Glasgow Coma Scale: Assessment and Pupillary Response

Introduction to the GCS

Published in 1974 by Graham Teasdale and Bryan Jennett, the GCS standardizes assessment of consciousness.

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Use a consistent sequence: check the patient, observe spontaneous behavior, stimulate if needed, then rate.
Begin with normal speech, then speak loudly; use light touch before considering a painful stimulus.
Use painful stimulation only when the patient does not obey commands and has no spontaneous movement.
Apply a suitable stimulus carefully, such as nail-bed pressure or a trapezius squeeze, and observe the response.

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Eye opening scores 4 spontaneously, 3 to speech, 2 to pain, and 1 for no eye opening.
Verbal response scores 5 oriented, 4 confused, 3 inappropriate words, 2 incomprehensible sounds, and 1 none.
Motor response scores 6 obeys commands, 5 localizes pain, 4 normal flexion, 3 abnormal flexion, 2 extension, and 1 none.
Record each component separately, since the same total score can represent different response patterns.

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Pupils are usually equal and round; assess their direct light response, controlled by the oculomotor nerve.
Approach the pupil from the side with a light source; note brisk, sluggish, or absent response.
Interpret GCS cautiously when language barriers, hearing loss, or intellectual and neurological deficits affect responses.
Intubation, sedation, orbital or cranial fracture, and spinal damage can also limit reliable assessment.

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GCS describes consciousness through eye, verbal, and motor responses; assess and document all three components.
Repeat assessments consistently to detect changes in consciousness and support timely clinical decisions.
Interpret scores alongside pupil findings and clinical context, accounting for factors that limit the examination.
Early recognition of deterioration can inform treatment, management, and prognosis for patients with impaired consciousness.