What the ER measures vs what your life needs
In the emergency room, clinicians often use the Glasgow Coma Scale (GCS) to check how awake and responsive someone is right after a head injury. It scores eye-opening, speech, and movement. It is designed for the acute phase, to aid in making immediate safety decisions within the first hours after trauma (Teasdale & Jennett, 1974).
GCS is helpful for triage. It is not a complete picture of brain function or life impact. Reviews show that many important problems after concussion or other TBIs live outside what GCS captures: fine motor control, attention, language, mood, fatigue, and the demands of your daily life and work (Carroll et al., 2004; Levin & Diaz-Arrastia, 2015).
This tool is handy in an emergency. However, when those scores are translated into a permanent label: mild, moderate, or severe, we encounter difficulties.
Because the truth is: if you have seen one brain injury, you have seen one brain injury. No two are the same.
A better lens: CBI-M
A new framework called CBI-M incorporates three additional elements alongside the clinical exam: blood biomarkers, imaging, and lifestyle modifiers such as work demands and social support. It is designed for the first 24 hours but preserves detail for follow-up. It does not replace care guidelines yet; however, it standardizes how we describe injuries, allowing care to be tailored and research to improve (Manley et al., 2025).
Blood tests such as GFAP and UCH-L1 can flag brain injury biology even when the ER exam looks “normal.” The FDA cleared a GFAP/UCH-L1 test to help decide who needs a head CT within 12 hours among adults with GCS 13–15 (U.S. Food and Drug Administration, 2018). Very early data also show GFAP rises within 30–60 minutes and tracks key early outcomes (Papa et al., 2024).
Big-picture updates in TBI care also emphasize that outcomes depend on biology, anatomy, and context over months or years, rather than just minutes in the ER (Maas et al., 2022).
Case example: the violinist
A world-class violinist sustains a brain injury. No loss of consciousness. GCS = 15 in the ER. He has a 5–10% loss of fine coordination in the bow hand. For most people, this is trivial. For him, it ends his career.
|
System |
What it records |
What it means here |
|
GCS |
15/15 in the ER; awake, follows commands |
Labelled “mild.” Risk of no follow-up. |
|
CBI-M: Clinical |
GCS components, pupils, amnesia, and early symptoms |
Still 15, but symptoms documented for follow-up. |
|
CBI-M: Biomarkers |
GFAP/UCH-L1 within 12 h to support CT decisions and flag occult injury |
A positive biomarker can justify imaging and early specialist review (FDA clearance; Papa et al., 2024). |
|
CBI-M: Imaging |
CT for safety; MRI for subtle axonal or microvascular injury where indicated |
Look for lesions that explain the fine-motor deficit. |
|
CBI-M: Modifiers |
Occupation, skill demands, mental health, supports, transport |
“Elite fine motor demands” elevate risk. Care plan targets hand function and return-to-work pathways. |
Clinical takeaway: GCS says “mild.” CBI-M says “high-stakes functional loss” and prompts a targeted rehab plan with documented follow-up.
Other “mild” injuries that are not mild
|
Person |
Subtle deficit after GCS 15 |
Life context and demand |
Real-world impact |
Early care steps to consider |
|
Microsurgeon |
Very slight hand tremor |
Micrometre-level precision |
Threatens accreditation and patient safety |
Early occupational therapy, task-specific simulation, and neurophysiology consultation; consider an MRI if symptoms persist. |
|
Commercial pilot |
Intermittent dizziness, motion sensitivity |
Rapid vestibular reflexes are required |
Not fit to fly until resolved |
Vestibular rehab, graded exposure; aviation medicine assessment. |
|
Teacher |
Word-finding pauses, slowed processing |
Language and multitasking every minute |
Inability to perform classroom duties |
Speech-language therapy, workplace accommodations, paced return. |
|
Parent of toddlers |
Fatigue, irritability, sensory overload |
Continuous caregiving, sleep disruption |
Family stress, relationship strain |
Energy management, sleep plan, counselling, and caregiver support. |
Bottom line
GCS is excellent for emergency triage. It was never designed to define your outcome or your identity. CBI-M keeps the ER score but adds biology, imaging, and your life context. That shift prevents people with “mild” labels from being ignored when the impact is anything but mild (Manley et al., 2025).
References
Carroll, L. J., Cassidy, J. D., Holm, L., Kraus, J., & Coronado, V. G. (2004). Methodological issues and research recommendations for mild traumatic brain injury: The WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. Journal of Rehabilitation Medicine, 36(43 Suppl), 113–125. https://doi.org/10.1080/16501960410023877
Levin, H. S., & Diaz-Arrastia, R. (2015). Diagnosis, prognosis, and clinical management of mild traumatic brain injury. The Lancet Neurology, 14(5), 506–517. https://doi.org/10.1016/S1474-4422(15)00002-2
Maas, A. I. R., Menon, D. K., Manley, G. T., et al. (2022). Traumatic brain injury: Progress and challenges in prevention, clinical care, and research. The Lancet Neurology, 21(11), 1004–1060. https://doi.org/10.1016/S1474-4422(22)00309-X
Manley, G. T., Dams-O’Connor, K., Mac Donald, C. L., et al. (2025). A new characterisation of acute traumatic brain injury: The NIH-NINDS TBI Classification and Nomenclature Initiative. The Lancet Neurology, 24(6), 512–523. https://doi.org/10.1016/S1474-4422(25)00154-1
Papa, L., Brophy, G. M., Welch, R. D., et al. (2024). Diagnostic performance of GFAP, UCH-L1, and MAP-2 within 30 and 60 minutes of traumatic brain injury. JAMA Network Open, 7(12), eXXXXXX. https://doi.org/10.1001/jamanetworkopen.2024.31115
Teasdale, G., & Jennett, B. (1974). Assessment of coma and impaired consciousness. A practical scale. The Lancet, 2(7872), 81–84. https://doi.org/10.1016/S0140-6736(74)91639-0
U.S. Food and Drug Administration. (2018). De novo classification request for Banyan BTI (DEN170045
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