UNCONTROLLED WHEN PRINTED
Indications
  • The Glasgow Coma Scale (GCS) aims to determine the state of a person's consciousness for initial and subsequent assessment using a numerical total (a score out of 15, the lowest available score (3) indicating a person is completely unresponsive).
Contraindications
Contraindications
Patient Factors & Considerations
  • The Glasgow Coma Scale allows you to apply numerical scores to patient responses in three separate areas. These are:
    • Eye opening (a score out of 4)
    • Verbal response (a score out of 5)
    • Motor response (a score out of 6)
Procedure
  • Note: It is important to use the best motor response in calculating the score. 
  • When assessing the motor response to pain we are looking to see whether the patient has a coordinated motor response to commands i.e. squeeze my hands, performs a basic localised movement or simply flexes or extends limbs and/ or spine in response to painful stimuli.
Assess the following:
1. Eye Opening:
ScoreAdult ResponseChild <2 years Response
4 SpontaneousSpontaneous
3 To VoiceTo Voice
2 To PainTo Pain
1 NoneNone
2. Best Verbal Response:
ScoreAdult ResponseChild <2 years Response
5 OrientedSmiles, listens, follows
4 ConfusedCries, consolable
3 Inappropriate wordsInappropriate persistent cry
2 Incomprehensible wordsAgitated, restless
1 NoneNo response
3. Best Motor Response:
ScoreAdult ResponseChild <2 years Response
6 Obeys commandsObeys commands
5 Purposeful movementPurposeful movement
4 Withdraws from painWithdraws from pain
3 Flexion to painFlexion to pain
2 Extension to painExtension to pain
1 NoneNone

Calculate the sum of the score from 1 (Eye Opening), 2 (Best Verbal Response) and 3 (Best Motor Response). This number will give you a Glasgow Coma Score out of 15.

For example (adult patient):

  • Eye Opening: To Voice (3)
  • Best Verbal Response: Confused (4)
  • Best Motor Response: Obeys commands (6)
  • GCS = 3 + 4 + 6 = 13 out of 15.
  • Record this on your ePCR as GCS 13/15 (E3, V4, M6)

Note: Painful stimuli refers to firm squeeze of trapezius muscle, must be adequate for task, but not excessive.

Success
Success
Discontinue
Discontinue
Additional Information

References
References

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