Neurological Assessment Observations in Children

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					                   Paediatric Critical Care Network

                        Regional Guidelines

                                for the

   Assessment of Level of Consciousness in Children

Date: June 2009
Review Date: June 2011
Lead Author: Dr Mark Darowski
Members of the Advisory Group

Mark Darowski (Chair), Paediatric Critical Care Network Lead Clinician/Consultant Intensivist,
Leeds PCT/Leeds Teaching Hospitals NHS Trust

Michael Clarke, Consultant Paediatric Neurologist, Leeds Teaching Hospitals NHS Trust

Fraser Scott, Consultant Paediatrician, Mid-Yorkshire Hospitals NHS Trust

Jo Smith, Lecturer in Children Health Nursing, School of Healthcare, University of Leeds

Michelle Milner, Children's Network Manager, Leeds PCT

Sarah Fletcher, Matron, Children's Services, Leeds Teaching Hospitals NHS Trust

Liz Clancy, Paediatric Nurse Practitioner, Calderdale & Huddersfield Foundation Trust

Linda Daniel, Paediatric Critical Care Network Educator, Leeds PCT

Heather McClelland , Nurse Consultant - Emergency Care, Calderdale & Huddersfield NHS
Foundation Trust

Jake Timothy, Consultant Neurosurgeon, Leeds Teaching Hospitals NHS Trust

Mick Stone, Charge Nurse, Neurosurgical Intensive Care Unit, Leeds Teaching Hospitals NHS

Mark Darowski                                    2                        11/29/2011

Target audience

All nursing and medical staff who, as part of their normal duties, care for children (0-16 years) with
impaired levels of consciousness. These include staff working in children’s wards, PICUs, A&E
departments, adult wards and ICUs, and theatre recovery areas caring for children.

Why perform the assessment?

To determine a patient’s level of consciousness and to monitor changes in their condition.

Abnormal baseline values or changes in values should trigger actions by staff.

Who performs the assessment?

Staff trained in the performance of the assessment.

Trained staff must understand the significance of the assessment in relation to changing levels of
consciousness and the importance of accurate documentation and communication of any changes
in the child’s condition.

Which children require neurological assessment?

Any child who
    Is suspected of having an altered or changing level of consciousness that is not associated
       with normal recovery from anaesthesia or sedation.
    Has behavioral changes, disorientation or confusion
    Has a condition associated with potential neurological impairment (Appendix 1).

How often is a child assessed?

Initial assessment should be performed on any child meeting the criteria above.

The frequency of neurological assessment depends on the child’s condition and will be agreed
between medical and nursing staff taking account of local protocols.

The frequency of assessment must be prescribed and recorded on the chart by the admitting
doctor or as described in local guidelines.

NICE guidelines for the management of patients with head injury suggest that observations
should be performed and recorded on a half-hourly basis until GCS equal to 15 has been
achieved. The minimum frequency of observations for head injured patients with GCS equal to 15
should be as follows, starting after the initial assessment in the emergency department:
       - half-hourly for 2 hours;
       - then 1-hourly for 4 hours;
       - then 2-hourly thereafter.
Should a patient with GCS equal to 15 deteriorate at any time after the initial 2-hour period,
observations should revert to half-hourly and follow the original frequency schedule.

In other situations, the agreed frequency may be half hourly, or more frequently, depending
on the child’s condition.

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What are the components of neurological assessment?

Neurological assessment includes the following components.

       James’ Modification of the Glasgow Coma Scale* (GCS)
       Pupillary responses
       Posture
       Abnormal eye movement or position
       Motor power in limbs (weakness)
       Heart rate, blood pressure, respiratory rate/rhythm, temperature and SpO2 if GCS is
       Palpation of fontanelle in infants
       Recording of other significant events: seizures, episodes of vomiting, complaints of
        head/neck pain or visual disturbance, difficulty in swallowing, CSF leak from ear or nose.

    *The terms Scale and Score are both commonly used. Throughout this document we have chosen to use Scale.


Before performing a neurological assessment check ABC.

1. The modified Glasgow Coma Scale

The level of consciousness is assessed by the patients’ ability to perform 3 activities, which are
scored individually as detailed in table 1.
           1. Eye opening
           2. Verbal response
           3. Motor response

For younger children the responses expected should reflect their stage of development (Table 1).

How do I perform the assessment?

It is usually helpful to include the child’s parent or main carer in the assessment process, e.g. in
speaking to the child in their own language or when trying to wake them. However the assessment
must be performed objectively and promptly. A painful stimulus may need to be applied and carers

The following steps enable the GCS to be assessed quickly and with the least possible disturbance
to the child. In order to this the different elements of the GCS need to be assessed simultaneously
(Table 2).

Be aware of the good practice points described in Box 1 below:

Box 1. Good practice points.
   A sleeping child should always be woken for neurological observations

   It is essential that the child’s normal neurological status and developmental level is
    established, by involving carers, if they are present.

   At any patient handover (ward transfer, shift change etc) the observations must be
    performed by the by both nurses together to ensure consistency.

Mark Darowski                                          4                           11/29/2011
Table 1: Overview of Child’s Glasgow Coma Scale (Kirkham et al 2008)

                                     Child’s Glasgow Coma Scale
                                       >5yr                                           <5yr
Eye opening
      E4                                               Spontaneous
      E3                                                 To voice
      E2                                                 To pain
      E1                                                  None
       C                                   Unable to open eyes (swelling, ptosis)
      V5              Orientated                       Alert, babbles, coos, words
                                                       or sentences – normal for age
        V4            Confused                         Less than usual ability,
                                                       irritable cry
        V3            Inappropriate words              Cries to pain
        V2            Incomprehensible sounds          Moans to pain
        V1                                    No response to pain
        T                                      Child is intubated
        M6            Obeys commands                              Normal spontaneous
        M5            Localizes to supraorbital pain              Withdraws to touch (<9mo)
        M4                                   Withdraws from nailbed pain
        M3                                   Flexion to supraorbital pain
        M2                                  Extension to supraorbital pain
        M1                                 No response to supraorbital pain
        P                       Child is paralysed – muscle relaxants or spinal injury


For children >5y the responses are similar to the adult Glasgow coma scale.

Pain should be made by pressing hard on the supraorbital notch (beneath medial end of eyebrow) with your
thumb, except for Motor score 4, which is tested by pressing hard on the flat finger nail surface with the barrel
of a pencil.
If there is facial trauma or swelling that prevents you form using the supraorbital ridge or there is doubt about
the response to the supraorbital stimulus, then pinch the earlobe as an alternative stimulus.

Score the best response if unclear or asymmetrical. If in doubt repeat after 5 minutes and ask for a second

Score as usual in the presence of possibly sedating drugs.

Plot scores over time on a suitable chart.

Mark Darowski                                                5                               11/29/2011
Step 1

If the child’s eyes are open (E4), the carer or nurse/doctor should talk to the child in a language
familiar to the child and appropriate for their age. Observe the child’s verbal and motor response
      babbling for a child less than 9months
      any words from 12months
      any sentences from 2years
      orientation in place and time from 5years
      waving bye for a child aged 9–12 months
      putting a hairbrush to the head for a child aged 12–15months
      pointing to body parts for a child aged 15–24months

Decide with the carer whether any verbal response obtained is appropriate for the child’s usual
ability (V5) or less than the child’s usual ability (V4).

If a child appears to understand what is said to them, even if they are not speaking, ask the child to
obey a simple command, e.g. squeeze the carer’s finger or squeeze his eyes shut (M6). In infants
and children with developmental delay, watch for normal spontaneous movement (M6).

If the child does not have any spontaneous speech or eye opening, proceed to Step 2.

Step 2

If the child’s eyes are closed, talk to them and observe whether their eyes open in response to a
verbal stimulus (E3).

If the child opens their eyes, observe whether they appear to recognize the carer and understand
what is said. If this is the case, elicit a verbal and motor responses as for Step 1.

If there is no attempt to verbalise or move when the assessor talks or gently touches the child,
proceed to Step 3.

Step 3

3.1 A painful stimulus must be applied to complete the assessment. Supraorbital pressure is the
stimulus of choice (Box 2). Explain to the carer that you are going to press on the child’s forehead
to see if they will respond to pain.

 Box 2. Applying the stimulus
    To apply supraorbital pressure, press firmly on the supra-orbital notch (beneath the medial end of the
     eyebrow) with your thumb.
    Apply nailbed pressure tested by pressing hard on the flat finger nail surface with the barrel of a pencil.
    If there are facial fractures or severe swelling involving the supraorbital ridge, pinch the ear lobe to
     provide an alternative stimulus.
    If you are not confident about supra-orbital pressure, or nailbed pressure, try the technique on yourself
     first: press hard enough to elicit a very focal sharp pain. This feels different to the pressing feeling and
     stops as soon as you stop pressing.

Mark Darowski                                         6                            11/29/2011
Observe and document the child’s response:
      1. The eyes open (E3)
      2. Cries or uses inappropriate words(V3); or moans or makes incomprehensible
      3. Moves their arms:
          – Above the clavicle (with supraorbital pressure), or to remove the painful stimulus if
             another stimulus is used (localization to pain, M5)
          – Below the clavicle but flexing at the elbow (flexion to pain, M3) Fig 1
          – Below the clavicle without flexion but with rotation at the shoulder (extension, M2)
             Fig 2
          – No movement (M1)

Fig 1 Decorticate Posture results from damage to one or both corticospinal tracts. In this posture, the arms are
adducted and flexed, with the wrists and fingers flexed on the chest. The legs are stiffly extended and internally rotated,
with plantar flexion of the feet.

Fig 2 Decerebrate posture results from damage to the upper brain stem. In this posture, the arms and adducted
and extended, with the wrists pronated and the fingers flexed. The legs are stiffly extended, with plantar flexion of the

 If the child does not move following the initial application of a painful stimulus, press more firmly
(as hard as you can) and observe whether there is movement of any body part, including the face
(grimace). An absence of body movement in a child whose face moves may suggest a spinal cord

If the child flexes but does not localize apply nail bed and pressure observe whether or not the
child moves the finger away (withdrawal to pain, M4). Flexion is assessed in the arms; do not use a
limb with an obvious injury.

If there is asymmetry when assessing record the best response. Record and report asymmetrical
movement, which could indicate impending uncal herniation, particularly if the pupil size and
response to light is also asymmetrical.

3.2 When assessing an infant touch and stroke the child on the hand and forearm and note any
withdrawal to touch (M5).
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3.3 If you cannot feel one or other supra-orbital notch, e.g. because of traumatic facial swelling,
apply an earlobe pinch.

Score localizes to pain (M5) if the child brings the contra-lateral (opposite) arm partly across the
body to dislodge the pain or makes a complex purposeful manoeuvre to remove the pain, not just a
simple withdrawal (M4).

Observe the eye opening and verbal responses to pain at the same time.

When assessing infants the eye opening score is often E1 (none), even when verbal and motor
scores are high, e.g. V4, V5, M5, or M6.

Step 4

Document the date and time at which the observations were performed.
Write down the response observed for eye opening, verbal response, and motor response. If there
is asymmetry of the motor or eye opening response, write down the better side.

The eye opening, verbal and motor responses are always assessed and communicated
separately; an aggregate score can mask important changes.

A decrease of 1 point in the motor score or an overall deterioration of two points is considered

A summated score can provide a quick guide to a child’s level of consciousness. A total score of
15 (E4,V5,M6) represents an alert, orientated patient. A score of 8 represents severely impaired
consciousness and may require airway support. A score of 3 indicates a deep coma.

Intubated children

For intubated patients, score eye opening and motor responses as above and write down T (for
‘tube’) for the verbal score. Many paediatric intensive care units have adopted the grimace scale in
place of the verbal scale. Although there is good inter-observer agreement it has not yet been
assessed as a tool for the prediction of outcome.

Paralysed children
If the child is paralysed (muscle relaxants or spinal cord injury) record P for motor response.

Mark Darowski                                     8                         11/29/2011
                                               Children’s Glasgow Coma Scale: A step-by step guide
 Step 1
             Eyes open?                                                                        Box 1- Normal Verbal Responses. If child’s eyes are open (E4) ask the carer to talk to the
 Eyes                                                                                          child in a familiar language. Ask carer to elicit a verbal and motor esponse appropriate to the
                                                                                               child’s age e.g.
                                                                                                     Babbling if < 9 months
            Yes                                                                                      Any words from 12 months
            E4      No                                                                               Any sentences from 2 years
                                                                                                     Orientation in place and time from 5 years

                   Do eyes open to                                                                 Waving bye for a child 9-12 months
                      speech?                                                                      Putting hairbrush to head for child aged 12 – 15 months
                                                                                                   Pointing to parts of the body for child aged 15 – 24 months
                   Yes            No           Elicit verbal response   (see Box 1)
 Step 2            E3
                                                 Normal     Impaired          No
 Verbal                                         response    response       response        Elicit motor response by asking the child to obey simple commands e.g.
                                                   V5          V4                                    squeeze the carer’s finger or squeeze his eyes shut.

                                                                                                                               Obeys Commands?

Step 3                                                                                     Yes - M6                                                   No

                                                                 Apply supra-orbital pressure. Infants – first assess withdrawal to touch

                                                                          Verbal                                                                  Motor
                          Eyes          Eyes                    Cries     Moans    No verbal               Localises         Flexes to pain          Extends           No response to pain
                          open         do not                    V3        V2      response                 to pain                                  to pain
                           E2           open                                          V1                      M5                                       M2
                                                                                                                            Apply nail                                Increase supra-
                                         E1                                                                                 bed pressure                              orbital pressure
                                                                                                                             Withdraws to                                     Grimace?
                                                                                                                                                                           No           Yes
                                                                                                                             Yes          No                               M1
                                                                                                                             M4           M3

Step 4     E4     E3      E2        E1             V5      V4      V3       V2        V1           M6           M5          M4          M3             M2             M1              ? Spinal
 Record                                                                                                                                                                                Injury

Mark Darowski                                                                      9 11/29/2011
2. How do I measure pupillary responses?

Responses should be elicited using a bright pen torch (not an opthalmoscope, otoscope or
laryngoscope), in low ambient lighting, if possible. Allow 5 seconds before testing the opposite
eye to allow for recovery of the consensual light reflex.

Both eyes should be central looking forward. Deviation may be normal (squint -ask the family).
New deviation may be the sign of significant disease.

          Open both eyes.
          Observe pupils without stimulation for size and equality
          Shine light into each eye in turn.
               Light in one eye should cause simultaneous constriction of both pupils.
               When light is withdrawn, both pupils should dilate simultaneously.

The responses of each pupil are described in terms of
        Size – recorded as pinpoint, small, moderate or dilated
        Reactivity to light - recorded as brisk (record as B), no response/fixed (F), sluggish
          (S) or closed (C)
        Equality - of size and of response

Pupillary responses may be affected by medication. Opiates cause constriction. Eye drops given
before ophthalmologic examination and adrenaline used during episodes of resuscitation cause

3. How is motor function assessed?

Each limb is assessed independently for:
        Spontaneous movement (yes of no)
        Purposeful movement (yes or no)
        Strength (normal, weak, none)
        Posture (normal, decerbrate, decorticate)

4. How should an infant’s fontanelle be assessed?

Palpate the fontanelle and record as normal, sunken, tense, bulging or pulsatile.

5. What vital signs should be recorded?

Vital signs are recorded to:
          Identify those children who may have impaired consciousness as a result of a
            systemic illness.
          Detect signs of cerebral ischaemia. (hypertension, bradycardia)
          Correlate changes in conscious level in children with hypoxia/hypovolaemia.
          Heart rate
          Blood pressure
          Respiratory rate and rhythm
          Temperature
          SpO2 in children with a decreased CGS.

Mark Darowski                            10                                11/29/2011
6. What else should be part of the assessment?

    Occurrence of seizures (time, duration, description)
    Episodes of vomiting
    New onset of an inability to swallow secretions (drooling)
    Complaints of headache or neck pain/stiffness
    Leak of CSF (clear fluid) from ears or nose

7. What action should be taken once the assessment has been performed?

Any deterioration in neurological status must:
           o Be reported to the nurse and the doctor in charge of the clinical area.
           o Result in an increased frequency of observations
           o Result in a review of vital signs (including SpO2) and appropriate treatment if
           o Ensure that the child is nursed under close observation.


Stevens E (2004) Neurological observations: clinical procedure guideline. GOSH

Kirkham FJ, Newton CRJ, Whitehouse W (2008) Paediatric Coma Scales Dev Med & Child
Neurol 50: 267-174

Smith J, Martin C (2008) Paediatric neurosurgery for nurses: evidence-based care for children
and their families. Rouledge, Abindon Oxon

Fairley D, Cosgrove J (2004) Clinical guideline for assessing the Glasgow Coma Scale and pupil
response in adult. Leeds general Infirmary

National Institute for Health and Clinical Excellence (2007) Head Injury. Triage, assessment,
investigation and early management of head injury in infants, children and adults. NICE, London

Mark Darowski                            11                             11/29/2011
Appendix 1

The paediatric coma scale should be used routinely in accident and emergency departments
and on wards and intensive care units for the assessment of any child with:

      trauma (including possible non-accidental injury)
      iInfection, e.g. meningitis, encephalitis, cerebral malaria
      epileptic seizures
      diabetes or other known underlying metabolic abnormality
      hepatic failure
      renal failure (including haemolytic–uraemic syndrome)
      hypertension

In addition, children at risk of the following complications should be assessed frequently:

      hypoxic–ischaemic injury, e.g. postoperatively (particularly after cardiac surgery)
      hypotension, especially with shock (e.g. meningococcal)
      hypertension
      intracranial hypertension, e.g. with an acute encephalopathy,
      diabetic coma
      intra-cranial tumour
      after a neuro-imaging procedure requiring sedation or anaesthesia
      after a neurosurgical procedure, e.g. shunt for hydrocephalus

Mark Darowski                            12                                 11/29/2011

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