Paramedic Program · Primary Assessment · Stage D

Glasgow Coma Scale / practice

Score eye opening, verbal response and motor response separately. Say all three out loud, every time.

Three questions, asked in a fixed order. Does the patient open their eyes, do they say something that makes sense, and do they move on command. The lowest possible total is 3, never 0 — an unresponsive patient still scores 1 in each column.

Score the best response you can get

If the left arm withdraws and the right arm localises, the motor score is 5. You are recording the best the brain can do, not the average of what it did.

The four that get mixed up

Almost every scoring error a student makes lives in one of these four pairs. Learn the discriminator, not the wording.

M5 — Localises
The hand comes toward the thing hurting them. It crosses the midline, reaches up past the chin, tries to push you off.
M4 — Withdraws
The limb pulls away. A reflexive retreat, no attempt to find the source.
Tell them apart — ask yourself whether the movement is going somewhere or just going. Toward you is 5, away from you is 4.
M3 — Abnormal flexion
Decorticate. Arms bend in toward the core, wrists curled on the chest, legs straight.
M2 — Extension
Decerebrate. Arms go straight and rotate outward, everything rigid and extended.
Tell them apart — flexion brings the arms to the core. Extension is worse, and the lesion is lower in the brainstem.
V4 — Confused
They hold a conversation, in sentences, and the content is wrong. Wrong year, wrong place, thinks you are their brother.
V3 — Inappropriate words
Words come out but there is no conversation. Random, disconnected, not a reply to anything you asked.
Tell them apart — can you have an exchange with them? If yes, it is 4 however wrong the answers are. If they are just producing words, it is 3.
E3 — To voice
Eyes open when you speak. Say their name, then say it louder. Speech only.
E2 — To pain
Nothing to voice. Eyes open only when you apply a painful stimulus.
Tell them apart — shaking a shoulder is touch, not voice. If they opened their eyes because you touched them, you have not tested E3 yet.

Getting a real motor response

Use a central stimulus — a trapezius pinch or supraorbital pressure. A peripheral stimulus like a nail bed can produce a spinal reflex that has nothing to do with the brain, and it will make you score a patient higher than they are.

Not everything can be scored

Eyes swollen shut, an intubated patient, a patient who does not speak your language. Document the component as non-testable rather than guessing a 1 — scoring a zero-information component as if it were a real finding is worse than admitting the gap.