Glasgow Coma Scale

Last revised by Daniel J Bell on 13 Mar 2021

The Glasgow Coma Scale (GCS) was developed in 1974 1 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 2,3

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.

Graded 1-4:

  1. no eye opening
  2. 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
  3. eye opening to speech
    • not to be confused with the awakening of a sleeping person (such patients receive a score of 4, not 3)
  4. eyes opening spontaneously

Graded 1-5:

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

Graded 1-6

  1. no motor response
  2. extension to pain
    • extensor posturing: abduction of arm, external rotation of shoulder, supination of forearm, extension of wrist, decerebrate response
  3. abnormal flexion to pain
    • flexor posturing: adduction of arm, internal rotation of shoulder, pronation of forearm, flexion of wrist, decorticate response
  4. 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
  5. localizes to pain
    • purposeful movements towards painful stimuli
  6. obeys motor commands

The Glasgow Coma Scale was developed by Graham Teasdale (fl. 2021) and Bryan Jennett (1926-2008) 4, two neurosurgeons working at the Institute of Neurological Sciences of the University of Glasgow 1. Bryan Jennett also coined the term persistent vegetative state and developed the Glasgow Outcome Scale (GOS) 4,5.

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