Glasgow Coma, AVPU Scales Have Limited Usability for Assessing Level of Consciousness in Pediatric Head Injury

IV in child's hand
IV in child’s hand
Investigators examined the use and equivalence of the Glasgow Coma Scale and the Alert, Voice, Pain, Unresponsive scale in children with head injury.

Approximately 25% of children who experienced a head injury did not have their Glasgow Coma Scale (GCS) score recorded in the emergency department, and failure to use the Alert, Voice, Pain, Unresponsive (AVPU) scale was highest in infants. Findings of this cross sectional study werepublished in BMJ Open.

Case notes for children age <15 years who were admitted to a hospital for a head injury were included in the analysis (n=5700). The investigators collected data for GCS total and component scores, AVPU score, age, hospital type, whether the children received a computed tomography (CT) scan, and diagnostic yield of intracranial abnormality or depressed fracture. The main outcomes included the equivalence of AVPU to GCS, GCS at the scene predicting GCS in the emergency department, CT results by age, and type of hospital.

According to the pooled data, clinicians recorded level of consciousness in 91% and 66.1% of patients in the emergency department and prehospital settings, respectively. Failure to use the AVPU and to record level of consciousness was more likely in infants. The researchers found a correlation between AVPU and median GCS in a total of 1147 children <5 years old (A=15, V=14, P=8, U=3) and for 1163 children ≥5 years old (A=15, V=13, P=11, U=3).

No difference was found in infants who had a CT whether AVPU=V/P/U or GCS <15. Despite this finding, diagnostic yield of depressed fracture or intracranial injury was greater for V/P/U than for GCS <15: 7/7: 100% (95% CI, 64.6%-100%) vs 5/17: 29.4% (95% CI, 13.3%-53.1%). Children age >1 year had more CT scans if GCS <14 was recorded vs V/P/U only.

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Limitations of the study included its retrospective design and small number of patients who experienced severe loss of consciousness.

“We would recommend that use of the simple AVPU is beneficial to initial assessment of infants with head injury but is not sensitive enough to monitor change in levels of consciousness and would, therefore, not be recommended for ongoing monitoring of clinical status in this age group,” the researchers concluded.


Nuttall AG, Paton KM, Kemp AM. To what extent are GCS and AVPU equivalent to each other when assessing the level of consciousness of children with head injury? A cross-sectional study of UK hospital admissions. BMJ Open. 2018;8(11):e023216.