Glasgow Coma Scale (GCS)

geekymedics.com/glasgow-coma-scale-gcs/

Kauser October 31, 2018

Yousuf

Introduction
The Glasgow Coma Scale (GCS) allows healthcare professionals to consistently evaluate the
consciousness level of a patient. It is commonly used in the context of head trauma, but it is also
useful in a wide variety of other non-trauma related settings. By regularly assessing a patient’s GCS,
a downward trend in consciousness level can be recognised early, allowing time for appropriate
interventions to be performed.

There are three aspects of behaviour that are independently measured as part of an assessment of a
patient’s GCS – motor responsiveness, verbal performance and eye-opening. The highest
response from each category elicited by the healthcare professional is scored on the chart.

The highest possible score is 15 (fully conscious) and the lowest possible score is3 (coma or dead).

Eye-opening (E)

A maximum possible score of 4 points

Eyes opening spontaneously (4 points)

To assess eye response, initially observe the patient for spontaneous eye-opening.

If the patient is opening their eyes spontaneously , your assessment of this behaviour is
complete, with the patient scoring 4 points.

You would then move on to assessing verbal response, as shown in the next section.

If however, the patient is not opening their eyes spontaneously, you need to work through the
following steps until a response is obtained.

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Eyes opening to sound (3 points)
If the patient doesn’t open their eyes spontaneously, you need tospeak to the patient “Hey Miss
Smith, are you ok?”

If the patient’s eyes open in response to thesound of your voice, they would score 3 points.

Eyes opening to pain (2 points)

If the patient doesn’t open their eyes in response to sound, you need to move on to assessingeye-
opening to pain.

There are different ways of assessing response to pain, but the most common are:

Applying pressure to one of the patient’s fingertips

Squeezing one of the patient’s trapezius muscles (referred to as a “trapezius squeeze”)
Applying pressure to the patient’s supraorbital notch

If the patient’s eyes open in response to apainful stimulus, they would score 2 points.

No response (1 point)
If the patient does not open their eyes to a painful stimulus , they score 1 point.

Not testable (NT)

If the patient cannot open their eyes due to oedema, trauma, dressing etc, you should document
that eye response could not be assessed (NT).

Summary

Eye-opening 4 points
spontaneously

Eye-opening to sound 3 points

Eye-opening to pain 2 points

No response 1 point

Not testable NT

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Verbal response (V)

A maximum possible score of 5 points

Assessing a patient’s verbal response initially involves trying to engage the patient in
conversation and assess if they are orientated.

You should score the patient based on the highest scoring response they demonstrate during the
assessment.

Some common questions you can ask to help assess this might include:

“Can you tell me your name?”

“Do you know where you are at the moment?”
“Do you know what the date is today?”

Orientated response (5 points)

If the patient is able to answer your questionsappropriately, the assessment of verbal response is
complete, with the patient scoring 5 points.

Confused conversation (4 points)

If the patient is able to reply, but their responsesdon’t seem quite right (e.g. they don’t know
where they are, or what the date is), this would be classed as confused conversation and they
would score 4 points.

Sometimes confusion can be quite subtle, so pay close attention to their responses.

Inappropriate words (3 points)

If the patient responds with seemingly random words that are completely unrelated to the
question you asked, this would be classed asinappropriate words and they would score 3
points.

Incomprehensible sounds (2 points)

If the patient is making sounds, rather than speaking words (e.g. groans) then this would be classed
as incomprehensible sounds, with the patient scoring 2 points.

No response (1 point)
If the patient has no response to your questions, they would score1 point.
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Not testable (NT)
If the patient is intubated or has other factors interfering with their ability to communicate
verbally, their response cannot be tested , and for this, you would write NT (not testable).

Orientated 5 points

Confused conversation 4 points

Inappropriate words 3 points

Incomprehensible sounds 2 points

No response 1 point

Not testable NT

Motor response (M)

A maximum possible score of 6 points

The final part of the GCS assessment involves assessing a patient’smotor response.

You should score the patient based on the highest scoring response you were able to elicit in any
single limb (e.g. if they were unable to move their right arm, but able to obey commands with their
left arm, they’d receive a score of 6 points).

Obeys commands (6 points)

Ask the patient to perform a two-part request (e.g. “Lift your right arm off the bed and make a fist.”).

If they are able to follow this command correctly, they would score 6 points and the assessment
would be over.

Localises to pain (5 points)

This assessment involves you applying a painful stimulus and observing the patient for a
response.

There are different ways of assessing response to pain, but the most common are:

Squeezing one of the patient’s trapezius muscles (referred to as a “trapezius squeeze”)

Applying pressure to the patient’s supraorbital notch

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If the patient makes attempts to reach towards the site at which you are applying a painful
stimulus (head/neck) and brings their hand above their clavicle, this would be classed as localising
to pain, with the patient scoring 5 points.

Withdraws to pain (4 points)

This is another possible response to a painful stimulus, which involves the patient trying to
withdraw from the pain (e.g. the patient tries to pull their arm away from you when applying a
painful stimulus to their fingertip).

This response is also referred to as a “normal flexion response” as the patient typically flexes
their arm rapidly at their elbow to move away from the painful stimulus.

It differs from the “abnormal flexion response to pain” shown below due to the absence of the other
features mentioned (e.g. internal rotation of the shoulder, pronation of forearm, wrist flexion).

Withdrawal to pain scores 4 points on the Glasgow Coma Scale.

Abnormal flexion response to pain (3 points)

Abnormal flexion to a painful stimulus typically involves adduction of arm, internal
rotation of the shoulder, pronation of forearm and wrist flexion (known as decorticate
posturing).

Decorticate posturing indicates that there may be significant damage to areas including
the cerebral hemispheres, the internal capsule, and the thalamus.

Decorticate posturing

Abnormal extension response to pain (2 points)

Abnormal extension to a painful stimulus is also known as decerebrate posturing.

In decerebrate posturing, the head is extended, with the arms and legs also extended
and internally rotated.

The patient appears rigid with their teeth clenched.

The signs can be on just one side of the body or on both sides, and it may be just in the upper
limbs.

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Decerebrate posturing indicates brain stem damage. It is exhibited by people with lesions or
compression in the midbrain and lesions in the cerebellum.

Progression from decorticate posturing to decerebrate posturing is often indicative of

uncal (transtentorial) or tonsilar brain herniation (often referred to as “coning”).

Decerebrate posturing

No response (1 point)
The complete absence of a motor response to a painful stimulus scores 1 point.

Not testable (NT)

If the patient is unable to provide a motor response (e.g. paralysis), this should be documented
as not testable (NT).

Obeys command 6 points

Localises to pain 5 points

Withdraws to pain 4 points

Flexion decorticate posture 3 points

Abnormal extension decerebrate 2 points

posture

No response 1 point

Not testable NT

Summary
Once you have assessed eye-opening, verbal response and motor response you add the scores
together to calculate the patient’s GCS.

The GCS should be documented showing the score for each individual behaviour tested:

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 GCS 15 [E4, V5, M6]

Check out a fantastic summary assessment of GCS PDF created by the Royal College of Physicians
and Surgeons of Glasgow here.

References
1. Teasdale G, Jennett B; Assessment of coma and impaired consciousness. A practical scale. Lancet.
1974 Jul 13 2(7872):81-4. [Available here]

2. Royal College of Physicians and Surgeons of Glasgow. GLASGOW COMA SCALE: Do it this way.
[Available here]

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