LECTURER: MAAM PP2
BSN 4 | FIRST SEM | BATCH 2022 | TOPIC: GLASSGOW COMA SCALE
GLASGOW COMA SCALE
˗ A scoring scale of eye opening and motor and
verbal responses that can be administered to
individuals to objectively measure the level of
consciousness and severity of the head injury.
˗ The responses are scored between 1 and 5 with
the combined total score of 3 to 15, with 15
being normal.
˗ An initial score less than 5 is associated with an
80% chance of being in a lasting vegetative
state or death.
˗ An initial score of greater than 11 is associated
with 90% chance of recovery.
˗ Concussions are usually rated between 13 and
15.
˗ Its primary use in evaluating individuals for
concussion is to rule out more severe brain injury
and to help determine which individuals need
immediate emergent medical attention.
Using the GLASGOW COMA SCALE
⚫ eye opening, verbal response, and best
motor response
GABBYGIRL AND AYAPQT
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⚫ E2V4M6 = 12
⚫ a total score of 8 could be E2V2M4 or
E1V1M6
˗ In an effort to improve the accuracy, reliability,
and communication of the GCS after 40 years
of use, the scale has undergone revision to
follow a new structured approach to
assessment. That is to check, observe, stimulate,
and rate.
˗ The scale provides a standard reference for
level of consciousness in response to define
stimuli.
˗ It can describe an impairment of consciousness
from any cause but has been most useful in
cases of suspected or confirmed brain injury.
˗ The scale measure 3 responses to stimuli:
⚫ eye opening;
⚫ verbal response;
⚫ and best motor response.
˗ assigned as letter and number to each of
the possible responses within these
categories.
˗ Documenting serial findings on a coma scale
chart allows for clear communication of
observations and rapid appreciation of trends,
which makes clear any improvements or
deterioration in a patient’s condition.
˗ In addition to plotting trends on a coma scale
chart, documenting a patient’s rating
numerically in short hand helps to record and
communicate findings quickly, such as E2 or eye
2, V4 or verbal 4, and M6 or motor 6.
˗ However, when describing a patient in this way,
use of the full criteria alongside the numbers is
always necessary to ensure that others will
accurately understand the assessment finding
˗ Adding the short hand numbers together
provides a total coma score such as E2V4M6 =
12, which provides a summary of the severity of
the patient’s condition
˗ However, this score doesn’t communicate the
more informative detailed description of each
response which should always be used in
addition to the score, for example the total
score of 8 could be E2V2M4 or E1V1M6, which
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BSN 4 | FIRST SEM | BATCH 2022 |
have very different implications for the severity
of a patient’s condition
˗ Importantly, reporting of a total score should not
occur when the component is not testable
because the total score will be low which can
be confusing to the multidisciplinary team and
might imply that the patient’s condition is worse
than it actually is
EYE OPENING
- May occur spontaneously in response to speech
or pain, or there may be no response at all, each
of these responses is given a numerical value
o Spontaneous eye opening – 4
o Response to speech – 3
o Response to pain – 2
o No response – 1
- Spontaneous eye opening indicates functioning
of the ascending reticular activating system, this
finding does not necessarily mean that the
patient is aware of the surroundings or what is
happening but it is implied that the patient is in a
state of arousal
- A patient who opens his or her eyes in response
to the examiners voice is probably responding to
the stimulus of sound, not necessarily the
command to open the eyes, if unsure, the
examiner may use different sound making
objects example a bell to elicit appropriate
response
MANUAL ASSESSMENT METHOD
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LECTURER: MAAM PP2
TOPIC: GLASSGOW COMA SCALE
- To evaluate a patient’s pupil size, use the chart
that shows the various pupil sizes in increments of
1 mm with the normal diameter ranging 3-5 mm,
remember pupil size vary considerably, some
patients have normally unequal pupils or we call
it anisocoria
- Ask the patient to open the eyes, if the patient
doesn’t or cannot respond, gently lift the upper
eyelids, asses the pupils, inspect each pupil for
size and shape and compare the two for
equality then test pupillary response to light, also
see whether the pupils are positioned in or
deviated from the midline
- To test pupillary action to light, slightly darken the
room, ask the patient to look into the distance
and shine a penlight obliquely into each pupil in
turn, observe for direct reaction, pupillary
constriction in the same eyes, and consensual
reaction, the pupils should react briskly when you
shine light to it and dilate again when you move
the light away
- Grade the light reaction as brisk, sluggish or
nonreactive
- Test the accommodation by placing your fingers
about 4 inches or 10 cm from the patient’s eyes,
ask the patient to look at the fixed object in the
distance and then your finger, the patient’s eye
should converge and the pupil should constrict
MOTOR RESPONSE
- The patient is given a grade of 6 if there is a
response to a verbal command, otherwise the
patient is graded on a 5-point scale depending
on the motor response to a painful stimulus
- When scoring motor responses, it is the ease with
which the motor responses are elicited that
constitutes the criteria for the best response
- Commands given to the patient should be
simple such as move your arm, the patient should
not be asked to squeeze the examiners hand,
nor should the examiner place something in the
patients hand and then ask the patient to grasp
it, this action may cause a grasp reflex, not a
response to a command
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BSN 4 | FIRST SEM | BATCH 2022 |
- If the patient does not give a motor response to
a verbal command, then the examiner should
attempt to elicit a motor response to a painful
stimulus
- It is the type of quality of the patient’s reaction to
the painful stimulus that constitutes the scoring
criteria
- The stimulus should not be applied to the face
because painful stimulus in the facial area may
cause the eyes to close tightly as a protective
reaction, the painful stimulus may consist of
applying a knuckle to the sternum, squeezing the
trapezius muscle, or squeezing the soft tissue
between the thumb and index finger
- If the patient moves a limb when the painful
stimulus is applied to more than 1 point or tries to
remove the examiners hand, that is applying the
painful stimulus, the patient is localizing and a
value of 5 is given
- If the patient withdraws from the painful stimulus
rapidly, a normal withdrawal reflex is being
shown and a value of 4 is given
o A) knuckle to sternum
o B) Squeezing trapezius muscle
o C) Squeezing tissue between thumb and
index finger
o D) Squeezing a fingertip
o E) Squeezing an object between two
fingers
GABBYGIRL AND AYAPQT
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LECTURER: MAAM PP2
TOPIC: GLASSGOW COMA SCALE
- For a patient who doesn’t obey commands, a
central stimulus is necessary to assess the motor
component of the coma scale, that is the best
motor response
- use a trapezius pinch, first if this pinch doesn’t
elicit a response, apply a supraorbital notch
press, to perform a trapezius pinch, place your
hand over the patients shoulder and press your
fingers into the muscle above the shoulder
blade, apply increasing intensity for up to 10
seconds and observe the patients best response
- to perform a supraorbital notch press, place your
hand on the patient’s forehead, with your thumb
over the upper rim of the orbit, feel for the notch
in the supraorbital margin and apply increasing
pressure for up to 10 seconds observing the
patient’s best response
- don’t use the supraorbital notch press if the
patient has facial injuries close to the testing area
- if the patient exhibits different responses
between sides, record the response from the
better side
- guidelines strongly discourage stimulation by
rubbing the knuckles on the sternum because
this practice can cause bruising and responses
can be difficult to interpret
- if the patient doesn’t respond to commands or
to touch, apply stimulation, stimuli are classified
as central - or the response by the brain, or
peripheral - response by the spine
EVALUATING MOTOR FUNCTION
- if the patient is conscious, test their grip strength
in both hands at the same time, extend your
hands, ask the patient to squeeze your fingers as
hard as they can and compare the strength of
each hand
- test arm strength by having the patient close
their eyes and hold their arms straight out in front
of them with the palms up, see if either arm drips
downward or pronates
- test leg strength by having the patient raise their
legs one at a time against gentle downward
pressure from your hand, gently push down on
3
 LECTURER: MAAM PP2
BSN 4 | FIRST SEM | BATCH 2022 | TOPIC: GLASSGOW COMA SCALE

each leg at the midpoint of the thigh to evaluate o 5 – patient who converse
muscle strength appropriately and shows proper
- however, if application of a painful stimulus orientation, being aware of oneself
creates a decorticate or decerebrate posture, and the environment
an abnormal response is being demonstrated o 4 – confused/disoriented and unable
and a value of 3 is given for a decorticate to completely interact with the
posture, or injury above red nucleus, or a value environment; able to converse using
of 2 is given for decerebrate posture, that is the the appropriate words
brainstem or midbrain injury o 3 – inappropriate speech is unable to
- decorticate posturing results from lesions of the sustain a conversation with the
diencephalon area, whereas decerebrate examiner
posturing results from lesions of the midbrain o 2 – only groans or makes
- with decorticate posturing, the arms, wrists and incomprehensible sounds; the
fingers are flexed and the upper limbs are examiner should note any possible
adducted, and the legs are extended, medially mechanical reason for the inability for
rotated and plantar flexed the patient to verbalize
- decerebrate posturing which has a poorer o 1 – if the patient makes no sounds
prognosis involves extension, adduction and and thus have no verbal response
hyper pronation of the arms, whereas as the
lower limbs are the same as for decorticate
posturing
- decerebrate rigidity is usually bilateral, if the
patient exhibits no reaction to the painful
stimulus, a value of 1 is given, please note that it
is important to be sure that no response is caused
by a head injury and not a spinal cord injury
leading to lack of feeling or sensation
- any difference in reaction in limbs should be GLASGOW COMA SCALE
carefully noted, this finding may indicate a
specific focal injury - Obtain initial score as soon as possible after the
onset of the injury
- Repeat at 15- or 30- min intervals; specially in the
early stages if changes are noted
- If the score is between 3 and 8, emergency care
is required, initial score is used as basis for
determining the severity of patient’s head injury
- A score of 8 or lower for 6 hours or longer – serious
head injury
- Score between 9 and 11 – moderate head injury
and
VERBAL RESPONSE - Score 12 or higher is considered to have a mild
head injury
- graded on a 5-point scale to measure the
patient’s speech in response to simple question
such as “where are you?” or “are you winning
the game?”

GABBYGIRL AND AYAPQT 4

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