Cómo controlar la escala de coma de Glasgow en un caso de traumatismo craneoencefálico leve

«El GCS no tiene en cuenta los resultados a largo plazo. Se centra en ese breve lapso de tiempo inmediatamente posterior a la lesión, en la fase aguda». – Tom Crosley

Bienvenido a «Winning The TBI Case», presentado por el abogado litigante Tom Crosley. Escuche los consejos prácticos y útiles que Tom ofrece para litigar casos de lesiones cerebrales traumáticas. Este podcast está dirigido a abogados litigantes que desean explorar los aspectos esenciales de los casos de lesiones cerebrales traumáticas para representar con confianza a clientes que han sufrido este tipo de lesiones.

Desactivar el arma de defensa

Esto va dirigido a los abogados litigantes que necesitan comprender por qué una puntuación normal en la escala de Glasgow (GCS) no significa que su cliente no haya sufrido lesiones. Tom revela cómo los abogados defensores toman una sola cifra de los historiales médicos de urgencias y la utilizan para socavar casos enteros. Explica el contexto histórico de la escala de Glasgow, creada en 1974 como una herramienta de uso clínico diseñada para que los neurocirujanos evaluaran la profundidad del coma y decidieran sobre la necesidad de una intervención quirúrgica de urgencia, y no para predecir los resultados a largo plazo.

El GCS mide tres funciones básicas:

• Una revelación
• Respuesta oral
• Comandos del motor

Pruebas que cualquier alumno de primaria o cualquier perro doméstico podría superar. Tom ofrece analogías y técnicas de interrogatorio para poner de manifiesto que esta herramienta de triaje agudo no tiene ninguna relevancia para el funcionamiento de los pacientes años más tarde. Al comprender qué es lo que mide realmente la escala de coma de Glasgow (y qué es lo que no mide), tendrás la capacidad de informar a los jurados y neutralizar uno de los argumentos favoritos de la defensa, que a menudo resulta engañoso.

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Winning the TBI Case — Episode 21: Defusing GCS in a Mild TBI Case

Crosley Law | Aired: May 27, 2026 | Runtime: 20:24 | Speakers: Narrator, Tom Crosley

[0:00] Tom Crosley: A GCS is not looking at long-term outcomes. It’s looking at that little slice in time right after the injury happened in the acute phase.

[0:09] Narrator: TBI cases can feel like navigating uncharted territory. Your client’s injury is real, but proving it, that’s where the real challenge begins. If you’ve ever felt like you’re missing crucial pieces of the puzzle, you’re in the right place. Welcome to Winning the TBI Case, where Tom Crosley shares the insights he’s gained from over 60 injury trials. Not just the victories, but the lessons learned along the way that make all the difference. Winning the TBI Case: Strategy, Science, and Storytelling.

[0:45] Tom Crosley: Welcome back to Winning the TBI Case: Strategy, Science, and Storytelling. I’m Tom Crosley. Today I want to talk about the Glasgow Coma Scale, or GCS, and why it gets misused in mild traumatic brain injury cases. Here’s how this usually shows up in litigation. The defense will point to a normal GCS score in the EMS record or the ER record and say, therefore, ladies and gentlemen of the jury, this was not a significant head injury. There’s no good explanation for the symptoms that allegedly persisted because look, we have this normal GCS score on the day of. And so that’s the defense move. They take one number from the acute medical records and they try to use it to discredit the entire case. If nobody explains what the GCS actually measures, what it was designed for, then that defense argument can sound stronger than it really is. Jurors might hear normal neurological score and assume it means the brain was fine. But that is not what the Glasgow Coma Scale was designed to measure. So let’s talk about a little historical context. It was first introduced in 1974 in Glasgow, Scotland by two neurosurgeons.

[2:01] Tom Crosley: They were really looking for a common language for doctors to use as a bedside tool that would help them communicate about a patient’s level of consciousness after acute brain injury. And in particular, when it would become important to call a neurosurgeon. Because maybe the neurosurgeon might have to do some life-saving surgery. That was the original mission. How awake is this person? How responsive are they to simple commands? And are they getting better or worse? So that matters because it tells you the lane that this GCS tool was originally built for. Acute assessment in the minutes or hours following the injury. Bedside communication. Triage. Later, researchers began using GCS scores to correlate severity grading and long-term patient outcomes because GCS became very popular. It’s used worldwide. It’s been cited 37,000 times in the medical literature. So it’s definitely the most common neurological assessment tool in the acute phase. So you’re going to see it in your medical records. You’re going to see it in your cases. So with all that data, researchers who study long-term outcomes for TBI, ranging from severe to moderate to mild, will often look back at what was that early GCS score.

[3:22] Tom Crosley: And we learn in the mild category that long-term outcomes are not predicted by GCS score. We learn with moderate and severe injuries, long-term poor outcomes are more predictive based on GCS score. So let’s talk about the name itself because the name matters. If we’re teaching it to a jury, it is the Glasgow Coma Scale. Coma. It’s not the Glasgow Executive Function Scale. It’s not the Glasgow Working Memory Scale. It’s the Coma Scale. It is fundamentally a scale of responsiveness and depth of impaired consciousness. The lower the score a person has, then the more deep their coma. It’s measuring three domains. Eye response. Are the person’s eyes open spontaneously or are they closed? Are they out? And now if they are out, do they open in response to a verbal command? If not, do they open when we give them some noxious stimuli? For example, we rub their sternum. Does that make their eyes open? These are testing levels of depth of coma. Verbal response is the second of the three things they’re looking at. Are they oriented normally? Do they know where, in broad strokes, where they are, what year this is, what city they are in?

[4:44] Tom Crosley: Literally, those are the types of questions. Or are they unable to make any sounds because they’re out of it, they’re in a coma? Or are the sounds they’re making guttural and incomprehensible? That’s kind of what they’re looking for on the verbal side. When I see an abnormal GCS in a mild case where they lose a point or two points, it’s almost always on the verbal side. And it’s because the patient is confused. They’re not completely oriented. They might be asking the same question over and over again and not really responding to the examiner’s very basic questions. The third thing that GCS is looking at, remember number one, eyes, number two, verbal, number three is motor response. Can the person obey simple commands? So all the way from no motor response whatsoever, out completely cold, to extension or flexion in response to painful stimuli or trying to withdraw from pain. Again, that sternum rub can be useful there. Or can the person obey simple commands? So I’m typically seeing in the mild case four out of four for eye response, six out of six for motor response, and usually five out of five for a total score of 15 for the verbal response.

[6:01] Tom Crosley: Sometimes I’m seeing a four out of five on the verbal response because the person is clearly confused at the scene and keeps repeating themselves. All right. So what is that telling us? When I teach it in CLE, I will often put up a slide showing a doctor talking to a patient on an exam table. And that patient’s sitting there and he’s got his eyes open and the doctor’s holding a clipboard and a stethoscope around his neck wearing a white coat. And I’ll say, “This is what a normal GCS looks like.” And while that slide’s still up, I’ll tell the audience something like this. I’ll say, “You know, I don’t care how much I’m boring you right now. I could be the most boring speaker you’ve ever heard in your entire life. You could be on the verge of falling asleep, but if your eyes are still open, if you’re sitting in this room listening to me, you have a normal GCS.” And then I’ll say, “Do you know what else has a normal GCS?” And then I’ll advance the slide and it’ll be a picture of my dog, a chocolate lab. And that’s the part that gets the laugh. And it works because this point kind of hits home. My dog, his eyes opened spontaneously.

[7:16] Tom Crosley: Remember the eyes were category one. The second was verbal response, but it’s really testing is the patient oriented to time, place, and person. And so my dog knows where his food bowl is. He knows where his bed is. He can bark on command. So he’s kind of passing that one too. And then motor response. He can sit. He can shake hands. He can roll over. My dog can pass that one too. So how high is the bar to get a normal GCS? That’s my point. And that’s why this joke kind of hits home. I even got to do it once in a trial. I had a well-known and sneaky defense expert on the stand in trial in Houston. And he was harping on the normal GCS on day one for my patient. And here we are three years later and he’s trying to say this normal GCS somehow means that this patient should be well by now. And so I showed the slide, got the doctor to admit, “Yep, that’s a normal GCS.” Got him to admit that everybody in the courtroom, all the people on the jury, the people in the gallery, those were all normal GCS. And then I said– And we’re about to break for lunch, and so the timing was important here. And then I said, “Doctor, you know what else is a normal GCS?” And then I showed the picture of my dog.

[8:35] Tom Crosley: And I said, “That’s my dog. He’s got a normal GCS too.” The jury starts laughing because they’ve immediately kind of clicked how this early acute triage tool that’s just measuring coma is not that relevant in the big picture for the mild TBI case. And the doctor’s response, I still remember it vividly. He said, “Yes,” over the jury’s laughter. “Yes, but he’s not verbal.” And then the judge said, “I think now would be a good time to break for lunch.” So the timing of that worked out well. That is how I’m defusing GCS when the defense wants to make a big deal out of it. I just make it the very low bar that it really is. And if you think about it, any elementary school student can get a normal GCS, but that doesn’t mean if you take Einstein’s brain and damage it, and now in the days, minutes, or hours following the injury, he can only respond as well as an elementary school student. That doesn’t mean he’s normal, does it? So lawsuits, when we try them to juries, we communicate very effectively sometimes with analogies. So use my dog analogy or use this elementary school analogy. A GCS is not looking at long-term outcomes. It’s looking at that little slice in time right after the injury happened in the acute phase.

[9:55] Tom Crosley: So let’s now talk about what does a fifteen on GCS really mean. It means the eyes open spontaneously. The person can give a verbal response. They can obey simple commands, touch your nose. It means the person is oriented as to time and place and person. Who are you? What is your name? Where are you? What city are you in? What month and year is it? Those are the very basic kind of questions that they’re being asked. It’s not a subtle evaluation of high brain function. It’s not a test of working memory, of processing speed, executive function, headache, mental fatigue. It’s not testing multitasking. It’s not testing whether they can tolerate noise or light, or handle their emotions, or it’s– it certainly doesn’t test whether they function in the real world the way they used to before their injury. It’s a very blunt but useful tool in the acute setting. Doctors will mostly agree it has very little post-acute value. What do I mean by that? After those days, minutes, or hours, it doesn’t matter that much what their GCS used to be. That’s the point. So I wouldn’t say GCS means nothing. It is certainly in the more severe cases, GCS can be correlated with long-term poor outcomes.

[11:15] Tom Crosley: And it certainly has real clinical value in the early stages. It’s important. I understand why they collect that data. I just don’t think you can fairly use that data in a mild TBI case a year, two years, or three years later to say anything about how the patient must not have been hurt. All right. So here is my key point for lawyers handling mild TBI cases. A GCS score tells you very little about the individual patient sitting in your courtroom years later. The defense likes to take a number recorded in the first minutes or hours after trauma, and they like to try to use it as though it somehow meaningfully answers what’s happening three years later. It does not. A normal GCS may tell us something narrow and useful about the acute moment. It may tell us whether the patient was awake enough to answer basic questions. It really is there to help the doctors decide, “Hey, do we need to call the neurosurgeon? Do we need to call him now? Do we need to wake him up in the middle of the night? Do we need him to jump in his Porsche and race down to the hospital to do a life-saving brain surgery?” That’s really what it’s trying to do in the triage setting. So think about how that’s different than what a jury is deciding in our cases.

[12:31] Tom Crosley: When we’re in trial a few years later in a mild TBI case, the real questions are completely different. Can this person still process information the way they used to? Can they still work the same way? Can they still tolerate noise, chaos, multitasking? Can they regulate their emotions, or do they fly off the handle? Can they remember what they just read, what they were just told? Do they lose their train of thought? Can they function effectively in work, in family life, in daily life the way they used to? GCS does not and never will answer those questions, and that’s why the defense use of it in mild TBI cases is often so misleading. Many patients with a mild TBI present with a GCS of fifteen. That’s pretty typical. It’s built into that category. We all know from experience and from the literature that a patient can look fairly normal in the ER and still have symptoms and deficits that persist days, weeks, months, or even years, and that’s why the defense can’t take a fifteen from the ER and act like it disproves the case years later. Here is another useful point that I will often make if my client has depression, and I’m often teaching this sometimes to my own experts or the treating physicians and then having them testify to it during the trial.

[13:52] Tom Crosley: Some of the long-term things we care about most in these cases do not track neatly with initial GCS scores. Take depression, for example. It would be a mistake to assume that if the, you know, the worse the GCS score, then therefore the worse the depression would later be. There’s lots of studies on this that show that depression post TBI tracks about the same whether it was mild, moderate, or severe TBI. In other words, GCS is completely irrelevant to the question of whether a post TBI victim is likely to have depression. So… and then that’s true with other symptoms as well, especially when you’re talking about the mild class. All right. How would I handle GCS in litigation? Well, if I thought the defense was going to hang their hat on a normal GCS score as a core point that they were going to make in defending the case, then I would jump out in front of it. I would teach GCS early. I would not wait for the defense to turn it into some kind of punchline. Rather, my own expert or treating physician in plain English would talk about what the scale is and what it does and does not do, and I would make the low bar for that scale memorable, my dog example, the elementary student example compared to Einstein, and I would pin any defense expert down on the limits of the scale.

[15:13] Tom Crosley: So examples of questions I might ask a defense expert if they are relying on GCS normal scores in the acute setting to somehow prove the defense. I would probably start with asking them what the GCS really is. It’s measuring consciousness, correct? It’s evaluating eye opening, verbal response, and motor response, correct? A fifteen simply means the patient can open his eyes, answer simple questions, obey simple commands. Correct, Doctor? The orientation questions are very basic things, aren’t they, Doctor? Like what is your name? Where are you right now? What city are you in? What is the month and year? And Doctor, you would agree that this test does not test executive function, working memory, processing speed, or any of those items? And then here’s the kicker. Doctor, you would agree a patient can have a GCS of fifteen and still suffer a mild traumatic brain injury with long-term, even lifelong consequences, correct? If they’re being honest, they have to answer correct ’cause there’s no debate in the medical literature on the answer to that question. I might go into the fact that the score was taken in the acute setting. It doesn’t tell us anything by itself about how the patient will do three months later or three years later.

[16:30] Tom Crosley: And so ultimately where I’m heading with this is the GCS is not answering the question of is the patient brain damaged? Do they have a mild TBI? The GCS is answering a completely different question. It’s telling us something important about acute responsiveness in the minutes or hours following the head injury. It’s helping doctors decide how worried they need to be right now in terms of the treatment we need to provide this patient right now. It doesn’t tell you whether the plaintiff will likely get back to normal. So where does the real case, especially in a mild TBI case, live? We prove the mechanism of injury. We prove the symptoms, confusion, disorientation, amnesia, dizziness, headache, nausea, sensory sensitivity, altered mental status. We prove those things, none of which have anything to do with GCS in the long-term setting. What did the witnesses see? What changed in the patient? What do the treating doctors say? What do the experts say? What does the imaging show? None of those are really tied to GCS in our mild TBI case. We’re really looking at how is the plaintiff functioning now as compared to before, the study in contrast that I’ve talked about on prior episodes. We’re not talking about whether an injured person in the ER could open his eyes and say what city he was in.

[17:50] Tom Crosley: So those are my final takeaways. Number one, GCS was developed as a bedside tool for assessing impaired consciousness or coma following acute brain injury. Number two, it is fundamentally a scale of coma depth, not a test for TBI. Number three, orientation questions are very basic. Any elementary school student could pass them, and even my dog could pass them. Fourth, it has good value in managing acute trauma patients for more severe injuries and also for correlating long-term outcomes for those more severe injuries. Fifth, a normal GCS doesn’t rule out real injury in the mild TBI case, and it certainly does not mean much by itself even if the defense is trying to use it years later at trial to suggest otherwise. Sixth, some important long-term consequences, such as depression, do not map neatly onto the initial GCS score. The initial GCS score doesn’t have any bearing on a patient’s likelihood to develop a lot of the symptoms that are commonly associated with TBI. So the last point I wanna leave you with is a normal GCS is a very low bar that isn’t used in the real world in treating patients for anything outside the first 24, max 72 hours.

[19:18] Tom Crosley: So where your case lives is now two years or three years later. It has very little to do in the mild TBI case with what their initial GCS was, and that’s why it’s important for us to teach our juries that the very basic GCS is something that any child could do and has no relevance to what the myriad symptoms your TBI client continues to live with following their injury. That’s it for this episode. This has been Winning the TBI Case: Strategy, Science, and Storytelling. I’m Tom Crosley.

[19:56] Narrator: If today’s episode helped you see your current case in a new light, share it with a colleague who’s facing the same challenges in a case. Subscribe wherever you get your podcasts and join our community of trial lawyers who refuse to settle for average results. This has been Winning the TBI Case: Strategy, Science, and Storytelling with Tom Crosley.