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The Glasgow Coma Scale (GCS)

This gives a reliable, objective way of recording the conscious state of a person. It can be used by medical and nursing staff for initial and continuing assessment. It has value in predicting ultimate outcome. Three types of response are independently assessed and are recorded on an appropriate chart (and the overall score is made by summing the scores):


1. Best Motor Response (6 grades)
1. No response to pain.
2. Extensor posturing to pain: The stimulus causes limb extension (adduction, internal rotation of shoulder, pronation of forearm) - "decerebrate posture"
3. Abnormal flexor response to pain: Pressure on the nail bed causes abnormal flexion of limbs - "decorticate posture".
4. Withdraws to pain: Pulls limb away from painful stimulus.
5. Localizing response to pain: Put pressure on the patient's finger nail bed with a pencil then try supraorbital and sternal pressure: purposeful movements towards changing painful stimuli is a 'localizing' response.
6. Obeying command: The patient does simple things you ask (beware of accepting a grasp reflex in this category).
2. Best Verbal Response (5 grades) Record best level of speech. If patient is intubated, a "derived verbal score" is calculated via a linear regression prediction.
1. None.
2. Incomprehensible speech: Moaning but no words.
3. Inappropriate speech: Random or exclamatory articulated speech, but no conversational exchange.
4. Confused conversation: Patient responds to questions in a conversational manner but some disorientation and confusion.
5. Orientated: Patient knows who he is, where he is and why, the year, season, and month.
3. Eye Opening (4 grades)
1. No eye opening;
2. Opening to response to pain to limbs as above
3. Eye opening in response any speech (or shout, not necessarily request to open eyes);
4. Spontaneous eye opening.
Glasgow Coma Scale Score (max 15): (Derived Verbal score: )
Interpretation of Symptoms: (Severe: less than 8; Moderate: 9-12; Mild: 13-15)

Note: an abbreviated coma scale, AVPU, is sometimes used in the initial assessment ('primary survey') of the critically ill

  • A = alert
  • V = responds to vocal stimuli
  • P = responds to pain
  • U = unresponsive
Some centres score GCS out of 14, not 15, omitting 'withdrawal to pain'.

References, footnotes and further reading:
  1. G Teasdale and B Jennett; Assessment of Coma and Impaired Consciousness; Lancet(1974) ii 81-84
  2. Meredith W. Rutledge R. et al.; The conundrum of the Glasgow Coma Scale in intubated patients: a linear regression prediction of the Glasgow verbal score from the Glasgow eye and motor scores; Journal of Trauma (1998) 44(5):839-44 and 844-5
  3. G M Teasdale; Head Injuries; 3e pp4044-50
  4. The Patient in Coma; OTS pp150-153
  5. C B T Adams; Neurosurgery and Head Injuries; OTS 2137-53

Acknowledgements EMIS is grateful to Dr Huw Thomas for writing this article. The final copy has passed peer review of the independent Mentor GP authoring team. ŠEMIS 2005.

    Last issued 30 Aug 2006















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