Glasgow Coma Scale (GCS)

Elements Of The Scale

  1 2 3 4 5 6
EYE does not open eyes open eyes in response to pain open eyes in response to voice open eyes spontaneously N/A N/A
VERBAL makes no sounds makes sounds words confused, disoriented oriented, converses normally N/A
MOTOR makes no movements

extension to painful stimuli

(decerebrate response)

abnormal flexion to painful stimuli

(decorticate response)

flexion or withdrawal to painful stimuli localizes to painful stimuli obeys command

Note that a motor response in any limb is acceptable.4 The scale is composed of three tests: eye, verbal and motor responses. The three values separately as well as their sum are considered. The lowest possible GCS (the sum) is 3 (deep coma or death), while the highest is 15 (fully awake person).

Eye response (E)

There are four grades starting with the most severe:

  1. No opening of the eye
  2. Eye opening in response to pain stimulus. (a peripheral pain stimulus, such as squeezing the lunula area of the person’s fingernail is more effective than a central stimulus such as a trapezius squeeze, due to a grimacing effect).5
  3. Eye opening to speech. (Not to be confused with the awakening of a sleeping person; such people receive a score of 4, not 3.)
  4. Eyes opening spontaneously
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Verbal response (V)

There are five grades starting with the most severe:

  1. No verbal response
  2. Incomprehensible sounds. (Moaning but no words.)
  3. Inappropriate words. (Random or exclamatory articulated speech, but no conversational exchange. Speaks words but no sentences.)
  4. Confused. (The person responds to questions coherently but there is some disorientation and confusion.)
  5. Oriented. (Person responds coherently and appropriately to questions such as the person’s name and age, where they are and why, the year, month, etc.)

Motor response (M)

There are six grades:

  1. No motor response
  2. Decerebrate posturing accentuated by pain (extensor response: 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. Decorticate 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 pain 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 person does simple things as asked)
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