Name: Paediatric Glasgow Coma Scale for Children 4 Years of Age

OUR LADY’S CHILDREN’S HOSPITAL, CRUMLIN 12 NEUROLOGICAL ASSESSMENT RECORD Name: HCRN: Paediatric Glasgow Coma Scale DOB: Ward: DAT E TIME

s Spontaneously

E To verbal stimuli 3 i

n Eyes closed by To pain 2 e swelling - C p No response 1 O g n

e 4+ yrs Oriented and converses

n as norm

o 0-4 years. Vocalises or coos/ p

s smiles/cries appropriately e

R 4+ years Disoriented 4

e 0-4 Spontaneous irritable c Endotracheal

a cry tube/ m Cries/Screams to pain

r tracheostomy

G Grunts/Moans to pain 2 / - T l

a No Response 1 b r e V

t s e B r Usual mobility/obeys o 6 t command o

M Localises pain 5

s Withdraws from pain 4 e Record best B Abnormal flexion 3

e arm response s Extension to pain 2 n

o No Reaction to pain

p 1 s e R Total GCS A total GCS of ≤ 13 needs Medical review, Any individual score in the (orange) section needs medical review. A total GCS of ≤ 9 needs Urgent Anaesthetic review/PICU. Any individual score in the red section requires urgent anaesthetic review. R T

230 e e c m 220 40 o r p d e

210 i n a t

38 R 200 u e r e d

190 37 0 C

36 180

35 170

150 33 140 32 130 31 120 30 110 100 90 80 70 60 50 40 30 20 10 0

S Right Size (mm) Reaction (+)Reacting L I

P (SL) Sluggish

U (-) Not P Left Size (mm) Reaction reaction

B Normal Power Record Right M I [R] and Left L Mild Weakness Neuro-obs (All children) January 2015, Review 2018 OUR LADY’S CHILDREN’S HOSPITAL, CRUMLIN 12 NEUROLOGICAL ASSESSMENT RECORD Name: HCRN: Paediatric Glasgow Coma Scale DOB: Ward:

T Arms Moderate [L] separately N

E Weakness if there is a M difference E Severe Weakness

V between two

O No response sides M Normal Power (P)-paralysed Mild Weakness Legs Moderate Weakness Severe Weakness No response Initials

Guide to using Neurological Observation Chart for all infants/Children Involve carers in assessment to establish normal response EYE OPENING EXPECTED RESPONSE PROMPT Waken a sleeping infant/child 4 = Spontaneously Eyes open without stimulation Prior to assessment, touch to waken. 3 = To verbal stimuli Eyes open to sound or verbal stimuli. Use appropriate language and familiar 2 = To pain Eyes open to painful stimulus only. names. Involve the family. 1 = No response No response to painful stimuli Painful Stimulus: Use Trapezius squeeze. Apply gentle stimulus, gradually increasing for 10 seconds or less, or until eye opening is seen. BEST VERBAL EXPECTED RESPONSE PROMPT RESPONSE Assess patient with Intellectual disability in 0-4years age group 5 = 4+ years Vocalises to usual ability Ask age appropriate questions. Orientated and Young child-answers simple questions, gives name on request, Involve carers to establish what’s converses as normal can name toys, parents etc. normal. Infant- smiles, coos or cries appropriately

0-4 years Vocalises Intellectual disability / Non-verbal Infant/child: normally or communicates to usual ability. Screeching/shouting or grunting may coos/smiles/ be appropriate in an infant/child with cries/screeches intellectual disability. Involve carer in appropriately assessment (where possible).

Cry is high pitched and inconsolable The infant/child with Intellectual 4 =Spontaneous Cry is irritable and infant is difficult to pacify disability or who is non verbal has a irritable change in normal vocalisation pattern cry/disoriented or ability Cry is in response to pain only. Painful Stimulus: As above 3 = Cries/screams to Grunts or moans in response to pain. pain Painful Stimulus: As above No response to painful stimuli 2 = Grunt/Moans to Painful Stimulus: As above pain

1 =No Response BEST MOTOR EXPECTED RESPONSE – Please assess best response PROMPT (Visual or Verbal) RESPONSE 6 = Usual mobility/ The child will perform a task correctly. Ask carers if mobility is normal Obeys commands Intellectual disability / Non-verbal child: task performed to Offer child a toy/ bottle usual ability

5 = Localises pain Fig1. Localises Pain- Painful Stimulus: Note: Infants 0-6 months will not localise pain but should demonstrate normal flexion in response to pain. Infants/ children with physical disability Infants > 6 months should bring hand to source of pain and may try to may have abnormal posture. Flexion push it away(Purposeful). may be a normal position for these infants/children.

4 = Withdraws from Fig 2. Withdraws from Pain: The child moves limb away from painful Painful Stimulus: As above

Neuro-obs (All children) January 2015, Review 2018 OUR LADY’S CHILDREN’S HOSPITAL, CRUMLIN 12 NEUROLOGICAL ASSESSMENT RECORD Name: HCRN: Paediatric Glasgow Coma Scale DOB: Ward: pain stimulus

3 = Abnormal flexion Fig 3. Abnormal Flexion: The elbow flexes and the wrist rotates in Painful Stimulus: As above response to a central painful stimulus Flexion may be the normal position for a child. This does not indicate a low score.

2 = Extension to Fig 4. Painful Stimulus: As above pain Extension: Arm straightens at the elbow and there may be internal rotation of the lower arm 1 = No Response Painful Stimulus: As above

Neuro-obs (All children) January 2015, Review 2018