Head Trauma, Acute — Modified Glasgow Coma Scale for Infants and Children — Clinical Pathway: Emergency

Acute Head Trauma Clinical Pathway — Emergency Department

Modified Glasgow Coma Scale for Infants and Children

  • ≤ 12 suggests non-mild TBI
  • ≤ 8 suggests need for intubation and ventilation
  • ≤ 6 suggests need for intracranial pressure monitoring

If the patient is intubated, unconscious, or preverbal, the most important part of this scale is motor response.
This section should be carefully evaluated.

Area Assessed Infants Children Score
Eye Opening Open spontaneously Open spontaneously 4
Open in response to verbal stimuli Open in response to verbal stimuli 3
Open in response to pain only Open in response to pain only 2
No response No response 1
Verbal Response Coos and babbles Oriented, appropriate 5
Irritable cries Confused 4
Cries in response to pain Inappropriate words 3
Moans in response to pain Incomprehensible words or nonspecific sounds 2
No response No response 1
Motor Response Moves spontaneously and purposefully Obeys commands 6
Withdraws to touch Localizes painful stimulus 5
Withdraws in response to pain Withdraws in response to pain 4
Responds to pain with decorticate posturing (abnormal flexion) Responds to pain with flexion 3
Responds to pain with decerebrate posturing (abnormal extension) Responds to pain with extension 2
No response No response 1