Last Updated on July 5, 2022
Scoring
BEHAVIOUR | SCORE | RESPONSE |
4 | Eyes open spontaneously | |
3 | Eyes open to speech | |
2 | Eyes open to pain | |
1 | Eyes not opening | |
5 | Orientated to time, place, person | |
4 | Confused / Not-orientated | |
3 | Inappropriate words | |
2 | Incomprehensible sounds | |
1 | No verbal response | |
6 | Obeys verbal commands | |
5 | Moves to localize pain | |
4 | Flexion withdrawal from pain | |
3 | Abnormal flexion (decorticate) | |
2 | Abnormal extension (decerebrate) | |
1 | No response | |
• TOTAL SCORE: 15 | ||
Notes
• How to document GCS during daily review?
3 separate components documented separately, then total up
Example: E4 V 3 M4 (11/15)
• Severity
GCS 13 – 15:: mild brain injury
GCS 9 – 12: moderate brain injury
GCS 3 – 8: severe brain injury (impending coma)
• GCS <8, especially in trauma, is an indication for intubation
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Further reading / References
1. https://australiaot.com/en/glasgow-coma-scale-gcs/
2. https://pubmed.ncbi.nlm.nih.gov/19272743/