Graham Teasdale and Bryan J. Jennett, professors of neurosurgery University of Glasgow's Institute of University Neurological Sciences at the city's Southern General Hospital
Guidelines Ensure that the
best response is recor recorded ded for
each category If
possible, have the same person assess the patient’ss GCS each time patient’
Contraindication Not
used in newborns. n ewborns. APGAR score will be
used for this age group.
Equipments Pen
light
Glasgow Coma
SPERM
Scale Assessment As sessment tool
Assessment Tool
SPERM Sensorium Awake: Perceives the environment clearly and responds quickly and appropriately to visual, auditory, and other sensory stimuli. Drowsy:
Dooends s nsottopst ceuivlieatpp heroepnrviiartoenlymbeuntt sfluolw lylyanodr w reistp nd setirm ppr h delay. He or she may be roused by verbal stimuli but may ignore some of them.
SPERM
Sensorium Stuporous:
Aroused by intense stimuli only. Loud noise may elic el icit it a no nons nspe peci cifi ficc react eactio ion. n. Comatose:
Does not perceive the environment and intense stimuli produce a rudimentary response if any
SPERM
Pupils 2-4mm (Normal)
Pinpoint -Seen with opiate overdose and pontine hemorrhage
Small-
Normal in w well ell lighted lighted environmen environment. t. May May also mean pontine pontine hemoorrhage, hemoorrhage, and metabolic metabolic coma coma
Midposition-Norm -Normal al
but brain if in in midpositi midpo sition on and non non reactive the cause is mid damage Large-Normal in dark room, seen with drug intake Dilated-T -Terminal erminal stage stage of severe ano anoxia-ishemia xia-ishemia or at death
SPERM
Eye Movement Spontaneous Full Spontaneous Limited (+) Doll’s Eye Sign (-) Doll’ Dol l’ss Eye Sign
AKA: oculocephalic refle reflex, x, It is where rotation/flexion rotation/flexion of the of the head cause transient ey eye e movement in the opposite direction. Assesses brain stem functioning. Only present in unconscious patients.
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