Pediatric emergency medicine trisk 911
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Sign
Glasgow Coma
Scale [1]
Pediatric
Glasgow Coma
Scale [2]
Score
Eye Opening
Spontaneous
To command
To pain
None
Oriented
Spontaneous
To sound
To pain
None
Age-appropriate
vocalizations,
orientation to
sound, follows
objects,
interacts,
smiles
Cries, irritable
4
3
2
1
5
Cries to pain
Moans to pain
3
2
Verbal
Response
Confused,
disoriented
Inappropriate words
Incomprehensible
sounds
None
Motor Response Obeys commands
None
Spontaneous
movements
Localizes pain
Withdraws to
touch
(localizes
pain)
Withdraws
Withdraws to
pain
Abnormal flexion to Abnormal
pain
flexion to pain
(decorticate
posture)
4
1
6
5
4
3
Abnormal extension Abnormal
to pain
extension to
pain
(decerebrate
posture)
None
None
Best total score
2
1
15
Adapted and modified with data from Teasdale G, Jennett B. Assessment of coma and impaired
consciousness. A practical scale. Lancet 1974;2(7872):81–84; 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):814–819.
TABLE 113.2
CLINICAL FEATURES ASSOCIATED WITH HIGHER RISK OF
ciTBI
Children <2 yrs
of age
Children ≥2 yrs of age
Altered mental
status or
abnormal
behavior per
caregiver
Nonfrontal
location of
scalp
hematoma
Loss of
consciousness
>5 sec
Depressed or
basilar skull
fracture
Bulging anterior
fontanelle
Persistent
vomiting
Posttraumatic
seizure
Focal neurologic
findings
Suspicion of
nonaccidental
trauma
Altered mental status
Depressed or basilar skull fracture
Posttraumatic seizure
Loss of consciousness
Focal neurologic findings
Worsening severe headache
Adapted with permission from Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children
at very low risk of clinically important brain injuries after head trauma: a prospective cohort study.
Lancet 2009;374(9696):1160–1170.
Diagnostic Imaging. Plain skull radiography has a limited role in
evaluating blunt head injury as it cannot provide details regarding
intracranial injury. Because computed tomography (CT) is noninvasive and
widely available, it is used for screening and diagnosis of intracranial
injuries. Current generation 16-detector scanners are capable of rendering
very high resolution images along with high speed data acquisition. CT
findings detect mass lesions that may be surgical, early signs of cerebral
edema including compression of the ventricular system and/or
perimesencephalic cisterns, midline shift, or loss of gray to white matter
interface. CT is preferred for detection of fractures and subarachnoid
hemorrhage.
Magnetic resonance imaging (MRI) is more sensitive than CT as it
provides greater anatomical detail of the brain and ventricles, but it can be
less readily available and requires longer periods of time to obtain imaging.
As an alternative, “fast” MRI techniques are being used to assess TBI. This
option is not the current standard protocol in many facilities. MRI utilizing
T1, T2, and fluid-attenuated inversion recovery (FLAIR) images is more
sensitive allowing delineation of the nature and timing of hemorrhage.
Additionally, diffusion-weighted imaging (DWI) outlines hypoxic–ischemic
or DAI.
Management. As with any trauma evaluation, the initial assessment should
focus on Airway, Breathing, Circulation, Disability, and Exposure per
trauma guidelines. Management principles focus on airway management
while maintaining cervical spine immobilization to provide adequate
oxygenation and ventilation to prevent hypoxia and hypercarbia.
Intravascular volume should be maintained to provide adequate cerebral
perfusion pressure, thereby, preventing secondary brain injury. Certain
adjuncts should be used in management of patients with suspected head
injuries. Immobilization of the cervical spine should be maintained until the
determination that there is not a concomitant cervical spine injury. (Spinal
Cord Injury is covered in Chapter 112 Neck Trauma .) This is accomplished
with using the chin lift maneuver thus avoiding jaw thrust, application of
