The first in a series of fundamental classes in neuro nursing.

1. Glasgow Coma Scale (GCS)
– The fundamentals for
nurses
Dr Ravi Dadlani
Consultant Neurosurgeon
05th October 2015

2. Past: Background
• In 1974
– (Sir) Graham Teasdale (1940 - )
– Bryan Jennett (1926-2008)
Neurosurgeons in Glasgow

3. Clinical Implications I
• Severity of Head Injury (HI):
– 13-15 (mild HI)
– 9-12 (moderate HI)
– < 8 (severe HI)

4. Clinical Implications II
• Prognostic Significance
• Glasgow Outcome Score (GOS)

5. GCS – The Stimuli
• 1. Spontaneously – No stimuli
• 2. To Verbal stimuli
• 3. To painful stimuli

6. Where do you give painful stimuli?
1. Supra-orbital notch ---- Central stimulation
2. Sternal rub - A V O I D
3. Nipple
4. Trapezius squeeze ---- Central stimulation
5. Nail bed ---- Peripheral stimulation
6. Retromandibular /Styloid process (behind the
jaw)---difficult to apply and interpret

7. GCS – The responses
• Patients may localize or exhibit a variety of
responses, asymmetry is important
• GCS is about the responses

8. Glasgow Coma Scale (GCS)
Best eye
response (E)
Best verbal
response (V)
Best motor
response (M)
4 spontaneously 5 Oriented 6 Obeys commands
3 to speech 4 Confused 5 Localizes to pain
2 to pain 3 Inappropriate
words
4 Withdraws from
pain
1 No eye opening 2
Incomprehensible
sounds
3 Flexion in response
to
pain
1 None 2 Extension to pain
1 No motor response
1976

10. How are the components assessed?
• Eyes Opening:
– Score 4: eyes open spontaneously;
– Score 3: eyes open to speech;
– Score 2: eyes open in response to pain only, for
example trapezium squeeze (caution if applying a
painful stimulus);
– Score 1: eyes do not open to verbal or painful
stimuli.
– ‘C’ is recorded for patients unable to open eyes
due to for example swelling

11. How are the components assessed?
• Verbal Response:
– Score 5: orientated; must be able to tell you their full
name, the place in which they are and the date. If the
patient doesn’t know any of these it is assumed they
are confused.
– Score 4: confused; not able to answer orientation
questions
– Score 3: inappropriate words; swearing, aggression,
unrelated words to the questions being asked
– Score 2: incomprehensible sounds;
– Score 1: no verbal response.
– ‘D’ is marked for patients who are dysphasic (unable
to speak coherently. ‘T’ is marked for those with a
tracheostomy or ET tube

12. How are the components assessed?
Best Motor Response:
• Score 6: obeys commands. The patient can perform two
different movements; primative reflexes should not be tested
• Score 5: localises to central pain. The patient does not
respond to a verbal stimulus but purposely moves an arm to
remove the cause of a central painful stimulus
• Score 4: normal flexion. The patient flexes or bends the arm
towards the source of the pain but fails to locate the source of
the pain (no wrist rotation)
• Score 3: abnormal flexion to pain
• Score 2: extension to pain
• Score 1: no response to painful stimuli.

13. M5- Attempts to remove the offending
painful stimuli PURPOSIVE MOVEMENT
M4- Normal flexion – Withdrawal
SEMI-PURPOSIVE MOVEMENT
M3 – Abnormal flexion– Decortication
REFLEX NON-PURPOSIVE MOVEMENT
M2- Extensor
REFLEX NON-PURPOSIVE MOVEMENT

14. Abnormal flexion and extension to
pain

15. GCS – The Stimuli
• 1. Spontaneously – No stimuli E4 M V
• 2. To Verbal stimuli E3 M V4,V3,V2
• 3. To painful stimuli E2,E1 M5-1 V1,V2

16. The pediatric scale

17. Glasgow Coma Score Video
• GCS video

18. Resources
• www.glasgowcomascale.org