• 
• 

Three Part Question

[In children] is [the Glasgow Coma Scale (GCS) a better prognostic indicator than best motor response] in [head injuries]?

Clinical Scenario

A two year old boy - 'Lance' - presents to the emergency department after falling off his bike. He sustained a head injury and is currently drowsy. After recently completing the ATLS course, you try to apply the ABCDE mnemonic to Lance. You remember GCS forms parts of 'D for Disability' but struggle to assess speech in a this child. You wonder if best motor response is sufficient in children?

Search Strategy

MEDLINE
(gcs OR glasgow coma scale) AND (cranial OR head OR brain) AND (injury OR trauma) AND (child OR children OR paediatric OR toddler OR adolescent) AND motor

Search Outcome

46 results
43 results when limitted to humans and english language
2 relevant to all parts of the question

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Fortune PM, Shann F May 2010 Australia	130 children (79 boys) admitted to paediatric intensive care unit 01/01/1997 - 31/12/1999 with a diagnosis of traumatic head injury. Age range of 3 months to 16 years.	Retrospective observational study. GCS and best motor score recorded in the first 24 hours of admission compared to GCS at 6 months. Initial motor response was found to to predict outcome as well as the full GCS.	GCS <=6 predicted poor outcome with positive predictive power of 84%	Motor response of abnormal flexion predicted poor outcome with positive predictive power of 83%	Follow-up limitted to 6 months. 38/168 patients excluded from analysis. Boys>girls. GCS, motor response and follow-up GCS assessed by different people.
Van de Voorde P,Sabbe M,Rizopoulos D,Tsonaka R,De Jaeger A,Lesaffre E,Peters M,PENTA study group February 2008 Belgium	96 children (57 boys) admitted to one of 18 hospitals with 'traumatic brain injury' for more than 48hours (or died). Age range 0-18 (median 8).	Admission GCS and motor subscore analysed as predictors of outcome at hospital discharge (measured using Paediatric Overall Performance Category). Authors found that both the GCS and motor subscore have 'excellent predictive performance'. Age and sex analysed as possible predictors of outcome (found to be insignificant).	Admission GCS predictive perfomance (Somers’ Dxy rank correlation) = 0.972	Admission motor score predictive perfomance (Somers’ Dxy rank correlation) = 0.983	Exclusion of children with severe injury in any other body region. Non-severe head injury (median GCS value =14.5, motor score=6). No mention of length of follow-up.

Comment(s)

There are a number of limitations to the studies: - There are few studies and the studies use relatively small numbers of patients. - The patients are not grouped according to type of head injury. - The age range is wide. - Inter-rater reliability for scoring GCS is low. It would be of value to compare total GCS, eye response, motor response and verbal response as individual variables of outcome.

Clinical Bottom Line

GCS and motor subscore are comparible, accurate predictors of outcome in children with head injuries. In cases where GCS is difficult to ascertain (children with undeveloped verbal skills, intubation etc.), the motor subscore may be preferable.

References

1. Fortune PM, Shann F The motor response to stimulation predicts outcome as well as the full Glasgow Coma Scale in children with severe head injury Pediatric Critical Care Medicine May 2010, pp 339-342
2. Van de Voorde P,Sabbe M,Rizopoulos D,Tsonaka R,De Jaeger A,Lesaffre E,Peters M,PENTA study group Assessing the level of consciousness in children: A plea for the Glasgow Coma Motor subscore Resuscitation February 2008, Pages 175-179