Adult Glasgow Coma Scale Score (GCS)

6.8.1 Adult Glasgow Coma Scale Score (GCS)
 
 

EYE OPENING

  1. Spontaneous: At this point, with no further stimulation, the patient has eyes open.
  1. To Voice: If the patient's eyes are unopened, a request to "open your eyes" should be spoken, and if necessary, should be shouted.
  1. To Pain: If verbal stimulation is unsuccessful in eliciting eye opening, the standard painful stimulus is applied. NOTE: Document if eyes are closed due to swelling, facial injuries, or other causes.
  1. None: No eye opening.

BEST VERBAL RESPONSE

  1. Oriented: After the patient is aroused, he/she is asked who he/she is, where he/she is, and what the year and month are. If accurate answers are obtained, this is recorded as oriented.
  1. Confused: Although the patient is unable to give correct answers to previous questions, he/she is capable of producing complete phrases, sentences, and even conversational exchange.
  1. Inappropriate Words: The patient speaks or exclaims only a word or two. Such a response is usually obtained only by physical stimulation rather than a verbal stimulus, although occasionally a patient will shout obscenities or call relatives names for no apparent reasons.
  1. Incomprehensible Words: The patient's response consists of groans, moans, or indistinct mumbling and does not contain any intelligible words.
  1. No Verbal Response: Prolonged and, if necessary, repeated stimulation does not produce any phonation.

BEST MOTOR RESPONSE

  1. Obeys Command: This requires an ability to comprehend instructions, usually given in some form of verbal commands but sometimes by gestures and writing. The patient is required to perform the specific movements requested. The command is given to hold up two fingers (if physically feasible); the patient should respond appropriately.
  1. Localizes Pain: If the patient does not obey commands, a painful stimulus may be applied as firm pressure to the sternum or nail bed for 5 seconds. The patient should reach to and/or try to remove source of pain
  1. Withdrawals: After painful stimulus: Elbow flexes, Rapid movement, No muscle stiffness, Arm is drawn away from the torso
  1. Flexion Response: After painful stimulation: Slow movement, Accompanied by stiffness, Forearm and head held against the body, Limbs assume hemiplegic position
  1. Extension Response: After painful stimulation: Legs and arms extend, Accompanied by stiffness, Internal rotation of shoulder and forearm
  1. None: No motor response.

Note: The Glasgow Coma Scale measures cognitive ability. Therefore, if injury (chronic or acute) has caused paraplegia or quadriplegia, alternate methods of assessing motor response must be used (e.g., ability to blink eyes = obeys commands).