The Glasgow coma scale (GCS)

The Glasgow coma scale (GCS)
This gives a reliable, objective way of recording the conscious state of a person. It can be used by medical and nursing staff for initial and continuing assessment. It has value in predicting ultimate outcome. 3 types of response are assessed:

a)Best motor response
This has 6 grades:
6 Carrying out request (obeying command): The patient does simple things you ask (beware of accepting a grasp reflex in this category).
5 Localizing response to pain: Put pressure on the patient's fingernail bed with a pencil then try supraorbital and sternal pressure: purposeful movements towards changing painful stimuli is a localizing response.
4 Withdraws to pain: Pulls limb away from painful stimulus.
3 Flexor response to pain: Pressure on the nail bed causes abnormal flexion of limbs decorticate posture.
2 Extensor posturing to pain: The stimulus causes limb extension (adduction, internal rotation of shoulder, pronation of forearm)—decerebrate posture.
1 No response to pain.
Note that it is the best response of any limb which should be recorded.

Best verbal response
This has 5 grades:
5 Oriented: The patient knows who he is, where he is and why, the year, season, and month.
4 Confused conversation: The patient responds to questions in a conversational manner but there is some disorientation and confusion.
3 Inappropriate speech: Random or exclamatory articulated speech, but no conversational exchange.
2 Incomprehensible speech: Moaning but no words.
1 None.

Record level of best speech.
Eye opening
This has 4 grades:
4 Spontaneous eye opening.
3 Eye opening in response to speech: Any speech, or shout, not necessarily request to open eyes.
2 Eye opening in response to pain: Pain to limbs as above.
1 No eye opening.

An overall score is made by summing the score in the 3 areas assessed. Eg: no response to pain + no verbalization + no eye opening = 3. Severe injury, GCS 8; moderate injury, GCS 9-12; minor injury, GCS 13-15.
NB: An abbreviated coma scale, AVPU, is sometimes used in the initial assessment (˜primary survey) of the critically ill:
A = alert
V = responds to vocal stimuli
P = responds to pain
U = unresponsive
Some centres score GCS out of 14, not 15, omitting ˜withdrawal to pain.
NB: The GCS scoring is different in young children;