AMC Clinical Exam Station: Pediatric Glasgow Coma Scale (pGCS)

Station Title & Timing

Title: Neurological Assessment of a Pediatric Patient (Head Injury)
Duration: 10 minutes (2 minutes reading time + 8 minutes performance)

Learning Objectives

Examination Skills: Correctly perform and verbalize a modified Pediatric Glasgow Coma Scale (pGCS) on a mannequin.
Clinical Reasoning: Adapt scoring criteria for the developmental stage of a toddler/infant.
Emergency Management: Identify the clinical threshold for airway intervention in a pediatric trauma context.
Professionalism: Demonstrate respect and appropriate clinical technique when using painful stimuli on a pediatric surrogate.

Patient Profile

Name: “Leo”
Age: 22 months old
Relative: Mother (Sarah) is present in the room, visibly distressed.
Context: Leo fell from a height of approximately 1.5 meters from a playground slide onto a bark-chip surface 30 minutes ago.

Presenting Complaint

Leo is currently lying on the resuscitation trolley. He is “sleepy” and not responding to his mother’s voice. He had one episode of vomiting en route to the hospital.

Contextual Information

HPC: Immediate cry after the fall, followed by a period of lethargy. No witnessed seizure activity.
PMH: Born at full term; meeting all developmental milestones (currently using single words and babbling).
Immunizations: Up to date.
Allergies: Nil.

Exam Instructions

Candidate Instructions

You are the Registrar in a Pediatric Emergency Department.

Perform a formal Pediatric Glasgow Coma Scale (pGCS) assessment on Leo (the mannequin).
Provide a running commentary for the examiner, justifying the scores you assign based on developmental age.
Report the final score and your immediate clinical priorities to the examiner.
Briefly communicate the situation to Leo’s mother.

Standardised Patient (SP) Instructions (The Mother)

Affect: Anxious. You are hovering near the trolley.
Interactions: If the doctor talks to Leo, you say: “He’s not answering me, doctor. He’s normally so chatty.”
If the doctor performs a painful stimulus: You may look concerned and ask: “Is that necessary? You’re hurting him!”

Mannequin Findings (To be provided by Examiner upon correct maneuver)

Eyes: Remain closed. If the candidate calls Leo’s name or shakes his shoulder, they stay closed. Upon trapezius squeeze, the eyes open briefly.
Verbal: When stimulated, Leo makes a “weak, grunting sound” but no recognizable words or coos.
Motor: When a painful stimulus is applied to the supraorbital notch, Leo reaches his hand up and successfully crosses the midline to push the doctor’s hand away.

Key Clinical Findings (Current Assessment)

Component	Finding	Pediatric Score
Eyes (E)	Opens only to pain/pressure.	2
Verbal (V)	Moans/grunts to pain (incomprehensible).	2
Motor (M)	Localizes to painful stimulus (crosses midline).	5
Total	pGCS 9

Communication Triggers (Murtagh-Aligned)

Open-ended: “Sarah, I can see this is very frightening. Can you tell me if Leo was acting normally immediately after he fell?”
Signposting: “I need to perform a specific neurological check now to see how awake Leo’s brain is. This involves checking his eyes, his sounds, and his movements.”
Addressing Pain: “I’m going to apply a small amount of pressure here on his shoulder. It is a necessary test to see how his nervous system responds to discomfort.”
Summarizing: “Based on my check, Leo has a score of 9 out of 15. This confirms he is quite drowsy and needs urgent monitoring.”

Assessment & Marking Guide

Domain	Key Performance Indicators
Technique	Used “COWS” (Can you hear me? etc.) before applying pain. Used professional central pain sites.
Developmental Accuracy	Explicitly stated that “Orientation” (V5) is not applicable for a 22-month-old.
Scoring	Correctly assigned V2 for grunting (rather than V3 for crying). Correctly identified M5 for localizing.
Clinical Reasoning	Recognized GCS 9 as “Moderate Head Injury” requiring urgent CT and neurosurgical consult.
Professionalism	Treated the mannequin with dignity; communicated empathetically with the mother.

Sample Answers / Model Performance

The Running Commentary:

“I am assessing 22-month-old Leo.

Eyes: No spontaneous opening. No response to verbal command. I am applying central pressure to the trapezius. The eyes open. That is E2.
Verbal: Leo is not cooing or using his usual words. To the painful stimulus, he is only grunting and moaning. For a pre-verbal child, this is V2.
Motor: Leo does not obey commands to wave or squeeze. On supraorbital pressure, he brings his hand up to the site of pain and crosses the midline. This is localizing, which is M5.
Total: Leo’s pGCS is 9.”

Explaining the Plan to the Examiner:

“A GCS of 9 in a pediatric patient indicates a moderate traumatic brain injury. My priorities are:

Airway/Breathing: Leo is currently maintaining his airway, but at GCS 9, he is nearing the threshold for intubation (GCS ≤8). I will keep suction ready and prepare for definitive airway management if he drops further.
Imaging: I will arrange an urgent non-contrast CT Brain to rule out intracranial hemorrhage.
Consultation: I will notify the Pediatric Surgical/Neurosurgical team and the ICU.”

Statistical Context for Head Injuries:

In pediatric trauma, approximately 80% of head injuries are classified as mild (GCS 13-15), while 10% are moderate (GCS 9-12), and 10% are severe (GCS ≤8). Leo falls into the moderate category, which carries a significantly higher risk of intracranial pathology compared to the mild group.