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Assessment of conscious level in a child with a head injury

So we are going to complete the assessment and some oxygen on his face for now. Then we'll do everything again, that you'll probably see. Ok. A bit more detailed.  Toby, you ok?  Yes we should try to work out his GCS yes absolutely. So we go 4 for the eyes opening them to voice voice. Ok. 3 for those can I pop a little mask on you today, Toby, yes? That's it well done. Good boy.
let's have the checklist ready. So we can do a GCS properly. Toby, how old are you? 
5 and a half - nearly 5 and three quarters perfect good boy. Pop that like that. That's it perfect
let’s work out the GCS properly then. So we got open to speech for eyes which is a 3. Yes? uh-huh Verbal response: have we got appropriate words or social smiles?  Fixing on foreign objects. Yes, so that's a 5 Motor - Obeying commands or localising pain yes yes. so we got a 6. So we got a 3, 5 and a 6. Yes. So GCS at 14 14, yes ok. excellent. Good
so we just do a head to toe assessment again yes absolutely. So let's go from the top then. So again, let's have a quick little look check at the top up there. No blood there. Wonderful. Just do the best as we can. Is there any pain in your neck there? no no, good. Brilliant. Ok. Can I have a quick look in your eyes? Just have a look at my nose. Look at my nose. Just keep looking at my nose. Wonderful. So can I have a quick look in your ears?
There’s no blood in the right and there’s no blood in the left and there’s no blood in the nostrils either, which would be suggestive of a basic skull fracture which is good. Ok, can we listen to your chest, Yeh.
just lie nice and still. Take some big deep breaths And out. Excellent, keep going. And out

Early recognition of a rising intercranial pressure will lead to the best chance of an early intervention and prevention of additional injury to the brain. The way we recognise changes in the conscious level is by using a formalised score.

In the initial stages, we can use something called AVPU. This is an abbreviation standing for Alert, Voice, Pain or Unresponsive.

  1. An alert individual is a child or adult who is talking to you normally and aware of their surroundings.
  2. Alternatively, the individual may respond to a voice and vocalise but may not be coherent, or perhaps not as aware of their surroudnings as you would like.
  3. Other individuals may only respond to pain. If you rub them on their sternum or prick them, they will withdraw to that pain or be upset by that pain but otherwise seem quite reduced in consciousness.
  4. Finally, somebody who is unresponsive does not react to any stimulus you give them, painful or otherwise.

In addition to this, we also use the Glasgow Coma Scale. This exists in two forms, the first is the adult Glasgow Coma Scale and the second is the modified paediatric Glasgow Coma Scale.

While these are separate, the principles are the same. The second is modified for children, whose verbal responses and responses to instructions cannot be quantified as an adult’s would be because of their developmental level. When using the adult Coma Scale, we score them as out of a maximum of 15, with the lowest possible score being 3. The three categories we think of are the eyes, the voice and the motor component of these i.e. the movement. The eyes are scored out of 4, initially people who are alert and awake have their eyes spontaneously open. Those who are less responsive will open their eyes to a voice maybe to calling their name and for this they would score a 3. Those who open their eyes only if you give them a painful stimulus would score 2 and for those who would not open their eyes at any point they would score a 1.

In this short clip we see Toby’s GCS being assessed by the paramedics inside the ambulance. Toby is only opening his eyes when spoken to and technically this would give him a GCS of 14. This goes to show the difficulty of assessing these things in children because Toby’s clear, coherent and detailed answer to the question about his age tells us that there is really no alteration in his conscious level at all. When doing a GCS assessment you should always mark the best possible response seen. Given time in the ambulance, Toby would open his eyes spontaneously, giving him a GCS of 15.

Consider the questions below and discuss with the group.

  1. What do you consider when faced with a child with a head injury?
  2. Is there anything in particular you need to be prepared for on the way to hospital?
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Emergency and Urgent Care for Children: a Survival Guide

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