Simplified Evaluation of CONsciousness Disorders (SECONDs)

The SECONDs is an 8-item consciousness assessment derived from the CRS-R, designed for faster administration in the acute hospital setting. Where the full CRS-R takes 25–45 minutes to complete, the SECONDs can typically be administered in under 10 minutes. It produces a score directly mappable to the standard DoC diagnostic categories — coma, VS/UWS, MCS−, MCS+, and eMCS — making it clinically useful for repeated bedside monitoring without the full CRS-R time burden.

Target Population

The same population as the CRS-R: adults with disorders of consciousness following traumatic or non-traumatic brain injury who are not reliably following commands. Validated in the acute hospital and ICU setting (Sanz et al., 2021).

The 8 Items

The assessment is administered in sequence. Two items are conditional — administered only if the patient passes the preceding item.

1. Observation: passive observation before any stimulus

2. Command following: can the patient produce a reproducible movement to verbal command?

3. Communication (conditional): assessed only if command following is present — intentional or functional communication

4. Visual pursuit: smooth tracking of a moving stimulus across midline

5. Visual fixation: sustained gaze directed toward a stimulus

6. Localization to pain (conditional): withdrawal or directed response to noxious stimulus; given only if patient fails pursuit and fixation

7. Oriented behaviors: automatic or context-appropriate behavior (e.g., reaching toward a tube being pulled)

8. Arousal: observed level of wakefulness and eye opening

Items are scored as present or absent.

Scoring

Total score is mapped to a diagnosis:

• 8: Emerged from MCS (eMCS)

• 6–7: MCS+ (command following and/or intelligible verbalization present)

• 2–5: MCS− (non-linguistic purposeful behaviors present — visual pursuit, fixation, localization)

• 1: VS/UWS (arousal without awareness)

• 0: Coma (unarousable)

When to Use SECONDs vs. CRS-R

Use the SECONDs for daily or twice-daily monitoring when repeated full CRS-R administrations aren't feasible, or as a quick check at the start of a session to calibrate your treatment approach. Use the full CRS-R when you need a complete behavioral profile — which specific behaviors are present, which subscales are scoring above baseline — for formal diagnostic documentation, goal-writing, or prognostication.

If the SECONDs comes back positive (MCS or above) for the first time, follow up with a full CRS-R to confirm and document the specific behaviors driving the score.

How to Use It Clinically

The SECONDs score at the start of a session tells you where to pitch your treatment. An MCS− score suggests the patient can benefit from targeted sensory and motor stimulation with careful observation for responses. An MCS+ score means command following is emerging and your session can incorporate simple task demands and communication attempts. A VS/UWS score means your session plan should include the arousal facilitation protocol and close attention to signs of change.

Track the score over time. A patient who consistently scores MCS− on SECONDs but has a single CRS-R session scoring MCS+ may be in a fluctuating MCS — document the variability and administer at multiple time points before drawing conclusions about diagnosis.