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166 Paediatric Injury Scoring and Trauma Registry

Table 26.5: Modified Glasgow Coma Scale for infants and children.
Area assessed Infants Children GCS
Eye opening Open spontaneously Open spontaneously E4
Open in response to verbal stimuli Open in response to verbal stimuli E3

Open in response to pain only Open in response to pain only E2
No response No response E1
Verbal response Alert, coos, and babbles Oriented, appropriate V5
Spontaneous irritable cry Confused V4
Cries in response to pain Inappropriate words V3
Moans in response to pain Incomprehensible words/sounds V2

No response to pain No response V1
Motor responses Moves spontaneously and purposefully Obeys commands M6

Withdraws to touch Localises painful stimulus M5
Withdraws in response to pain Withdraws in response to pain M4

Response to pain with decorticate posturing (abnormal flexion) Abnormal flexion to pain M3
Response to pain with decerebrate posturing (abnormal extension) Abnormal extension to pain M2
No response to pain No response to pain M1
Grimace G5
component Spontaneous normal facial/or motor activity (e.g., sucks tube, coughs)
Less than usual spontaneous ability or only responds to touch G4
Vigorous grimace to pain G3
Mild grimace or some change in facial expression to pain
G2
No response to pain
G1

examinations. One major disadvantage of the GCS is the inability to assesses four physiologic components including respiratory rate (RR),
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obtain complete data from patients who are intubated and/or sedated. degree of respiratory expansion/effort, systolic blood pressure (SBP),
This is usually signified by placing the letter “T” after the computed and capillary refill, in addition to the GCS (Table 26.6). These are all
score (i.e., 3T indicates a patient with a GCS of 3 who is intubated). scored and added together to give the TS value, which ranges from
The total GCS score is more meaningful when considered together 1 to 16. For each value, the probability of survival [P(s)] has been
with its components, that is: eye opening (E3), best verbal response determined. If a patient has a TS value of 1, the associated P(s) is 0,
(V3), and best motor response (M4). A GCS score ≤8 signifies coma or indicating a likely fatal process. A TS value of 16 is associated with a
severe brain injury; a score of 9–12, moderate brain injury; and a score P(s) of 99%.
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≥13, mild or no brain injury. The advantages of the TS are that it uses parameters that are
Some workers add grimace to the GCS for adults and the modified commonly measured in the prehospital and emergency department
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GCS for infants and children, as shown in Table 26.5. settings, it is easy to understand, it accurately predicts outcome, and
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The grimace component appears to be more reliable than the verbal it has a good interobserver (interrater) reliability. The TS has also
component and may be useful in intubated and nonverbal patients when been validated for use in paediatric patients. Its limitations lie in its
the verbal response is impossible to use. 14 use of two subjective measurements, including respiratory expansion/
AVPU effort and capillary refill, which can be difficult to gauge in the field.
During prehospital triage and primary assessment, the AVPU method In addition, it is somewhat cumbersome, with five separate measures,
may be used as a quick and simple tool to assess level of conscious- and also underestimates the severity of head injury in patients who
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ness. The AVPU is a simple scale of whether a patient is responsive are in a stable cardiovascular state. A TS value calculated in the field
(Alert), responds to verbal stimuli (Verbal), responds to painful stimuli or emergency department will naturally underestimate severity in the
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(Painful), or is unresponsive to any stimuli (Unresponsive). It provides trauma patient who becomes unstable later.
a rough guide as to whether a patient needs airway protection. The Revised Trauma Score
AVPU method does not belong to any of the groupings mentioned In order to eliminate the subjectivity of TS, the degree of respiratory
above—physiologic, anatomic, or combined, and is not a scoring sys- expansion/effort and capillary refill were removed, resulting in the
tem as such. Revised Trauma Score. The RTS is a physiologic scoring system with
Trauma Score high interobserver reliability and demonstrated accuracy in predicting
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The TS is a physiologic measure based on information gathered in the mortality. It is frequently used to rapidly assess patients at the scene
prehospital setting, and capable of predicting patient outcome. 1,15 It of an accident. The score consists of the patient’s data from the GCS,