The clinical assessment of consciousness is often crucial in the care of a patient when the acute brain injury. This film will provide you with a practical guide to using the coma skill that we developed in Glasgow to ensure reliable assessment and clear communication about the patient. We'll show you how to make a series of standard observations of three aspects of the patient's responsiveness, eye opening, verbal and motor responses to stimulation. Steps in each component can be rated according to fine criteria to show the degree of impairment present. We'll show you how to record and communicate to findings, how these can be used and provide you with a downloadable summary. When assessing a patient, there are four steps. Check, observe, stimulate and rate. The preliminary check is used to identify any factors that might interfere with your assessment. It is important to identify local factors such as a hearing impairment that could cause a lack of capacity to respond. While in these preliminary checks, we observe the patient, noting any spontaneous behaviors in any of the three components of the scale, eyes, verbal or motor. The patient is rated in each component by matching findings with a corresponding criterion. There are four criteria for eyes, five for verbal and six for motor score. For each component, the top criterion is a normal response, while the lowest criterion is no response. If the patient's eyes opens spontaneously, spontaneous is recorded. Remember, there may be local factors such as swelling that prevent eye opening. If spontaneous opening is not demonstrated, a verbal stimulus is used by introducing yourself clearly and requesting eye opening, if necessary by shouting. If the patient opens their eyes, to sound is recorded. If the patient does not open their eyes when you speak to them, a physical, peripheral stimulus is then applied. Stimulation starts at a low level by pressing on the nail tip and is applied with increasing intensity for up to 10 seconds until the patient demonstrates a response or until maximum stimulus has been applied. If the patient opens their eyes, record to pressure. If they do not open their eyes, record as none. If there are local factors such as swelling, interfering with eye opening, record eyes not testable. To assess a verbal response, ask the patient to tell you their name, where they are and what month it is. If the answer correctly, record, orientated. If during conversation, the patient is able to speak in phrases or sentences, but is unable to give the correct answers to these questions about orientation, record, confused. If they do not talk sensibly, but are to single words, record words. If the patient mows and groans with no recognizable words, record sounds. If the patient makes no sounds at all, then record none. Remember, speechlessness may resort from factors other than depressed consciousness. For example, the presence of an endotracheal tube. In these cases, record verbal not testable. To assess the motor component to the comerscale, first ask the patient to perform a two-step action by asking them to grasp and release your fingers with their hand or opening their mouth and sticking out their tongue. If the patient does this, record a bathe commands. If the person can't move their arms, for example because of his spinal injury, you should ask them to open their mouth and stick out their tongue. In a patient who does not obey commands, a peripheral stimulus alone is inadequate to assess the motor component to the comerscale, and an additional central stimulus is needed. This is first applied by the trapezius pinch. To perform this, place your hand over the patient's shoulder and press your fingers into the muscle above the shoulder blade. Apply pressure with increasing intensity for up to 10 seconds, until you are sure that the response you observe is a patient's best response. The second location for central stimulus is the super-orbital notch. Apply this stimulus if there has been no low-closing response to the trapezius pinch. This stimulus is applied by placing your hand on the forehead with a thumb over the upper rim of the orbit. Feel for the notch in the super-orbital margin. Apply pressure with increasing intensity for up to 10 seconds until you observe the patient's best response. The patient should not be rated as having an absence of response, until the maximum stimulus has been applied. This stimulus should not be used on patients with facial injuries adjacent to the super-orbital notch. If the patient moves their hand above their clavicle or collarbone, in an attempt to move the stimulus away, record localizing. If their upper limb does not reach above the clavicle, but does flex, then they are either normally or abnormally flexing. In clinical practice, the assessment of these non-localizing responses is based on the combination of both peripheral and central stimulus. In normal flexion, the elbow bends and the arm moves rapidly away from the body and from the stimulus. In abnormal flexion, the elbow bends slowly and the arm comes across the body. If in doubt, record normal flexion. If the patient extends their elbows, rather than flexing them, record extension. A patient who makes no responses recorded as none. If they are paralyzed by other factors, such as paralysis by drugs, record motor not testable. If different responses are exhibited between limbs, on right and left sides, record the better side response as the best index of overall responsiveness. The response of the worst side may reflect focal brain damage or local injury. So to recap, check for factors that might interfere with your assessment. Observe the patient for spontaneous eye opening, speech and movement. If necessary, then stimulate the patient, first verbally and then physically. Finding should be documented clearly on a coma scale chart. The observations can then be clearly communicated and the trend rapidly appreciated so that any improvement or deterioration in a patient condition can be seen. Patient ratings can be documented numerically, as a shorthand aid to quickly record findings. When describing the patient, always use a full criteria alongside the numbers to ensure that the assessment is accurately understood. The shorthand numbers can also be added together to give a total coma score. This provides an overview summary of the severity of the patient's condition, but this score does not communicate the more informative detailed description of each response, which should always be used in addition to the score in clinical care of an individual patient. This approach to assessment has been drawn together into a structured summary that you can download from the website, GlasgowComerscale.org. Here you can also find more information about the use of the coma scale assessment.