Pediatric Glasgow Coma Scale (pGCS)

Introduction

The Pediatric Glasgow Coma Scale (pGCS) adapts the Glasgow Coma Scale for infants and young children, who can’t yet speak in sentences or follow commands. The standard GCS relies on being oriented and obeying commands, so it underscores young children who are behaving normally for their age. The pGCS replaces those items with age-appropriate behaviors, such as cooing, crying, and spontaneous movement. It’s used in emergency departments, pediatric intensive care, and trauma care to assess and track a child’s level of consciousness, especially after head injury.

Who it’s for: It’s typically used for preverbal children, most often under age 2. Some versions extend the adapted scoring to about age 5. Older children who can talk and follow instructions are usually assessed with the standard GCS.

• Use for children 2 years and younger only.

• For older children, use the standard Glasgow Coma Scale (GCS).

• Intended for infants with head trauma, altered mental status or neurologic abnormalities.

• Use in initial and serial assessments.

• Best to obtain pGCS prior to the administration of analgesics or other interventions that could alter the score.

• Record the patient's BEST response in each of the three categories: eye opening, verbal response, and motor response.

• Note: The Glasgow Coma Scale (applicable if any of the three components is NOT testable) is different than the Glasgow Coma Score (applicable when all three components are testable).

What it assesses: Like the adult GCS, the clinician records the best response in three areas depending on age range

Ages ≤2 years

• Eye opening (1–4): 4 = spontaneous; 3 = to verbal stimuli; 2 = to pain only; 1 = no response

• Verbal response (1–5): 5 = coos, babbles; 4 = irritable cries; 3 = cries to pain; 2 = moans to pain; 1 = no response

• Motor response (1–6): 6 = moves spontaneously and purposefully; 5 = withdraws to touch; 4 = withdraws to pain; 3 = flexure posturing to pain; 2 = extensor posturing to pain; 1 = no response

Ages >2 years

• Eye opening (1–4): 4 = spontaneous; 3 = to verbal stimuli; 2 = to pain only; 1 = no response; Not testable (NT)*

• Verbal response (1–5): 5 = oriented/appropriate; 4 = confused; 3 = inappropriate words; 2 = incomprehensible words/sounds; 1 = no response; Not testable (NT)*

• Motor response (1–6): 6 = obeys commands; 5 = localizes to pain; 4 = withdraws to pain; 3 = flexure posturing to pain; 2 = extensor posturing to pain; 1 = no response; Not testable (NT)*

How it’s scored: The three component scores of the Glasgow Coma Score are added for a total from 3 (no response) to 15 (spontaneous). An additional result is also recorded as a Glasgow Coma Scale (E3 V3 M4), because the same total can describe very different patients.

*Individual components may be not testable due to any of the following (note this is not a comprehensive list):

• Eye: local injury and/or edema.

• Verbal: intubation.

• All (eye, verbal, motor): sedation, paralysis, and ventilation eliminating all responses. 

Untestable components: Sometimes a response can’t be tested. A patient who is intubated can’t speak, and swelling may keep the eyes shut. That component should be recorded as NT (not testable), not scored as 1, because a score of 1 means “no response” and would make the patient appear more impaired than they are. In that case the components are reported individually, for example “E3 V-NT M5,” rather than combined into a total. Some hospitals add a “T” suffix for intubated patients, such as “8T,” but that’s a local convention, not official scoring.

Results

• The Glasgow Coma Score is calculated by addition of the total points selected under each component (eye, verbal, motor) below, e.g. "15 points".

• The Glasgow Coma Scale is comprised of the individual components, e.g. "E(4) V(5) M (6)".

How results are interpreted: For traumatic brain injury, totals are grouped as 13–15 mild, 9–12 moderate, and 3–8 severe. A score of 8 or less signals a severely reduced level of consciousness, and is often used as a threshold to consider protecting the airway. A falling score over repeated checks is a warning sign that needs urgent assessment, even if each single score looks moderate.

Management Considerations

• If a component is untestable, a score of 1 should not be assigned (Teasdale 2014). In this circumstance, summation of the findings into a total Glasgow Coma Score is invalid.

• Clinical decisions should not be based solely on the GCS score.

• Consider intubation if the GCS ≤8 and there is clinical concern the patient is unable to protect their airway or that they have an expected worsening clinical course based on exam or imaging findings.

• A rapidly declining or waxing and waning GCS is concerning and intubation should be considered in the context of the patient's overall clinical picture.

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