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Comparing AVPU and Glasgow Coma Scales Among Children Seen by Emergency Medical Services
Sriram Ramgopal1,2,3, Christopher M Horvat4, Rebecca E Cash5
1Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, and Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
Insights
This study establishes Glasgow Coma Scale (GCS) cut points for the Alert, Verbal, Pain, Unresponsive (AVPU) scale in pediatric emergency care. These findings improve clinician communication and aid in developing predictive models for pediatric EMS encounters.
Area of Science:
- Pediatric Emergency Medicine
- Neurological Assessment
- Prehospital Care
Background:
- Consciousness assessment is critical in pediatric prehospital care.
- Both the Glasgow Coma Scale (GCS) and Alert, Verbal, Pain, Unresponsive (AVPU) scales are utilized.
- Standardized correlations between these scales are needed for pediatric EMS.
Purpose of the Study:
- To determine specific Glasgow Coma Scale (GCS) cut points that correspond to the Alert, Verbal, Pain, Unresponsive (AVPU) scale.
- To facilitate consistent consciousness assessment in pediatric emergency medical services (EMS).
- To enhance data interpretation and clinical decision-making in pediatric prehospital care.
Main Methods:
- Retrospective analysis of the 2019-2022 National EMS Information System data.
- Inclusion of pediatric patients (<18 years) with documented GCS and AVPU scores.
- Evaluation of GCS cut points against AVPU categories using performance measures.
Main Results:
- Analysis of over 4.3 million pediatric EMS encounters.
- Optimal GCS cut points identified: 14-15 (Alert), 11-13 (Verbal), 7-10 (Pain), 3-6 (Unresponsive).
- High overall accuracy (0.95) and moderate agreement (kappa 0.61), with lower performance in Verbal and Pain categories.
Conclusions:
- A cross-walking between AVPU and GCS scales was successfully developed for pediatric EMS.
- The established cut points demonstrate high overall accuracy but require careful consideration for Verbal and Pain categories.
- Findings support improved clinician handovers and the development of EMS-based prediction models for pediatric patients.
Objectives:
Consciousness assessment is an important component in the prehospital care of ill or injured children. Both the Glasgow Coma Scale (GCS) and the Alert, Verbal, Pain, Unresponsive (AVPU) scale are used for this purpose. We sought to identify cut points for the GCS to correspond to the AVPU scale for pediatric emergency medical services (EMS) encounters.
Methods:
We conducted a retrospective cross-sectional analysis using the 2019-2022 National EMS Information System data set, including children (<18 years) with a GCS and AVPU score. We evaluated several approaches to develop cut points for the GCS within the AVPU scale and reported measures of performance.
Results:
Of 6 186 663 pediatric encounters, 4 311 598 with both GCS and AVPU documentation were included (median age was 10 years [interquartile range 3-15]; 50.9% boys). Lower AVPU scores correlated with life-sustaining procedures, including those for airway management, seizure, and cardiac arrest. Optimal GCS cut points obtained via a grid-based search were 14 to 15 for alert, 11 to 13 for verbal, 7 to 10 for pain, and 3 to 6 for unresponsive. Overall accuracy was 0.95, with kappa of 0.61. Intraclass F1 statistics were lower for verbal (0.37) and pain (0.50) categories compared with alert (0.98) and unresponsive (0.78).
Conclusions:
We developed a cross-walking between the AVPU and GCS scales. Overall performance was high, though performance within the verbal and pain categories was lower. These findings can be useful to enhance clinician handovers and to aid in the development of EMS-based prediction models.
