Glasgow Coma Scale

Eye Opening
1. Spontaneous: 4
2. To speech: 3
3. To pain or pressure: 2
4. No Response: 1
Best Verbal Response
1. Oriented (Infant coos or babbles): 5
2. Confused (Infant irritable cries): 4
3. Inappropriate words (Infant Cries to pain): 3
4. Incomprehensible sounds (Infant Moans to pain): 2
5. No Response: 1
Best Motor Response
1. Obeys (Infant moves spontaneous/purposefully): 6
2. Localizes (infant withdraws to touch): 5
3. Withdraws to pain: 4
4. Abnormal Flexion (Decorticate Posturing): 3
5. Abnormal Extension (Decerebrate Posturing): 2
6. No Response: 1

Total: 3-15
Mild Head Injury: 13-15 (at two hours post-injury)
Moderate Head Injury: 9-12 (at two hours post-injury)
Severe Head Injury (Coma): <= 8 (at two hours post-injury)
1. Confers Significant Mortality Risk
Modifiers
1. 2T-8
  1. 2T refers to the verbal score uninterpretable due to Endotracheal Intubation
  2. Only motor (1-6) and eye opening (1-4) are calculated (maximum 2T-10)
    1. In this case (2T-8), refers to cut-off for Severe Traumatic Brain Injury
2. Not-Tested (NT)
  1. Use NT to mark items that could not be tested (e.g. intubated patient)
  2. Example: E-1, V-NT, M-3

In Head Injury, document exactly what is seen (in addition to the score)
1. Describe what painful did in response to painful stimuli (e.g. sternal rub, trapezius squeeze)