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

OBJECTIVE To evaluate utility and equivalence of Glasgow Coma Scale (GCS) and the Alert, Voice, Pain, Unresponsive (AVPU) scale in children with head injury.
DESIGN Cross sectional study.
SETTING UK hospital admissions: September 2009-February 2010.
PATIENTS <15 years with head injury.
INTERVENTIONS GCS and/or AVPU at injury scene and in emergency departments (ED).
MAIN OUTCOME Measures used, the equivalence of AVPU to GCS, GCS at the scene predicting GCS in ED, CT results by age, hospital type.
RESULTS Level of consciousness was recorded in 91% (5168/5700) in ED (43%: GCS/30.5%: GCS+AVPU/17.3%: AVPU) and 66.1% (1190/1801) prehospital (33%: GCS/26%GCS+AVPU/7%: AVPU). Failure to record level of consciousness and the use of AVPU were greatest for infants. Correlation between AVPU and median GCS in 1147 children<5 years: A=15, V=14, P=8, U=3, for 1163 children ≥5 years: A=15, V=13, P=11, U=3. There was no significant difference in the proportion of infants who had a CT whether AVPU=V/P/U or GCS<15. However diagnostic yield of intracranial injury or depressed fracture was significantly greater for V/P/U than GCS<15 :7/7: 100% (95% CI 64.6% to 100%) versus 5/17: 29.4% (95% CI 13.3% to 53.1%). For children>1 year significantly more had a CT scan when GCS<14 was recorded than 'V/P/U only' and the diagnostic yield was greater. Prehospital GCS and GCS in the ED were the same for 77.4% (705/911).
CONCLUSION There was a clear correlation between Alert and GCS=15 and between Unresponsive and GCS=3 but a wider range of GCS scores for responsive to Pain or Voice that varied with age. AVPU was valuable at initial assessment of infants and did not adversely affect the proportion of infants who had head CT or the diagnostic yield.

as reported in: BMJ Open. 2018 Nov 28; 8(11): e023216