Glasgow Coma Scale: How to Perform the Assessment

Glasgow coma scale is an assessment that helps physicians to evaluate the level of consciousness in the patient. It is primarily used in trauma and can be applied in non-trauma settings as well. The regular evaluation of GCS helps identify the early signs of deterioration.

How The Assessment Is Done?

Three aspects of behavior are taken into consideration when calculating a GCS. This includes eye opening, motor responsiveness, and verbal output. The highest score is 15 (full consciousness) and the lowest score is 3 (coma or dead).

Eye Opening

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CriteriaScoreEye-opening spontaneously4 pointsEye-opening to sound3 pointsEye-opening to pain2 pointsNo response1 pointNot testableNT

Eyes Opening Spontaneously (4 Points)

The eye response is tested to see if the patient is naturally able to open his eyes. If the patient could open their eyes spontaneously, the assessment is complete and the score can be 4 points. Further assessment is required if the patient cannot open the eyes spontaneously.

Eyes Opening To Sound (3 Points)

The healthcare provider will question the patient if the response isn’t spontaneous ” Hello Sivakumar, are you all right?” The score is three points if the patient’s eyes open in the reaction to the sound.

Eyes Opening To Pain (2 Points)

Where the patient is not able to open the eyes to the sound, the next approach would be taken. There exist different methods to evaluate the response to pain. The following are the common ones.

1. Pressing one of the hands of the patient

2. Squeeze one of the trapezius muscles of the patient

3. Pressure on the supraorbital notch of the patient

When the patient opens her eyes, the score is two points in response to a painful stimuli.

No Response (1 Point)

The result is 1 point if the patient does not open his eyes for a painful stimulation.

Not testable (NT)

If reasons like trauma or a patient’s dressing makes the testing impossible, it should be stated that eye response cannot be assessed (NT).

Verbal Response (V)

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CriteriaScoreOrientated5 pointsConfused conversation4 pointsInappropriate words3 pointsIncomprehensible sounds2 pointsNo response1 pointNot testableNT

A verbal response is measured by keeping the patient present and involved in the discussion. The often asked questions included

1. “Can you tell me your name?”

2. “Where are you at the moment, do you know?”

3. “What the date is today, do you know?”

Orientated Response (5 Points)

The response would be full and a score of five points will be granted if the patient will answer his questions correctly and speak correctly.

Confused Conversation (4 Points)

In some instances, a patient may respond, but the reply may not be right to your question. This is classified as a confusing conversation and the score of 4 points is given.

Inappropriate Words (3 Points)

If the patient uses random and inappropriate words to your question, a score of 3 points is given.

Incomprehensible Sounds (2 Points)

Instead of talking, as the patient makes noises, he is graded as understandable sounds and has a score of 2 points.

No Response (1 Point)

The patient will score 1 point if they will give no response to your questions.

Not Testable (NT)

If, due to factors like intubation, the patient cannot speak orally, the response is considered non-testable.

Motor response (M)

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The motor response is classified as below. CriteriaScoreObeys command6 pointsLocalises to pain5 pointsWithdraws to pain4 pointsFlexion decorticate posture3 pointsAbnormal extension decerebrate posture2 point

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 the patient can perform this correctly, a score of 6 points is given.

Localizes To Pain (5 Points)

This part of the evaluation entails an unpleasant stimulation and a patient’s observation of the response.

There are many ways to evaluate pain response, but the most important ones are:

1. Squeeze one of the trapezius muscles of the patient (known as a trapezius squeeze)

2. Pressure on the supraorbital notch of the patient

When the patient tries to find the site of a painful stimulation (i.e. head, neck) and puts his hand over his clavicle, the patient is classified as pain finder, with a patient rating of 5 points.

Withdraws To Pain (4 Points)

If the patient reacts to the painful stimulation, moving his arm out of the region in which the stimuli is delivered, there is a score of 4 points. This response is classified as “normal flexion response”.

Abnormal Flexion Response to Pain (3 Points)

An Abnormal bending to a painful stimulus also includes the arm abduction, the inward rotation of the elbow, forearm pronation, and wrist bending.

Abnormal Extension Response to Pain (2 Points)

This is known as decerebrate postures, which stretch the head of the patient and extend the arms and legs as well. With their tight teeth, the patient may appear rigid. The symptoms may be on one or both sides of the body.

No Response (1 Point)

In response to a painful stimulus, if there is a complete absence of motor response, a score of 1 point is given.

Not testable (NT)

If the patient is experiencing paralysis and shows no signs of motor response, it should be documented as “not testable”

After performing the assessments for three types of responses, add the scores together to calculate the patient’s GCS. A representation of the score would be GCS 15 [E4, V5, M6].

Pediatric Glasgow Coma Scale

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For children who are less than 5 years, a modification of the Glasgow scale called the Pediatric Glasgow Coma Scale is used. The assessment is done as follows.

Best Eye Response

1. No eye-opening / 1 No eye-opening

2. Eye-opening to pain / 2 Eye-opening to pain

3. Eye-opening to sound / 3  Eye-opening to sound

4. Eyes open spontaneously / 4 Eyes open spontaneously

Best Verbal Response

1. None / 1 None

2. Moans in response to pain / 2 Incomprehensible sounds

3. Cries in response  to pain / 3 Incomprehensible words

4. Irritable/cries / 4  Confused

5. Coos and babbles / 5 Orientated – appropriate

Best Motor Response

1. No motor response / 1 No motor response.

2.  Abnormal extension to pain / 2 Abnormal extension to pain

3. Abnormal flexion to pain / 3  Abnormal flexion to pain

4. Withdrawal to pain / 4 Withdrawal to pain

5.  Withdraws to touch / 5 Localizes to pain

6. Moves spontaneously and purposefully / 6 Obeys commands