Pediatric Glasgow Coma Scale (pGCS)

About pGCS

This is the modified version of the Glasgow Coma Scale (adapted for use in pediatric patients younger than 2 years old). The scale evaluates the mental status of patients presenting to ER with head trauma.

Because of its use in infant patients, the scale looks for specific reactions to stimuli, for example the verbal response focuses on cry and orientation, thus bypasses the verbalization requirement that the adult scale has.

The three domains of nervous function that are analysed, can be found in the table below:

The result from the pGCS helps clinicians choose the appropriate management of the acute condition (head injury).

There are other examples of adult scales adapted for use in infant and child patients, such as the Pediatric Early Warning Score (PEWS) or the PELD, the pediatric version of the End Model for Liver Disease (MELD).

Result interpretation

The pGCS is scored in a similar manner to the adult version, with results ranging from 3 to 15, where 3 indicates coma or exitus and 15 indicates a patient that is fully aware and awake.

Any score below 12 is indicative of moderate to severe head injury. Patients who score below 8 are likely to require intubation and those scoring below 6 should also have the intracranial pressure monitored.

When the score is reported, it is sometimes broken down per components to communicate more information. For example, a score of 11 could be followed by E4V4M3.

This describes a patient that may suffer from moderate to severe head trauma, who is not likely to require intubation, with spontaneous eye opening, with cry that is consolable and with abnormal flexion to pain for an infant (decorticate response).

Strengths and limitations

The original study dates from 1986 when the GCS was adapted for pediatric use by James.

Subsequent validation studies have been performed on cohorts of patients with blunt head trauma or other types of infant trauma.

The pGCS was found to be as efficient in evaluating and tracking a patient’s mental status in its target population as the standard adult version.

The scale was found to have relatively lower accuracy in identifying traumatic brain injury on CT than the standard version. Also, in the original study, only 36% of subjects have been examined by CT, thus not knowing for sure whether all patients ruled out from traumatic brain injury by the scale, did not have any traumatic findings.

Another limitation is that given by the age 2 threshold, thus the scale is only addressed to preverbal pediatric populations.

Original source

James HE. Neurologic evaluation and support in the child with an acute brain insult. Pediatr Ann. 1986; 15(1):16-22.

Validation

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; 23(8):878-84.

Other references

1. 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; 4(1):30-3.

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

3. 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; 7(4):183-90.