Glasgow Coma Scale

Question 1

PPE

Answer 1

Hand sanitiser, disposable gloves, clinical waste bag

Question 2

Indications

Answer 2

Any patient requiring a physiological
assessment
Patients with illnesses that may
rapidly affect the patient’s level of
consciousness (LOC)

Question 3

Contraindications

Answer 3

Patient who need immediate
correction of an airway, breathing or
circulation problem, use AVPU scale
instead.

Question 4

Prepare patient

Answer 4

Patient positioned for airway
patency, comfort, and safety.
Check for factors that will interfere
with communication or ability
to respond.

Speech, hearing, language
difficulty, pain, injuries,
distractions, can lead to an
inaccurate result.

Assess both sides for best results of each.

Question 5

Assess eye response

Answer 5

Observe for spontaneous purposeful eye opening.

Question 6

Eyes open

Answer 6

Scores 4

Question 7

If eyes are not open, ask the patient
loudly and clearly to open
them. Eyes open.

Answer 7

Score 3

Question 8

If no response to verbal request,
elicit pain response by applying
central pressure. Eyes open

Answer 8

Score 2.

Question 9

If the eyes do not open

Answer 9

Score 1

Question 10

Assess verbal response

Answer 10

Assess orientation to person, time
and place by asking, ‘What
is your name?’, ‘What time/day is it
today’? and ‘Do you know
where you are now?’.

Question 11

Oriented verbal response

Answer 11

Scores 5

Question 12

If the patient answers these
questions but provides incorrect
answer(s), they are confused

Answer 12

Scores 4

Question 13

Random or muddled speech
unrelated to questioning is
inappropriate

Answer 13

Scores 3

Question 14

Intentional orally formed sounds
that are not clear as words or
are incomprehensible

Answer 14

Scores 2

Question 15

No verbal reaction

Answer 15

Scores 1

Question 16

Assess motor reponse

Answer 16

Ask patient to reach up with both
hands to grasp paramedic’s
corresponding hands.

Question 17

Obeys motor commands

Answer 17

Scores 6

Question 18

Apply stimulus and observe for
ability to localise to pain.
Localising with purposeful attempts to remove the pain

Answer 18

Scores 5

Question 19

Apply stimulus to the nailbeds and observe for ability to localise to pain.
Localising with purposeful attempts to remove the pain

Answer 19

Scores 4

Question 20

patient’s arm moves towards
the chest, with fingers and
wrists flexed, elbow bent
(decorticate posturing), this is
abnormal
flexing

Answer 20

Scores 3

Question 21

If the patient’s arms and legs extend,
wrists rotate away from
their body (decerebrate posturing),
this is abnormal extension

Answer 21

Scores 2

Question 22

No motor response

Answer 22

Scores 1

Question 23

Report

Answer 23

Accurately document and handover the relevant information