Test: Glascow Coma Scale

Video Link

Background/Purpose

Procedure

The scale uses three tests: eye, verbal and motor responses. The three responses as well as their sum are considered. The lowest sum is 3 (deep coma or death), while the highest is 15 (fully awake person). Eye response (E)- The four grades starting with the most severe are: 1. No eye opening 2. Eye opening in response to pain stimulus. 3. Eye opening to speech. 4. Eyes opening spontaneously Verbal response (V)- There are five grades starting with the most severe: 1. No verbal response 2. Incomprehensible sounds. (Moaning) 3. Inappropriate words. 4. Confused (disorientation and confusion) 5. Oriented. Motor response (M)- There are six grades: 1. No motor response 2. Extensor posture accentuated by pain (adduction of arm, internal rotation of shoulder, pronation of forearm and extension at elbow, flexion of wrist and fingers, leg extension, plantarflexion of foot) 3. Flexor posturing accentuated by pain (flexor response: internal rotation of shoulder, flexion of forearm and wrist with clenched fist, leg extension, plantarflexion of foot) 4. Withdrawal from pain (Absence of abnormal posturing; unable to lift hand past chin with supraorbital pressure applied but does pull away when nailbed is pinched) 5. Localizes to pain (Purposeful movements towards painful stimuli; e.g., brings hand up beyond chin when supraorbital pressure applied.) 6. Obeys commands (The patient does simple things as asked.) Interpretation Individual elements as well as the sum of the score are important and expressed as GCS 9 = E2 V4 M3. General classification is: Severe, with GCS < 8–9 Moderate, GCS 8 or 9–12 Minor, GCS ≥ 13.
Performed: Unilaterally

Dialog

GCS

Criteria

• GCS cummulative score of 15 or higher

Measurement

0.00

LOINC Code

0

Scale/Grading

Pass/Fail