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How does this Pediatric Glasgow Coma Scale calculator work?

This is a health tool that evaluates the mental status of child patients in the emergency room based on an adaptation of the Glasgow Coma Scale (with more infant specific reactions and stimuli analysis).

1. Johnson, MA, Nishijima, DK & Kuppermann, N 2020, ' The association of glasgow coma scale score with clinically important traumatic brain injuries in children ', Pediatric emergency care, vol.
2. Moreover, a Modified Glasgow Coma Scale (MGCS) was adopted from Tatman and co-authors (1997) to identify the LOC for intubated and non-intubated adult patients and children above 5 years old.
3. The aptly-named ‘Pediatric Glasgow Coma Scale (PGCS)’ includes modifications for this patient population. Similar to the adult version, the sum of the eye response, motor response, and verbal response equals the PGCS. The highest score is a 15 (fully awake and aware) and the lowest is 3 (deep coma or brain death).
4. Moreover, a Modified Glasgow Coma Scale (MGCS) was adopted from Tatman and co-authors (1997) to identify the LOC for intubated and non-intubated adult patients and children above 5 years old.

Each of the three types of response analyzed is described below:

■ Best eye response [E] – focuses on eye movement and recognition of external stimuli:

- Eyes opening spontaneously (4 points);

CHILD’S GLASGOW COMA SCALE British Pediatric Neurology Association 33. CONCLUSIONS Although initially described four decades ago, the Glasgow approaches to assessment of initial severity and outcome of brain damage have weathered the test of time.

- Eye opening to speech (3 points);

- Eye opening to pain (2 points);

- No eye opening or response (1 point).

■ Best verbal response [V] – analyses the ability of the infant/ child to interact with people and surrounding objects:

- Smiles, oriented to sounds, follows objects, interacts (5 points);

- Cries but consolable, inappropriate interactions (4 points);

- Inconsistently inconsolable, moaning (3 points);

- Inconsolable, agitated (2 points);

- No verbal response (1 point);

■ Best motor responses [M] – evaluates the degree of mobility of the pediatric patient and whether they are able to exert the normal reflexes of withdrawal from the painful stimuli:

- Infant moves spontaneously or purposefully (6 points);

- Infant withdraws from touch (5 points);

- Infant withdraws from pain (4 points);

- Abnormal flexion to pain for an infant (decorticate response) (3 points);

- Extension to pain (decerebrate response) (2 points);

- No motor response (1 point).

After the results in each of the three tests are registered, the Pediatric Glasgow Coma Scale calculator sums them and provides an indication of the patient status.

Once the modified version of the Glasgow Coma Scale has been published, given the reluctance in applying it, several studies concerning its performance have followed, with areas such as blunt head trauma or other types of infant trauma.

The medical world was concerned whether administering the scale based test to a patient not able to speak or exhibit unaltered neurological response, would be a reliable mean to base subsequent clinical decision making upon.

There are other tests and evaluation criteria that have been adapted for pediatric use, such as PELD, the pediatric version of the End Model for Liver Disease (MELD).

The main findings have been that the pediatric version is comparable in efficiency with the standard adult version in infants of 2 years and below. Score results provide a helpful tool in aiding clinicians choose for acute intervention. This version is preferred to other standard consciousness assessments as AVPU who are not as specific as to account for pediatric patient age.

PGCS scores interpretation

Results range from 3, associated with coma or death to 15, indicating the child is fully aware and awake. Scores of 12 indicate severe head injury, scores below 8 require intubation and ventilation while scores below 6 should also be monitored intracranial pressure.

Clinicians often break down the score per its components to communicate more information so often the PGCS result will be something like GCS of 9 followed by E3V4M2.

This describes a patient in critical condition, nearing the mark that requires intubation and artificial ventilation, with the best eye response to speech stimulation, an infant or child who cries but consolable and might portray inappropriate interactions and exhibiting extension to pain (decerebrate response).

References

1) Wilberger JE, Dupre DA. (2013) ‘Traumatic Brain Injury’ in Merck Manual Professional Version

2) Holmes JF, Palchak MJ, MacFarlane T, Kuppermann N. (2005) Performance of the pediatric glasgow coma scale in children with blunt head trauma. Acad Emerg Med; 12(9):814-9.

3) Davis RJ et al: Head and spinal cord injury. In Textbook of Pediatric Intensive Care, edited by MC Rogers. Baltimore, Williams & Wilkins, 1987; James H, Anas N, Perkin RM: Brain Insults in Infants and Children. New York, Grune & Stratton, 1985; and Morray JP et al: Coma scale for use in brain-injured children. Critical Care Medicine 12:1018

Glasgow Coma Scale

Glasgow Coma Scale is a neurological scale developed by Teasdale and Jennett and is also known as Glasgow Coma Score. Glasgow coma scale is used to record consciousness levels of the person.

Glasgow coma scale is routinely used in head injuries and other central nervous system conditions

The scale comprises three tests: eye, verbal and motor responses.

The three values separately, as well as their sum, are considered. The lowest possible GCS (the sum) is 3 (implies deep coma or death), whilst the highest is 15 (implies fully awake person).

Best eye response (E)

There are 4 grades starting with the most severe:

1. No eye opening
2. Eye opening in response to pain. (Patient responds to pressure on the patient’s fingernail bed; if this does not elicit a response, supraorbital and sternal pressure or rub may be used.)
3. Eye opening to speech. (This should not be confused with an awakening of a sleeping person. In such cases a score of 4 is given, not 3.)
4. Eyes opening spontaneously

Best verbal response (V)

There are 5 grades starting with the most severe:

1. No verbal response
2. Incomprehensible sounds. (Moaning but no words.)
3. Inappropriate words. (Random or exclamatory articulated speech, but no conversational exchange)
4. Confused. (The patient responds to questions coherently but there is some disorientation and confusion.)
5. Oriented. (Patient responds coherently and appropriately to questions such as the patient’s name and age, where they are and why, the year, month, etc.)

Best motor response (M)

There are 6 grades starting with the most severe:

1. No motor response
2. Extension to pain (adduction of arm, internal rotation of the shoulder, pronation of forearm, an extension of the wrist, decerebrate response)
3. Abnormal flexion to pain (adduction of arm, internal rotation of the shoulder, pronation of forearm, flexion of wrist, decorticate response)
4. Flexion/Withdrawal to pain (flexion of elbow, supination of the forearm, flexion of the wrist when supra-orbital pressure applied; pulls part of the body away when nailbed pinched)
5. Localizes to pain. (Purposeful movements towards painful stimuli; e.g. hand crosses mid-line and gets above clavicle when supra-orbital pressure applied.)
6. Obeys commands. (The patient does simple things as asked.)

How To Interpret The Score?

Individual elements, as well as the sum of the score, are important in the Glasgow Coma Scale. Hence, the score is expressed in the form “GCS 9 = E2 V4 M3 at 17:35”.

Generally, comas are classified as:

• Severe, with GCS less than or equal to 8
• Moderate, GCS 9 – 12
• Minor, GCS 13 or greater.

In a severely injured patient with intubation and severe facial/eye swelling or damage, it is not possible to test the verbal and eye responses. In these circumstances, the score is given as 1 with a modifier attached e.g. ‘E1c’ where ‘c’ = closed, or ‘V1t’ where t = tube.

A composite might be ‘GCS 5tc’. This would mean, for example, eyes closed because of swelling = 1, intubated = 1, leaving a motor score of 3 for ‘abnormal flexion’.

The Glasgow Coma Scale has limited applicability to children, especially below the age of 36 months because then the verbal performance of even a healthy child could be labeled to be poor).

To avoid this Pediatric Glasgow Coma Scale, a separate yet closely related scale, has been developed for assessing younger children.

Pediatric Glasgow Coma Scale

The Pediatric Glasgow Coma Scale or Pediatric Glasgow Coma Score (PGCS) is the equivalent of the Glasgow Coma Scale and is used to assess the consciousness of infants and children.

Pediatric Glasgow Coma Scale is used in cases of head injury of children mostly.

The scale has been modified from the original Glasgow coma scale as s many of the assessments for an adult patient would not be appropriate for infants and young children.

The Pediatric Glasgow Coma Scale comprises of three tests: eye, verbal and motor responses as in Glasgow coma scale(GCS).

Best eye response: (E)

4. Eyes opening spontaneously
3. Eye opening to speech
2. Eye opening to pain
1. No eye opening

Best verbal response: (V)

The main difference from adult Glasgow coma scale comes in the verbal response. Here the responses are different age wise

Age 0-23 Months

5. Infant coos or babbles or smiles appropriately (normal activity)

4. Infant cries but consolable

3. Persistent crying and or screaming

2. Infant moans to pain, grunts, agitated and restless

1. No verbal response

Age 2-5 Years

5. Appropriate words or phrases

4. Inappropriate words

3. Persistent Cries or screams

2. Grunts

1. No response

Age> 5 Years

5. Oriented

4. Disoriented, confused

3. Inappropriate words

2. Incomprehensible sounds

1. No response

In children greater than 5 years of age, the responses are similar to adult Glasgow Coma Scale.

Best motor responses: (M)

6. Infant moves spontaneously or purposefully
5. Infant withdraws from touch
4. Infant withdraws from pain
3. Abnormal flexion to pain for an infant (decorticate response)
2. Extension to pain (decerebrate response)
1. No motor response

Interpretation of Pediatric Glasgow Coma Scale

Glasgow Coma Scale For Paediatrics

A Coma Score of 13 or higher correlates with a mild brain injury, 9 to 12 is a moderate injury and 8 or less a severe brain injury. Any combined score of less than eight represents a significant risk of mortality.

In writing the score, along with total score individual components are also mentioned. For example E3V3M5, GCS 11.

Glasgow Coma Scale For Pediatrics

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Glasgow Coma Scale Interpretation

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