Glasgow Coma Scale in Children

Glasgow Coma Score in children

In emergency medicine, we often use illness scripts and protocols to help drive our decision-making.  I recall a shift I had with Dr. Fox while I was early in fellowship (not so many years ago).  We had just received a young child from EMS who was post-ictal with decreased mentation.  Dr. Fox asked me what I wanted to do next to care for the child, and as I calculated his GCS… 7 at the time… I felt somewhat obligated to say that I should intubate the child.  “Less than 8, intubate!”  What followed was a sly smile from Dr. Fox (this was before COVID and masking), indicating that a tasty educational on-shift real-time morsel of knowledge was coming my way.  The Glasgow Coma Scale and score is a useful tool, but it is not the end-all-be-all decision-maker for intubating a patient.  

We have mentioned the Glasgow Coma Scale in multiple delicious morsels: Minor closed head injuries in <3 month olds and in the rebaked morsel, Blunt cerebrovascular injury, Cerebral edema in DKA, Pediatric Trauma Pitfalls, and Carbon monoxide poisoning.  We use the GCS score in both trauma and medical patients, but where did this score come from? When is it useful and what does it tell us?  Is it actually validated in children, like the Ottawa Ankle Rules or are we using a tool for something other than that for which it was designed and validated, like using Kocher criteria for knee and ankle joints?  Let’s wrap our heads around the Glasgow Coma Scale in children.

Glasgow Coma Scale in Children – Basics

  • First proposed by Dr. Teasdale and Dr. Bryan Jennett in 1974 at the University Department of Neurosurgery, Institute of Neurological Sciences, Glasgow [Teasdale 1974]
    • They recognized the need for a clinical scale that measured the depth and duration of impaired consciousness
      • Objective description of impaired consciousnessNeeded to be easy to assessRepeatable by doctors and nurses with good interrater reliabilityMonitors patient clinical changes over timeHelps with communication of patient statusUses 3 different aspects of behavior, independent of each other
      Initially intended for use in all forms of decreased consciousness [Teasdale 1974]
    • But was initially validated in severe head injury [Jennett 1976, Jain 2022]
  • Widespread use in 1980’s after the Advanced Trauma and Life Support (ATLS) course recommended it be used during assessment of all trauma patients [Jain 2022]
  • In 1988, the World Federation of Neurosurgical Societies adopted the scale for patients with subarachnoid hemorrhage. [Jain 2022]
  • Now used for critically ill trauma and medical patients in >75 countries. [Jain 2022]

Glasgow Coma Scale in Children – How do you perform it correctly?

  • Motor
    • Fingernail bed pressure with a pencil first
    • If flexion outcome, then apply painful stimulus to neck or head (trapezius or supraorbital notch) to look for localization
    • Spinal reflex can result in a falsely elevated score if lower extremity pain induced
  • Verbal
    • Orientated- Able to answer all questions.
    • Confused- Can hold a conversation but some answers indicate confusion.
    • Inappropriate speech- No conversation. May have shouts or exclamations.
    • Incomprehensible speech- Moans and groans.
  • Eye
    • Spontaneous eye opening indicates awakeness but not always awareness
    • Opening eyes to speech is opening them to any noise, shout, or command
    • In response to pain should be pain inflicted on an extremity, as grimace from neck/head pain could cause eye closure

Glasgow Coma Scale in Children – It is Useful

  • Most useful as a trauma tool since that is where it has been validated 
  • A PEDIATRIC (or PAEDIATRIC) version was proposed by Reilly et al in 1988 in Adelaide. [Reilly 1988, Jain 2022]
    • This score was then tested prospectively in 60 head injured patients and found to be appropriate to use in this age/population [Simpson 1991]
    • Noted that “conscious level in infants has limited value as an index of brain injury” and suggested complementary use of other brain injury indices “such as brainstem reflexes.”
  • PECARN compared the pediatric GCS (pGCS) in preverbal children (<2yo) to the standard GCS in verbal children (>2yo) in over 42,000 patients [Borgialli 2016]
    • Looked at how well each scale predicted traumatic brain injury (TBI) findings on head CTAlso looked at how well each scale predicted clinically important TBI
    • pGCS was slightly less sensitive for TBI on head CT than standard GCS, but was similarly sensitive for ciTBI
  • Others note GCS to be a good outcome predictor for children with head trauma [Chung 2006]
    • A critical score of GCS 5 – under which mortality dramatically increases
    • GCS and derivations such as mGCS also useful to predict morbidity and mortality outcomes [Chaturvedi 2001, Prabha 2003, Biradar 2015]
  • The GCS score shows good reliability and reproducibility!
    • Systematic review showed 85% of studies with substantial reliability with kappa statistic >0.6 [Jain 2022]
    • “Excellent” interrater reliability in PICU nurses, though somewhat less when patients had developmental delay [Kirschen 2019]
    • A few studies describe less than stellar, more average interrater reliability, but these studies are in the minority [Drews 2019, Gill 2004, Rowley 1991]

Glasgow Coma Scale in Children – Where is it less useful?

  • GCS does not give an accurate rating for certain groups [Tasker 2019]
    • Those with intellectual disability at baseline
    • Those with pre-existing neurological deficits
    • Those who are treated with sedatives or neuromuscular blocking agents
    • Those who are intubated
  • Not all severe intracranial lesions cause a decreased GCS right away, and a normal GCS can be falsely reassuring [Baldock 2015]
    • Case series of 2 patients with GCS 15, 
      • First with posterior fossa mass who went from GCS 15 to 3 in 25 minutes, and died from herniation
      • Second with subdural hematoma who had a GCS 15 until he started to herniate while being taken into OR
  • Still no large validation study for medical causes of altered mentation in children, though it is widely used for this purpose

Glasgow Coma Scale in Children – “Less than 8, intubate“??

  • GCS is NOT a great predictor of aspiration risk in intoxicated patients. Gag reflex is much better predictor (45% vs 6%) [Conzelmann 2021]
    • Positive predictive value of GCS indicating aspiration in intoxication was only 3%.
    • 88% of patients with GCS < 9 did NOT aspirate
  • A systematic review of multiple studies of trauma-injured versus non-trauma patients with GCS <8 found no difference in aspiration risk between those who were intubated vs not intubated. [Orso 2020]
    • One pediatric study in this systematic review, and the intubated patients had worse outcome than non-intubated
  • Early airway protection = lower rates of complications (in TRAUMA), but this is not always true with medical patients.

Glasgow Coma Scale in Children – Other options

  • The AVPU (alert-verbal-pain-unresponsive) scale
    • Shows good correlation with GCS in a limited study [Raman 2011]
  • The FOUR score
    • Assesses Motor, Eye, Brainstem Reflexes, and Respirations
    • Has been shown to be equivalent to GCS in predicting in-hospital mortality and functional outcome at discharge, and both are good predictors [Kochar 2014, Jamal 2017, Pandwar 2022]
    • Useful for both medical and trauma patients
  • Other potential tools:
    • Duncan et al 15 point scale for neonates [Reilly 1988]
    • Raimondia and Hirschauer 11 point coma scale for infants [Reilly 1988]
    • Seshia et al more elaborate 9 spontaneous and 12 stimulus-provoked responses up to 4 points each [Reilly 1988]
    • James Adaptation of Glasgow Coma Scale [Tatman 1997] 
    • Simpson and Reilly Scale [Simpson 1982]
    • Children’s Coma Scale of Raimondi and Hirschauer [Raimondi 1984]
    • Children’s Coma Scale of Hahn [Hahn 1988]
      • Does not use a verbal score, only ocular and motor
    • Children’s Orthopedic Hospital and Medical Center Scale [Morray 1984]
    • Jacobi’s Scale [Gordon 1983]
    • Glasgow Coma Scale Pupils Score (GCS-P) [Brennan 2018]
  • “Review of the literature confirms that there is general agreement on the clinical utility of some system of grading responses in head injured children and infants.” [Simpson 1991]
    • No one system universally accepted like adult standard GCS [Simpson 1991, Jain 2022]
    • “There is an evident need for valid standards of paediatric head injury severity, to permit comparisons of different methods of treatment.”

Scales are derived from GCS and compared to GCS

  • The GCS is the basis for other scores and scales that have been developed [van Heuven 2007]
    • World Federation of Neurological Surgeons (WFNS) Committee scale
    • Prognosis on Admission of Aneurysmal Subarachnoid Hemorrhage (PAASH) grading scale
  • It has been used along with other indices to improve mortality predictions [Lammers 2020]
    • Reverse shock index multiplied by GCS score is better than SIPA (Shock index and its pediatric adjusted derivative) alone at predicting mortality in children with warzone injuries.
  • Fun fact for animal lovers!- cats and dogs have their own GCS scores [Lapsley 2019, Ash 2018]

Moral of the Morsel

  • Modified can make it Merrier! The standard GCS score is useful even for verbal children, but there are modified pediatric Glasgow Coma Scales for nonverbal (<2yo) patients.
  • Not a universal tool. GCS scores are validated in trauma populations, but it has its limitations in the medical populations.
  • It’s complicated. Less than 8 doesn’t always mean intubate! Consider other indicators of need for airway management, such as gag reflex.

References:

  1. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974 Jul 13;2(7872):81-4. doi: 10.1016/s0140-6736(74)91639-0. PMID: 4136544. 
  2. Jennett B, Teasdale G, Braakman R, Minderhoud J, Knill-Jones R. Predicting outcome in individual patients after severe head injury. Lancet. 1976 May 15;1(7968):1031-4. doi: 10.1016/s0140-6736(76)92215-7. PMID: 57446.
  3. Jain S, Iverson LM. Glasgow Coma Scale. [Updated 2022 Jun 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513298/
  4. Reilly PL, Simpson DA, Sprod R, Thomas L. Assessing the conscious level in infants and young children: a paediatric version of the Glasgow Coma Scale. Childs Nerv Syst. 1988 Feb;4(1):30-3. doi: 10.1007/BF00274080. PMID: 3135935. 
  5. Simpson DA, Cockington RA, Hanieh A, Raftos J, Reilly PL. Head injuries in infants and young children: the value of the Paediatric Coma Scale. Review of literature and report on a study. Childs Nerv Syst. 1991 Aug;7(4):183-90. doi: 10.1007/BF00249393. PMID: 1933914. 
  6. Borgialli DA, Mahajan P, Hoyle JD Jr, Powell EC, Nadel FM, Tunik MG, Foerster A, Dong L, Miskin M, Dayan PS, Holmes JF, Kuppermann N; Pediatric Emergency Care Applied Research Network (PECARN). Performance of the Pediatric Glasgow Coma Scale Score in the Evaluation of Children With Blunt Head Trauma. Acad Emerg Med. 2016 Aug;23(8):878-84. doi: 10.1111/acem.13014. Epub 2016 Aug 1. PMID: 27197686. 
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  13. Drews JD, Shi J, Papandria D, Wheeler KK, Sribnick EA, Thakkar RK. Prehospital Versus Trauma Center Glasgow Coma Scale in Pediatric Traumatic Brain Injury Patients. J Surg Res. 2019 Sep;241:112-118. doi: 10.1016/j.jss.2019.03.038. Epub 2019 Apr 22. PMID: 31022676.
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  18. Conzelmann M, Hoidis A, Bruckner T, et al. Aspiration risk in relation to Glasgow Coma Scale score and clinical parameters in patients with severe acute alcohol intoxication: a single-centre, retrospective study. BMJ Open 2021;11:e053619. doi: 10.1136/bmjopen-2021-053619
  19. Orso D, Vetrugno L, Federici N, D’Andrea N, Bove T. Endotracheal intubation to reduce aspiration events in acutely comatose patients: a systematic review. Scand J Trauma Resusc Emerg Med. 2020 Dec 10;28(1):116. doi: 10.1186/s13049-020-00814-w. PMID: 33303004; PMCID: PMC7726605. 
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  32. Lammers DT, Marenco CW, Do WS, Conner JR, Horton JD, Martin MJ, Escobar MA Jr, Bingham JR, Eckert MJ. Pediatric adjusted reverse shock index multiplied by Glasgow Coma Scale as a prospective predictor for mortality in pediatric trauma. J Trauma Acute Care Surg. 2021 Jan 1;90(1):21-26. doi:
  33. Lapsley, Janis, Galina M. Hayes, and Julia P. Sumner. “Performance Evaluation and Validation of the Animal Trauma Triage Score and Modified Glasgow Coma Scale in Injured Cats: A Veterinary Committee on Trauma Registry Study.” Journal of veterinary emergency and critical care (San Antonio, Tex. : 2000) 29.5 (2019): 478–483. Web.
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Christyn Magill
Christyn Magill
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