in the form of a number. It’s hard to do math when you’re stressed. It’s much easier to describe what you are seeing. One example of this is to use the AVPU scale plus a qualifier if needed (eg Responds to pain but heavily intoxicated or status post sedation etc)
If your system loves the GCS and wants the GCS you just have to try to do the GCS. If you know they aren’t following commands and you use that information to transport to the highest available trauma center, you wont under triage or do wrong by the patient. End of the day be honest: “I’m having a hard time doing the math in the heat of the moment but here is what I’m seeing.”
Bottom Line:
  • Not following commands = go to the highest level trauma center available to you in your system
  • GCS is not that great but your system may love it
  • What the GCS is trying to capture is a neurological exam in the trauma patient. This is what is important.
  • Communicate the same information in an honest way that will get the pt the care they need.

Serotonin Toxicity

Serotonin Toxicity

Serotonin Toxicity is a spectrum. Early recognition and treatment is key to preventing bad outcomes.
Typically seen in patients who have overdosed on party drugs like MDMA, ecstasy, Molly etc. Also seen in patients on multiple medications that increase serotonin levels. Most antidepressants increase serotonin levels. Be suspicious of serotonin syndrome in a patient with signs and symptoms who recently had medications changed or added.
Hyperthermia is what kills–serotonin increases muscle activity = heat
#1 predictor of mortality is temperature
Untreated serotonin toxicity leads to the final common pathway of most toxicological emergencies: seizure > coma > death.
Signs and Symptoms:

Clonus Video:

Ocular clonus video


Differential Diagnosis
  • Neuroleptic Malignant Syndrome – more gradual, usually related to dopaminergic meds like antipsychotics or medications used to treat patients with Parkinson’s disease
  • Malignant hyperthermia – almost always associated with exposure to anesthetics or paralytics
  • sympathomimetic toxicity – also causes increased HR, BP, agitation but less likely to see sustained clonus
Diagnosis of serotonin syndrome is a clinical diagnosis meaning it is made based on history, signs, and symptoms and not with a lab test or imaging study. Below are the Hunter Criteria Nik talks about in the show laid out in algorithm format:


Benzodiazepines are the mainstay of treatment – way more than you’re used to giving. Keep giving it until hyperthermia resolves or you need to intubate them.  Even if they are sedated keep giving if they are still hot. This will save their life.
Don’t be afraid to call med control for high and repeat doses of benzos. There is no maximum dose.
External cooling is helpful but do not delay benzo administration to perform cooling measures. Cooling is best done with evaporative cooling:  Take a sheet and use saline or water to get the entire sheet soaked. Place the wet sheet over the naked patient and fan them (windows down if needed)
Ice packs are less effective but can be used if available.
If you need to intubate these patients try to avoid succinylcholine for RSI and use rocuronium instead when choosing a paralytic. For induction, use etomidate if available. Avoid using opioids as they can be serotonergic.