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Nursing & Med-Math · Assessment scales

Glasgow Coma Scale

Score eye, verbal and motor response using the 2014 structured criteria.

Eye opening (E)
Best response observed, scored 1–4.
Verbal response (V)
Best response observed, scored 1–5.
Motor response (M)
Best response in any limb, scored 1–6.
Glasgow Coma Scale
15/ 15Mild brain injury (13–15)

Report the components, not just the sum: E4V5M6

Eye
4 / 4
Verbal
5 / 5
Motor
6 / 6

The Glasgow Coma Scale rates conscious level on three responses: eye opening out of 4, verbal out of 5 and motor out of 6. The total runs from 3 to 15, and a patient scoring E3 V4 M5 has a GCS of 12 — the moderate band. Always report the three parts, not only the sum.

Three responses, scored separately

The scale was published by Teasdale and Jennett in 1974 to replace vague descriptions such as “drowsy” or “stuporous” with something two observers could agree on. It works by recording the strongest response the patient gives in each of three domains — whether the eyes open, what sounds or words come out, and what the limbs do — against a defined stimulus.

Because a patient cannot score below 1 in any domain, the minimum total is 3, not 0. There is no such thing as a GCS of 0: a patient with no response at all scores E1 V1 M1, totalling 3.

Report the components, not just the total

A total of 9 can describe very different patients. E2 V2 M5 and E4 V1 M4 both come to 9, but the first is opening eyes only to pressure while localising, and the second is awake-eyed with no speech and only withdrawal. The 2014 structured update stresses reporting the three figures — written E3 V4 M5 — precisely so this information survives handover. Where a component cannot be assessed, because of swelling or an endotracheal tube, it is recorded as not testable rather than scored 1.

  1. 1
    Check, observe, stimulate, rate — in that order. First check for anything that interferes with a response, then observe spontaneous behaviour before applying any stimulus.
  2. 2
    Score eye opening out of 4. Open before any stimulus is 4, to a spoken or shouted request 3, to fingertip pressure 2, and never 1.
  3. 3
    Score the verbal response out of 5. Correct name, place and date is 5; coherent but disorientated 4; single words 3; moans or groans 2; nothing audible 1.
  4. 4
    Score the motor response out of 6. Obeying commands is 6, localising to the stimulus 5, normal withdrawal 4, abnormal flexion 3, extension 2, no movement 1.
  5. 5
    Add the three and report all four numbers. E3 + V4 + M5 gives a total of 12, recorded as E3 V4 M5 = 12 so the pattern is not lost.

The 2014 structured criteria

The best response observed in each domain is the one scored; in the motor domain, the best response in any limb.

ScoreEye openingVerbal responseMotor response
6——Obeys commands
5—OrientatedLocalising to pressure
4SpontaneousConfusedNormal flexion (withdrawal)
3To soundWordsAbnormal flexion
2To pressureSoundsExtension
1NoneNoneNone

How the total is banded

Bands describe the severity of a traumatic brain injury; they are a summary, not a diagnosis.

TotalBand
13–15Mild
9–12Moderate
3–8Severe

What shifts a score without the brain changing

Several things confound the scale. Sedation, paralysing agents, alcohol and hypoglycaemia all depress responses; an intubated patient cannot produce a verbal score at all; severe facial swelling can close the eyes mechanically. None of these mean the brain injury has worsened, which is why the structured approach begins by checking for interfering factors before anything is scored.

The trend is also more informative than any single reading. A falling total, and particularly a falling motor score, is the change that matters, so serial observations are recorded together. Scoring, interpretation, and any escalation belong to a qualified professional working to local protocol.

What is the lowest possible GCS?
Three. Each of the three domains has a minimum of 1, so an entirely unresponsive patient scores E1 V1 M1 = 3. A GCS of 0 does not exist.
Why record E3 V4 M5 rather than just 12?
Because different patterns share a total. E2 V2 M5 and E4 V1 M4 both add to 9 but describe very different patients, and the component breakdown is what carries that information through handover.
How do I score an intubated patient?
The verbal component cannot be tested, so it is recorded as not testable rather than given a 1. Some units annotate the total with T; the structured approach prefers reporting the testable components and marking the rest NT.
What changed in the 2014 update?
The wording and the method, not the scores. “To pain” became “to pressure” and a fingertip stimulus was specified, the motor levels were renamed to normal and abnormal flexion, and a structured check-observe-stimulate-rate sequence was set out to make scoring more consistent.
What is the difference between localising and normal flexion?
Localising means the patient brings a hand up above the clavicle towards the stimulus — a purposeful move, scoring 5. Normal flexion is a rapid withdrawal away from it without that targeting, scoring 4.
Which band counts as a severe brain injury?
A total of 8 or less is conventionally described as severe, 9 to 12 as moderate and 13 to 15 as mild. The bands summarise severity in traumatic brain injury and are not a diagnosis on their own.
Can sedation change the score?
Yes, and so can alcohol, paralysing agents and hypoglycaemia. They depress the responses without the injury changing, which is why interfering factors are identified before the score is recorded.