Assessing Patient For Consciousness-Glasgow Coma Scale

After ABC (Airway, Breathing, Circulation) comes D which stands for disability.

After patient has been assessed for ABC and resuscitated if required, patient is assessed for neurological function. The patient’s level of consciousness, pupillary response sensation, and motor activity in all extremities is rapidly assessed. A rectal examination to determine sphincter tone must be performed to complete the assessment.

A precise measurement of neurologic function is provided by the Glasgow Coma Scale. This scale was developed by Teasdale and Jennett and is also known as Glasgow Coma Score.

The scale comprises 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 (implies deep coma or death), whilst the highest is 15 (implies fully awake person).

Best eye response (E)
There are 4 grades starting with the most severe:

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, supraorbital and sternal pressure or rub may be used.)
3. Eye opening to speech. (This should not be confused with an awaking of a sleeping person; such patients receive a score of 4, not 3.)
4. Eyes opening spontaneously

Best verbal response (V)

There are 5 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)
4. Confused. (The patient responds to questions coherently but there is some disorientation and confusion.)
5. Oriented. (Patient 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)

There are 6 grades starting with the most severe:

1. No motor response
2. Extension to pain (adduction of arm, internal rotation of shoulder, pronation of forearm, extension of wrist, decerebrate response)
3. Abnormal flexion to pain (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 supra-orbital pressure applied ; pulls part of body away when nailbed pinched)
5. Localizes to pain. (Purposeful movements towards painful stimuli; e.g. hand crosses mid-line and gets above clavicle when supra-orbital pressure applied.)
6. Obeys commands. (The patient does simple things as asked.)

How To Interpret The Score?

Individual elements as well as the sum of the score are important. Hence, the score is expressed in the form “GCS 9 = E2 V4 M3 at 17:35″.

Generally, comas are classified as:

• Severe, with GCS less than or equal to 8
• Moderate, GCS 9 – 12
• Minor, GCS 13 or greater.

In severely injured patient with intubation and severe facial/eye swelling or damage, it is not possible to test the verbal and eye responses. In these circumstances, the score is given as 1 with a modifier attached e.g. ‘E1c’ where ‘c’ = closed, or ‘V1t’ where t = tube.

A composite might be ‘GCS 5tc’. This would mean, for example, eyes closed because of swelling = 1, intubated = 1, leaving a motor score of 3 for ‘abnormal flexion’.

The Glasgow Coma Scale has limited applicability to children, especially below the age of 36 months because then verbal performance of even a healthy child could be labeled to be poor).

To avoid this Paediatric Glasgow Coma Scale, a separate yet closely related scale, has been developed for assessing younger children.