The

Aye, it’s
been revised
Sue Kadyschuk, November 2016 MAY BE USED FOR EDUCATIONAL PURPOSES ONLY
 The Revised Glasgow Coma Scale (GCS)
A practical tool used to assess Level of Consciousness using 3 Indicators

Eye Opening Best Verbal Response Best Motor Response

Comparison of Terms: Original GCS and Revised GCS Indicators

1979 2014
• Spontaneous • Spontaneous
• To Speech • To Sound
• To Pain • To Pressure
• None • None

• Orientation • Orientation
• Confused conversation • Confused
• Inappropriate speech • Words
• Incomprehensible speech • Sounds
• None • None

• Obeying commands • Obey commands

• Localising • Localising
• Flexor • Normal flexion
• Abnormal flexion
• Extensor posturing • Extension
• None • None
Principle of assessing Level of Consciousness is to determine degree of (increasing)
stimulation needed to elicit a response
Four Stages in Assessment Using Glasgow Coma Scale
Check Observe Stimulate Rate
Preliminary check to The assessor must look for Stimulation is applied in increasing Assign number
identify factors that evidence of spontaneous intensity until response is obtained. according to best
might interfere with behaviours and observe Sound: Spoken then shouted response observed
communication, ability to eye opening, content of Physical: light touch, pressure to
speech and movements of finger tip, trapezius or supraorbital
respond and other
left and right sides notch
injuries

Sue Kadyschuk, November 2016 MAY BE USED FOR EDUCATIONAL PURPOSES ONLY
 Guidelines for Performing a Basic Neuro Assessment
Glasgow Coma Scale
Eye Opening Criteria Rating Score
Assesses level  Eyes open spontaneously, before any stimulus Spontaneous 4
of wakefulness  Patient opens eyes to speech – progress to shout if necessary To sound 3
 Patient opens eyes to fingertip pressure To pressure 2
 No eye opening to verbal or physical stimulus - no interfering factor None 1
 Closed by local factor (swelling, injury) and not testable Non testable NT
Best Verbal Criteria Rating Score
Response
Reflects  Correctly gives name, place and date Orientated 5
integrity of  Gives inaccurate answers, but speech coherent Confused 4
higher,  Intelligible single words Words 3
cognitive and  Only moans/groans Sounds 2
interpretive  No audible response, no interfering factor None 1
centers of  Factor interfering with communication (e.g. Non testable NT
brain tracheostomy/endotracheal tube)
Best Motor Criteria Rating Score
Response
Following  Obeys 2-part request: squeeze and release my fingers; raise and Obeys 6
commands is lower your arms; or stick out and put back your tongue commands
the highest  Brings hands above clavicle to stimulus on head/neck Localizing 5
level of motor  Bends arm at elbow rapidly but features not predominately Normal flexion 4
response abnormal
 Bends arm at elbow, features clearly predominately abnormal Abnormal 3
flexion
 Extends arm at elbow Extension 2
 No movement in arms/legs – no interfering factor None 1
 Paralyzed or other limiting factor Non testable NT

Physical Stimulus Confounding factors rendering

Fingertip pressure Trapezius pinch Supraorbital notch component(s) of GCS untestable
Drugs: sedatives, anesthetics, intoxication
Hearing impairment
Ocular trauma and/or orbital swelling
Dysphasia, tracheostomy/endotracheal tube
Limb or spinal cord injury
Pre-existing disorders (e.g., dementia)
Language and culture
Motor Response Criteria
Localizing Normal flexion Abnormal Flexion Extension
Purposeful movement Rapid Slow Arms extend, close to body
Patient tries to remove Arm moves away from Arm moves across chest, elbow Feet extended
noxious stimuli body flexed, forearm rotates Thumb clenched
Elbows are flexed Thumb clenched, Feet extended Wrists turned out

Sue Kadyschuk, November 2016 MAY BE USED FOR EDUCATIONAL PURPOSES ONLY
 Assessment of Limb Movement and Strength Pronator Drift
st
 Evaluates upper and lower extremities for weaknesses  Often 1 indicator of motor
and potential differences between left and right side weakness
 Weakening extremity on one side may indicate evolving  Ask patient to close eyes, hold both
injury in the opposite side of the brain. arms out at shoulder height, palms
 Ask patient to grasp 2 fingers of your hand, note the extended
strength of grasp and if both sides are equal  Watch for downward drift and
 Ask patient to push both feet against your hands (plantar pronation
flexion) and pull both feet up towards their head against
your hands (dorsiflexion), and to wiggle their toes: noting
strength and if both sides are equal
Plantarflexion Dorsiflexion

Pupils

Features of Sensation  Assess size, shape & symmetry

 Briefly assesses intactness of peripheral nerves  Be aware of any history of pupil
 May be used for rapid spinal assessment after fall / spinal dysfunction or irregularity
injury  If eye(s) closed due to periorbital
 Ask patient to close eyes, then ask if he/she can feel light edema, gently pry open if able
touch on feet, legs, hands, arms  Pupils are best assessed in dim
 Note presence of numbness or tingling room, using a bright light
to extremities  Ask patient to focus on something
 May indicate pressure on spinal nerves Rapid Spinal (e.g. your nose) and quickly move
[Link] penlight in front of patient’s eyes
 Pupils should constrict briskly

Reference and Resources

Great Video Glasgow Coma Scale- A structured approach to
assessment - [Link]-HD.mp4

[Link]
Home Webpage for Glasgow Coma Scale
GCS-Assessment-Aid- Revised [Link] Forty-years-on-updati • Whats New
English[1].pdf ng-the-Glasgow-coma
• Frequently Asked Questions
• Self test

Physical Stimulus Illustrations used by permission: Guidelines for Basic Paediatric Neurological Observation, Critical Care Services Ontario 2016
Motor Response illustrations used by permission: Guidelines for Basic Adult Neurological Observation Webinar, Critical Care Services Ontario 2015

Sue Kadyschuk, November 2016 MAY BE USED FOR EDUCATIONAL PURPOSES ONLY