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 Cries to pain Moans to pain 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) Abnormal extension Abnormal to pain extension to pain (decerebrate posture) None None Best total score 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 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 ... 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