Coma Scale (GCS) is a neurological scale which aims to give a
reliable and objective way of recording the conscious state of a
person for initial as well as subsequent assessment. A patient is
assessed against the criteria of the scale, and the resulting points
give a patient score between 3 (indicating deep unconsciousness) and
either 14 (original scale) or 15 ( more widely used modified or
GCS was initially used to assess level of consciousness after head
injury, and the scale is now used by first responders, EMS, nurses,
and doctors as being applicable to all acute medical and trauma
patients. In hospitals it is also used in monitoring chronic patients
in intensive care.
The scale was published in 1974 by Graham Teasdale and Bryan J.
Jennett, professors of neurosurgery at the University of Glasgow's
Institute of Neurological Sciences at the city's Southern General
GCS is used as part of several ICU scoring systems, including APACHE
II, SAPS II, and SOFA, to assess the status of the central nervous
system, as it was designed for. The initial indication for use of the
GCS was serial assessments of patients with traumatic brain injury
and coma for at least 6 hours in the neurosurgical ICU setting, though
it is commonly used throughout hospital departments. A similar scale,
Rancho Los Amigos Scale is used to assess the recovery of
traumatic brain injury patients.
1 Elements of the scale
1.1 Eye response (E)
1.2 Verbal response (V)
1.3 Motor response (M)
5 See also
7 External links
Elements of the scale
Coma Scale 
Does not open eyes
Opens eyes in response to painful stimuli
Opens eyes in response to voice
Opens eyes spontaneously
Makes no sounds
Utters incoherent words
Oriented, converses normally
Makes no movements
Extension to painful stimuli (decerebrate response)
Abnormal flexion to painful stimuli (decorticate response)
Flexion / Withdrawal to painful stimuli
Localizes to painful stimuli
Note that a motor response in any limb is acceptable. The scale is
composed of three tests: eye, verbal and motor responses. The three
values separately as well as their sum are considered. The lowest
possible GCS (the sum) is 3 (deep coma or death), while the highest is
15 (fully awake person).
Eye response (E)
There are four grades starting with the most severe:
No eye opening
Eye opening in response to pain stimulus. (a peripheral pain stimulus,
such as squeezing the lunula area of the patient's fingernail is more
effective than a central stimulus such as a trapezius squeeze, due to
a grimacing effect).
Eye opening to speech. (Not to be confused with the awakening of a
sleeping person; such patients receive a score of 4, not 3.)
Eyes opening spontaneously
Verbal response (V)
There are five grades starting with the most severe:
No verbal response
Incomprehensible sounds. (Moaning but no words.)
Inappropriate words. (Random or exclamatory articulated speech, but no
conversational exchange. Speaks words but no sentences.)
Confused. (The patient responds to questions coherently but there is
some disorientation and confusion.)
Oriented. (Patient responds coherently and appropriately to questions
such as the patient’s name and age, where they are and why, the
year, month, etc.)
Motor response (M)
There are six grades:
No motor response
Decerebrate posturing accentuated by pain (extensor response:
adduction of arm, internal rotation of shoulder, pronation of forearm
and extension at elbow, flexion of wrist and fingers, leg extension,
plantarflexion of foot)
Decorticate posturing accentuated by pain (flexor response: internal
rotation of shoulder, flexion of forearm and wrist with clenched fist,
leg extension, plantarflexion of foot)
Withdrawal from pain (absence of abnormal posturing; unable to lift
hand past chin with supraorbital pain but does pull away when nailbed
Localizes to pain (purposeful movements towards painful stimuli; e.g.,
brings hand up beyond chin when supraorbital pressure applied)
Obeys commands (the patient does simple things as asked)
Individual elements as well as the sum of the score are important.
Hence, the score is expressed in the form "GCS 9 = E2 V4 M3 at 07:35".
Generally, brain injury is classified as:
Severe, GCS < 8–9
Moderate, GCS 8 or 9–12 (controversial)
Minor, GCS ≥ 13.
Tracheal intubation and severe facial/eye swelling or damage make it
impossible to test the verbal and eye responses. In these
circumstances, the score is given as 1 with a modifier attached (e.g.
"E1c", where "c" = closed, or "V1t" where t = tube). Often the 1 is
left out, so the scale reads Ec or Vt. A composite might be "GCS 5tc".
This would mean, for example, eyes closed because of swelling = 1,
intubated = 1, leaving a motor score of 3 for "abnormal flexion".
The GCS has limited applicability to children, especially below the
age of 36 months (where the verbal performance of even a healthy child
would be expected to be poor). Consequently, the Pediatric Glasgow
Coma Scale was developed for assessing younger children.
Coma Scale: While the 15-point scale is the predominant one in
use, this is in fact a modification and is more correctly referred to
as the Modified Glasgow
Coma Scale. The original scale was a 14-point
scale, omitting the category of "abnormal flexion". Some centres still
use this older scale, but most (including the Glasgow unit where the
original work was done) have adopted the modified one.
The Rappaport Coma/Near
Coma Scale made other changes.
Meredith W., Rutledge R, Fakhry SM, EMery S, Kromhout-Schiro S have
proposed calculating the verbal score based on the measurable eye and
The most widespread revision has been the Simplified Motor and Verbal
Scales which shorten the respective sections of the GCS without loss
The GCS for intubated patients is scored out of 10 as the verbal
component falls away
The GCS has come under pressure from some researchers who take issue
with the scale's poor inter-rater reliability and lack of prognostic
utility. Although there is no agreed-upon alternative, newer scores
such as the
Simplified motor scale and
FOUR score have also been
developed as improvements to the GCS. Although the inter-rater
reliability of these newer scores has been slightly higher than that
of the GCS, they have not gained consensus as replacements.
Blantyre coma scale
Early warning score
Rancho Los Amigos Scale
Revised Trauma Score
^ Teasdale G, Jennett B (1974). "Assessment of coma and impaired
consciousness. A practical scale". Lancet. 2 (7872): 81–4.
doi:10.1016/S0140-6736(74)91639-0. PMID 4136544.
^ Russ Rowlett. "Glasgow
Coma Scale". University of North Carolina at
^ Hutchinson’s clinical methods 22nd edition
^ "The Glasgow
Coma Scale: clinical application in Emergency
Departments". Emergency Nurse. 14 (8): 30–5. 2006.
^ Gill M, Windemuth R, Steele R, Green SM (2005). "A comparison of the
Coma Scale score to simplified alternative scores for the
prediction of traumatic brain injury outcomes". Ann Emerg Med. 45 (1):
^ Green S. M. (2011). "Cheerio, Laddie! Bidding Farewell to the
Coma Scale". Annals of Emergency Medicine. 58 (5): 427–430.
doi:10.1016/j.annemergmed.2011.06.009. PMID 21803447.
^ Iver, VN; Mandrekar, JN; Danielson, RD; Zubkov, AY; Elmer, JL;
Wijdicks, EF (2009). "Validity of the
FOUR score coma scale in the
medical intensive care unit". Mayo Clinic Proceedings. 84 (8):
694–701. doi:10.4065/84.8.694. PMC 2719522 .
^ Fischer, M; Rüegg, S; Czaplinski, A; Strohmeier, M; Lehmann, A;
Tschan, F; Hunziker, PR; Marschcorresponding, SC (2010). "Inter-rater
reliability of the Full Outline of UnResponsiveness score and the
Coma Scale in critically ill patients: a prospective
observational study". Critical Care. 14 (2): R–64.
doi:10.1186/cc8963. PMC 2887186 . PMID 20398274.
Teasdale G, Murray G, Parker L, Jennett B (1979). "Adding up the
Coma Score". Acta Neurochir Suppl (Wien). 28 (1): 13–6.
doi:10.1007/978-3-7091-4088-8_2. PMID 290137.
Meredith W, Rutledge R, Fakhry SM, Emery S, Kromhout-Schiro S (1998).
"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". J Trauma. 44 (5): 839–44; discussion
Website to calculate the Glasgow
Coma Scale Calculator
Coma Scale at the US National Library of Medicine Medical
Subject Headings (MeSH)
Dr. Graham Teasdale speaks with The Lancet - podcast, August 2014
Coma Scale at 40
Simplified Motor Score
Coma Scale Calculator for OS Android
Neurosurgical and other procedures (ICD-9-CM V3 01–05+89.1,
thalamus and globus pallidus:
Intracranial pressure monitoring
Anterior temporal lobectomy
Spinal cord and spinal canal
Spinal cord and roots
Vertebrae and intervertebral discs: see Template:Bone, cartilage, and
Computed tomography of the head
Magnetic resonance imaging of the brain
Mini–mental state examination
National Institutes of Health Stroke Scale
Cranial and peripheral nerves
Sympathetic nerves or ganglia
Endoscopic thoracic sympathectomy
Nerve conduction study