Table 1 Glascow coma score

Eye Opening

Verbal Response Motor Response


Spontaneous To voice

To pain




Inappropriate words

Obeys commands

Localizes painful stimulus

Withdraws from pain

Decorticate posturing (flexion)

Incomprehensible Decerebrate posturing sounds (extension)



The scores for each component are totaled. Severe head injury is defined as GCS=3 to 8, moderate head injury GCS=9 to 12, and mild head injury GCS=13 to 15

• Facial symmetry and corneal reflex (Vth and Vllth cranial nerves and pons).

• Gag reflex, tongue movements and respiratory effort (Xth and Xllth cranial nerves and medulla).

• Strength in major extremity muscle groups bilaterally or symmetry and gross strength of extremity movement (infants and toddlers).

• Sensation (by dermatome, if possible).

• Reflexes: biceps, patellar, ankle and plantar cutaneous (i.e., Babinski), plus cremasteric and bulbocavernosus if spinal-cord injury is suspected.

• Inspection and palpation of head: periorbital ecchymoses (Racoon's eye), retro-mastoid ecchymoses (Battle's sign), cerebrospinal fluid (CSF) rhinor-rhea or otorrhea, hemotympanum, lacerations and calvarial skull fractures.

• Inspection and palpation of the spine (trauma team log-rolls patient with cervical collar in place).

• Fundoscopic examination: retinal hemorrhages, retinal detachment.

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