Glasgow Coma Scale

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The Glasgow Coma Scale (GCS) was developed in 1974 to describe the level of consciousness specifically in patients with head injury although it is now used widely as a shorthand for all manner of presentations and has generally been validated, although concerns remain about its use in certain scenarios .

It measures the best eye, verbal, and motor responses. Each is graded from worst (=1) to best (4, 5 and 6 respectively) and the grades added together, such that the lowest possible score is 3 and the highest is 15.

Best eye response (E)

Graded 1-4:

  • no eye opening
  • eye opening in response to pain
    • patient responds to pressure on the patient’s fingernail bed 
    • if this does not elicit a response (or hands are unavailable) supraorbital and sternal pressure or rub may be used
  • eye opening to speech
    • not to be confused with the awakening of a sleeping person (such patients receive a score of 4, not 3)
  • eyes opening spontaneously

    • Best verbal response (V)

    Graded 1-5:

  • no verbal response
  • incomprehensible sounds
    • groaning or moaning but no words
  • inappropriate words
    • random or exclamatory articulated speech, but no conversational exchange
  • confused
    • responds to questions coherently but there is some disorientation 
  • oriented
    • responds coherently and appropriately to questions such as the patient’s name and age, where they are and why, the year, month, etc.

    • Best motor response (M)

    Graded 1-6

  • no motor response
  • extension to pain
    • extensor posturing: abduction of arm, external rotation of shoulder, supination of forearm, extension of wrist, decerebrate response
  • abnormal flexion to pain
    • flexor posturing: adduction of arm, internal rotation of shoulder, pronation of forearm, flexion of wrist, decorticate response
  • flexion/withdrawal to pain
    • flexion of elbow, supination of forearm, flexion of wrist when supraorbital pressure applied; pulls part of body away when nail bed pinched
  • localizes to pain
    • purposeful movements towards painful stimuli
  • obeys motor commands
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