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Sensorium in Children

Dr. Gurdev Chowdhary, et. al

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Topics

Glasgow Coma Scale depends upon higher integrative functions which are not present in the infant or very young child. In children the verbal and motor response are not readily graded and depend on the child’s age and development. Hence, in children several modifications of the Glasgow Coma Scale have become necessary.

In Pediatric practice, the scales used for clinical assessment of impaired conciousness are the Adelaide Paediatric Coma Scale, the Children’s Coma Scale and the Modified Children’s Coma Scale.

Adelaide Paediatric Coma Scale

Simpson and Reilly proposed that the best motor response of a child depends on his age and development status so the score of motor response should be adjusted according to age. And the verbal response be graded as follows:

  • oriented: 5
  • words: 4
  • vocal sounds: 3
  • cries: 2
  • no sounds: 1

The response to eye opening remaining the same as for Glasgow Coma Scale which is up to a maximum of 4.

Age Related Motor and Verbal Scores

0-6 Months

Motor response / Verbal response

  • flexes to pain: 3 / cries : 2
  • extends to pain:2 / no sound: 1
  • no movements: 1
  • Best score: 9

6 Months to 12 Months

Motor response / Verbal response

  • withdraws: 4 / vocal sounds : 3
  • flexes: 3 / cries: 2
  • extends: 2 / no sound: 1
  • no movements: 1
  • Best score: 11

1-2 Years

Motor response / Verbal response

  • localizes pain: 5 / words: 4
  • withdraws: 4 / vocal sounds: 3
  • flexes: 3 / cries: 2
  • extends: 2 / no sound: 1
  • none: 1
  • Best score: 13

2-5 Years
Best score 14

> 5 years
Best score : 15

Children’s Coma Scale (Raimondi and Hirschauer 1984)

Response Form of Occurrence Score

A. Ocular

  • pursuit: 4,
  • extra ocular muscles intact/pupil reacting: 3,
  • fixed pupils or extra-ocular muscles impaired: 2,
  • fixed pupils and extra-ocular muscles impaired: 1

B. Verbal

  • cries: 3,
  • spontaneous respiration: 3,
  • apnoeic: 1

C. Motor

  • flexes and extends: 4,
  • withdraws from painful stimuli: 3,
  • hypertonic: 2,
  • flaccid: 1

Modified Children’s Coma Scale
(James and Trauner, 1985

Response Form of Occurrence Score

A. Eye Opening

  • Spontaneous: 4
  • response to speech: 3
  • response to pain: 2
  • none: 1

B. Verbal

  • coos/babbles: 5
  • irritable, cries: 4
  • cries to pain: 3
  • moans to pain: 2
  • none : 1

C. Motor

  • normal spontaneous : 6
  • withdraws to touch : 5
  • withdraws to pain : 4
  • abnormal flexion : 3
  • abnormal extension : 2
  • none : 1

Clinical Focus

  • A rapid and accurate evaluation of a child with altered sensorium is necessary for appropriate management.
  • A detailed history and general physical examination provides vital pointers towards the underlying diagnosis.
  • The Glasgow Coma Scale (GCS) is an effective method of describing various states of impaired consciousness in a wide range of clinical settings.
  • In paediatric practice, the Adelaide Paediatric Coma Scale, the Children’s Coma Scale and the Modified Children’s Coma Scale offer clearly defined and accurately graded assessment of the degree of dysfunction of the central nervous system in children of various ages.

Conclusion

Impairment of consciousness in children may result from a wide range of aetiological conditions. History taking and a meticulous physical examination provide important clues to the underlying diagnosis. An accurate assessment of the cause and extent of altered sensorium not only helps in the management of coma, but also helps in focusing attention to a limited number of diagnostic possibilities, making expensive and exhaustive investigations unnecessary.

The Glasgow Coma Scale, earlier used for assessment of head injuries is considered to be an effective method of describing and grading of coma in children. However, since the motor and verbal responses in children depend upon their age and degree of development, several modifications of the GCS have come into existence which provide easy assessment of accurate grading of central nervous system dysfunction.

Dr. Gurdev Chowdhary,
Dr. Praveen C. Sobti,
Prof. Daljit Singh,

Dept. of Pediatrics, DMC and Hospital, Ludhiana


Dept. of Pediatrics, DMC and Hospital, Ludhiana

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