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.
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|
Eyes |
Voice |
Motor |
|
1 |
No eye opening |
No speech |
No movement |
|
2 |
Eyes to painful stimulus |
Incoherent speech |
Extending (Decerebrate) |
|
3 |
Opens eyes to voice |
Inappropriate words |
Flexing (Decorticate) |
|
4 |
Spontaneously opens eyes |
Confused |
Withdraws from painful stimulus |
|
5 |
|
Orientated |
Localised to painful stimulus |
|
6 |
|
|
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?