1. Glasgow Coma Scale and
Pupillary assessment
Dr Sumit Sinha
Asstt Prof Neurosurgery
JPNATC, AIIMS

2. Clinical Scenario
● A 20 year old white male presents to the team
physician unconscious 5 minutes after missing the
pole vault pit and landing with the occipital region of
his head hitting asphalt. After assessing the ABC’s
and finding them intact, the patient’s level of
consciousness was evaluated. The patient’s eyes,
initially closed, opened to the sound of his name, and
when asked where he was, the patient responded with
“my shoes to change.” The patient moved all of his
fingers and toes when prompted.
● What is this patient’s score on the Glasgow Coma
Scale?

3. Clinical correlate (revisited)
● The patient’s eyes, initially closed, opened to the sound of
his name.
● Eye opening
● 3
● When asked where he was, the patient said “my shoes to
change.”
● Verbal response
● 3
● The patient moved all of his fingers and toes when
prompted.
● Motor response
● 6
● Score
● GCS 12 = E3 V3 M6 at 16:34
● Head injury severity
● Moderate

4. ● Developed by neurosurgeons in 1974
● Quantifies level of consciousness
● Acute brain damage: traumatic and/or vascular injuries
or infections
● Metabolic disorders: hepatic or renal failure,
hypoglycemia, diabetic ketosis, toxic ingestion
● Assess initial level of consciousness
● Assess changes in level of consciousness
● Helps guide treatment and predict outcome
Glasgow Coma Scale:
What is it?

5. Glasgow scoring
2Incomprehensible speech
PointsResponseCategory
1No response
2Extensor (rigid) response, decerebrate posture
3Abnormal (spastic) flexion, decorticate posture
4Withdraws from pain
5Purposeful movement to painful stimulus
6Obeys commands for movement
Motor response
1TIntubated
1No response
3Inappropriate responses, words discernible
4Disoriented, confused conversation, able to answer questions
5Oriented conversation
Verbal response
1No response
2Opens to pain, not applied to face
3Opens to verbal command, speech, or shout
4Spontaneous, open with blinking at baseline
Eye opening

6. Verbal response in children
3Persistent cries and/or screamsPersistent inappropriate crying and/or screaming
4Inappropriate wordsCries and consolable
2GruntsGrunts or is agitated or restless
5Appropriate words or phrasesSmiles or coos appropriately
1No responseNo response
PointsVerbal ageNon-verbal age

7. Prognosis
12%82%11-15
27%68%8-10
53%34%5-7
87%7%3-4
Vegetative or DeadGood recovery or
Moderate disability
Highest score
observed during 1st
24 hours after injury

8. Glasgow Coma Scale
● (Teasdale & Jennett (1974)

9. Glasgow Coma Scale (GCS)
• Used in acute situations to assess patient’s
level of consciousness
• Need to record initial examination results
accurately
• This is only achieved using the same
questions each time patient is assessed !
• Treatment decision may depend on whether
subsequent examinations show improvement/
deterioration

10. Components of the GCS
● There are three components to the GCS:
• Best eye opening
• Best motor response
• Best verbal response
● Each is evaluated independently of the other two
● components.
● ALWAYS SCORE THE BEST RESPONSE FOR
THE PATIENT

11. Best Eye Opening (4 – 1)
• Assessment of eye opening shows that arousal
mechanisms located in the brain stem are
functioning.
• If patients have their eyes closed, their state of
arousal can be assessed by the degree of
stimulation needed to get them to open their
eyes.

12. Eye Opening Response
4 = eyes open spontaneously when a person
approaches the bedside. Indicates intact
arousal mechanism.
3 = eyes open to either spoken or shouted verbal
stimulation.
2 = eyes open to a painful stimuli (to be used only
when it is clear patient will not open eyes to
verbal stimuli).
1 = failure to open eyes regardless of stimuli.

13. Eye Opening
• If there is damage to the occulomotor nerve
from trauma, the patient may not be physically
able to open his or her eye.
• The occulomotor nerve is responsible for
movement of the eyelid and causes the eye to
open.

14. Best Motor Response (6 – 1)
• Obeys commands (6)
• Localises to pain (5)
• Withdraws from pain (4)
• Abnormal flexion (3)
• Extension (2)
• No response (1)

15. Obeys Commands (6)
• Patients are aware of their environment, have
understood the observer's instructions, and are
able to carry them out.
• Examples of possible commands are 'lift up your
arms' or 'hold up your thumb'.
• If patients are asked to 'squeeze my hands', they
must also be asked to release their grip.

16. Localises to Pain (5)
• This is a response to a central painful stimulus.
• It involves the higher centres of the brain, the
cerebral hemispheres or cerebrum.
• It tells the body to do something about removing
the source of the pain - usually a motor response
such as moving an arm towards the source of
the pain in order to remove it and stop the pain
from continuing

17. Withdraws from pain (4)
• Patients flex or bend their arm towards the
source of the pain, but do not actually
localise or try to remove the source of the
pain.

18. Abnormal Flexion (3)
• Patients flex or bend the arm at the elbow and
rotate the wrist, resulting in a spastic posture in
response to a central painful stimulus.
• It is an abnormal response and indicates
severe cerebral damage and an interruption of
nerve pathways from the brain's cortex to the
spine.
Mesencephalic region or corticospinal tract
damage

19. Extension (2)
• In response to a central painful stimulus,
patients will extend or straighten an arm at
the elbow, or may rotate the arm inwards.
• Abnormal response and emanates from the
brain stem.
• It shows that patients are not able to send
information to and from the cerebrum due to
damage to the brain stem.
● Brainstem damage below the red nucleus

20. Best Verbal Response (5 - 1)
• Verbal response assesses consciousness
by determining whether a person is aware
of him/herself and the environment.
• It involves the second aspect of
consciousness - cognition.

21. Orientation
There are six specific questions in the original
GCS
• What is your name
• Where are you
• Why are you here
• What month are we in?
• What year are we in?
• What season are we in?

22. Confusion (4)
• A patient may be able to hold a conversation with
the observer but responses are inappropriate or
disoriented.
• This category is sometimes referred to as
'sentences', which is a more specific
assessment used by neurocentres.
• A patient who talks in sentences, is confused but
not orientated, and will score four.

23. Inappropriate Speech (3)
• Does not carry on conversation, poor
attention span, uses inappropriate words
and phrases.
• Random/confused/repetitive.

24. Incomprehensible Speech (2)
• Patients are less aware of their
environment and their verbal response is
in the form of incomprehensible sounds.
• Moan or cry, unable to articulate.
• The observer may now have to use both a
painful and verbal stimulus to get a
response.

25. Levels of Consciousness
GCS ratings correlate with brainstem and
higher cortical functioning:
• GCS 13 - 15: mild traumatic brain injury
• GCS 9 -12: moderate traumatic brain injury
• GCS 3 – 8: severe traumatic brain injury