Glasgow Coma Scale

Prepared by : Assistant. Lecturer. Sara Hamza

Pediatric Nursing – Neurology Level 3

 1

Glasgow Coma Scale (GCS):

GCS is the most common scoring system used to describe the level of consciousness in a

person following a traumatic head injury.

3 three aspects are the measurement of GCS:

1. Eye opening

2. Verbal Response

3. Motor Response

E V M
Minimal score 1 Minimal score 1 Minimal score 1
Maximumum score 4 Maximumum score 5 Maximumum score 6

The The
minimum maximum
tota score total score
= =
3 15

Paediatric Glasgow Coma Scale (PGCS)

The Paediatric Glasgow Coma Scale (PGCS) was created for children too young to talk,

adjusting motor and verbal response criteria in relation to developmental stages from babies <

6 months of age to age 5 years.

 2

PEDIATRIC GLASGOW COMA SCALE (PGCS)

> 1 Year < 1 Year Score
Spontaneously Spontaneously 4

EYE To verbal command To shout 3

OPENING To pain To pain 2
No response No response 1
Not Testable (nt) Orbital Swelling- ptosis C
Obeys Spontaneous 6
Localizes pain Localizes pain 5
MOTOR Flexion-withdrawal Flexion-withdrawal 4
RESPONSE
Flexion-abnormal (decorticate rigidity) Flexion-abnormal (decorticate 3
rigidity)
Extension (decerebrate rigidity) Extension (decerebrate rigidity) 2
No response No response 1
Not Testable (nt) Paralysis- spinal injury P
> 5 Years 2-5 Years 0-23 months Score
Oriented Appropriate Smiles/coos appropriately 5
words/phrases
Disoriented/confused Inappropriate words Cries and is consolable 4
VERBAL Inappropriate words Persistent cries and Persistent inappropriate 3
RESPONSE screams crying and/or screaming
Incomprehensible Grunts Grunts, agitated, and restless 2
sounds
No response No response No response 1

Not Testable (nt) Intubated- tracheostomy T

TOTAL PEDIATRIC GLASGOW COMA SCORE: 3:15

3
 4

Non- Testable response scoring

▪ Child who are intubated are unable to speak, and their verbal score cannot be assessed.

They are evaluated only based on eye opening and motor scores, and the suffix T is added

to their score to indicate intubation. In intubated patients, the maximum GCS score is 10T

and the minimum score is 2T.

▪ Suffix C added to non-testable eye opening in cases such as orbital fracture or swelling. the

maximum GCS score is 11C and the minimum score is 2C.

▪ Suffix P added to non-testable motor response in cases such as paralysis. the maximum GCS

score is 9P and the minimum score is 2P.

GCS interpretation:

Mild head injury Moderate head injury Severe head injury

Conscious Semi-conscious Unconscious
13-15 9-12 3-8
Needs medical review Needs medical review with needs urgent anaesthetic
continuous monitoring review/PICU
 5

Steps of GCS Assessment:

1. Check

2. Observe

3. Stimulate

4. Rate

1. Check: What are Factors affecting GCS assessment?

o Language
o Intellectual and neurological deficit
o Hearing loss
o Speech impairment
o Physical factor impaired verbal communication: intubation- tracheostomy
o Pharmacological: sedation
o Mechanical: paralysis
o Orbital or cranial fracture
o Dysphasia
o Ptosis
o Orbital swelling
o Spinal cord injury
o Communication barriers
2. Observe:

o Eye opening
o Speech
o Movement
 6

3. Stimulate:

Verbal stimulas Painful stimulas

Spoken – shouted if needed Physical stimulation: Use Central Stimulas

- Supra-orbital pressure [press hard with thumb beneath
medial end of the eyebrow]
- Trapezius squeeze.
- DO NOT use sternal rub [can cause significant
bruising.
- If supra-orbital pressure is contraindicated [due to facial
swelling or fracture] pinch the ear lobe or as a last
option, the fingernail bed can be used (peripheral
stimulas).

4. Rate: Assign according to the highest response observed and interpret

 7

Skills for prompt the best eye-opening response:

1. Prior to assessment, touch to waken.

2. Use appropriate language and familiar names.

3. Involve the family.

4. Painful Stimulus: Use Trapezius squeeze. Apply gentle stimulus, gradually increasing

for 10 seconds or less, or until eye opening is seen.

Skills for prompt the best verbal response:

1. Ask age-appropriate questions.

2. Involve carers to establish what’s normal.

3. Screeching/shouting or grunting may be appropriate in an infant/child with

intellectual disability. Involve carer in assessment (where possible).

5. Painful Stimulus: Use Trapezius squeeze. Apply gentle stimulus, gradually increasing

for 10 seconds or less, or until respond.

Skills for prompt the best motor response:

1. Ask carers if mobility is normal

2. Offer child a toy/ bottle or Shick hands

3. Infants/ children with physical disability may have abnormal posture. Flexion may be

a normal position for these infants/children. This does not indicate a low score

4. Painful Stimulus: Use Trapezius squeeze. Apply gentle stimulus, gradually increasing

for 10 seconds or less, or until respond.

 8

Quiz
The Scenario:
You are a paediatric nurse at Neurological unit, received a 12-year-old child who has head
injury due to motor vehicle accident and with previous history of seizure.
Instructions to candidate:
1. If you were told by a colleague that their assessment of a patient’s Glasgow
Coma Scale was E2, V3, M5, how would you interpret this?
The patient’s eyes open to sound, they are orientated can obey commands
The patient’s eyes open to pressure, they can utter some words but do not
form sentences, and they can localize to trapezius pinch.
The patient’s eyes open spontaneously; they are orientated and able to obey
commands

2. According to the previous assessment of a patient’s Glasgow Coma Scale was E2,
V3, M5 the patient has:
Mild head injury
Moderate head injury
Severe head injury

3. According to the previous assessment of a patient’s Glasgow Coma Scale was E2,
V3, M5 the patient is:
Conscious
Semiconscious
Unconscious