At a Glance
- Use It For
- Choosing the validated score for a neuro, sedation, withdrawal, pain, chest pain, PE, sepsis, newborn or burn assessment, then reading its published cut-off.
- Fastest Answer
- Score the components the same way each time, total them, record the time, and trend the number. A score guides the next step; it does not replace the exam.
- Key Numbers
- GCS 3–15; ≤8 = severe TBI
- NIHSS 0–42; ≥6 is a common LVO screening threshold
- HEART 0–3 / 4–6 / 7–10 = MACE 1.7% / 16.6% / 50.1%
- RASS +4 to −5; CIWA-Ar 0–67
- Don't Miss
- A low score does not rule out the condition. PERC cannot be used when PE is a real concern or the patient is pregnant, and a CIWA-Ar is not valid once the patient is delirious. Trust the patient over the number.
- Verify Locally
- Cut-offs that trigger action (CIWA-Ar dosing level, sedation goal, NIHSS for thrombectomy, croup severity bands) vary by protocol. Your local protocol and medical direction win.
Reference Table
Every tool gets one row. Score the components the same way every time, then write the total down with the time.
| Tool | Use | Range | Key Cut-offs |
|---|---|---|---|
| Glasgow Coma Scale (GCS) (TBI) | Level of consciousness after trauma, stroke, overdose or sepsis | 3–15 | ≤8 = severe TBI (Brain Trauma Foundation, 4th edition); see components below |
| NIH Stroke Scale (NIHSS) | Stroke severity and large-vessel occlusion (LVO) screen | 0–42 (15 items) | ≥6 is a common screening threshold for suspected anterior LVO. Thrombectomy eligibility is set by vessel imaging and the stroke team; lower scores with disabling deficits can still qualify (stroke page) |
| Richmond Agitation-Sedation Scale (RASS) | Sedation depth in ventilated adults | +4 to −5 | Goal set by ICU protocol; the analgosedation page uses a light goal of −2 to +1 |
| Critical-Care Pain Observation Tool (CPOT) | Pain in adults who cannot report it | 0–8 | 3 or more suggests pain; reassess after each treatment |
| CIWA-Ar | Alcohol withdrawal severity for symptom-triggered dosing | 0–67 (10 items) | |
| HEART score | Short-term major adverse cardiac events (MACE) in adult chest pain | 0–10 | 0–3: MACE 1.7%; 4–6: 16.6%; 7–10: 50.1% (one 2013 cohort, 6 weeks). Pair with troponin per your chest pain pathway |
| Wells criteria for PE (PE page) | Pretest probability of pulmonary embolism | 0–12.5 | Two-tier: more than 4 = PE likely; 4 or less = PE unlikely, then D-dimer |
| PERC rule | Rule out PE without a D-dimer in low-probability patients | 8 criteria | All 8 negative only when clinical gestalt says PE is unlikely; any positive means PERC does not rule out PE |
| qSOFA (sepsis page) | Prompt to look for sepsis outside the ICU; prognostic | 0–3 | 2 or more: higher risk of in-hospital death; not a stand-alone sepsis screen (Surviving Sepsis Campaign 2021). Criteria, 1 point each: respiratory rate 22/min or higher; systolic BP 100 mmHg or lower; altered mentation (GCS below 15) |
How to Use & Interpret
- Pick the tool your protocol names. Agencies and hospitals fix the version and the action thresholds. The table gives the published cut-offs; the local protocol decides the action.
- Score the components, then total. Record each component, the total and the time. Mark an item you cannot assess as not assessed rather than guessing.
- Trend it. Don't single-shot it. One score is a snapshot. A repeated GCS, RASS, CIWA-Ar or NIHSS shows the direction of change, and most protocols re-score on a fixed schedule for that reason.
- Read the score against the patient. HEART, Wells, PERC and qSOFA estimate risk. They don't replace troponin, imaging or clinical judgment. The number is one input. The patient is the rest of the picture.
Institutions set the cut-offs: These tools are published. Your agency or hospital picks the version and the action thresholds. Where local protocol or medical direction differs from this page, follow them.
Additional Tables
Glasgow Coma Scale components
| Points | Eye opening (E) | Best verbal (V) | Best motor (M) |
|---|---|---|---|
| 6 | — | — | Obeys commands |
| 5 | — | Oriented | Localizes pain |
| 4 | Spontaneous | Confused | Withdraws from pain |
| 3 | To speech | Inappropriate words | Abnormal flexion to pain |
| 2 | To pain | Incomprehensible sounds | Extension to pain |
| 1 | None | None | None |
The Brain Trauma Foundation bands run 13–15 mild, 9–12 moderate, 3–8 severe. Intubated? Don't score the verbal part as 1. Record it as T (for example E2 VT M5) and write down why.
APGAR components
| Sign | 0 points | 1 point | 2 points |
|---|---|---|---|
| Appearance (colour) | Blue or pale | Body pink, extremities blue | Completely pink |
| Pulse (heart rate) | Absent | Below 100/min | 100/min or more |
| Grimace (reflex irritability) | No response | Grimace | Cry, cough or sneeze |
| Activity (muscle tone) | Limp | Some flexion | Active movement |
| Respiration | Absent | Slow or irregular | Good, crying |
RASS levels
| Score | Term | Description |
|---|---|---|
| +4 | Combative | Overtly combative or violent; immediate danger to staff |
| +3 | Very agitated | Pulls or removes tubes or catheters; aggressive |
| +2 | Agitated | Frequent non-purposeful movement; fights the ventilator |
| +1 | Restless | Anxious or apprehensive, but movements not aggressive or vigorous |
| 0 | Alert and calm | — |
| −1 | Drowsy | Not fully alert, but sustained awakening to voice (more than 10 seconds) |
| −2 | Light sedation | Briefly awakens with eye contact to voice (less than 10 seconds) |
| −3 | Moderate sedation | Movement or eye opening to voice, but no eye contact |
| −4 | Deep sedation | No response to voice; movement or eye opening to physical stimulation |
| −5 | Unarousable | No response to voice or physical stimulation |
HEART score components
| Component | 0 points | 1 point | 2 points |
|---|---|---|---|
| History | Slightly suspicious | Moderately suspicious | Highly suspicious |
| ECG | Normal | Nonspecific repolarization | Significant ST deviation |
| Age | Under 45 | 45 to 64 | 65 or older |
| Risk factors | None | 1 or 2 | 3 or more, or known atherosclerotic disease |
| Troponin | At or below normal limit | 1 to 3 times normal limit | More than 3 times normal limit |
Risk factors (count): hypertension, hypercholesterolemia, diabetes mellitus, BMI over 30, current smoker or stopped within 3 months, or family history of cardiovascular disease (parent or sibling, before age 65). Known atherosclerotic disease (prior MI, PCI or CABG, stroke or TIA, peripheral arterial disease) scores 2 points.
Wells criteria for PE
| Criterion | Points |
|---|---|
| Clinical signs of deep vein thrombosis | 3 |
| PE is the most likely diagnosis | 3 |
| Heart rate over 100/min | 1.5 |
| Immobilization of 3 days or more, or surgery in the previous 4 weeks | 1.5 |
| Previous PE or DVT | 1.5 |
| Hemoptysis | 1 |
| Malignancy (treatment within 6 months or palliative) | 1 |
PERC criteria
| Criterion | Rule |
|---|---|
| Age | 50 years or older |
| Heart rate | 100/min or higher |
| Oxygen saturation | Below 95% |
| Leg swelling | Unilateral |
| Hemoptysis | Present |
| Recent surgery or trauma | Present |
| Prior PE or DVT | Present |
| Hormone use | Present |
NIH Stroke Scale items (total 0–42)
| Item | Points |
|---|---|
| 1a Level of consciousness | 0–3 |
| 1b LOC questions (month, age) | 0–2 |
| 1c LOC commands (eyes, grip) | 0–2 |
| 2 Best gaze | 0–2 |
| 3 Visual fields | 0–3 |
| 4 Facial palsy | 0–3 |
| 5a Motor arm, left | 0–4 |
| 5b Motor arm, right | 0–4 |
| Item | Points |
|---|---|
| 6a Motor leg, left | 0–4 |
| 6b Motor leg, right | 0–4 |
| 7 Limb ataxia | 0–2 |
| 8 Sensory | 0–2 |
| 9 Best language (aphasia) | 0–3 |
| 10 Dysarthria | 0–2 |
| 11 Extinction and inattention | 0–2 |
Score each item the way you were trained. Can't test a limb because of amputation or joint fusion? Score it 0 and explain why.
Westley croup score components
| Sign | Points |
|---|---|
| Level of consciousness | Normal (including sleep) 0; disoriented 5 |
| Cyanosis | None 0; with agitation 4; at rest 5 |
| Stridor | None 0; when agitated 1; at rest 2 |
| Air entry | Normal 0; decreased 1; markedly decreased 2 |
| Retractions | None 0; mild 1; moderate 2; severe 3 |
Pediatric, neonatal and burn tools
| Tool | Use | Range | Key Cut-offs |
|---|---|---|---|
| APGAR | Newborn status at 1 and 5 minutes | 0–10 | 7–10 reassuring; 4–6 moderately abnormal; 0–3 low. Does not predict neurologic outcome on its own |
| Westley croup score (croup page) | Croup severity | 0–17 | Red flag at 8 or more per the croup page; components above |
| Phoenix Sepsis Score (pediatric sepsis) | Pediatric sepsis with suspected infection; not established for neonates | Integer score | Sepsis: score 2 or more. Septic shock: sepsis plus 1 or more cardiovascular point |
| Rule of Nines | Adult burn size (TBSA) | 100% | Head 9%; each arm 9%; anterior trunk 18%; posterior trunk 18%; each leg 18%; perineum 1%. Use Lund-Browder in children |
Calculations & Formulas
HEART score
History + ECG + Age + Risk factors + Troponin (each 0–2; total 0–10)
Worked case: moderately suspicious history (1), nonspecific repolarization (1), age 58 (1), two risk factors (1), troponin 2 times the normal limit (1). Add it up and you get 5, which lands in the 4 to 6 band.
Wells score for PE
Sum of the criteria in the Wells table (maximum 12.5)
Worked case: signs of DVT (3), heart rate 110/min (1.5), hemoptysis (1). That is 5.5. Over 4 on the two-tier rule, PE is likely.
Adult burn size (Rule of Nines)
Sum of the body regions that have partial- or full-thickness burns
Worked case: both arms (9% + 9%) and the anterior trunk (18%) burned gives 36% TBSA. Superficial erythema doesn't count toward it. For children, use Lund-Browder.
Special Populations
- Pediatrics: APGAR is for newborns. The pediatric GCS lives on the vital-signs page. HEART, Wells and PERC are adult tools and aren't established in children, so run the pediatric chest pain and PE pathway. Croup (Westley) and Phoenix sepsis are pediatric tools. Skip the adult Rule of Nines in a child. It's inaccurate there.
- Pregnancy: PERC is not validated in pregnancy. Never use it to rule out pulmonary embolism (PE) in a pregnant patient. The Wells score and the standard D-dimer cut-offs aren't validated in pregnancy either, so follow the pregnancy PE pathway your obstetric and emergency teams agreed on. Nor are the HEART and Wells cut-offs. qSOFA thresholds were never derived in pregnancy, so obstetric early-warning or sepsis tools apply, omqSOFA for example. GCS and NIHSS scoring stays the same. A low GCS in pregnancy can still be maternal stroke, eclampsia or magnesium toxicity. Treat it as an emergency.
- Older Adults: HEART adds 2 points for age 65 or older. Baseline deficits (prior stroke, dementia, hearing or language limits) make GCS and NIHSS look worse than the acute change. Compare against the known baseline.
- Renal Impairment: There's no established adjustment for these scores.
- Hepatic Impairment: There's no established adjustment for these scores.
Pitfalls & Safety Checks
- Error: A sedated, paralyzed or intubated patient, scored with no time and no last dose on the chart. Re-score after each sedative dose. Record the change, not just the total.
- Error: CIWA-Ar scored on a delirious or hallucinating patient. Now the score drives benzodiazepine doses for the wrong problem. Delirium is its own emergency (see the lorazepam page).
- Error: PERC used where PE is a real concern, or in a pregnant patient. Wrong tool. PERC only applies when your gestalt says PE is unlikely. Any positive criterion still needs a D-dimer or imaging per protocol.
- Error: Using qSOFA as the sepsis screen. Surviving Sepsis Campaign 2021 advises against using it alone. Use the screen your protocol names.
- Error: Reading a HEART score of 0–3 as clearance to discharge. Serial troponin per your chest pain pathway comes first, with ECG reassessment. Current chest pain guidance backs serial high-sensitivity troponin pathways, not a single value or a repeat ECG alone.
- Error: Reading an APGAR as a prognosis or as proof of asphyxia. It can't do either job. A score given during resuscitation isn't the same as one for a spontaneously breathing infant.
- Error: Estimating a child's burn with the adult Rule of Nines. Use a Lund-Browder chart for children.
Field & Transport Considerations
- EMS: Score the GCS and whichever stroke scale your protocol names. NIHSS lives on this page. Prehospital LVO screens (BE-FAST or LAMS, for example) vary by protocol and aren't scored here. Write down the last known well time. Your protocol sets the prehospital LVO cut-off.
- ED/ICU: Re-score sedation and withdrawal on the unit schedule. The RASS goal comes from ICU protocol, so check it before you chase a number.
- Transport: Every score goes over with its time: GCS, pain score, sedation score and CIWA-Ar. What's required varies by state and agency protocol.
Clinical Pearls
Discriminator: A GCS of 8 or less marks severe TBI by Brain Trauma Foundation standards. A GCS of 8 or less with a falling score is an airway conversation, not a scoring exercise.
HEART: One 2013 prospective validation cohort: 36.4% of chest pain patients scored 0–3, and 1.7% of those had MACE within 6 weeks. A low score lowers risk. It doesn't replace serial troponin or the ECG.
RASS measures arousal, not cause: A high RASS tells you the patient is agitated. It doesn't tell you why. Before you add sedation, check for pain, hypoxia, withdrawal and delirium, as the analgosedation page directs.
References
- Teasdale G, Jennett B (1974). Assessment of coma and impaired consciousness: a practical scale. Lancet, 2(7872), 81–84. https://doi.org/10.1016/s0140-6736(74)91639-0
- Brott T, et al (1989). Measurements of acute cerebral infarction: a clinical examination scale. Stroke, 20(7), 864–870. https://doi.org/10.1161/01.str.20.7.864
- Sessler CN, et al (2002). The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. American Journal of Respiratory and Critical Care Medicine, 166(10), 1338–1344. https://doi.org/10.1164/rccm.2107138
- Sullivan JT, et al (1989). Assessment of alcohol withdrawal: the revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). British Journal of Addiction, 84(11), 1353–1357. https://doi.org/10.1111/j.1360-0443.1989.tb00737.x
- Backus BE, et al (2013). A prospective validation of the HEART score for chest pain patients at the emergency department. International Journal of Cardiology, 168(3), 2153–2158. https://doi.org/10.1016/j.ijcard.2013.01.255
- Gulati M, Levy PD, Mukherjee D, et al (2021). 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain. Circulation, 144. https://doi.org/10.1161/CIR.0000000000001029
- Kline JA, et al (2004). Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. Journal of Thrombosis and Haemostasis, 2(8), 1247–1255. https://doi.org/10.1111/j.1538-7836.2004.00790.x
- Wells PS, et al (2001). Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and D-dimer. Annals of Internal Medicine, 135(2), 98–107. https://doi.org/10.7326/0003-4819-135-2-200107170-00010
- Seymour CW, et al (2016). Assessment of Clinical Criteria for Sepsis: for the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA, 315(8), 762–774. https://doi.org/10.1001/jama.2016.0288
- Sanchez-Pinto LN, et al (2024). Development and Validation of the Phoenix Criteria for Pediatric Sepsis and Septic Shock. JAMA, 331(8), 675–686. https://doi.org/10.1001/jama.2024.0196
Medical Disclaimer
- For Educational Purposes Only: This content is intended for educational reference and should not be used for clinical decision-making.
- Not a Substitute for Professional Judgment: Always consult your local protocols, institutional guidelines, and supervising physicians.
- Verify Before Acting: Users are responsible for verifying information through authoritative sources before any clinical application.
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