1. Spontaneous posture | |
• standing =0 | |
• tired but standing =1 | |
• lying but able to rise =2 | |
• lying but difficulty rising =3 | |
• unable to rise =4 | |
2. Palpebral reflex | |
• brisk =0 | |
• slow but with full corneal sweep =1 | |
• slow but with only partial corneal sweep =2 | |
• absent =3 | |
3. Eye position | |
• central =0 | |
• rotated forwards/downwards but not obscured by third eyelid =1 | |
• rotated forwards/downwards and obscured by third eyelid =2 | |
4. Jaw & tongue relaxation | |
• normal jaw tone, strong gag reflex) = 0 | |
• reduced tone, but still moderate gag reflex =1 | |
• much reduced tone, slight gag reflex =2 | |
• loss of jaw tone and no gag reflex =3 | |
5. Response to noise (handclap)a | |
• normal startle reaction (head turn towards noise/ cringe) = 0 | |
• reduced startle reaction (reduced head turn/ minimal cringe) = 1 | |
• minimal startle reaction =2 | |
• absent reaction =3 | |
6. Resistance when laid into lateral recumbency | |
• much struggling, perhaps not allowing this position =0 | |
• some struggling, but allowing this position =1 | |
• minimal struggling/ permissive =2 | |
• no struggling = 3b | |
7. General appearance/attitude | |
• excitable =0 | |
• awake and normal =1 | |
• tranquil =2 | |
• stuporous =3 |