Moderate-to-Severe Traumatic Brain Injury in Children

Complications and Rehabilitation Strategies

Myra L. Popernack, MSN, RN, CPNP; Nicola Gray, BSN, RN; Karin Reuter-Rice, PhD, CPNP-AC, FCCM, FAAN


J Pediatr Health Care. 2015;29(3):e1-e7. 

In This Article

Outcome Scoring Instruments

The Glasgow Coma Score (GCS) is the most commonly used measure of primary injury in the prehospital and acute care setting for grading TBI severity. The GCS is a standardized 15-point scale with three dimensions: eye opening, best verbal response, and best motor response. The resulting score reflects the primary event of direct brain injury to the parenchyma. A GCS of 13 to 15 indicates a mild brain injury, a GCS of 9 to 12 indicates a moderate brain injury, and a GCS of 3 to 8 is indicative of a severe brain injury (O'Brien, 2012). Recent studies have investigated the predictive value of the initial GCS for morbidity and long-term injury outcomes after TBI. Although there appeared to be a correlation between score and outcomes, other factors influenced outcomes, such as injury severity scores, associated hypoxic-ischemic injury, and provision of emergency care provided at a trauma versus nontrauma center (Cicero and Cross, 2013, Nesiama et al., 2012).

The Glasgow Outcome Scale (GOS) score has been used to define neurologic outcomes after TBI. The GOS score ranges from 1 (death), 2 (vegetative), 3 (severely disabled) to the more positive outcomes of 4 (moderately disabled) and 5 (good recovery). Immediate and aggressive interventions to address associated hypoxia and hypotension have been shown to prevent secondary brain insult and therefore positively affect the GOS (Zebrack et al., 2009).

The Rancho Los Amigos Scale, also known as Rancho Levels of Cognitive Functioning, includes an eight-level behavior/response scale developed in 1972 at the Rancho Los Amigos Hospital (Hagen, Malkmus, & Durham, 1972). The scale evaluates the patient's interaction with environmental stimulation as an indication of the stage of recovery from injury. Many of the responses are associated with executive functioning, such as judgment, reasoning, attention and focus, memory, orientation to environment, and appropriateness of verbalizations and actions. Also evaluated is the consistency of responses such as nonpurposeful behavior, agitation, or following commands to various stimuli. The scale ranges from level I (unresponsive to stimuli) to level VIII (purposeful and appropriate response to stimuli).

As injured children move to higher levels of recovery, there are recommended strategies to suggest for families to assist and support the child, to promote comfort, and to provide orientation to the environment. Even at level VIII of the Rancho Levels of Cognitive Functioning, children may continue to have difficulty in new situations. They may become stressed or easily overwhelmed when challenged, have difficulty with problem solving, and/or need guidance in decision making. The variability in agitation level at level IV presents a particularly difficult stage of recovery, not only in terms of safety but also of contributing to the family's anxiety at seeing the child appear uncomfortable and difficult to calm. Because the child may advance to this stage while in the intensive care setting, it can be challenging for caregivers to differentiate agitation as a stage of neurocognitive recovery from withdrawal from narcotics or sedatives. One can reassure the family that once a child reaches this level, progress generally advances forward to additional stages of cognitive recovery.