Conducting GCS

The most known structured approach of conducting GCS examination is to check, observe, stimulate and rate on the separate elements (eyes, verbal and motor). These scores should then be added to give a final GCS score. 

Check

A check for any pre-existing factors that may interfere with communication, ability to respond to commands or injuries.

Observe

When conducting the exam observe for eye opening, speech, and movements of right and left sides.

Stimulate

Stimulation should then be carried out if abnormal findings on observe, such as eyes closed, no movement etc.

Rate

A rating should be assigned according to the highest response observed.

Eyes

Maximum of 4 points can be recorded.

Eyes Open Spontaneously (4 Points)

Observe if eyes are opening spontaneously.

If yes, record 4 points and move to verbal. If no, continue to the next steps below until a score can be recorded. If no, continue to the following steps until a response is obtained.

Eyes Opening To Sound (3 Points)

Observe if eyes open after speaking or shouting a request. If yes, record 3 points. If no, then proceed to the next step below.

Eyes Opening To Pain (2 Points)

If the patient did not open eyes to sound, then a stimulus is needed to assess for eyes opening to pain.

As mentioned in the Conducting GCS section, you can assess for pain by the patient’s fingertips, trapezius muscle or supraorbital notch.

If eyes open to pain, record score as 2. If not, move to the final stage.

No Response (1 Point)

If during the above assessment the patient did not open their eyes, then record score as 1.

Not Testable (NT)

There may be circumstances where the patient is unable to open eyes such as oedema, dressings etc. Record as NT if eyes could not be assessed.  

Verbal

Maximum of 5 points can be recorded.

Observe if the patient can converse and if they are orientated. You can check orientation by asking questions such as where they are, the day etc.

Orientated (5 Points)

If when observed the patient can hold a conversation and is orientated, then the score is 5 and move to motor response. If not, continue to the next step below.

Confused (4 Points)

If the patient can respond to your questions but seem confused, such as not knowing the day etc., this is scored as confused conversation and score 4 points.

Inappropriate Words (3 Points)

The patient may be responding with random words or intelligible single words and would be scored a 3.

Incomprehensible Sounds (2 Points)

If sounds, such as moans/groans rather than speaking words are heard then this will score a 2.

No Response (1 Point)

If no audible response or sounds, then this will score a 1

Not Testable

There may be circumstances where the patient is unable to respond such as learning difficulties. Record as NT if verbal could not be tested.

Motor

Maximum of 6 points can be scored.

The patient should be scored based on the highest scoring response in any single limb (e.g., if they are unable to move left arm but can move right arm on command, then they receive 6 points).

Obeys Commands (6 Points)

A 2-part request is needed to be obeyed to achieve a score of 6 e.g., lifting left arm and clenching fist. If unable to do a 2-part request, move on to the next step below.

Localises To Pain (5 Points)

Use the sites for physical stimulation mentioned above (trapezius pinch/supraorbital notch) and observe patient for a response.

If the patient attempts to reach for the site at which the stimuli is applied this would be classed as localising to pain and scores a 5.

Withdraws To Pain (4 Points)

The same process is followed above but the patient withdraws from the pain known as a normal flexion response. This is where the patient typically flexes their limb to move away from the stimulus. A patient withdrawing from pain would score a 4.

Abnormal Flexion Response To Pain (3 Points)

When the stimuli is applied as above, abnormal flexion may be the response which involves adduction of arm, flexion of elbow and wrist flexion also known as decorticate posturing.

Decorticate posturing can suggest damage to cerebral hemispheres, internal capsule and the thalamus.

If abnormal flexion is the response to pain, then score a 3.

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Abnormal Extension Response To Pain (2 Points)

If abnormal extension is seen during painful stimulus, then this scores 2 points.

Abnormal extension is also known as decerebrate posturing. This is where the head is extended, limbs extended and internally rotated. Can be seen on one or both sides of the body.

Decerebrate posturing can indicate brain stem damage, compression in the midbrain or lesions in the cerebellum.

If decorticate posturing progresses to decerebrate posturing this can suggest tonsillar brain herniation (also known as coning).

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No Response (1 Point)

Absence of movement to painful stimuli scores a 1.

Not Testable (NT)

There may be circumstances where the patient is unable to respond such as paralysis. Record as NT if motor could not be tested.

Interpreting Results 

Once a score has been recorded from each element (eyes, verbal and motor) then you can add these scores together to calculate GCS. GCS is documented with the total score followed by the individual score e.g., 15 [4,5,6]

The GCS score provides valuable information about a patient’s level of consciousness and neurological status. A higher GCS score generally indicates a less severe brain injury and better neurological function, whereas a lower score implies a more significant brain injury and compromised neurological function.

Here’s a breakdown of the GCS score interpretation:

Severe Brain Injury: GCS score 3-8

Moderate Brain Injury: GCS score 9-12

Mild/No Brain Injury: GCS score 13-15

While the GCS is a valuable tool, it does have some limitations. It may not be as reliable in certain populations, such as infants, young children, or individuals with pre-existing neurological conditions. Additionally, factors such as sedation, alcohol or drug use, or language barriers can affect the accuracy of the verbal response assessment.