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    Pediatric Glasgow Coma Scale (pGCS)

    Assesses the mental state of child patients.
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    INSTRUCTIONS

    Use for children 2 years and younger only. For older children, use the standard Glasgow Coma Scale (GCS).

    When to Use
    Pearls/Pitfalls
    Why Use
    • Infants with head trauma, altered mental status or neurologic abnormalities.
    • Use in initial and serial assessments.
    • The Pediatric Glasgow Coma Scale (pGCS) allows providers to obtain, track and communicate the mental status and level of consciousness in preverbal children (≤2 years of age).
    • Variation of the standard Glasgow Coma Scale (GCS) with age appropriate modifications to the motor and verbal components.
    • Scored 3-15 (eye, verbal and motor response) like the standard GCS
    • Should be reported as a sum and include the scores of each of the individual components because of the difference in prognostic value and variations of individual components versus the summed score. Example: Total pCGS 12=E3+V4+M5. (Healey C 2003)
    • As accurate for identifying clinically important traumatic brain injury (ciTBI) as GCS in verbal children.

    Points to keep in mind:

    • Best to obtain pGCS prior to the administration of analgesics or other interventions that could alter the score.
    • Somewhat less accurate in identifying those with ANY traumatic brain injury (TBI) on CT compared to the GCS in older children. (Borgialli DA 2016)
    • In intubated patients (for whom the verbal score may not be obtained), consider using the Full Outline of UnResponsiveness (FOUR score). This is a validated, expanded scoring system. (Wijdicks EF 2005) (Sadaka F 2012)
    • Distinction between normal and abnormal flexion may be challenging, especially for the non-specialist. (Reilly 1991)
    About the Creator
    Dr. Graham Teasdale
    Content Contributors
    • Joyce Brown, MD
    • Reviewed by Matthew Meigh, DO

    Result:

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    Next Steps
    Evidence
    Creator Insights

    Advice

    • The score can be used to assess and track a patient’s mental status and level of consciousness. However, like the standard GCS, the score alone is not sufficient to guide diagnosis or management. (Teasdale 2014)

    Management

     

    • Although a valuable diagnostic tool, the score alone should not be used for management decisions in the acute setting.
    • Common applications include the need to consider intubation/definitive airway management in those with a GCS less than 8. However, the entire clinical picture must be taken into account.
    • Due in part to the value in identifying those with ciTBIs, any patient with an abnormal GCS warrants close assessment and monitoring.

     

    Critical Actions

    • All patients with a GCS <15 need appropriate monitoring.
    • All patients with concern for mental status or neurologic compromise should be closely monitored and reassessed.

    Facts & Figures

    Score interpretation:

    • Scores of ≥13 suggests minor head injury.
    • Score of 9-12 suggests moderate head injury.
    • Score of ≤8 suggests severe head injury.

    Evidence Appraisal

    • Several modified pGCS have been created. However, this scale is the only one that has been evaluated in a large, prospective, observational, multicenter, cohort study. (Borgialli DA 2016)
    • Sub-analysis of a large prospective observational multicenter cohort study of children with blunt head trauma that compared the accuracy of the pGCS in preverbal children to the standard GCS score in older children for identifying those with TBIs after blunt head trauma (in the ED) demonstrated statistically similar test performance as that of the standard GCS in older children in identifying ciTBIs.
    • It also demonstrated somewhat lower accuracy in identifying those with traumatic brain injuries on CT than that of the standard GCS in older children.
    • With a 95% confidence interval, the area under the ROC curve for association between GCS score and TBI on CT was 0.61 in the younger cohort and 0.71 for the older cohort. The area under the ROC curve for the association between the GCS score and the ciTBI was 0.77 for the younger cohort and 0.81 in the older cohort.
    • Demonstrated statistically similar test performance as that of the standard GCS in older children in identifying ciTBIs.
    • Demonstrated somewhat less accuracy in identifying those with traumatic brain injuries on CT than that of the standard GCS in older children.
    • With a 95% confidence interval, the area under the ROC curve for the association between GCS score and TBI on CT was 0.61 in the younger cohort and 0.71 for the older cohort. The area under the ROC curve for the association between the GCS score and the ciTBI was 0.77 for the younger cohort and 0.81 in the older cohort. (Healey C 2003)
    • Inter-observer agreement in each cohort for the total score and all individual score components met the criteria for at least moderate inter-observer agreement (kappa 95% lower confidence limit >0.4).
    • Limitations in the study:
      • Age threshold of 2 years to define the preverbal pediatric population.
        • Only 36% of the study population underwent cranial CT imaging. It is possible that some of the children who were not imaged may have had traumatic findings on CT.

    Literature

    Other References

    Research PaperReilly PL, et al. Assessing the conscious level in infants and young children: a paediatric version of the Glasgow Coma Scale. Childs Nerv Syst. 1988 Feb;4(1):30-3Research PaperHolmes JF, et al. Performance of thepediatric glasgow coma scale in children with blunt head trauma. Acad Emerg Med. 2005 Sep;12(9):814-9Research PaperHealey C, et al. Improving the Glasgow Coma Scale Score: Motor Score Alone Is a Better Predictor. The Journal of Trauma: Injury, Infection, and Critical Care; 2003, 54(4), 671-680.Research PaperWijdicks EF, et al. Validation of a new coma scale: The FOUR score. Annals of Neurology; 2005, 58(4), 585-593.Research PaperSadaka F, et al. The FOUR Score Predicts Outcome in Patients After Traumatic Brain Injury. Neurocritical Care; 2011, 16(1), 95-101.Research PaperTeasdale G. Forty years on: updating the Glasgow Coma Scale. Nursing Times; 2014, 110: 42, 12-16.Research PaperTeasdale G, Jennett B.Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974 Jul 13;2(7872):81-4.Research PaperSimpson D, et al. Head injuries in infants and young children: The value of the Paediatric Coma Scale. Child's Nervous System; 1991, 7(4).
    Dr. Graham Teasdale

    About the Creator

    Sir Graham Teasdale, MBBS, is an honorary professor at the Institute of Health and Wellbeing, University of Glasgow. He was previously Professor of Neurosurgery, Head of the Department of Neurosurgery and Associate Dean for Medical Research. Sir Teasdale was President of the Royal College of Physicians and Surgeons of Glasgow (2003-2006), and he was knighted in 2006 for his services to neurosurgery.

    To view Dr. Graham Teasdale's publications, visit PubMed

    Content Contributors
    • Joyce Brown, MD
    • Reviewed by Matthew Meigh, DO