Immediate Assessment/Neuro Screen - Step 2 - Glasgow Coma Scale

Step 2: Glasgow Coma Scale

The Glasgow Coma Scale is used to identify mental deterioration, an important standard measure for all patients and can be repeated over time to monitor deterioration of consciousness.






No eye opening

No speech

No movement


Eyes to painful stimulus

Incoherent speech

Extending (Decerebrate)


Opens eyes to voice

Inappropriate words

Flexing (Decorticate)


Spontaneously opens eyes


Withdraws from painful stimulus




Localised to painful stimulus




Obeys commands


Step 3: Cervical Spine Assessment

A cervical spine assessment should be completed immediately with the athlete. In an athlete who is not lucid or fully conscious, a cervical spine injury should be assumed and spinal precautions taken.

  • Does the athlete report neck pain at rest?
  • Is there tenderness to palpation?
  • If NO neck pain and NO tenderness, does the athlete have a full range of ACTIVE pain free movement?
  • Are limb strength and sensation normal?


Step 4: Coordination & Ocular/Motor Screen

An assessment of the athletes coordination and eye movements should be assessed

  • Coordination: Is finger-to-nose normal for both hands with eyes open and closed?
  • Ocular/Motor: Without moving their head or neck, can the patient look side-to-side and up-and-down without double vision?
  • Are observed extraocular eye movements normal?


Step 5: Memory Assessment Maddocks Questions

  • What venue are we at today?
  • Which half is it now?
  • Who scored last in this match?
  • What team did you play last week / game?
  • Did your team win the last game?